microsoft word 6 journal of medical ethics and history of medicine        brief report: the third annual medical ethics congress in iran   pooneh salari1, farzaneh zahedi2, kiarash aramesh3 and bagher larijani4   1assistant professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran; 2 md, endocrinology and metabolism research center, endocrinology and metabolism clinical sciences institute, endocrinology and metabolism research institute, tehran university of medical sciences, tehran, iran; 3associate professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran; 4professor, medical ethics and history of medicine research center & endocrinology and metabolism research institute, tehran university of medical sciences, tehran, iran.   corresponding author: bagher larijani e.mail: emrc@tums.ac.ir published: 02 may 2013 j med ethics hist med, 2013, 6:6 http://journals.tums.ac.ir/abs/23609 © 2013 pooneh salari et al.; licensee tehran univ. med. sci. the third national congress on medical ethics was held on february 21-23, 2013 in tehran, iran by medical ethics and history of medicine research center (mehrc) in cooperation of the ministry of health and medical education and the ministry of science, research and technology. this occasion provided an opportunity for medical ethics experts as well as lawyers, philosophers, and jurisprudences to discuss related issues in different fields of medical ethics. the congress attended by more than 100 participants provided an oral presentation and also more than 120 participants who presented their work as posters. the congress covered a wide range of subjects. it is worth mentioning that the secretary of the annual medical ethics congress of iran was developed in the medical ethics and history of medicine research center of tehran university of medical sciences in 2010. this secretary was created by cooperation of ministry of health, treatment and medical education in order to organize the annual congresses of medical ethics in different medical universities all over the country. following the first annual congress in tehran university of medical sciences (tums) (sep 19-21, 2010) and the second congress in isfahan university of medical sciences (feb 22-24, 2012), recent congress was held in tums. in accordance with the approved schedule, the first two days was dedicated to the subject of “medical ethics and reproductive health” and the third day was on “ethics in teaching”. at the first day, the opening ceremony was included the official welcome by the scientific secretary dr kiarash aramesh, and then professor bagher larijani, the congress chairman and the head of mehrc, opened the 3rd congress by his lecture on “ ethics in reproductive health”. the next key speaker of the congress was dr jihan tawilah, the representative of the world health organization (who), who delivered the message of this important organization on behalf of dr alwan. in addition to mentioning the name of famous iranian scholars including avicenna and razi as the iranian pioneers in health care services, she appreciated the iranians efforts in addressing ethical issues in health care. furthermore she insisted on the role of national ethics committees in providing a proper support in the dialogue between medical, jurisprudence, law, and social sciences in health care services. j med ethics hist med 6:6 may, 2013 jmehm.tums.ac.ir pooneh salari et al. page 2 of 2 (page number not for citation purposes)     then, dr ninuk widyantoro from indonesia presented ethical issues in family planning and dr sarah jane hawkes from england gave a presentation on the ethical issues of screening hiv and provided facts about opt in and opt out methods of getting informed consent. the expert panels during two days presented and discussed the most important and critical ethical challenges of the assisted reproductive technologies, surrogacy, embryo donation, abortion, etc. patients’ autonomy, justice and beneficence in various legal, cultural and religious contexts were discussed too. in the third day, the congress on “ethics in teaching” was launched. after opening ceremony and the welcome speech by dr pooneh salari the scientific secretary, the congress chairman professor bagher larijani gave a lecture on the issues by overview of ethics in teaching including ethics education in iran and the recent advances in the tehran university of medical sciences including establishing phd degree in medical ethics as well as reforms in teaching medical ethics. in this day, several international guests from all over the world attended the congress. dr ninuk widyantoro from indonesia gave a speech on teaching ethics in formal education and the ethical issues surrounding teaching in hpv vaccination was reviewed by dr sarah jane hawkes from england. dr kate moriarty from unesco (paris) described the mission statement of unesco about ethics, human rights, and education while other lecturers presented the ethical issues in other different areas of education including medical and clinical education, designing medical examinations, communication skills, internalization of ethical standards and their implications, the role of ethical intelligence in teaching, ethics in virtual teaching, role models, and compiling ethical guidelines for teaching. in all sessions and during coffee breaks, discussions were continued and created a chance for attendees to network. the congress indentified different aspects of ethical challenges regarding the differences in cultural and religious principles and highlighted new areas for cooperation in future. hhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh copyright © 2023 tehran university of medical sciences. this work is licensed under a creative commons attribution-non commercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. keywords: medical ethics; microbiota; fecal microbiota transplantation. introduction: the human microbiome is defined as the population of microorganisms, including bacteria, viruses, fungi and protozoan, as well as their genetic material, which live on and inside the human body as a host (1). according to the historical understanding, the general public thinks of microorganisms as pathogens and ignores the majority of harmless or beneficial species. in recent decades, emerging high-throughput sequencing technologies have caused swift advances in microbiome science, leading to dramatic changes in our understanding of ourselves, health and disease (2). this view of the human being as a superorganism and the human body as a dynamic ecosystem has led to a more comprehensive vision of health and a paradigm shift in clinical practice and public health. in the past, a distinction was drawn between the role of envi *corresponding author bagher larijani address: endocrinology and metabolism research institute, north kargar ave., tehran university of medical sciences, tehran, iran. postal code: 1411713135 tel: (+98) 21 88 22 00 38 email: emrc@tums.ac.ir received: 6 feb 2023 accepted: 19 apr 2023 published: 7 jul 2023 citation to this article: ejtahed hs, parsa m, larijani b. ethical challenges in conducting and the clinical application of human microbiome research. j med ethics hist med. 2023; 16: 5. -ronmental and genetic factors in developing diseases, and the microbial communities were defined as environmental factors; but recent evidence representing the interactions between the microbiome and the host genome underscores the need to reconsider the former as a hidden organ of the human body (3, 4). ethical challenges in conducting and the clinical application of human microbiome research 1. assistant professor, obesity and eating habits research center, endocrinology and metabolism clinical sciences institute, tehran university of medical sciences, tehran, iran; endocrinology and metabolism research center, endocrinology and metabolism clinical sciences institute, tehran university of medical sciences, tehran, iran. 2. assistant professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran; research center for war-affected people, tehran university of medical sciences, tehran, iran. 3. professor, endocrinology and metabolism research center, endocrinology and metabolism clinical sciences institute, tehran university of medical sciences, tehran, iran; medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. hanieh sadat ejtahed1, mojtaba parsa2, bagher larijani3* ethical challenges in conducting and the clinical application…. j. med. ethics. hist. med. 2023 (july); 16: 5. 2 advances in microbiome research combined with significant progress in “-omics” technologies such as genomics, transcriptomics, proteomics and metabolomics have generated valuable insights into the fundamental impact that microbiomes have on human health, including digestion, vitamin production, immunity, child growth, development and ageing. however, our knowledge about the microbiome is still preliminary compared to its complexity and we still do not know the exact role and function of many microbes living in our bodies. seeing as microbiome studies have come to be a hot topic in the last decade, it is essential to identify the ethical challenges raised by human microbiome studies to advise both the researchers and participants. challenges in defining the healthy microbiome particular cautions should be taken in determining the clinical indications and risk-benefit assessments associated with the applications of microbiome research findings at bedside. in spite of the increasing enthusiasm to modify the human microbiome, there is no exact definition for the healthy microbiome. it should be noted that specific species of bacteria might be beneficial for one person and harmful for another. the different responses of people to bacteria make reaching a unique definition for the normal microbiome more complicated. moreover, we must keep in mind that human microbiota undergoes daily variations and is influenced by environmental factors such as food intake and medications. all these issues make it difficult to offer a single definition for the healthy microbiome. in addition, we face ethical challenges in manipulating an individual’s microbiome because any alterations may affect the surrounding community (5, 6). microbiome sampling and privacy protection in microbiome studies sampling is mostly done through noninvasive procedures with minimal risk, including skin brushes, oral, vaginal and nasal swabs, saliva collection, and fecal self-collection. therefore, the risks of human microbiome research are often negligible, except for invasive sampling by endoscopy to collect and analyze the gut microbiome (4). since human microbial profile could provide transparent information about the individual’s habits and lifestyle, sufficiency of existing regulations in protecting information privacy should be examined in microbiome studies. moreover, considering the possibility to identify individuals based on microbial samples, it is recommended to extend the current protections of ejtahed hs., et al. 3 j. med. ethics. hist. med. 2023 ( july); 16: 5. genetic information and privacy safeguards of human tissue samples to microbiome research (4). according to an online survey on the privacy risks of microbiome studies, most people believe that the risks are similar to those associated with genome studies or medical records, and they prefer to receive detailed explanations in informed consent forms (7). biobanking biobanks as key infrastructures for microbiome research comprise another ethical aspect of human microbiome studies. the human microbiota biobanks and the associated stored clinical information may have different purposes and scopes than biobanks storing human tissue samples; however, microbiota samples provide valuable health resources with considerable potential in treating various diseases and require privacy considerations similar to human tissue samples. a growing number of stool banks have been organized by research institutes and clinics worldwide, helping to advance the goals of personalized medicine and optimize the therapeutic application of stool samples such as fecal microbiota transplantation (fmt) (5, 8). like other biobanks, ethical issues to be considered in microbiota biobanks are mainly focused on information privacy, informed consent, ownership of samples and associated information, secondary use of biological specimens, future benefit sharing and return of results to participants. in biobanks, it is necessary to determine who can access the samples and which related information may be shared (4, 8). the human microbial genome, which is considered the second genome, may be as personal as the human genome, and therefore ownership of samples is a valid consideration. on the other hand, the human microbiome is a dynamic ecosystem that, unlike the human genome, is not static throughout life. considering the lack of stability of the microbiota composition and the gradual changes in each person’s eating habits and use of antibiotics and other medications, the question of sample ownership may become more complex in microbiome research. in order to clarify this issue, there are questions that need to be answered, for instance: “is there a core microbiome for a human being?” “how permanent could changes to the human microbiome be?” and “could microbiome changes be transmitted to offspring?”. another important issue is lack of scientific consensus over the identification capacity of human microbiome data, like human genome data. however, the dynamic nature of microbiota creates an excellent opportunity for therapeutic interventions based on ethical challenges in conducting and the clinical application…. j. med. ethics. hist. med. 2023 (july); 16: 5. 4 modification of microbiota. this microbiome instability makes it more clinically actionable compared to the human genome (4, 8, 9). disclosure of the results of microbiome research since microbiome tests are not considered routine medical examinations, translation of human microbiome research findings and returning the results to participants is another challenge in microbial studies. it is suggested that “findings that are analytically valid, reveal an established and substantial risk of a serious health condition, and are clinically actionable” be explained to participants (8). the clinical significance and actionability of findings are the major reasons for the disclosure of medical research results; however, in microbiome studies, the validity and reliability of findings should also be confirmed. moreover, in some cases, microbiota tests and sequencing are done long after sampling and biobanking, and considering the instability of microbiota, the benefit of returning the results is unknown. furthermore, it should be noted that misinterpretation or inadequate interpretation of the results is a potential risk due to a lack of appropriate knowledge about the clinical significance of microbiome findings. therefore, before deciding to disclose or not to disclose, a risk-benefit assessment should be done to avoid creating stress for the participant on account of something we may not have a correct interpretation of. as a result, ethical guidelines and practices regarding the return of human microbiome results should be developed (8, 9). fecal microbiota transplantation (fmt) and probiotics as novel therapeutic strategies fmt has rapidly received attention worldwide in treating recurrent and refractory c. difficile infection (cdi) (10 14). after two cases of serious infections caused by multi-drug resistant organisms in immunocompromised adults who received investigational fmt and one case of death, the food and drug administration (fda) has introduced some donor screening and testing standards regulations (15). more research is required regarding the efficacy, risk assessment, long-term safety and possible consequences of fmt. therefore, we should proceed with caution, especially in the case of non-cdi diseases that are not responding to standard therapies. these interventions should be conducted in the context of a clinical trial (15). one prevalent method of modulating the microbiota composition is the use of probiotic products. with increased public awareness of the health benefits and nutritional effects of fermented ejtahed hs., et al. 5 j. med. ethics. hist. med. 2023 ( july); 16: 5. foods and probiotic products, the supply and demand markets for these products are anticipated to increase. it should be considered, however, that the beneficial effects of probiotics are strainspecific and there is no fit-for-all strain since different individuals have various health statuses (16). therefore, regulations and monitoring are needed to examine the health claims of probiotic products. moreover, genetically modified probiotics and disease-specific use of probiotics might challenge the existing regulations, and stricter regulations and ethical considerations may be needed (17). safety and accurate labeling are the other ethical issues relating to probiotic foods and supplements. according to the new labeling recommendations, labels on probiotic supplements should contain the organisms in a product down to the strain level, the existing quantitative amount of probiotics expressed in colony-forming units (cfus), and the expiration date (18). conclusion microbiome studies improve our prior perceptions regarding the interactions between microorganisms and the human body. along with the increasing awareness of the role of dysbiosis in pathogenesis of different diseases, novel approaches to modify the composition of the microbiota are becoming widespread. we highlight the urgent need to develop ethical guidelines concerning informed consent, privacy, microbiome biobanks, disclosure of the results of microbiome research, and translation of human microbiome research into practical applications such as fmt. acknowledgements the study was not funded. conflict of interests there are no competing interests to declare. ethical challenges in conducting and the clinical application…. j. med. ethics. hist. med. 2023 (july); 16: 5. 6 references: 1. ejtahed hs, soroush ar, angoorani p, larijani b, hasani-ranjbar s. gut microbiota as a target in the pathogenesis of metabolic disorders: a new approach to novel therapeutic agents. hormone and metabolic research. 2016; 48(6): 349-58. 2. shamarina d, stoyantcheva i, mason ce, bibby k, elhaik e. communicating the promise, risks, and ethics of large-scale, open space microbiome and metagenome research. microbiome. 2017; 5(1):1-9. 3. ejtahed hs, hasani-ranjbar s, larijani b. human microbiome as an approach to personalized medicine. alternative therapies in health and medicine. 2017; 23(6): 8-9. 4. ma y, chen h, lan c, ren j. help, hope and hype: ethical considerations of human microbiome research and applications. protein & cell. 2018; 9(5): 404-15. 5. rhodes r. ethical issues in microbiome research and medicine. bmc medicine. 2016;14(1):1-4. 6. smith hj. an ethical investigation into the microbiome: the intersection of agriculture, genetics, and the obesity epidemic. gut microbes. 2020; 12(1):1760712. 7. shin a, xu h. privacy risks in microbiome research: public perspectives before and during a global pandemic. ethics & human research. 2022; 44(4): 2-13. 8. chuong kh, hwang dm, tullis de, waters vj, yau yc, guttman ds, et al. navigating social and ethical challenges of biobanking for human microbiome research. bmc medical ethics. 2017;18(1):1-0. 9. lange l, berg g, cernava t, champomier-vergès mc, charles t, cocolin l, et al. microbiome ethics, guiding principles for microbiome research, use and knowledge management. environmental microbiome. 2022; 17(1): 1-8. 10. drekonja d, reich j, gezahegn s, greer n, shaukat a, macdonald r, et al. fecal microbiota transplantation for clostridium difficile infection: a systematic review. ann intern med. 2015; 162: 630–8. 11. kelly cr, khoruts a, staley c, sadowsky mj, abd m, alani m, et al. effect of fecal microbiota transplantation on recurrence in multiply recurrent clostridium difficile infection: a randomized trial. ann intern med. 2016; 165: 609–16. ejtahed hs., et al. 7 j. med. ethics. hist. med. 2023 ( july); 16: 5. 12. staley c, hamilton mj, vaughn bp, graiziger ct, newman km, kabage aj, et al. successful resolution of recurrent clostridium difficile infection using freeze-dried, encapsulated fecal microbiota; pragmatic cohort study. am j gastroenterol. 2017; 112: 940–7. 13. goloshchapov ov, olekhnovich el, sidorenko sv, moiseev is, kucher ma, fedorov de, et al. long-term impact of fecal transplantation in healthy volunteers. bmc microbiol. 2019; 19: 312. 14. sachs re, edelstein ca. ensuring the safe and effective fda regulation of fecal microbiota transplantation. j law biosci. 2015; 2: 396–415. 15. grigoryan z, shen mj, twardus sw, beuttler mm, chen la, bateman-house a. fecal microbiota transplantation: uses, questions, and ethics. medicine in microecology. 2020; 6: 100027. 16. hill c, guarner f, reid g, gibson gr, merenstein dj, pot b, et al. the international scientific association for probiotics and prebiotics consensus statement on the scope and appropriate use of the term probiotic. nat rev gastroenterol hepatol. 2014; 11: 506-14. 17. harrison kl, farrell rm, brinich ma, highland j, mercer m, mccormick jb, et al. ‘someone should oversee it’: patient perspectives on the ethical issues arising with the regulation of probiotics. health expectations. 2015;18(2): 250-61. 18. mazzantini d, calvigioni m, celandroni f, lupetti a, ghelardi e. spotlight on the compositional quality of probiotic formulations marketed worldwide. frontiers in microbiology. 2021;12: 693973. journal of medical ethics and history of medicine review article the right to information and their exceptions in medical practices in the iranian legal system maysam sheykh-talimi 1* , sadegh shariati-nasab 2 , mohammad kazem zare 3 , reza omani-samani 4 1 department of epidemiology and reproductive health, reproductive epidemiology research center, royan institute for reproductive biomedicine, academic center for education, culture, and research, tehran, iran; 2 research supervisor, department of epidemiology and reproductive health, reproductive epidemiology research center, royan institute for reproductive biomedicine, academic center for education, culture, and research, tehran, iran; 3 phd candidate in criminal law and criminology, university of tehran, tehran, iran; 4 phd candidate in medical ethics, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran; assistant professor, department of epidemiology and reproductive health, reproductive epidemiology research center, royan institute for reproductive biomedicine, academic center for education, culture, and research, tehran, iran. corresponding author: maysam sheykh-talimi address: royan institute, tehran, iran. postal code: 16635148 email: maysam.talimi@gmail.com tel: 98 21 22306481 fax: 98 21 22306481 received: 7 oct 2015 accepted: 1 nov 2016 published: 8 nov 2016 j med ethics hist med, 2016, 9: 15 © 2016 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract the right to information act was implemented in the iranian legal system through accession of the merida convention ensuring the right to information as a fundamental right for the public. one significant aspects of this subject is the ratification of the "disclosure and access to information act" by which it is recognized as a right of all persian individuals and citizens to access state-held information in iran administration. the iranian legislature, with regard to the role of access to information and its significance, clarified the scope, permitted subjects of access, and exceptions of the right to state-held information. in this essay, we will discuss the legal aspects and scope of ensuring access to medical information in the iranian statutes and their exceptions. it is argued that the iranian legislation ensures the principle of maximum disclosure, while sensitive subjects’, specially classified and private information, are exempted. therefore, the related rules in iran’s statutes not only do not threaten patient’s information, but also protect them by criminalizing the breaching of the mentioned right. keywords: right to information, access to information, scope of access to information, patients' information, access to information exceptions mailto:maysam.talimi@gmail.com j med ethics hist med 9: 15 november, 2016 jmehm.tums.ac.ir maysam sheykh talimi et al. page 2 of 5 introduction the right to state-held information can be defined as the right of members of the public to know what state knows and accordingly state obligation to disclose information (1, 2). this act was implemented in the iranian legal system by accession to the united nations convention against corruption (merida). chapter ii of the convention recognizes the right to access to information (3). articles 10 and 13 of the mentioned chapter explicitly oblige state parties to ensure that the “public has effective access to information”. consistent with provisions of the merida convention, state parties are obliged to report information to the public without any request from them and ensure their effective access to information. by ratification of the “disclosure and access to information act” in august 2009, the legislature in iran recognized the right of access to state-held information for members of the public and presented the subjects and scope of disclosure. the iranian legislature then ratified the “raising health in administration body and corruption combating act” in november 2011. in this act, preventive measures against corruption are the main purpose according to its provision, which predicted subjects of information dissemination and their exceptions. in the mentioned acts, disclosure before filing a request and requesting before disclosure of accessible information have been considered. on the one hand, the state is obliged to disclose information and the public has the right to file a request for retrieving information from public bodies. on the other hand, sensitive medical issues are under protection to respect the privacy of patients, except under special circumstances in which social benefit shall be achieved by disclosure of such information or personal information as discussed (4, 5). the main purpose of this essay was the description of the citizen’s right to access to public information and the clarification of patient rights and their exceptions in the area of right to information. ensuring the right to information in the iranian legal system the outset of ensuring the right to access to stateheld information in iran was the accession to the united nations convention against corruption (merida convention). not too long after the accession, two significant acts (6, 7) which ensure access to information with preventive approaches for fighting against corruption and increasing transparency were passed through the iranian legislature body. thus, the obligation to ensure access to information established by the accession of the merida convention, and then, its recognition in the mentioned ratified acts after the accession shall be discussed in this article. obligation to ensure access to information chapter ii of the merida convention, which is the first and only international treaty for combating corruption, recognizes and declares the obligation of state parties to ensure access to information. article 5 of the convention mandates state parties to “develop anti-corruption policies that promote the participation of society” and “periodically evaluate legal instruments and administrative measures with a view to determining their adequacy to prevent and fight corruption”. a variety of different measures are highlighted in chapter ii, among which are recognition and ensuring of the right of access to state-held information. provisions of article 10 and 13, respectively, consider the obligation of the state to disclose information actively and ensure effective access to information, both of which constitute the elements of the “right to state-held information”. in other words, there are two ways for accessing stateheld information; individuals request to access information, and receiving it, or information is disseminated voluntarily by the state without any request from a user (8). article 10 of the merida convention obliges state parties to “public reporting” which is the latter sort of access to information. therefore, the state parties’ obligation is not only limited to accept file requests from users, but also includes reporting information proactively. article 13 of the convention, with the purpose of promoting active participation of individuals and groups outside the public sector, mandates state parties to promote transparency, participation of the public in the decision-making process, and effective access to information (9). in fact, the article 13 is a repetition for ensuring access to information in order to recognize the right of access to information by individuals’ direct request without which the repetition of the right to information in article 13 could be unnecessary. ensuring the right to information has some fundamental demands without which access would be impossible; infrastructures and access without any discrimination for all members of the public. thus, recognition of the right to information, and then, construction of primaries are state parties’ obligations. therefore, article 10 and 13 together constitute the obligation to disclose information before and after any request, which are elements of the right of access to information. ensuring the right to information in the iranian statutes in response to the obligation to ensure the right to information in basis of articles 10 and 13 of the merida convention, which this convention is now a part of the iranian legal system, as article 9 of the civil law adjudicate “ratified treaties (conventions) in parliament are a part of domestic law”, legislature j med ethics hist med 9: 15 november, 2016 jmehm.tums.ac.ir maysam sheykh talimi et al. page 3 of 5 recognized the mentioned right in iran statute both in “disclosure and access to information act” and “raising health in administration body and combat corruption act” just after accession to the convention. as mentioned above, these acts, some parts of which are allocated to ensuring the right of access to information, have preventive approaches to combating corruption. as we can find at the chapeau of article 8 of the “raising health in administration body and combat corruption act”, the legislature considers access to information for the public as an instrument for prevention of corruption. for this purpose, the “disclosure and access to information act” observes that “each persian individual has the right to access information”. thus, article 5 in chapter 1 titled “right to information” states that “public bodies should disclose information which are subject to this act as soon as possible and without any discrimination”. the right to state-held information as mentioned in the previous section of the text includes the right of individuals to file a request and obligation of the state to provide public reports. these elements can be found in article 2 and 5 of the “access to information act”. article 2 explicitly recognizes the right to information for all persian people and article 5 holds that publishing the information is a duty for public bodies. scope of access to state-held information in iran to ensure access to information, according to the “access to information act”, the state in a general notion is obliged to disclose all its information. thus, the mentioned act clarifies what information should be disclosed by public authorities in order to execute this right. it also considers exceptions of dissemination to clarify the duties of public bodies in order to perform disclosure rules precisely and for the purpose of protection of personal information. subjects which must be disclosed in order to clarify public bodies’ duties, the “raising health in administration body and combat corruption act” and “disclosure and access to information act” explain what information can be disclosed. all information is accessible and inaccessibility is an exception; thus, the legislature in iran named subjects which must be disclosed and their exceptions. article 5 of the “disclosure and access to information act” holds public bodies responsible for the disclosure of information. however, article 10 states that “each public body should publish public information including at least their work results and functions annually in order to protect public benefit and citizenship rights using computer facilities and book guides…” and continues with naming some issues which must be disclosed by authorities. it seems that topics which should be disclosed are not limited to the mentioned issues and “computer facilities” are not limited to filing a request before a public body, but publishing through the internet as a useful and costless way. in the “raising health in administration body and combat corruption act”, several subjects of disclosure have been declared to clarify the duties of authorities to protect the right of accessing information. what should be disclosed in the latter act can be considered as interpretation of the “disclosure and access to information act” which makes the subjects of access and exceptions more precise by explicitly declaring some subjects of access to information one by one such as proactively disseminating public contracts (article 3). but it does not make any limit through the accessible subjects, on the basis of “principle of maximum disclosure” which can be perceived by “disclosure and access to information act” (10) which means all information are accessible unless the law prohibits them to be disseminated. thus, it seems that all medical information and statistics can be accessible unless an act explicitly prohibits them. this at first glance seems contrary to the privacy and rights of patients to their information because these acts, on the basis of maximum disclosure, make all information accessible unless an act establishes an obstacle. exceptions of access to state-held information article 13 of the merida convention recognizes certain restrictions in the way of access to information. in iran, as discussed above, the legislature have respected the principle of maximum disclosure, but, in order to respect privacy and public benefits, have banned access to some types of information. section 4 of the "disclosure and access to information act" provides a number of exceptions including state secrets and classified documents, honoring privacy, health and commercial information protection, public security and tranquility, and etcetera. therefore, the disclosure of sensitive information like name, address, personal habits, and body illness are explicitly excluded from disclosure and public access based on part (b) of article 1 of the "disclosure and access to information act". it is also imperative for authorities to refuse disclosure in case of the possibility of any harm or damage to life of individuals or their properties. therefore, it seems that access to medical and sensitive information is restricted. one of the main exceptions to the right to information, as article 14 of the above act states, is the request of access to information related to privacy of persons or reached by breaching their privacy. preserving the privacy and confidentiality of patients is also a legal duty of medical healthcare providers (11, 12). hence, as access to information ensures the fundamental rights of the public, exceptions to this right ensure trust between patients and healthcare providers, and protect the patient’s right to privacy and confidentiality. in other word, the other side of the same coin, is duty of healthcare providers, binding j med ethics hist med 9: 15 november, 2016 jmehm.tums.ac.ir maysam sheykh talimi et al. page 4 of 5 by article 648 of the ta’azirat act, which criminalized breaching confidentiality (13). the above article not only provides an absolute prohibition of the disclosure of private information by all healthcare providers and other persons who have gained private information through their professions, but also makes it punishable by imprisonment or fine. therefore, article 648 of the ta’azirat act is presumed as the criminal sanction of the “disclosure and access to information act" restrictions. by this interpretation, the “disclosure and access to information act” can be seen as a protective measure for patient’s medical information instead of a threat to it and article 648 of the ta’zirat act as a complementary to the mentioned restrictions. as an exception to these rules, if the patient permits access through informed consent or if the patient has no legal capacity, the mentioned act in article 15 prescribes the access of those who the patient permitted and patient’s guardians or attorney, respectively. it seems these exceptions to exceptions solve many legal issues in medical practices, which had remained unresolved and were an ethical dilemma for many years (14). however, according to the “disclosure and access to information act”, checking cases of exceptions is the duty of the “access to information commission” in the ministry of culture of iran, the purpose of which is ensuring the right of access to state-held information. conclusion the right to state-held information was implemented in the iranian legal system by accession to the merida convention in the frame of ratification of the two significant acts of the “disclosure and access to information act” and “raising health in administration body and combat corruption act”. according to the first act, access to information is recognized as a right for all persian individuals and disclosure of information is mandatory for public bodies. the legislature by ensuring this right recognizes two ways of accessing information; voluntary dissemination of information by public bodies and disclosure by user request, which constitutes elements of the right of access to stateheld information. in the mentioned acts, the legislature has declared what information shall be disclosed and has also determined their exceptions. in accordance with the iranian legislature volition, disclosure is a general principle, while nondisclosure is presumed an exception. as a result, subjects of exceptions have been precisely determined in these acts, and access to medical information is one of them. in the other words, in the era of freedom of information whereby the right to information ensures transparency in medical decision-making as a general rule, for the purpose of amelioration, its exception to patients information ensures privacy and confidentiality and trust between patients and healthcare providers. medical information has been specifically exempted by the argued acts from access, unless an act gives permission to file a request for access; under some special and precise conditions such as informed consent or for the patients without legal capacity merely for their guardians or attorney. j med ethics hist med 9: 15 november, 2016 jmehm.tums.ac.ir maysam sheykh talimi et al. page 5 of 5 references 1. mendel t, unesco nd. freedom of information: a comparative legal survey. paris: unesco; 2008. http://portal.unesco.org/ci/en/files/26159/12054862803freedom_information_en.pdf/freedom_information_en.pdf (accessed in 2015) 2. ansari b. [azadiye etela'at]. tehran: dadgostar; 2008. [in persian] 3. unodc. united nations guide for anti-corruption policies. vienna: united nations; 2003. https://www.unodc.org/pdf/crime/corruption/un_guide.pdf (accessed in 2015) 4. marzilli a. the right to privacy. usa: chelsea house publishers; 2003. 5. nicholas n. confidentiality, disclosure and access to medical records. the obstetrician & gynaecologist 2007; 9(4): 257-63. 6. anonymous. islamic parliament research center [ghanoone enteshar va dastrasie azad be ete’la’at]. http://rc.majlis.ir/fa/law/show/780303 (accessed in 2016) [in persian] 7. anonymous. islamic parliament research center [ghanoone ertegha’e salamate nezame edari va moghabele ba fesad]. http://rc.majlis.ir/fa/law/show/802617 (accessed in 2016)[in persian] 8. darbishire h. proactive transparency: the future of the right to information. washington: world bank institute governance working paper series. 2010. http://siteresources.worldbank.org/extgovacc/resources/darbishireproactivetransparency.pdf (accessed in 2015) 9. unodc. technical guide to the united nations convention against corruption. newyork: united nations; 2009. https://www.unodc.org/documents/corruption/technical_guide_uncac.pdf (accessed in 2015) 10. mendel t. the right to information in latin america: a comparative legal survey: paris: unesco, quito office; 2009. http://unesdoc.unesco.org/images/0018/001832/183273e.pdf (accessed in 2015) 11. clark cl, clark c, mcghee j. private and confidential?: handling personal information in the social and health services. uk: policy press; 2008. 12. flight m, meacham m. law, liability, and ethics for medical office professionals. usa: cengage learning; 2010. 13. mir mohamad sadeghi h. offences against the person. 11 ed. tehran: mizan legal foundation; 2013. 14. jansen la, ross lf. patient confidentiality and the surrogate's right to know. the journal of law, medicine & ethics 2000; 28(2):137-43. http://onlinelibrary.wiley.com/doi/10.1111/j.1748-720x.2000.tb00003.x/abstract (accessed in 2015) ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ 1 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e commentary volume 13 (suppl.) number 31 december 2020 copyright © 2020 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. heroes or cowards: healthcare workers’ autonomy right versus patient care duties during the covid-19 pandemic sina azadnajafabad* researcher, non-communicable diseases research center, endocrinology and metabolism population sciences institute, tehran university of medical sciences, tehran, iran. introduction since the advent of covid-19 spread, humankind has become helpless and hopeless in the face of this tragic pandemic that has claimed the lives of numerous people worldwide. moreover, no one still knows when and how this crisis will end (1, 2). healthcare workers (hcw), referred to by social media and governments as health advocates, have been rescuing and protecting many lives during this pandemic. because hcws and medical staff, like other members of human society, are entitled to human rights including the right to health, many ethical controversies and dilemmas arose about the hcws’ role as heroes or cowards in this crisis (3). such controversies need to be appropriately addressed as this pandemic will not be the last health disaster to face. the burden of covid-19 on hcws during the covid-19 pandemic, hcws have been experiencing an overwhelming physical and mental pressure and exposed to a high risk of infection and death due to direct and indirect contact with the hospitalized patients. world countries have reported numerous mortalities among their healthcare and medical staff that providing care to the infected patients (4). major causes of the high infection rate among hcws are as follows (5): (i) limited supplies of personal protection equipment (ppe), (ii) low awareness about using protection at the beginning of the pandemic, (iii) long-time exposure to the infected cases in emergency and other wards, *corresponding author sina azadnajafabad non-communicable diseases research center, endocrinology and metabolism population sciences institute, no. 10, jalal al-e-ahmad and chamran highway intersection, tehran, iran. postal code: 1411713137 tel: (+98) 21 88 63 12 93 email: s.azad@ncdrc.info received: 20 nov 2020 accepted: 29 nov 2020 published: 27 dec 2020 citation to this article: azadnajafabad s. heroes or cowards: healthcare workers’ autonomy right versus patient care duties during the covid-19 pandemic. j med ethics hist med. 2020; 13(suppl.): 31. heroes or cowards: healthcare workers’ autonomy right versus patient care … 2 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 31 december 2020 and (iv) insufficient training in infection prevention and control protocols. hcws experience a heavy mental burden because they face stress and burnout in caring for patients (6). common psychiatric consequences of this mental burden on hcws are psychological distress, anxiety, depression, fear, post traumatic stress disorder (ptsd), and stigmatization (7). fear and avoidance of hcws lead to significant stigmatization to them, resulting in social isolation and further physical and emotional solitude (7). such hcws’ efforts and pressures either have not been acknowledged or have been underestimated because healthcare systems have currently focused on coping with the pandemic as the main target. heroes or cowards? during the covid-19 pandemic, social media, mass media, and governments have called medical staff health advocates and heroes. however, the refusal of various groups of hcws to provide care in threatening situations, such as an epidemic of highly infectious disease, caused them to be called cowards by others, including colleagues or the general public, since society expected them to make sacrifices to save human lives (8). the controversy over these two conflicting attitudes stems from a fundamental debate about the duty of care or treatment versus the right to refuse to provide care, rooted in hcws’ eligibility for human rights as others. this controversy led to major moral distress in hcws which adversely affected the quality of care provided to patients (9). in addition, hcws’ heroic narratives and calling them brave soldiers in fighting against covid-19 can have a serious psychological impact on them. these narratives and labels obscure the real situation of hcws and lead to ignorance of the pressure on them, and hence mislead the public about their needs, rights and duties in caring for the covid-19 patients (10). this article focused on hcws’ autonomy, as one of their human rights, to make decisions to fulfill their care-related duties or refuse to provide care (11). given the high risk of developing covid-19 symptoms for hcws, they are concerned about the safety and health of themselves and their families, a concern caused by instinctual feelings that cannot be overlooked. moreover, if hcws are in a healthy state, they can provide effective services to patients, and hence the society’s priority should be to ensure hcws’ health and safety. in addition, hcws’ right to maintain safety must be respected whenever they feel threatened. hcws should morally act according to the two major principles of medical ethics: beneficence and nonmaleficence (9). practical approaches to resolve the dilemmas practical approaches to resolve the aforementioned dilemmas are required for hcws to provide good quality patient care and have reasonable job satisfaction level. to do so, key steps involve clarifying the duties and rights of hcws in a health emergency, as well as determining the conditions under which hcws must perform or should leave their duties during such emergencies (12). azadnajafabad s. 3 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 31 december 2020 the obligatory nature of hcws’ duties are due to the followings: (i) their professional responsibilities were defined to care for patients and they were trained to do so; (ii) they have accepted the potential dangers of their profession from the outset of their commitment to the job; (iii) they have to be loyal to their profession, dutiful and vigilant even under unfavorable circumstances and difficult conditions; (iv) the society expects them to make their utmost effort to save patients’ lives, even at the cost of their own health and wellbeing (13). other factors affecting hcws’ willingness to stay and perform duties during health disasters such as pandemic are as follows: (i) significant influx of patients seeking care, (ii) professional code of beneficence, a major code of medical ethics, and (iii) duty of accepting risks to help other hcws and taking on a share of the burden (14). risk assessment, management and communication are other practical approaches to handle the crisis following the emergence of a highly infectious disease. successful crisis management at such times includes a series of measures to improve the knowledge of the public and hcws about the disease, proper evaluation of the risks, and taking effective steps to minimize identified risks. successful risk management can also support hcws and reduce the known and unknown fears of facing the disease and infected patients (14, 15). risk communication, one of the fundamentals of the action plan proposed by the centers for disease control and prevention (cdc) presented as a brief guide named cerc (cdc’s crisis and emergency risk communication), has a remarkable role in handling outbreaks. risk communication includes being the first to share information about the disease, spreading the right information, providing honest and evidencebased information, expressing empathy to both patients and caregivers, promoting actions to stop disease spread, and showing respect to vulnerable populations affected by the disease to promote maximum cooperation (16). other necessary action plans to mitigate hcws’ concerns and fears during an outbreak fall into four main categories. (i) protect hcws’ safety by providing adequate ppe and giving them a priority for vaccinations and treatments when they become available; (ii) honest and transparent communication with hcws about the pandemic’s current situation by providing reliable information enabling them to act more effectively; (iii) disaster relief programs that enlighten the road of disease management by hcws; and, (iv) providing enough knowledge to professionals of disease prevention and control at the workplace to answer hcws’ concerns promptly (17, 18). other action plans should target the political authorities and media, which impose additional burdens on hcws and call them heroes during the pandemic. such labels and verbal support activities cover shortcomings that political and governmental authorities could not address in an emergency. calling them heroes dose not empower them in fighting against disease, and realistic heroes or cowards: healthcare workers’ autonomy right versus patient care … 4 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 31 december 2020 approaches as well as actions are required, instead (11). using proposed approaches, brainstorming as well as reviewing controversies and resolving differences can help improve hcws’ safety during the pandemic and encourage them to perform their duties willingly and resiliently. medical professionalism and covid-19 both medical ethics and medical professionalism have been challenged by the covid-19 pandemic. professions related to medical and healthcare involve a social obligation or commitment to humanity. the purpose of this profession is to provide advice and services without certain expectations (e.g., financial compensation, personal benefits), which makes this profession different from other occupations that provide specific services in exchange for living expenses (19). covid19 has raised many challenges to altruism, a core idea in medical practice and professionalism defined as giving priority to others’ benefits at the cost of losing selfinterest, as hcws may lose their lives in caring for the covid-19 patients (20). this condition can be regarded as a major rolerelated conflict of interest that ethically and professionally affects healthcare providers and needs to be investigated and clarified by experts to illuminate the ambiguities for medical staff and hcws (1). future pandemics and bioethics an established field in bioethics, concerning health emergencies and disasters such as epidemics and pandemics, focuses on the proper allocation of limited resources in times of need. this field aimed to help clinicians and healthcare professionals respond to disasters or emergencies as effectively as possible, and receive special ethical attention in public restrictions, such as lockdown or quarantine, in such emergencies (21). however, in public health emergencies such as the pandemic, ethics of hcws as well as their safety and autonomy in providing patient care while maintaining safety need further investigations (15). the controversies highlighted in this article were first raised at the time of the outbreak of severe acute respiratory syndrome (sars) in china and south-east asia in the early 2000s (11, 14). a decade later, covid-19, a more infectious and hostile epidemic affected almost all world nations, leading to the pandemic and public health emergency of international concern (pheic). healthcare and bioethical professionals, authorities, and policymakers should consider the current situation as a warning regarding the inadequacy of existing ethical guidelines and discuss with all the healthcare stakeholders to provide more practical guidelines for hcws in the face of public health disasters. conclusion hcws’ autonomy versus their duty to patient care, or human rights guidelines versus responsibilities, during an infectious disease outbreak is a controversial issue. this systematic review discussed the existing ethical controversy over healthcare professionals’ autonomy and the proposed practical approaches to solve related dilemmas. moreover, medical and professional ethics azadnajafabad s. 5 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 31 december 2020 professionals need to provide up-to-date policies and research results to offer more practical solutions for health care providers and help health officials and clinicians find the best way to ethical practice. conflict of interests the author declares no competing or conflicting interests. funding this article received no funding or financial support. heroes or cowards: healthcare workers’ autonomy right versus patient care … 6 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 31 december 2020 references 1. ćurković m, košec a, ćurković d. medical professionalism in times of covid-19 pandemic: is economic logic trumping medical ethics? intern emerg med. 2020;15: 1585-6. 2. anonymous. world health organization: coronavirus disease (covid-19): weekly epidemiological update. [cited december 2020]; available from: https://reliefweb.int/report/world/coronavirus-disease-covid-19-weekly-epidemiological-update-8december-2020 3. malm h, may t, francis lp, et al. ethics, pandemics, and the duty to treat. am j bioeth: 2008; 8(8): 4-19. 4. papoutsi e, giannakoulis vg, ntella v, pappa s, katsaounou p. global burden of covid-19 pandemic on healthcare workers. erj open res. 2020; 6(2): 00195-2020. 5. wang j, zhou m, liu f. reasons for healthcare workers becoming infected with novel coronavirus disease 2019 (covid-19) in china. j hosp infect. 2020; 105(1): 100-1. 6. kannampallil tg, goss cw, evanoff ba, strickland jr, mcalister rp, duncan j. exposure to covid-19 patients increases physician trainee stress and burnout. plos one. 2020;15(8): e0237301. 7. salazar de pablo g, vaquerizo-serrano j, catalan a, et al. impact of coronavirus syndromes on physical and mental health of health care workers: systematic review and meta-analysis. journal of affective disorders. 2020; 275: 48-57. 8. tai dyh. sars plague: duty of care or medical heroism? ann acad med singap. 2006; 35(5): 374-8. 9. zhu j, stone t, petrini m. the ethics of refusing to care for patients during the coronavirus pandemic: a chinese perspective. nurs inq. 2020: e12380. 10. cox cl. 'healthcare heroes': problems with media focus on heroism from healthcare workers during the covid-19 pandemic. journal of medical ethics. 2020; 46(8): 510-3. 11. hsin dhc, macer drj. heroes of sars: professional roles and ethics of health care workers. j infect. 2004; 49(3): 210-5. 12. ruderman c, tracy cs, bensimon cm, et al. on pandemics and the duty to care: whose duty? who cares? bmc medical ethics. 2006; 7: e5. 13. clark cc. in harm's way: ama physicians and the duty to treat. j med philos. 2005; 30(1): 65-87. 14. iserson kv, heine ce, larkin gl, moskop jc, baruch j, aswegan al. fight or flight: the ethics of emergency physician disaster response. ann emerg med. 2008; 51(4): 345-53. 15. iserson kv. healthcare ethics during a pandemic. west j emerg med. 2020; 21(3): 477-83. 16. veil s, reynolds b, sellnow tl, seeger mw. cerc as a theoretical framework for research and practice. health promot pract. 2008; 9(4 suppl.): 26s-34s. 17. garrett al, park ys, redlener i. mitigating absenteeism in hospital workers during a pandemic. disaster med public health prep. 2009; 3(suppl.2): s141-7. 18. gershon rrm, magda la, qureshi ka, et al. factors associated with the ability and willingness of essential workers to report to duty during a pandemic. j occup environ med. 2010; 52(10): 9951003. 19. dhai a, veller m, ballot d, mokhachane m. pandemics, professionalism and the duty of care: concerns from the coalface. s afr med j. 2020; 110(6): 450-2. 20. feldman md. altruism and medical practice. j gen intern med. 2017; 32(7): 719-20. singer pa. the cambridge textbook of bioethics, 1st ed. uk: cambridge university press; 2008. ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ really good stuff copyright © 2021 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e painting as a reflective method in teaching medical professional values *corresponding author mina mobasher address: afzalipour faculty of medicine, kerman university of medical sciences, 22th bahman blvd., kerman, iran. postal code: 7616914115 tel: (+98) 34 33 25 76 60-4 email: m.mobasher@kmu.ac.ir received: 15 sep 2020 accepted: 16 jan 2021 published: 30 jan 2021 citation to this article: mobasher m. painting as a reflective method in teaching medical professional values. j med ethics hist med. 2021; 14: 1. mina mobasher assistant professor, department of medical ethics and history of medicine, school of traditional medicine, kerman university of medical sciences, kerman, iran. introduction teaching medical ethics is an effort to deliver the dominant values in the relationship between physicians and their patients, colleagues, and eventually the whole society. furthermore, medical ethics education requires appropriate methods in addressing these topics for pre-clinical and postclinical courses. one study showed that the final purpose of medical ethics education is to train medical students and physicians who have acquired the fundamental skills in professionalism, such as responsiveness, altruism, excellence, integrity, respect, and justice (1). in another study, the authors defined the principles of professional commitment, stating that the main purpose is to internalize the meaning of professional commitment and behaviors among medical students and physicians (2). another author believed that the internalization of ethical concepts can assist doctors in dealing with tough situations and emergencies, since in these circumstances ethical sensitivity and personal feelings substitute ethical reasoning (3). education plays a vital role in changing these non-cognitive components, which can be presented semi-directly or indirectly in group discussions, or through introducing ethical issues in stories or role modeling. in fact, students should deeply understand the concepts and behavioral values in medical practice and observe the principles of professional conduct through a highly practice-based approach, and not just completely depend upon lectures or theoretical knowledge. painting as a reflective method in teaching medical professional values 2 j med ethics hist med. 2021 (jan); 14: 1. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e the importance of medical ethics education and the associated challenges when the aim of education is to convey values to the learners, the professors could have a vital role in the academic atmosphere. in fact, medical students and professionals should understand patients’ values and beliefs in their family and cultural contexts. thus, the main concern of medical education is to introduce humanities to medical practitioners. however, this is not a simple issue, and many studies have investigated the problems of teaching the concepts and values of professionalism. one of the main reasons why conveying behavioral values is difficult is that what students see in the educational setting is in contrast to what is discussed in the medical ethics class about values and behaviors. sometimes, it seems that students are hesitant to accept such values, and therefore the main question is about the ways that we can teach those topics more effectively. in a study, the author showed that the medical ethics curriculum in the undergraduate level is inclined towards being student-centered, and emphasizes the importance of applying the principles of adult teaching in medical ethics education (4). it is also possible to use other methods such as small group discussion, which can make students sensitive to human values based on professionalism. in one study, the author has emphasized the need for formal education in ethics for students in their clinical training course (5). in this study, the educators used ethical rounds with anonymous cases. this author pointed out that this continuous clinical ethics training could highlight professional behavior and help students to better manage ethical challenges and improve their problem-solving skills. painting in the medical ethics class achieving educational goals in this field requires the engagement of learners in the educational process, and this is what i can claim to have achieved based on several years of experience in teaching this course. that is why i have always sought ways to facilitate learning and at the same time make the class intriguing for the students. therefore, i participated in a workshop named “ethics teachers’ training course” organized by unesco in malaysia in 2016 and implemented the methods taught in the workshop in my own classes. in that workshop, they explained how to apply various methods such as painting in order to educate adults about ethical concepts. professionalism and medical humanities play a paramount role in medical ethics curricula, but it is difficult to deliver topics related to professionalism using routine methods such as case presentation and problem-solving. therefore, i used drawing as an instruction tool for training students in professional behaviors. in this article, i presented this educational method and my students’ viewpoints about it. also, i explained how they reflected on professional values by illustrating their conceptions about it on a piece of paper. in the university that i currently work for, medical ethics is a mandatory course delivered in two units, which i present in mobasher m. 3 j med ethics hist med. 2021 (jan); 14: 1. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e fourteen to fifteen sessions each semester. usually, after five sessions dedicated to ethical analysis tools, informed consent, truth-telling and confidentiality, i start teaching about patient-physician relationship issues. at the beginning of the session, i play a seven-minute clip to the class without any introduction or pre-talk. this thoughtprovoking clip presents sentiments, values and beliefs that health care providers and clients believe in. then, i ask the students to paint their feelings and perceptions about the clip in fifteento twenty-member groups. each group receives drawing tools (papers and color markers) and is given 40 minutes to prepare their painting. the drawing of each group is shown to the class and a member of that group gives a short presentation about it. then, i choose a group that has successfully used drawing to propose a novel idea about the values in medicine and their importance in patientphysician relationships. nevertheless, as a staple of all team projects, a small number of students usually carry a bolder role in either coming up with an idea or presenting it. after three semesters, in the second semester of 2018 at the department of medical ethics in kerman university of medical sciences of iran, i interviewed a number of my students about their drawing experiences. six students participated in a 15-30minute interview. i purposefully selected the students based on their final scores and how effective they were in their groups. a secretary invited them to participate in the interview and obtained informed consent while assuring them that we would keep their information confidential. also, she explained to them that the risk of this study was minimum. she asked the participants four main questions: what was your experience in the painting session in the medical ethics class? what do you think of this method for teaching behavioral values in the course of medical ethics? did it help you learning the concepts and goals of this lesson? do you think that using this approach will improve your performance as an ethical practitioner? in addition, she asked probing questions to guide and continue the interviews. she transcribed each interview immediately after performing to extract the codes. then, the contents of the interviews were analyzed by the six-step methodology proposed by braun and clarke (6). content analysis showed five main themes related to students’ experiences about this teaching method, including variety in education, pleasant experience, active cooperation among the group members and giving every student a voice, expressiveness and memorable experience, and imagining the values and drawing them. some samples of the students’ paintings can be found in figures 1, 2, 3. painting as a reflective method in teaching medical professional values 4 j med ethics hist med. 2021 (jan); 14: 1. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e fig 1students’ perspective about professional values in patient-physician relationship in this picture: “we drew a tree with our fingertips which were a symbol for our cooperation, and the red color around the tree shows our blood and how we are untied to cure our patients.” fig 2students’ perspective about professional values in patient-physician relationship in this picture: “i wanted to show my assistance and sympathy toward patients, so i drew a hand holding a rope tightly.” fig 3students’ perspective about professional values in patient-physician relationship in this picture: “the painting from the concept in the quran which read: a person would save one of the people is equal that she/he save the whole life. humans are the greatest asset.” mobasher m. 5 j med ethics hist med. 2021 (jan); 14: 1. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e 1variety in education: some students felt good that there was a variation in their class routine. they believed that such methods are better than solely explaining theories in lectures. one student stated, “painting has a fun factor, and when it is coupled up with education, it will certainly make the class less boring and more effective “. 2a pleasant experience: students unanimously considered the painting session as a good experience. a few of the interviewees' comments about this event are as follows: “painting has an artistic aspect to it which enabled us to illustrate the spirit and feelings of a doctor in a meaningful way. even after the class, i felt happy to know others’ ideas about medicine…. it was very interesting.” 3active cooperation among the group members and giving every student a voice: many students mentioned the bold teamwork nature of this activity. although their classes usually include group discussions and supposedly active engagement of everyone, they admitted that utilizing painting to express their thoughts and feelings was much more inclusive and democratic. as one student put it, “it was a wonderful experience in terms of cooperation between classmates and how everyone was trying to achieve a certain goal. “ 4expressiveness and memorable experience: the students had a consensus that the painting session was a memorable experience and they would never forget it. below are some comments by the interviewees: “i clearly remember the painting session and every time i feel unmotivated to study or do my professional duties, remembering what we painted in that session about our values helps me to get back on track.” “this method will help us to internalize the conveyed meanings and values in the unconscious part of our minds.” 5imagining the values and drawing them: all the students mentioned that they have to thoroughly think about their duties as physicians and this has caused them to view their profession from a different perspective. some mentioned that they were reminded of the famous quote in the quran, “saving a single life is tantamount to saving the whole humanity”. a few of their responses are provided below: “painting about the concept in the quran which says, ‘saving one person is equal to saving the whole life and existence’ represented an interesting concept of human preservation. humans are the greatest assets”. “i wanted to show my support and sympathy for patients, so i drew a hand holding a rope tightly”. “there is sorrow and joy in the hospital. it was a tree we drew; the tree could be cut off, and it would crumble away, but it is always saved when an ally is green with green leaves”. “we drew a tree with our fingertips which were a symbol for our cooperation, and the red color around the tree showed our blood and how we are untied to cure our patients”. painting as a reflective method in teaching medical professional values 6 j med ethics hist med. 2021 (jan); 14: 1. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e a critical reflection on utilizing painting as a teaching method according to what the students expressed about their experience in this class, it seems that painting has been an intriguing method, and they have been participating in this class enthusiastically. students learn from this event as an experience that will remain with them for the rest of their professional careers and even their lives. students also emphasized that they have understood the concept of teamwork and cooperation and the values involved in medical settings in this session. also, they expressed that the sanctity of the medical profession has been pronounced in their minds and their standards. in a study, the author stressed that medical ethics should be taught in flexible and critical ways (7). another author emphasized the role of art in understanding the human aspects of medicine. when medical professionals are interacting with individual, cultural and social values, arts such as painting, poetry, music, movies, etc., can help them to understand the human aspects of their profession (8). authors of another study also stated that the arts can help learners and medical professionals to improve their skills for critical thinking and to understand the human aspects of medicine as well as improve their practice (9). i have not been able to find a study that used painting to train professional behaviors. in this study, however, the students contemplated concepts of professionalism by painting, and understood the humanities of medicine when interacting with patients, colleagues, and the society, which was evident in their interviews. the medical students drew down their feelings and understanding regarding the topic in each group and showed their ability to portray professional values by reflecting them in their paintings. they stated that they had acquired a good grasp of professional behaviors such as responsibility, empathy, integrity, etc. in the patient-physician relationship. it seems that painting is a flexible and thought-provoking approach to teaching medical ethics, and can improve critical thinking in students while being effective in achieving the educational goals in medical school. limitations the groups were relatively large due to a lack of sufficient classroom facilities. if this method is used in smaller groups of students, more students will be encouraged to think about professional values and come up with novel ideas, which will also diversify the shared ideas among students. also, the study did not examine the effectiveness of this method on the students’ performance in real clinical settings. acknowledgments the author is grateful to the medicine faculty of kerman university of medical sciences for the educational facilities. also, the author appreciates the participation of medical students in the painting session of the medical ethics class, and ms. fatemeh iranmanesh for interviewing the participants. conflict of interests the author reports no conflict of interests. mobasher m. 7 j med ethics hist med. 2021 (jan); 14: 1. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e references 1. muller ps. teaching and assessing professionalism in medical learners and practicing physicians. rambam maimonides med j. 2015; 6(2): e0011 . 2. cruss sr, cruess rl. teaching professionalismwhy, what, and how. facts views vis obgyn. 2012; 4(4): 259–65. 3. madani m, larijani b, madani e, ghasemzadeh n. establishment of medical education upon internalization of virtue ethics: bridging the gap between theory and practice. j med ethics hist med. 2017; 10: 3. 4. goldie j. review of ethics curricula in undergraduate medical education. med educ. 2000; 34(2): 108-19 . 5. parker l, watts l, scicluna h. clinical ethics ward rounds: building on the core curriculum. j med ethics. 2012; 38(8): 501-5. 6. braun v, clarke v. using thematic analysis in psychology. qualitative research in psychology. 2006; 3(2): 77–101. 7. carrese ja, malek j, watson k, et al. the essential role of medical ethics education in achieving professionalism: the romanell report. acad med. 2015; 90(6): 744-52. 8. ahlzen r. medical humanitiesarts and humanistic science. med health care philos. 2007; 10(4): 385-93. 9. jones ds. a complete medical education includes the arts and humanities. virtual mentor. 2014; 16(8): 636-41. dentist editted 4-92e-2-fainal journal of medical ethics and history of medicine dental and oral diseases in medieval persia, lessons from hedayat akhawayni kazem khodadoust1, mohammadreza ardalan2*, reza pourabbas3, majid abdolrahimi4 1phd, philosophy and history of medicine research center and faculty of dentistry, tabriz university of medical sciences, tabriz, iran; 2professor, chronic kidney disease research center, tabriz university of medical sciences, tabriz, iran; 3professor, dental and periodontal research center, tabriz university of medical sciences, tabriz, iran; 4researcher, faculty of dentistry, tabriz university of medical sciences, tabriz, iran corresponding author: mohammadreza ardalan address: chronic kidney disease research center, tabriz university of medical sciences, tabriz, iran email: ardalan34@yahoo.com tel: 98 9141168518 fax: 0411 3366579 received: 03/28/2013 accepted: 10/26/2013 published: 11/2/2013 j med ethics hist med, 2013, 6:9 © 2013 kazem khodadoust et al.; license tehran univ. med. sci. abstract persian physicians had a great role in assimilation and expansion of medical sciences during the medieval period and islamic golden age. in fact the dominant medical figures of that period were of persian origin such as avicenna and razes, but their works have been written in arabic that was the lingua franca of the period. undoubtedly the most substantial medical book of that period that has been written in persian belongs to abubakr rabi ibn ahmad al-akhawayni al-bokhari and his book, hidayat al-mutallimin fi-al-tibb (learner’s guide to medicine).there are two chapters related to oral and dental diseases in the hidayat, a chapter on dental pain and a chapter on bouccal pain. akhawayni's views on dental diseases and treatments are mainly based on anatomical principles and less influenced by humeral theory and no mention about the charms, magic and amulets. false idea of dental worm cannot be seen among his writings. cutting of the dental nerve for relieving the pain, using the anesthetizing fume, using the natural antiseptic and keeping the tooth extraction as the last recourse deserves high praise. keywords: dental diseases, akhawayni, history of medicine, medieval period, persian mailto:ardalan34@yahoo.com j med ethics hist med 6:9 sep, 2013 jmehm.tums.ac.ir mohammadreza ardalan et al. page 2 of 6 (page number not for citation purposes) introduction during the islamic scientific golden age that started in the 9th century, islamic medicine greatly influenced european science, an effect that continued until the renaissance. islamic scientists not only accumulated the existing information, but added to this knowledge through their own observations, trials and skills (1-3). persian physicians had a great role in this period of innovation, commentary and systematization, and the dominant medical figures of that period were of persian origin: ali ibn sahl rabban al-tabari (807 870 ad, 194 257 hijra), muhammad ibn zakariya al-razi (865 925 ad, 252 312 hijra), ali ibn al-abas al-majusi (930 994 ad, 317 381 hijra) and abu-ali al-husayn ibn abdallah ibn sina (9811037 ad, 368 424 hijra). all their great works, however, have been written in arabic, as it was the lingua franca of the period (1, 2). the samanid dynasty (875 999 ad, 262 386 hijra) established an autonomic state and nurtured the revival of persian literature and traditions. persian language that had lost its official status after the arab conquest once again started to be used in the arts and sciences with increasing nationalistic vigor (1, 2). undoubtedly the most substantial medical book of this period belongs to abubakr rabi ibn ahmad al-akhawayni al-bokhari (died 983 ad, circa 370 hijra), and his book, hidayat almutallimin fi-al-tibb (learner’s guide to medicine). the hidayat consists of 185 chapters (bab), the first six chapters are on the humors (akhlat) and faculties (quwa), followed by 28 chapters on anatomy, 21 on physiology, symptoms and comments on diet and hygiene, and 130 chapters on the diseases of various organs. hidayat almutaallemin fi-al-tibb (learner's guide to medicine) is the oldest treatise on medicine written in persian. some years after the death of akhawayni, three known manuscripts of the hidayat were copied. the oldest one, copied in 1058, is the manuscript in the bodleian library, university of oxford. dr. jalal matini, a contemporary persian writer, compared the three existing manuscripts and published a literary edition of the hidayat in 1965 that has been published by mashhad university press (4). it is an attempt to increase our understanding of the dental problems and their management in medieval persia. we intend to introduce specific chapters of this book to dentists and other specialists who are interested in the subject. this would increase our historical understanding of the dental problems that existed more than one thousand years ago, and some of those old remedies and herbal products may have certain clinical benefits and could reenter modern medicine. method what we did in this research at first was to find chapters that are related to dental and oral medicine. our criteria were to select those chapters that contained more clear descriptions of diseases and related therapies. we tried to understand the basic concepts and meanings of those chapters, and in order to preserve the genuine form of those passages, we tried to translate some segments word for word. in the discussion part we have tried to clarify the concepts and to compare them with those of akhawayni’s predecessors and successors, and modern medicine ideas. there are two chapters related to oral and dental diseases in akhawayni’s book: a chapter on dental pain and one on buccal pain. what follows is a translation of some parts of these two chapters (4). at first we will present the original text and then try to explain them with a modern outlook. we have tried to translate the original passages word for word, and in those instances where it was difficult to convey the concept through existing words, we added some words or sentences in brackets. passages and descriptions in the following passage there is an interesting elaboration of the role of the dental nerve in generation of pain, and also considerations on the periodontal soft tissue inflammation, and infections that could mimic dental pain. the implementation of natural antiseptics such as vinegar and some other probable antiseptic and anti-inflammatory herbal and nonorganic remedies are also interesting. nerve cautery has also been discussed and dental extraction has been mentioned as the last therapeutic option. there are also interesting prescriptions of some natural breath fresheners and the need for differentiation between different causes of this symptom including dental or gastrointestinal origins. [pages 298, 299, 302, 303] . passage 1 if the tooth is painful, it means that the nerve that is under the tooth and around it [is painful] ; if the pain is accompanied by inflamed gum that is red and burning, it could be alleviated with cold objects… and gurgling with oxime, and chewing plantago psyllium soaked in vinegar… and the tooth is not painful unless [because of] a faulty meal … and if those incompatible matters remain there, they create inflammation and if they remain within the dental body, they decay the tooth and blacken the tooth… and if the pain does not improve with oil of flower (salix babilonia) and pistacia lentiscus, [in the second stage] you should use the vinegar and salt frequently until those faulty materials dry out…. [page 298] . passage 2 j med ethics hist med 6:9 sep, 2013 jmehm.tums.ac.ir mohammadreza ardalan et al. page 3 of 6 (page number not for citation purposes) and if the pain is without inflammation, it is phlegmatic … and the patient should gargle [a mixture of] muscari comosum mill and tar, and if the pain does not improve [then] boil the citrullus colocynthis schrad with vinegar and gargle until the phlegm is removed … or boil dried leaves of ruscus aculeatus and dried pine tree wood and two cloves of garlic with vinegar and gargle this mixture when it is still warm … or grind and mix the anthemis pyrethrum with the skin of the root of capparis spinosa and then boil with vinegar and gargle the mixture. if the pain does not subside then incise the periphery of the tooth with a lancet to separate the nerve from the tooth, and if [this method] is ineffective then one deramsang (4.6 grams) of the seed of black hyoscyamus niger and two deramsangs of wet styrax officinale should be ground, mixed, burned and the fume [of the burned mixture] should be conducted by a tube to the painful tooth to anesthetize it…. [page 298] . and if you did all and none was effective and the pain does not improve, then the tooth should be extracted or cauterized, and if it is hollow, extraction is inevitable.... [page 299] (look at figures 1 and 2). figure 1 : albucassis dental cautery and the tube through which it was applied. albucassis (abu'l qasim khalaf ibn abbas, 1050-1122 ad) genius of arabian surgery. born in alzahra and died in cordova in spain . he is the greatest medieval surgeon in regard to dental art. among his book is the treaties de chirurgia (the picture copied from guerini v. a history of dentistry. chapter 8. philadelphia: lea & febiger, 1909 with permission) figure 2; albucassis (abu'l qasim khalaf ibn abbas, 1050-1122 ad) dental scrapers. (the picture copied from guerini v. a history of dentistry. chapter 8 .philadelphia: lea & febiger, 1909 with permission) passage 3 under each tooth there is a nerve … a tooth that does not have the nerve (sense) does not feel the pain … the nerve that is under the tooth feels the pain (is painful).... when the tooth is painful, the nerve that is under the tooth or within the tooth is painful [page 298] ... and if the teeth are yellow, they should be whitened with sea-salt and sea-foam (meerschaum) and ghozareh chini (we were unable to find the exact meaning of this substance) and khashar (cuminum cyminum?) all ground together, and you should brush the teeth with this mixture and you should be careful not to damage the gum ... [page 299] . j med ethics hist med 6:9 sep, 2013 jmehm.tums.ac.ir mohammadreza ardalan et al. page 4 of 6 (page number not for citation purposes) description 1 it is obvious in the above passages that akhawayni had an anatomical insight into the diseases of the teeth and treated them based on a somehow logical framework. his methods of treatment included herbal gargles, pastilles, fumigations and purges as well as cautery and surgery. akhawayni has mentioned that if application of herbal remedies with different methods fails then the physician should consider the cauterization of the area with hot iron, and if this step also fails, tooth extraction should be considered. akhawayni and medieval persian physicians were also aware that dental pain is directly related to the nerve and if we separate the nerve from the painful tooth it wouldn’t be painful anymore. anesthetizing the tooth by conducting a fume directly to the painful point is a very interesting method that has been discussed by akhawayni. he prescribed sea-foam (magnesium silicate, mg4si6o15 (oh)2·6h2o) for discolored teeth (5, 6). passage 4 … and the cause that is named malus spiritus (bad breath) could be from three sources.: from stomach and [it is] accompanied by a high fever … from the teeth that should be extracted, and it is possible that it originates from the lung… (page 300) and its treatment is the tablet of mask, [that includes] skin of dried bergamot, caryophyllus aromaticus, valeriana celtic,vinegar and aquilaria malaccensis lamk, one deramsang (4.6 grams) from each should be mixed and ground with a half dangsang (2.3 grams) of moschus moschiferus. the tablet should be taken in mouth every morning… … and painful oral cavity or cavitatis oris has three causes; one is because of bilious blood and [the oral cavity] is erythematous and burning…; and it is possible that painful oral cavity is accompanied by [mucosal] whiteness that is worse than the previous case …; and it is also possible that painful oral cavity is because of corrosive ulcer, and the mouth and teeth are blackened and putrefied and the tooth may be destroyed and lost.… [page 302] and this [situation] needs foldfiun tablet, [which is made by] grinding and mixing yellow auripigmentum lime, oak apple and aluminum sulphate together and then drenching [the mixture] in old vinegar for one week and then [foldfiun] tablets are made [from this mixture] …. … if it is necessary, brush the mouth [gum] with a rough cloth (sackcloth) and vinegar until it bleeds, and [as a second stage] wash the mouth with vinegar and apply this medicine [powdered foldfiun tablet] morning and evening until the condition improves…. i have treated many of these patients and what i have mentioned here are methods that i have experienced myself and i did not mention those that i have not examined… [pages 302 – 303] . description 2 in the above passages akhawayni discusses the diseases of the mouth. he maintains that bad breath could be due to an infected tooth that should be extracted. stomach and lung problems are two other reasons for bad breath. he also describes conditions that create a painful oral cavity. he categorizes them into conditions that are accompanied with erythema, conditions that are accompanied with malakoplakia, and a corrosive and gangrenous ulcer of buccal mucosa. for treatment of gingivitis gums should be rubbed with a strong linen cloth until they bleed in order to remove the rotten flesh, and then the mouth should be rinsed with vinegar and specific remedies may be applied (5, 6). discussion man has suffered from oral and dental diseases since prehistoric era. in egyptian hieroglyphs there are remedies for relieving the throbbing pain of a dental blister. dental diseases have been mentioned in sumerian records quite vividly. during late antiquity, dental care and even prosthetic dentistry reached a high degree of development in the roman period, but fell into decadence when western roman empire began to decline and christianity rose (7). it appears that the major dental problems mentioned by akhawayni are toothaches related to dental caries, oral ulcer and gingival disease. he starts with noninvasive methods mostly using herbal remedies, and if those are ineffective, then surgical interventions are applied. he reiterates that he has examined his methods of treatments many times and believes in their effectiveness. akhawayni’s treatments are mainly based on anatomical principles and less influenced by humoral theory, and there is no mention of charms, magic and amulets. false ideas of dental worms cannot be seen in his chapter on dental disease (4). the idea of ‘tooth worm’ that was first mentioned in sumerian scripts continued to be discussed by romans and arabs, as well as in medieval europe and even late anglo-saxon documents (7, 8). akhawayni describes the dental anatomy very minutely, and interestingly there is no mention of tooth worm gnawing away the dental substance. he believes in an incompatible material that remains within the dental body and decays the tooth (4). the medieval cure for tooth worm was, inhaling the smoke of burned hyoscyamus niger as mentioned by roman doctors (7, 8). akhawayni prescribes the smoke of hyoscyamus niger and styrax officinale for toothaches but there is no mention of tooth worm. interestingly we can see this false idea entering persian medical texts showing the weakness of j med ethics hist med 6:9 sep, 2013 jmehm.tums.ac.ir mohammadreza ardalan et al. page 5 of 6 (page number not for citation purposes) scientific thinking and lack of innovation until the world stepped toward the modern period. akhawayni subdivides toothaches into those that are associated with inflammation, redness and burning, and those that are not associated with severe inflammation. he prescribes gurgling with oxime and chewing plantago psyllium soaked in vinegar for the first group. those without severe inflammation are due to a retained phlegm that should be removed through gargling muscari comosum mill and a mixture of citrullus colocynthis schrad and vinegar and gargling until the phlegm is removed (4). medieval european manuscripts of gilbert anglicus and guy de chauliac (13th century ad) have mentioned effective pain relief using papaver somniferum and oil of caryophyllus aromaticus. alum and punica granata have been mentioned by roger of frugard as ingredients in a lotion to overcome suppuration (8). akhawayni’s recommendations for periodontal disease and gingivitis include scarification of the gum to bleed and then application of vinegar and other solutions with probable antiseptic characteristics. the same prescription has been recommended by razes (7, 8). he believes that tooth extraction is the last recourse when every other attempt has proven useless, a method that no doubt deserves high praise. in akhawayni’s writings we cannot find any direct description of drilling and emptying the painful teeth as described by avicenna and late byzantine-roman physician archigenes (7). akhawayni is one of the few authors who have mentioned the cutting of the dental nerve for relieving the pain. he describes a method of gently pricking a lancet around the tooth and cutting the nerve (4). however, because akhawayni wrote his book in persian, which was not the lingua franca of the islamic world in that period, it did not receive the credit that it deserved. we should consider that akhawayni was indirectly a student of razes who created the great medical encyclopedia of “alhavi”, which covers most subjects and principles of medical science. one of those subjects is dentistry, which contains definitions, diagnosis, treatment and prognosis of dental and oral cavity diseases and associated medical care leading to oral health and management (9-11). alli ibn al-abbas al-ahvazi, the great pillar of the third century, also was a great pillar of medicine with very interesting ideas on dental and oral medicine, as he believed bad breath could originate from the stomach. differentiation between gingivaland dental-originated pain is paramount because in the first case there is no need for the tooth to be extracted. avicenna (370 428) also gathered the ideas of his great predecessors such as razes al ahvazi and akhawayni and with his novel outlooks became one of the remaining figures of science worldwide (9-11). it is interesting that in the more recent medical books we can see the entrance of false ideas such as the tooth worm, as well as some novel ideas such as using anthemis pyrethrum (anacyclus prethrun) in vinegar for loosening the painful tooth for its easier extraction (12). conclusion our article was an attempt to introduce hidayat al-mutallimin fi-al-tibb (learner’s guide to medicine) as an important and forgotten 10th century persian medical treasure. the passage on dental and oral disease shows the importance of oral and dental care in medieval persia. it was very interesting that we found great considerations of anatomical based diagnosis and therapeutic considerations. it shows that medieval islamiciranian physicians were aware of the importance of the dental nerve as a root of sensation, and the oral soft tissue and periodontal inflammation that can very easily be confused with dental originated pain. references 1. ardalan mr, shoja mm, tubbs rs, eknoyan g. diseases of the kidney in medieval persia the-hidayat of alakawayni. nephrol dial transplant 2007; 22(12): 3413–21. 2. khodadoust k, ardalan mr, ghabili k, golzari se, eknoyan g. discourse on pulse in medieval persia-the hidayat of al-akhawayni (?–983ad). int j cardiol 2012; 166(2): 289-93. 3. elgood c. a medical history of persia and the eastern caliphate: from the earliest times until the year 1932. uk: cambridge university press; 1951. 4. al-akhawaini ara. a guide for medical students, revised by matini j. mashhad: mashhad university press; 1965. [in persian] 5. ardalan m.r, khodadoust.k. lexicon of persian medical terms in olden medical pandects. tehran: shervin publication; 2012. 6. abu al-rayhan biruni. al-saydana fi al-teb, revised by zaryab khoyi a. tehran: iran university press; 1991. [in arabic] 7. guerini v. a history of dentistry from the most ancient times until the end of the eighteenth century. philadelphia: lea & febiger; 1909. 8. anderson t. dental treatment in medieval england. br dent j 2004; 197(7): 419–25. 9. zakaria razi m. al-mansuri fi teb, translated by zaker me. tehran: tehran university of medical sciences; 2008, p. j med ethics hist med 6:9 sep, 2013 jmehm.tums.ac.ir mohammadreza ardalan et al. page 6 of 6 (page number not for citation purposes) 868. [in persian] 10. tabatabaei sm, goldani moghadam m, tabatabaei sma. razes, al ahvazi, and avicenna’s basis of dental therapy and compared it with modern sciences. j dent sch 2012; 30(3): 192-197.[in persian] 11. tabatabaei sm. view of razes and traditional medicine about dentistry and oral health. j mashhad dent sch 2005; 29(1): 141-4. [in persian] 12. baigbabapour.y. mohamad ibn alaedin ibnhebat-ol lah sabzevari. zobdeh-gavanin al alaj fi jami ol amraz. ganjine-ye baharestan , medicine. tehran: the center for education and research of the islamic republic of iran’s councils library publication; 2007, p. 356-362 [in persian] microsoft word 1 journal of medical ethics and history of medicine         teaching medical ethics: problem‐based learning or small group  discussion?    akram heidari1, seyyed-hassan adeli2, sadegh-ali taziki1, valliollahe akbari1, mohammadreza ghadir1, seyyed-majid moosavi-movahhed1, roghayyeh ahangari1, parvaneh sadeghimoghaddam1, mohammad-rahim mirzaee1 and vahid damanpak-moghaddam2 1medical ethics department, qom university of medical sciences, qom, iran; 2clinical research development center, qom university of medical sciences, qom, iran. corresponding author: hassan adeli clinical research development center, shahid beheshti hospital, shahid beheshti boulevard, qom, ir iran. phone: +98 9121245422 fax: +98 251 6122949 e-mail: adeli@muq.ac.ir received: 20 jan 2012 accepted: 12 dec 2012 published: 01 jan 2013 j med ethics hist med, 2013, 6:1 http://journals.tums.ac.ir/abs/22980 © 2013 akram heidari et al.; licensee tehran univ. med. sci. abstract lecture is the most common teaching method used in ethics education, while problem‐based learning (pbl) and  small group discussion (sgd) have been introduced as more useful methods. this study compared these methods  in teaching medical ethics.    twenty students (12 female and 8 male) were randomly assigned into two groups. the pbl method was used in  one group, and the other group was taught using the sgd method. twenty‐five open‐ended questions were used  for assessment and at the end of the course, a course evaluation sheet was used to obtain the students' views  about the advantages and disadvantages of each teaching method, their level of satisfaction with the course, their  interest in attending the sessions, and their opinions regarding the effect of teaching ethics on students' behaviors.  the mean score in the pbl group (16.04 ± 1.84) was higher than the sgd group (15.48 ± 2.01). the satisfaction  rates  in the two groups were 3.00 ± 0.47 and 2.78 ± 0.83 respectively. these differences were not statistically  significant.  since the mean score and satisfaction rate in the pbl group were higher than the sgd group, the pbl method is  recommended for ethics education whenever possible.     keywords: medical ethics, medical education, problem-based learning, small group discussion introduction medical ethics is taught using traditional methods in many universities (1). it can be argued that medical ethics is a collection of behaviors and if it is taught through traditional methods, it may not change the students' attitudes and practice satisfaction. therefore, departments of medical ethics have showed an interest in using student-centered methods. student-centered approaches to learning enable students to distinguish ethical dilemmas, solve problems and make proper decisions (2-4). akram heidari et al. j med ethics hist med 6:1 jmehm.tums.ac.ir january, 2013  page 2 of 6 (page number not for citation purposes)     it is known that problem based learning (pbl) is a desirable method for teaching and learning in medical ethics. it is desirable, because the nature of ethical enquiry is highly compatible with the learning processes which characterize pbl (5). learning ethics in small groups is widely accepted and is practiced in some universities (1, 6-9). on the other hand, tysinger et al. suggested a combined lecture/small group discussion (sgd) in teaching ethics because it offers the advantage of systematically covering the chosen breadth of theory and the chosen range of common moral problems in medicine (10). we did not find studies that compared pbl and sgd methods, but we believe that problem based learning is more complex and time consuming than sgd. in addition problem based learning requires more resources that may not be available in all medical schools. medical ethics was a part of the curriculum for medical students in traditional iranian medicine in medieval times, and great iranian physicians have paid special attention to ethics in their practice, teaching and manuscripts. when the faculty of medicine was first established in tehran university in 1934, teaching medical ethics comprised a part of medical students' education courses (11). in recent years, there has been an increased emphasis on classic ethics education and nowadays ethics is taught in all medical universities of iran (12). in qom university of medical sciences, the ethics course is offered to medical students during their fourth year. all medical universities in iran are instructed on the components of the ethics curriculum by the ministry of health and medical education. the contents of the course are planned for 16 sessions as seen in table 1. table 1. the headings of the ethics course in iran session heading 1 introduction, history and importance of ethics 2 ethics in islam and the basic theories of ethics 3 professionalism 4 four principles of ethics 5 physician–patient and physiciancolleagues relationship 6 confidentiality and privacy 7 informed consent 8 patients’ rights 9 education ethics 10 research ethics 11 conflict of interests 12 resource allocation 13 medical errors and physicians responsibility 14 beginning of life ethical issues 15 end of life ethical issues 16 new technologies and problems in medicine up to the present time, ethics has been taught using the lecture method in qom university of medical sciences. it is clear that the traditional systems for teaching ethics are no longer sufficient to meet the needs of practitioners and societies and new methods, particularly those emphasizing active learning, individual participation, group interactions and a process-based approach should be developed and implemented (13). we know that pbl and sgd methods are very useful methods in ethics education (1, 5-7); however, it is unknown if they have different effects on learning or not. this study aimed to compare pbl and sgd methods in teaching medical ethics. method in the first semester of the academic year 20102011, twenty students were introduced for ethics course. there were 12 females and 8 males. none of them had registered for this course before. the students were randomly assigned into two groups using a table of random numbers (6 females and 4 males in each group). since pbl and sgd were new to most students and some faculties, both students and facilitators received separate course orientations to meet their particular needs. in the student orientation, the course director gave an overview of the course, explained the two teaching methods and suggested references. in this study, nine members of the medical ethics department (the first nine authors) acted as facilitators. facilitators' orientation was provided using a teaching guideline. in the pbl group, students received scenarios one week before the relative session. in the week between the sessions, students were required to search and study the learning issues they identified akram heidari et al. j med ethics hist med 6:1 jmehm.tums.ac.ir january, 2013  page 3 of 6 (page number not for citation purposes)     in the cases, organize and summarize the key information in their learning issues to present to the group, and try to resolve the cases’ ethical dilemmas. during the sessions, the students presented the learning issues they had searched and discussed and resolved the case problems under supervision of facilitators. in the sgd group, students only had the sessions' headings. facilitators stated the problems and questions about the heading in each session, and then the students tried to solve the problems and answer the questions by brainstorming. each session lasted for 1.5 hours in both methods. there was one facilitator presented at each session whose main function was to help the discussion and enable the students to think about the problems and solve them rather than act as a source of knowledge. twenty-five open-ended questions were used for assessment. these questions were used for summative assessment of the course too. the questions were prepared by the facilitators. validity of these questions was confirmed by the medical ethics department of qom university of medical sciences. examination papers were coded before correction. each facilitator scored his/her own questions for all participants. maximum score was 20 and was divided among topics equally. a course evaluation sheet was used at the end of the course to obtain the students' views about the advantages and disadvantages of each teaching method (using two open-ended questions), their satisfaction (using four point likert scale questions: 1 = very low, 2 = relatively low, 3 = relatively high, 4 = very high), their interest to attend the sessions, and their opinion regarding the effect of teaching ethics on students' behavior. pbl students were asked if they had studied the scenarios and if they said yes, they were asked how many sessions they had searched. this sheet was anonymous but the teaching method was assessed. validity of the sheet was confirmed by the medical ethics department of qom university of medical sciences. the reliability of questionnaires based on the chronbach's alpha coefficient of internal consistency was 0.66. distribution and collection of the sheets was done by a person outside the research team. statistics the spss statistical package version 17 was used to test whether there were any statistically significant differences between the pbl and the sgd students in the mean open-ended question scores and their satisfaction rate. both independent sample t-test and mann-whitney test were used. a p-value of < 0.05 was considered to be statistically significant. results open-ended questions mean and standard deviation of scores in pbl and sgd groups were 16.04 ± 1.84 and 15.48 ± 2.01 respectively. in order to detect the difference between the learning outcome in pbl and sgd methods, we compared the mean of students' scores in both groups. there was no significant difference in learning outcome between the pbl and the sgd students in the mean scores as assessed by openended questions. course evaluation a course evaluation sheet was used to determine the students' opinions about the course. nineteen out of 20 students completed the course evaluation sheet (response rate = 95%). the results from questions showed no significant difference between the two groups (table 2). table 2. the results of course evaluation variable response pbl group sgd group n (%) mean ± sd n (%) mean ± sd your interest to attend the sessions very high 3 (30.0) 3.10 ± 0.74 1 (11.1) 2.89 ± 0.60 relatively high 5 (50.0) 6 (66.7) relatively low 2 (20.0) 2 (22.2) very low 0 (0) 0 (0) your satisfaction with the volume of content very high 1 (10.0) 2.50 ± 0.85 2 (25.0) 3.00 ± 0.76 relatively high 4 (40.0) 4 (50.0) relatively low 4 (40.0) 2 (25.0) very low 1 (10.0) 0 (0.0) your satisfaction with the amount of time dedicated to each topic very high 0 (0.0) 2.70 ± 0.68 1 (11.1) 2.44 ± 1.01 relatively high 8 (80.0) 4 (44.4) relatively low 1 (10.0) 2 (22.2) very low 1 (10.0) 2 (22.2) your total satisfaction with the teaching method very high 1 (10.0) 3.00 ± 0.47 1 (11.1) 2.78 ± 0.83 relatively high 8 (80.0) 6 (66.7) relatively low 1 (10.0) 1 (11.1) very low 0 (0.0) 1 (11.1) akram heidari et al. j med ethics hist med 6:1 jmehm.tums.ac.ir january, 2013  page 4 of 6 (page number not for citation purposes)     effect of ethics teaching on your behavior very high 2 (20.0) 3.00 ± 0.67 2 (22.2) 2.67 ± 0.87 relatively high 6 (60.0) 2 (22.2) relatively low 2 (20.0) 5 (55.6) very low 0 (0.0) 0 (0.0) some of the student comments about the advantages and disadvantages of teaching methods in the two groups were listed in table 3. table 3 positive and negative comments about pbl and sgd group positive comments negative comments pbl better group discussion and students' participations more freshness and alertness better concentration better understanding because of studying between sessions less forgetfulness more questions being raised having better knowledge of topics improvement of communication skills using peers’ opinions time restriction for adequate study need to create incentives for studying sgd improvement in ability to think and analyze cases using peers’ opinions and their reasons better understanding because of thinking group discussion and students' participations time restriction for discussion need to create incentives for participation in discussion engagement of the mind with problems that were not completely related to the discussion subject all of the students in the pbl group stated that they studied the scenarios in the week between sessions. the mean (± sd) of sessions that they studied was 10.33 ± 4.3 ranging from 4 to 16 sessions. discussion despite of efforts for promotion of teaching medical ethics in iran, the method of teaching is still lecture-based in most medical schools. a suitable teaching ethics program, however, would be based on using new methods especially those emphasizing active learning and student participation. two key features related to the teaching of medical ethics have been widely recognized as beneficial; the first feature is actively involving students in the learning process, and the second is assessing how students apply their knowledge of ethical principles in simulated and actual situations (10). the purpose of this study was to compare pbl and sgd for teaching medical ethics through applying these methods to two separate groups of students. although the results did not show any significant difference between the learning outcomes in either group, the mean score of pbl students was higher than sgd students. one possible explanation for the findings may be related to the nature of ethical concepts, as most ethical problems could be solved by unassisted thinking. another explanation may be related to the smaller sample size. however, it should be noted that although the pbl group students stated that they searched and studied between sessions, we cannot be certain that they spent enough time on problem solving and did not use their peers' search results. as the students stated, their workload did not permit them to spend enough time on search and consequently there was no significant difference between the two methods. as mentioned in the introduction, we did not find studies comparing pbl and sgd methods. nevertheless, the results are in agreement with those of goodyear's study that found no significant difference in learning outcome between the traditional and pbl courses, but the pbl course was well appreciated by his study population (14). likewise, fesharaki et al. did not report any significant difference between scores of students in lecture and pbl groups (15). moreover, salimi et al. showed that lecture and sgd methods had similar effects on drug calculation skills (16). these studies had compared pbl and sgd methods with the lecture method and did not find any significant difference either. the results of our study showed more satisfaction rate among pbl students. hence, in 4 out of 5 questions the mean score of pbl subjects was higher than the other group even though this difference was not statistically significant. johnston and haughton reported that their students certainly preferred small group teaching as a way of promoting debate and discussion (17). thus, tan et al. found that 3-5 years after participation in the pbl akram heidari et al. j med ethics hist med 6:1 jmehm.tums.ac.ir january, 2013  page 5 of 6 (page number not for citation purposes)     method, 68% of students perceived pbl as helpful in collaboration with colleagues, working in small groups, taking responsibility for contribution to the group and accountability to other group members (18). in another study about students’ satisfaction after sgd in a medical ethics education program, students reported greater satisfaction with self-case, presentation experience, in-class discussion, and instructor’s comments, but less satisfaction with self-study and before class and post class discussion. reported overall satisfaction score was 3.8 ± 0.9 (mean ± sd) (19). we did not assess the students' satisfaction with specific components of an sgd but the overall satisfaction mean score in both studies were similar. also fawzi reported that 56% of the medical students in his study preferred daily confusing ethical issues problem solving, 24% case and solution and 13.3% small group study. only 6.7% of them chose the lecture-based method (4, 20). the usefulness of pbl and sgd methods is obvious since students actively participate in learning, although there are disadvantages to each of these methods. in pbl the need for providing the necessary resources to students has to be considered. in our study, for instance, we had to provide ethics references such as books for students as our library did not have sufficient books. on the other hand, one important disadvantage of sdg is the need for longer sessions, since the students are generally not familiar with the topics prior to each session. it is noteworthy that some universities have added other methods such as monthly ethics grand rounds and mandatory ethics seminars to pbl and sgd methods (1, 21). interactive lectures and small research projects in a hospital or clinic (2) are performed as well (22). ward rounds (7, 23) and role-playing (24) may likewise be used along with these methods (3). there were some limitations to our study, the most important one being the small sample size. another limitation pertained to examining the effects of the pbl and sgd methods on areas that we did not cover in this study, for instance clinical practice. furthermore, the students' ethical knowledge was assessed only a short time after the course, and therefore the effectiveness of each method over a longer time span could not be verified. the reliability of the open-ended questions used for the purpose of assessment was yet another limitation. conclusion in view of the most important limitation of this study, namely the small sample size, and taking into account the students' comments on the advantages and disadvantages of each method, we suggest pbl rather than sgd for teaching ethics. this opinion is strengthened when we consider the results of the course evaluation. considering the process of the pbl method and unavailability of the required resources, however, this method may not be suited to ethics education under the present circumstances. acknowledgment this research was approved and funded by qom university of medical sciences. we would like to thank miss sakineh bagheri for coordinating the sessions and mrs. mahboobeh akhlaghi for managing the examinations and paper coding. references 1. claudot f, alla f, ducrocq x, et al. teaching ethics in europe. j med ethics 2007; 33(8): 491–5. 2. al-haqwi ai, al-shehri am. medical students' evaluation of their exposure to the teaching of ethics. j family community med 2010; 17(1): 41-5. 3. jones nl, peiffer am, lambros a, et al. developing a problem-based learning (pbl) curriculum for professionalism and scientific integrity training for biomedical graduate students. j med ethics 2010; 36(10): 614-9. 4. ozan s, timbil s, semin s, musal b. interns’ perceptions on medical ethics education and ethical issues at the dokuz eylul university school of medicine in turkey. educ health 2010; 23(3): 1-11. 5. parker m. autonomy, problem-based learning, and the teaching of medical ethics. j med ethics 1995; 21(5): 305–10. 6. mattick k, bligh j. teaching and assessing medical ethics: where are we now? j 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[in persian] 17. johnston c, haughton p. medical students’ perceptions of their ethics teaching. j med ethics 2007; 33(7): 418–22. 18. tan ch, amin z, khoo he, et al. student perceptions of the benefits of problem-based learning. med teach 2007; 29(2-3): 284. 19. joh hk, shin js. student satisfaction and self-assessment after small group discussion in a medical ethics education program. korean j med educ 2009; 21(3): 243-57. 20. fawzi mm. medical ethics educational improvement, is it needed or not?! survey for the assessment of the needed form, methods and topics of medical ethics teaching course amongst the final years medical students faculty of medicine ain shams university (asu), cairo, egypt 2010. j forensic leg med 2011; 18(5): 204-7. 21. derse ar. the evolution of medical ethics education at the medical college of wisconsin. wmj 2006; 105(4): 18-20. 22. moodley k.teaching medical ethics to undergraduate students in post-apartheid south africa, 2003-2006. j med ethics 2007; 33(11): 673-7. 23. parker l, watts l, scicluna h. clinical ethics ward rounds: building on the core curriculum. j med ethics 2012; 38(8): 5015. 24. miyasaka m, sakai s, yamanouchi h. how should ethics be taught to medical, nursing and other healthcare students? eubios j asian int bioeth 2011; 21: 91-95. chorasmia 224 seyyed alireza golshani 28-6-94.docx journal of medical ethics and history of medicine review article chorasmia medical school from the beginning until the mongol invasion seyyed alireza golshani 1, fatemeh seddigh2, hadi pirouzan3, babak daneshfard*4 1phd student, department of history, faculty of literature and humanitiesdr ali shariati, ferdowsi university of mashhad, mashhad, iran, and research office for the history of persian medicine, shiraz university of medical sciences, shiraz, iran; 2paramedical school, shiraz university of medical sciences, shiraz, iran; 3phd student, department of history, faculty of literature and humanities, shiraz university, shiraz, iran; 4md, phd student in traditional persian medicine, research center for traditional medicine and history of medicine; essence of parsiyan wisdom institute, traditional medicine and medicinal plant incubator, shiraz university of medical sciences, shiraz, iran. corresponding author: babak daneshfard address: research center for traditional medicine and history of medicine; essence of parsiyan wisdom institute, traditional medicine and medicinal plant incubator, shiraz university of medical sciences, shiraz, iran email: babakdaneshfard@gmail.com tel: 09166725988 fax: 07132345145 received: 25 jan 2015 accepted: 15 jul 2015 published: 14 nov 2015 j med ethics hist med, 2015, 8: 11 © 2015 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract in research on the history of medicine, less attention is paid to the subject of historical geography. considering the importance of this subject in the history of science, this paper discusses one of the most important science centers in the world. this outstanding medical research center was located in gorganch city, chorasmia area, in the eastern part of the islamic. chorasmia medical school was one of the important iranian medical schools before the mongols’ attack. its history (305-1231 a.d.) can be divided into three eras; ale iraq, ale ma'mun, and era of the khwarazmian dynasty. this geographical area in the northeast of iran has escaped the notice of researchers in recent studies. the presence of great persian physicians and scientists throughout history in this area indicates its scientific importance. the present article focuses on chorasmia medical school since its establishment until the mongols’ attack. keywords: chorasmia, historical geography, history of medicine, medical school, iranian scholars mailto:babakdaneshfard@gmail.com j med ethics hist med 8:11 nov, 2015 jmehm.tums.ac.ir seyyed alireza golshani et al. page 2 of 6 (page number not for citation purposes) introduction the honorable history of chorasmia has undoubtedly been shaped by various educational and experimental links which have formed various scientific doctrines and have played a role in the training of different scientists and scholars. chorasmia medical school, with the support and encouragement of khwarazm shahs, raised many physicians, scientists and scholars in the field of mathematics, engineering, astronomy, philosophy, religion sciences, and medicine. this piece of research is the first general study about gorganch, uzbekistan, and chorasmia medical school. the great medical school appeared when the afrighids or ale iraq took up the reins and grew in power with the governing of ma'munids or ale ma'mun. this medical school flourished with the khwarazmian dynasty, but faded with the mongols’ attack to iran, and only its reputable name remains in history. in this study, we aimed to study the role of the chorasmia medical school in the development of medicine and reasons for its flourishing. another goal was to introduce its scholars and their most important work. method for this purpose, library resources were reviewed. moreover, google scholar and noormags databases were searched using khwarazm, gorganch, and chorasmia keywords both in english and persian. geographical characteristics in many references, gorgan and gorganch have mistakenly been considered to be the same place. gorgan, called esterabad in the past, is located in the north of iran about 80 kilometers to the east of the present gorgan province (1). konye-urgench or jorjan or gorganch, which is called jorjanyh by arabs, gorganch by iranians, and urgench by the mongols and turks, is located on the banks of the amu river (figure 1). it was considered as one of the most important cities of chorasmia (2, 3, 4). in the 12th century, gorganch was the capital of the powerful khwarazmian dynasty and gained reputation. since the khwarazmian dynasty was promoted to the highest level of power in the islamic world, its capital had to be enriched with treasures of conquered countries (3). yaqut al-hamawi, who lived in gorganch at the end of 1219 a.d. and the beginning of 1220 a.d., believed that gorganch was the biggest and the richest city ever seen (5). this area even had its own literature and language. according to professor iosef mikhailovich oranski, khwarezmian (khwarazmian, khorezmian, chorasmian) is an extinct east iranian language closely related to sogdian1. the language was spoken in the area of khwarezm (chorasmia), centered in the lower amu darya south of the aral sea (the northern part of the modern republic of uzbekistan, and the neighboring areas of turkmenistan) (figure 2) (2,6). our knowledge of khwarezmian is limited to its middle iranian stage and, as with sogdian, little is known of its ancient form (6). from the writings of the great khwarezmian scholars, biruni and zamakhshari, we know that the language was in use at least until the 13th century, when it was gradually replaced by iranian in most parts, and several dialects of turkic (7). khwarezm played a vital role in the civilization of central asia since antiquity, had major cities such as jorjanyh, khiva, and kath, and was seen as the northernmost base for civilization in the past (3, 8). to the present day, khwarazm and urgench are still alive as a province and city, respectively, beside the amu river in the republic of uzbekistan (9). historical eras of chorasmia the first example of culture and civilization of chorasmia is related to the neolithic age. it is called “kel teminar” culture and has been archeologically explored. in the bronze age, khwarazm was the historical site of “kokcha-iii”, and in the iron age, it witnessed the flourishing of agriculture and industry. ancient khwarazm was referred to for the first time in avesta as “iranvij” which was the birth place of the aryan tribe (10, 11). this geographical area was under the rule of different empires, from the achaemenid dynasty to sassanid dynasty, until the advent of islam (10). 1 “the sogdian language was an eastern iranian language spoken in the central asian region of sogdiana, located in modern-day uzbekistan and tajikistan. sogdian is one of the most important middle iranian languages, along with bactrian, khotanese saka, middle persian and parthian. it possesses a large literary corpus. the language is usually assigned to a northeastern group of the iranian languages, although this is an aerial rather than genetic group. no direct evidence of an earlier version of the language ("old sogdian") has been found, although mention of the area in the old persian inscriptions means that a separate and recognisable sogdiana existed at least since the achaemenid era. like khotanese, sogdian possesses a more conservative grammar and morphology than middle persian. the modern eastern iranian language yaghnobi is the descendant of a dialect of sogdian spoken around the 8th century in ustrashana, a region to the south of sogdiana” (6). j med ethics hist med 8:11 nov, 2015 jmehm.tums.ac.ir seyyed alireza golshani et al. page 3 of 6 (page number not for citation purposes) the capital of khwarazm was initially kath or cus (4). kath was destroyed in the 10th century due to political events between ale ma'mun and ale iraq and the outflow of the oxus river. therefore, the people had to migrate to the east bank of the oxus river called gorganch. chorasmia was an important area and had many cities and towns such as xazorasp, zamakhshar, drghan, khiva, ardkhshish, safredz, nozvar, korder, kerdran khvash, madmineh, mardjqan, zaragoza, and otrar (3, 10). the flourishing and development of medicine in chorasmia, which is known as the original home of the aryan tribe (10, 11), was actually due to the presence of kings who loved and admired science and governed it for centuries. the advancement of medicine in this part of the world can be divided into three historical eras; the afrighids or ale iraq, ma'munids or ale ma'mun, and the khwarazmian dynasty. figure 1geographical location of urgench (available from: http://en.wikipedia.org/wiki/amu_darya) figure 2historical geography of khwarazm (available from: http://en.wikipedia.org/wiki/file:afrighidsmap.png) http://en.wikipedia.org/wiki/amu_darya) http://en.wikipedia.org/wiki/file:afrighidsmap.png) j med ethics hist med 8:11 nov, 2015 jmehm.tums.ac.ir seyyed alireza golshani et al. page 4 of 6 (page number not for citation purposes) first era chorasmia was divided into two parts by the oxus river (amu river). before islam, from 305 to 892 a.d., both parts were governed by the afrighids or ale iraq who considered themselves as belonging to the kai khosrow kiani dynasty (12). then, in 892 a.d. khwarazm was broken into two parts. the afrighids continued to govern the part of chorasmia which was located in the north of the oxus river and its capital was kath. however, the south of the oxus river was governed by a ruler under the title of amir of gorganch and the ale ma'mun dynasty (13). evidently, the afrighid dynasty cannot be considered as an independent government, since in 706 a.d., during the arab conquest, they were entitled to pay tax and continued to do so until the abbasid caliphate (14). when amr-i laith saffari came into power, the afrighids lived in harmony with this government at first. however, with amr-i laith’s defeat, they accepted the rule of shah ismail samani and remained obedient until the ale iraq dynasty collapsed (14). according to al-biruni, afrig was the first person to be assigned as a ruler in chorasmia by the afrighid dynasty. al-biruni then talks about the governing of bagra, sahhasak, askajamuk i, azkajwar i, sahr i, shaush, hamgari, buzgar, and arsamuh [it is believed that he was contemporary with prophet muhammad (pbuh)] (12). he subsequently talks of sahr ii, sabri, azkajwar ii, askajamuk ii (lived during the islamic conquest), sawashfan, torkasbatha, abdollah ibn torkasbatha (the first government of chorasmia with an islamic name), mansur ibn abdollah, eraq ibn mansur (contemporary with shah ismail samani), muhammad ibn eraq, and abu sa'id ahmad ibn muhammad (12). finally, he talks of abu 'abdollah muhammad ibn ahmad who was killed in 995 a.d. by ma'mun ibn muhammad, the founder of the ma'munids (12). unfortunately, there is not enough information about khwarazm shahs of the afrighid dynasty. some researchers even consider this dynasty to be the same as ale ma'mun (15). very little information exists about other scholars and scientists. however, the rulers of chorasmia were undoubtedly strong supporters of science. muhammad ibn eraq founded the soltani school of kath in chorasmia. other scientific centers which were known as the “king’s links” were also established. this indicates that the kings of this dynasty supported scientific activities (16). some of the most famous scientists and physicians of this era were al-gaurizin (780-850 a.d.) (mathematician, astronomer, philosopher, geographer, and historian), al-biruni (pharmacologist, historian, mathematician, and astronomer), and abu nasr iraqi (mathematician and astronomer). after the collapse of the afrighid dynasty, many of them continued to live under the rule of ale ma'mun (17). second era' the second era started with the ruling of the ale ma'mun, an anonymous dynasty of chorasmia’s local rulers. their name appeared in history in about 995 a.d. and they governed chorasmia until 1017 a.d. the capital of ale ma'mun was gorganch or jorjanyh (18). at first, ma'munids, or ale ma'mun, were under the rule of the samanids. after the collapse of the samanid dynasty, they governed independently for a short period of time (18). by the rise to power of the ghaznavids, they were under the rule of mahmud of ghazni, and with his attack in 1017 a.d., this golden era came to an end (18). as previously mentioned, the khwarazm shahs loved and supported scientific activities, but there is no information about the ancient kings of this dynasty and only the names of four kings are mentioned in history. these rulers were abu-ali ma'mun i (ruled in 997), abu al-hasan ali ibn ma'mun (ruled 997-1008), abu abbas ma'mun ii (ruled 1008-1017), and abu'l-harith muhammad (ruled in 1017) (19). the rulers of ale ma'mun attracted great scientists and physicians such as avicenna, abu sahl 'isa ibn yahya al-masihi, to chorasmia. avicenna (980-1037), the famous scholar and physician, conducted scientific research in ma'mun’s court for 13 years. during this period, he spent his time in teaching, writing, and curing patients. he wrote many books and treatises during his presence in chorasmia. two of these treatises in medicine are “angiology; a treatise on the pulse” in persian and “asbab al-hozn” in arabic, which is about depression (18). abu sahl 'isa ibn yahya al-masihi al-jurjani, scholar, physician, and mentor of avicenna, was from gorganch. some of his publications on medicine are al-mā'a fi-l-sanā'a al-tabi'iyyah (medical encyclopedia in 100 chapters), al-teb alkolli (a book about general treatment in 39 chapters), ezhar hekmat allah fe khalgh al-ensan (a book on human physiology and the purpose of its creation) and resaleh fe al-jderi va tadbireh (a treatise about smallpox and its treatment). his other medical researches include resaleh fe amr al-vaba va al-ahteraz anho va eslahat eza vagha (a treatise about cholera and its prevention), resaleh fe tahghegh soe al-mezaj ma howa va kom asnafe (a treatise on different types of gastric disease), and a book under the title of “principles of the pulse” (20). most of these medical treatises were dedicated to abu abbas ma'mun ii. abu sahl died in 1010 a.d. at the age of 40 when he and his student, avicenna, were caught in a sand storm while escaping from mahmud of ghazni’ agents (21). al-biruni (974-1048) was an astronomer, mathematician, historian, researcher, and a famous botanist from birun, a village near kath in chorasmia. he wrote kitab al-saydana fi'l-tibb, j med ethics hist med 8:11 nov, 2015 jmehm.tums.ac.ir seyyed alireza golshani et al. page 5 of 6 (page number not for citation purposes) which consists of a list of herbal medicine in alphabetic order, in the field of pharmacology in arabic (21). abolhasan ahmad ibn muhammad soheyli khwarazmi (1027-?) was a skillful physician and scientist and was appointed as a vizier in chorasmia for a while. later, he went to baghdad, and then, to samarra. among his medical works are two books under the titles of tadrok al-khata fe tadbir alabdan and al-rozat alsoheyliat (20). abolkheir khamar khwarazmi (943-1049 a.d.), physician and famous philosopher, was from chorasmia. he showed innovation both in theoretical and practical medicine. among his works are “alhawamel”, a book on pregnancy, a treatise which was used for testing physicians; and “ketab fe khalgh al-ensan va tarkib aazayeh” consisting of four treatises. he wrote “ketab al-tadbir almashayekh” which is an adaptation of the work of hunayn ibn ishaq (809-873 a.d.) with the same title. khwarazmi gathered the viewpoints of galen (greek physician, surgeon, and philosopher) and rufus (greek philosopher, physician, and botanist of ephesus) in this book. he has a treatise about epilepsy and a book on nutrition (kitab al-agdiya) (20). among other physicians from gorganch who professor fuat sezgin talks about is abu-saeid jorjani who was a 10th century scholar. he wrote a book on botany which al-biruni referred to in his work. sezgin also mentions abu al-futuh jorjani, a physician who lived in the second half of the 10th century, and some other writers have also mentioned his book on medicine (20). the important point of this period is the fact that in the golden era of the ale ma'mun dynasty, many scholars and physicians were attracted to the small and safe geographical zone of chorasmia (18). third era the third era of development of chorasmia started again a hundred years later with the governorship of qutb al-din muhammad anushtegin (ruling 10971128). after him, ala al-din abul-muzaffar atsiz (ruling 1120-1156), taj al-din abul-fath il-arslan ibn qizil arslan atsiz (ruling 1156-1172), jalal aldin mahmud sultan shah ibn il-arslan (ruling in 1172), ala al-din tekish ibn il-arslan (ruling 11721200), ala al-din muhammad ibn ala al-din tekish (ruling 1200-1220), and jalal al-din mingburnu ibn ala al-din muhammad (1220-1231), respectively, governed chorasmia until the attack of the mongols. these rulers were under the influence of the seljuq dynasty for a period of time. however, they moved toward independence after atsiz, and in addition to chorasmia, they dominated some parts of transoxiana, khorasan, mazandaran, sistan, kerman, fars, and jibal. since the rulers of this dynasty, after atsiz, were supporters of science, they could gather great scholars and physicians in their imperial court (22). mahmud ibn umar jeghmini khwarizmi (?-1221 a.d.) was a famous physician in jeghmin, which was located in chorasmia. this scholar and astronomer wrote a book under the title of “sharh-eqanunche” which is an abridgment of the canon of medicine written by avicenna (23). zayn al-din sayyed isma‘il gorgani (1042-1137 a.d.) was born is gorganch (2,24). some of his works are “khafi alayee”, “al-tib al-muluki”, “zubdah al-tib”, “zakhireh kharazmshahi”, “yadegar dar teb”, and “al-aqraz al-tebbieh va al-mabahis al-alaieh”. he presented his works to qutb ad-din muhammad and his son, atsiz (25). due to writing great medical works, jorjani became a high rank scientist. first, he was promoted as a governmental senior physician, and then, he was appointed as the physician of qutb ad-din tekish and atsiz. he was the manager of the teaching hospital in chorasmia (2, 25). at the age of 90, jorjani moved to marv in khorasan, the capital of seljuqs, perhaps to improve his scientific work and make use of the large library of the capital. he joined the imperial court of seljuq ruler, sultan sanjar, and finally, died in marv at the age of 95 (2, 24, 26). other physicians of chorasmia medical school were abu bakr abolkheir ibn abdur rahman jorjani, shahabodin abusaeid khivaghi khwarazmi, and jamal ad-din qarshi (1114-1201 a.d.) (27, 28). after the attack of the mongols, many of the scholars and physicians were killed or they had to immigrate to egypt, india, anatolia, or fars. this terrible event caused the decline of culture and science in north-east iran and chorasmia (29). the last spark of gorganch was sayyed sharaf al-din jorjani (1340-1413 a.d.) who was respected in the courts of shah shuja muzaffarid (ruling 1358-1384 a.d.) and timur beg gurkhani (ruling 1370-1405 a.d.). he was the manager of dar al-shafa mozzafari hospital of shiraz in southern iran (30). conclusion the presence of great iranian scholars and physician in chorasmia (at the time of ale iraq, ale ma'mun, and the khwarazmian dynasty) indicates the scientific importance of this geographical zone. this significant presence, no doubt, is a sign of the appealing characteristics of chorasmia medical school. the influence of this school can be noticed many years after that era. the scholars of this area were fortunate, since ale iraq and ale ma'mun governments and the khwarazmian dynasty all loved and supported culture and science. with their widespread support of research activities, they created a golden era in all scientific fields, especially in medicine. j med ethics hist med 8:11 nov, 2015 jmehm.tums.ac.ir seyyed alireza golshani et al. page 6 of 6 (page number not for citation purposes) references 1. matofi a. 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[morori bar tarikh va mabani teb sonati islam va iran]. tehran: sahbaye danesh; 2010, p. 35-7. [in persian] 25. ravandi m. [tarikh ejtemaee-e iran]. tehran: negah publication; 2004, vol 8, p. 462, vol 10, p. 296. [in persian] 26. elgood cl. medical history of persia and the eastern caliphate. translated by forghani b. tehran: amir kabir; 2007, p. 248. [in persian] 27. ghayeb oops ma, oraz b. [naghsh pezeshkan dar dolathayeh khorazm (gharnhayeh 10-13 meladi)]. journal of central asia and the caucasus studies 1999; 28(4): 1999. 28. heydariyan mh. [dar astaneh tahghigh: moarefi yek nam va yek farhang]. j r ayene miras 2009; 44(3): 343-4. [in persian] 29. hamidi mh. [bim va omid roykardhaye seyasi dar adabiyat farsi]. tehran: nashr safir; 2000, p. 79. [in persian] 30. golshani sa, bosmia an, ahmadi a, adloo s, tubbs rs, bayazidi a, golshani ah, shoja mm. the mozzafari hospital of shiraz, persia. childs nerv syst 2014; 30(5): 803. ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ commentary copyright © 2021 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. journal of m edical ethics and h istory of m edicine the impact of archaism discourse on iranian medical historiography from the achaemenid period masood kasiri assistant professor, department of history, faculty of literature and humanities, university of isfahan, isfahan, iran. introduction the post-constitutional period, especially in the pahlavi period, witnessed the peak activity of several thought streams sought to create national unity and modernization in the straggling society of the qajar period (1). majority of such streams considered islam and the arab invasion among main reasons of iran’s retrograde and destruction (2), which led to the formation of a discourse based on antiquity. this discourse became the foundation of cultural context in the pahlavi period and most of the subsequent changes and developments occurred in this historical context, referred to as antiquity (3). the impact intensity of this discourse was such that it affected majority of iran’s cultural and scientific heritage (4), including the field of historiography. one of the main cultural fields in this period was historiography, including medical historiography. retrieving the glory of ancient iran and reacquiring pre-islamic iranian civilization’s peak required special attention to historiography and new readings of iranian and world history, followed by writers and historians. however, how close to reality was this process of historiography influenced by the dominance of nationalist sentiments, and to what extent was this style of historiography subject to political theories? hence, several items were addressed in this article: (i) in this process of historiography, for what purposes has the medical history of iran been written? (ii) to what extent does this written history corresponded to historical facts? the authors of this article believe that iranian medical historiography has been strongly influenced by the discourse of antiquity. this article first explained diverse styles of historiography in medical sciences, and then discussed medical historians’ claims. moreover, after explaining the achaemenid religion, the reasons for rejecting historians' claims regarding this period’s medical history were inspected. *corresponding author masood kasiri address: university of isfahan, hezar-garib, isfahan, iran. postal code: 8174673441 tel: (+98) 31 37 93 31 21 email: masoodkasiri@ltr.ui.ac.ir received: 3 mar 2021 accepted: 1 nov 2021 published: 1 dec 2021 citation to this article: kasiri m. the impact of archaism discourse on iranian medical historiography from the achaemenid period. j med ethics hist med. 2021; 14: 16. the impact of archaism discourse on iranian medical historiography …… 2 j med ethics hist med. 2021 (december); 14: 16. journal of m edical ethics and h istory of m edicine the beginning of the medical historiography in iran medical historiography has existed in iran for hundreds of years. however, the style of medical historiography and the approach of historians to this subject have not always been the same and changed over time (5), which can be divided into two categories of old and new style. old style medical services have been considered as one of the primary human needs for thousands of years, and medical history has been valued since then. while some consider the principles of medicine to be derived from divine sources (6), others consider them to be semi-divine and semi-experimental (7). contemporary historians consider the basis of medicine to be experimental (8) and believe that, in the beginning, women practiced medicine in primitive societies (9). over time, medicine became sacred and associated with divinity, and the divine gods communicated with humans through priests or clergies (8). ordinary people expected the clergy to save them from the sins and diseases, which was not the case in all places and times (e.g., in babylon (7)). ancient historians, regardless of the origin of medicine, used almost similar method for their work, and most of them based their method on a traditional view of the medicine. by studying ancient medical texts, they enumerated the author's advantages and highlighted the technical and knowledge aspects of those texts. such a history of medicine was an introspective and thoughtprovoking method that based its research on medical geniuses’ life. although this style of historiography had changed in the west during the contemporary period, it continued in iran until about two decades ago. although the field of medicine’s social history has been recognized and studied by researchers in the west, it has not received much attention in muslim countries, especially in iran (10). regarding the methods used in the medical history of muslim countries and iran, not much differences has been observed in various resources including ibn abi asiba'ah (11), ibn al-'ebri (12), well-known book by the philosopher al-dawlah (13) to recent decades’ studies by manfred ullmann, german historian and arabic scholar, and his two other counterparts, max meyerhof, german historian and joseph schacht, british-german professor of islamic and arabic studies at columbia university. new style in recent years, new perspectives on the medicine’s history have emerged seeking to achieve a different outlook of medicine. the purpose of these new approaches arising from such new perspectives is to present the social aspects of medicine as a socio-scientific phenomenon, including methods such as the social history of medicine, and to examine past societies through these new lenses. with such approaches, these ancient medical texts and data can be used as a source for studying social history, along with other known sources such as historiographical texts or historical documents. such trend began with the work of george kasiri m. 3 j med ethics hist med. 2021 (december); 14: 16. journal of m edical ethics and h istory of m edicine rosen (1910-1977), an american historian in the 1970s and 1980s. the history of modern medicine, which began with foucault (14), referred to as the history of mentality, or socalled mentalities history. this history type, the main author of which can be considered analytics (16) in france, deciphered the requirements for producing medical discourse. in such approaches, more emphasis is placed on representations than on historical data mining, common in classical historical research. in terms of foucault each historical period had only one style of discourse that it is a reflection of the epistemology of the historians of that period. iranian medical historiography in the pahlavi period the new discourse that had been formed since the post-constitutional period in all areas of social life as well as in the political and cultural scopes of the society, extended its scope to historiography field. this style of general historiography, initiated by mirza aga khan kermani (17) and continued by mirza hassan mushir al-dawla (18), extended its scope to the medical historiography field and caused the history of iranian medicine in ancient iran’ medical history to be intensely influenced by the prevailing text-based and introspective discourse. the first historian to write iran’s medical history was cyril lioyd elgood, who was fluent in persian and familiar with arabic. he began to study the history of medicine in islam and iran from the very beginning, on the advice of edward brown and max meyerhoff, and by consulting with iranian scholars at that time. his presence in iran coincided with the rise of the nationalist movement in iran and the emergence of the pahlavi government. due to his presence in that period, he published two important writings entitled medical history of iran and the lands of the eastern caliphate. moreover, he wrote medicine in the safavid period as well as several articles on iranian medicine’s history. mahmoud najmabadi was the second historian to write regarding the medicine’s history with his famous book history of medicine. in presenting historical data and judgments, the writings of these two historians, especially in the field of ancient iran, had many similarities. for example, both historians cited an almost similar paragraph in terms of literature and even terminology when writing the history of medicine during the five hundred years of the parthian ruling. in the only paragraph devoted to the parthian medicine’s history, elgood believed that they lacked great culture and civilization and the inherent harmony and the chivalry helped them last (7). najmabadi also shared elgood’s viewpoint in different expressions and wording (19). although najmabadi briefly made a few references to parthians medical traditions’ related narrations after the aforementioned viewpoint, he still insisted on his claim that was fully investigated and rejected in the present work’s author in (20). the impact of archaism discourse on iranian medical historiography …… 4 j med ethics hist med. 2021 (december); 14: 16. journal of m edical ethics and h istory of m edicine however, the most dubious comments of these two historians were on the medical situation in iran during the achaemenid period. both historians, especially najmabadi, after scattering reference to iran, detailed the medical school, which today is known as the zoroastrian school of medicine (7, 19). both historians considered the achaemenid period as the glorious era of the school of zoroastrian medicine, which was widely accepted as a principle in the history of medicine and opposition to it was not tolerated by historians. some of these comments were as follows: in the mazdisna school, the students were taught the methods of treatment and recovery by the clergy and using the rules of religion (19) in the early achaemenid period, a group of moghan zoroastrian students studied medicine in the educational centers of hamedan, rey, and persepolis (21). most of the educational centers in the ancient iran were located near fire temples and physicians were mainly selected from the moghan (zoroastrian clergy) group (21). in this period, darius i, more than other kings, paid attention to medicine by establishing large hospitals and schools and supporting physicians (19). at that time, physicians included two groups, "dorstpad" and "tan-basezag". (7) these comments have led most historians of medical history to consider the achaemenid period as the glory era of iranian civilization and insist on it, because they correspond the glory of civilization to the characteristics of a successful world school derived from the religion of zoroaster. discussion the achaemenid era coincided with the presence of three major religions in the world: zoroastrianism, buddhism and judaism. the ancient religion of the iranian aryans was accepted, along with these three great religions. scholars who have commented on the achaemenid religion are divided into two categories: (i) the first group, in minority, believe that the achaemenids’ religion was zoroastrian; (ii) the second group of orientalists and scholars of ancient iran (22) believe that achaemenids’ religion was not zoroastrian (23). some historians considered darius the first zoroastrian king. one of these historians is omstad, who believed that when the prophet zarathustra was a guest of goshtasb's court in eastern iran, he often talked to the young darius, resulted in a religious mission that darius carried out in spreading zoroastrian thought and establishing a religious-political government (24). the name of the greatest god in the achaemenid inscriptions was always written in the form of ahura mmazda while it was never the case in avesta. before darius, none of the achaemenid kings believed to be chosen by ahura mazda, and therefore ahura mazda emphasized in the writings of darius a single and powerful god, not a zoroastrian god (25). there is no definite opinion about the religion and religious policy of the achaemenid kasiri m. 5 j med ethics hist med. 2021 (december); 14: 16. journal of m edical ethics and h istory of m edicine kings, and apparently the achaemenids’ religion is closer to the religion of ancient iran than the zoroastrians’ religion. according to the researches of historians and archaeologists, achaemenids did not follow a specific religion and even if they had religious beliefs, they were certainly not zoroastrians (24). medical data from the achaemenid period at the court, according to xenophon, the first achaemenid emperor (cyrus) provided free medical services, and, sometimes, paid for treatment from the state budget. he sent each of his suffering individuals, attributed to king, to a physician and thanked that physician. however, this special attention was not based on the principles of zoroastrian medicine, but on those of the egyptian medicine (7). at that time, the presence of foreign, nonzoroastrian physicians, especially egyptian physicians, increased in the court, and the state of the zoroastrian moghans diminished (26). achaemenid kings such as cyrus and darius might choose their medical advisers from abroad due to the lack of trust in zoroastrian physicians, as herodotus wrote: "when cyrus asked amazis to send him the most skillful ophthalmologists from egypt, he chose the best doctor, who became cyrus' adviser (7)”. greek physicians were more loyal than iranian physicians, indicating a strong distrust regarding the iranian physicians, who were dependent on the clergies and moghans (27). among the people regarding the first group of physicians among the iranian tribes, due to the nature of medical science, which was not separate from sciences such as astronomy and religion, physicians were chosen from religious leaders (28). the word mogh in ancient iran’s history referred to scholars, scientists, and physicians (23). most historians believed that the mogh were a special group whose duties were inherited from generation to generation (29). prophet zarathustra acquainted many moghans with his beliefs and change theirs. with the arrival of the aryans in the land of iran and the subsequent spread of the zoroastrian religion among the people, major changes were made in the ancient people’s lifestyle (30). the moghans and the achaemenid kings did not have a good relationship because the moghans, which were expelled from their lofty position, took every opportunity, albeit quite hostile, to return to their former position. moghan's position in the achaemenid system was shaken and collapsed because they and their associates were considered liars, insurgents and enemies of the government, and sometimes even the rest of the rebels were attributed to the moghans (24). in such a situation, the zoroastrian moghans, who inherited the ancient iranian’s medical traditions, did not find the environment favorable for living, and a group of them might have migrated to find a more suitable environment. the impact of archaism discourse on iranian medical historiography …… 6 j med ethics hist med. 2021 (december); 14: 16. journal of m edical ethics and h istory of m edicine conclusion in the process of historiography, for what purposes has the medical history of iran been written? the efforts and distortions of the pahlavi government made the culture of antiquity seem unreal and even exaggerated. this exaggeration led the ancient times, antiquity, to be called the golden age of culture and civilization, and kings such as cyrus and darius being considered the symbol of culture, civilization and human rights. following these exaggerations, unrealized, magnified images of the history of culture were also presented, and some historians were misled by the discourse of antiquity. they attributed the medical history of the sassanid era and zoroastrian medicine to the achaemenid era, with about seven hundred years of incorrect time shifting. to what extent does this written history corresponded to the historical facts? the writings and discussions of contemporary writers on the history of medicine in the achaemenid period belong to the sassanid period and mistakenly attributed to the achaemenid period. this wrong attribution was because official religion was considered zoroastrian in the achaemenid period while many writers and historians believe that no official religion was approved in that period. kasiri m. 7 j med ethics hist med. 2021 (december); 14: 16. journal of m edical ethics and h istory of m edicine references 1. kajbaf aa, ahmadvand z. 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[tareikh pezeshki iran va sarzaminhaye khelafat sharqi], 2nd. tehran: amirkabir publications; 1383, p. 19,20,56,29-35,40. [in presian] 8. durant w. our oriental heritage. [cited on dec 2021]; https://books.google.de/books?hl=en&lr=&id=ru4lpymaxxkc&oi=fnd&pg=pt36&dq=8%09durant+w.+%27%27our+oriental+heritage+&ots=tfcghtkm_z&sig=bxnm4wvubqpg6 vhuwovb4sfbipe&redir_esc=y#v=onepage&q=8%09durant%20w.%20’’our%20oriental%20heritage&f=false 9. retief fr, cilliers l. the healing hand: the role of women in ancient medicine: the graeco-roman world. acta theologica. 2005; 26(2): 165-88. 10. abdollahi m. on the importance of medical history writing. research on history of medicine. 2012; 1(1): 21-2. 11. ibn abi usaybi‘a, muwaffaq al-din. [cited on dec 2021]; https://www.oxfordreference.com/view/10.1093/acref/9780199754731.001.0001/acref9780199754731-e-159 12. ebn al-ebri, abul-faraji. [cited on dec 2021]; https://iranicaonline.org/articles/ebn-al-ebri 13. shorche b, panjeh m. non-muslim physicians in the islamic middle age courts. [tarikh wa tamaddun-i islami]. 2019; 15(29): 27-56. 14. karimi b. muslim medical historiography: studies and research. the journal of islamic history and civilisation. 2014; 9(18:18): 141-61. 15. foucault m. the birth of the clinic: an archaeology of medical perception. usa: vintage; 1994. 16. karimi b. annales historiography school. the journal of islamic history and civilization. 2011; 6(11:11): 167-91. 17. agahodeini a, mahdipour a. a deconstructionist approach to the discourse of the first wave of intellectualism in iran: mirza malkum khan, akhond zadeh and mirza agha khan kermani. political knowledge. 2014; 9(18): 45-58. 18. nazaria a. nạsywnạlysm and iranian identity: case study first pahlavi era. public law. 2007; 9(22): 141-73. 19. najmabadi m. [tarikh pezeshki iran]. tehran: art print; 1342, vol.1, p. 92-104,214. [in persian] 20. kasiri m. analysis of the medical history in iran during the parthian rule. journal of medical ethics and history of medicine. 2016; 8(6): 1-10. the impact of archaism discourse on iranian medical historiography …… 8 j med ethics hist med. 2021 (december); 14: 16. journal of m edical ethics and h istory of m edicine 21. azizi mh. gondishapur school of medicine: the most important medical center in antiquity. arch iran med. 2008; 11(1): 116-9. 22. rasouli a. achaemenid beliefs based on their inscriptions. journal of iran history. 2017; 10(1): 5976. 23. hosseini sarabi f, zarrinkoob r. magi in achaemenid era according to classic texts and persepolis fortification tablets. cultural history studies. 2016; 7(27): 25-43. 24. ahmadvand s, bordbar a. state formation in ancient iran: transition from mythological age to the establishment of achaemenid state. state studies. 2019; 5(19): 81-106. 25. frye rn. the history of ancient iran. germany: munchenc.h. beck; 1984, p.90-105 . 26. pourahmad j. history of medical sciences in iran. the iranian journal of pharmaceutical research. 2008; 7(2): 93-9. 27. sangari e, karbas a. historiography in ancient iran its nature and style with respect to different approaches to the concept of history. journal of history of islam and iran. 2016; 30(120):167-218. 28. dewald c, marincola j. the cambridge companion to herodotus. .uk: cambridge university press; 2006, vol.3. 29. fekripour k. the duty of clergymen in ancient iran. journal of historical researches. 2009; 1(1): 101-12. 30. nodehi k, kasiri m. effect of health teachings of zoroaster in ancient iranian nutrition. journal of islamic and iranian traditional medicine. 2014; 4(4) :381-8. introduction references ____________________________________________________________________________________________________________________________________________ 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____________________________________________________________________________________________________________________________________________ 1 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e commentary volume 13 (suppl.) number 32 december 2020 copyright © 2020 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. covid-19 and collective responsibility: a lesson from the smallpox outbreak in moscow in 1960 *corresponding author yana g. grigoryan b. patriarchiy per., no.3, st. no.1, moscow 123001, russia. tel: (+7) 91 65 96 56 70 email: grigoryan.yg@1msmu.ru received: 19 nov 2020 accepted: 15 dec 2020 published: 28 dec 2020 citation to this article: grigoryan yg, krylov nn. covid-19 and collective responsibility: a lesson from the smallpox outbreak in moscow in 1960. j med ethics hist med. 2020; 13(suppl.): 32. yana g. grigoryan1*, nikolay n. krylov2 1.associate professor, department of humanities, the i.m. sechenov first moscow state medical university (sechenov university), moscow, russia. 2.professor, department of humanities, the im sechenov first moscow state medical university, moscow, russia. the covid-19 outbreak has been an unprecedented challenge for modern countries. the pandemic has spread around the world in several months and has already claimed more than 1.75 million lives (1). the most important question all countries around the world have to address is how to protect people from infection in a safe, equitable and effective manner. russia is among those countries that have responded to the pandemic by introducing severe restrictive measures in the country. upon announcement of the lockdown on march 25, 2020, people were advised not to go out. individuals over 65 stayed home and could only go to the grocery store, bank or pharmacy. schools, universities, concert halls, libraries, cafes and restaurants closed down. it was impossible to use public and private transportation without a special electronic pass issued by the authorities. international travel control was introduced and borders were closed. as a result of this policy, the society has been divided into two warring camps. people from one camp were in denial about the virus threat. they did not feel threatened by infection, demonstratively disregarded preventive measures, deliberately broke the rules imposed by the state and wanted to live their ordinary lives. those in the other camp demanded strict compliance with all the restrictions imposed on themselves or others and did not allow any compromises. covid-19 and collective responsibility: a lesson from the smallpox outbreak in moscow in 1960 2 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 32 december 2020 disputes between the two have raised the question of what measures can be taken to quickly limit the epidemic, and where the dividing line between the interests of the society as a whole and the personal rights of the individual citizen is. over the past few decades, public health ethics experts have come to the conclusion that “the conceptual resources for clinical ethics are inadequate for dealing with issues in public health practice” (2). numerous studies based on beauchamp and childress' key text “principles of biomedical ethics” have addressed to a great extent the moral issues concerning professional-patient interactions based on the principles of autonomy, beneficence, non-maleficence and justice (3). by contrast, public health programs aim to preserve and promote health at the level of the entire population, so the methods used to maintain the public good may violate some ethical principles. this is due to the key difference between public health and clinical medicine, which is the preventive nature of the former. in the face of infectious disease threats, public health often aims to impose restrictions on healthy people who are the potential victims of the disease but do not suffer when these restrictions are applied. the emerging ethical dilemmas of public health therefore go beyond the established consensus in most contemporary bioethical norms. this article aims to reflect on what ethical constraints are permissible during an epidemic, and what these constraints are dependent on. this perspective is historical, represented by the history of the smallpox outbreak in moscow in 1959 1960, in the context of which the authors analyze the principles that justify public health intervention during the covid-19 pandemic. by comparing approaches to public health in the two epidemic situations, the authors offer arguments justifying the need to recognize the moral obligations of citizens to each other to protect the society from threats to health and safety. vaccination against smallpox began in 1801 in russia, when a well-known doctor, efrem o. mukhin (1766 1850), vaccinated a boy against cowpox in a moscow educational home. as in other countries, vaccination in russia first met with resistance from part of the population, but after a while the method became widespread. before the 1917 revolution, however, vaccination was not compulsory in russia. the decree of the council of people's commissars of the russian soviet federative socialist republic (rsfsr) “on compulsory vaccination”, signed by vladimir lenin on 10 april 1919, and the new law on vaccination and revaccination of 1924 made vaccination in the country strictly observed. thanks to these measures, smallpox was considered to have been defeated in the union of soviet socialist republics (ussr) in 1936 (4), but after 23 years, a dangerous disease that everyone had forgotten about returned. in this case, patient zero was a soviet poster artist, alexei kokorekin, who contracted grigoryan yg., et al. 3 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 32 december 2020 smallpox in india in 1959. the contagion was caused when kokorekin purchased the carpet of the late indian brahmin after attending a traditional indian funeral (5). upon returning to moscow on december 23, 1959, he felt unwell. on december 27 the patient was hospitalized in the infectious disease unit of botkin hospital, where he died on december 29. on the same day, after an autopsy, doctors suspected toxic plague. on december 31 the body was cremated in accordance with the requirements for particularly dangerous infections (6). on january 11, 1960, doctors began to register people with natural smallpox in moscow. doctors could establish a connection between smallpox and the deceased artist only 13-16 days after kokorekin's death. his medical record stated that he had received a smallpox vaccine two weeks before he left for india, but did not have a vaccine reaction. the government decided not to inform muscovites about the threat of the epidemic to avoid panic among citizens. instead, all available resources in the city including hospitals, clinics, police, military and so on were immediately mobilized to combat the deadly threat. all efforts were focused on finding the people who had come into contact with potential carriers of the virus. epidemiologists identified three foci of smallpox: the first was discovered in the artist's family, and the second in the hospital; the third source of infection, however, was the most dangerous. it included everyone who had contacted the infected people, but had not been found. the number of these people could have been huge and was growing by the minute. everyone who was involved in the search for infected individuals worked around the clock. between january 16 and 31, investigators found and isolated 9,342 people. although several hospitals were designated as quarantine centers, there were not enough beds for all those who were infected. the medics sorted all those people into two groups. the first group included 1,500 people who had personally communicated with the infected. they were isolated in hospitals in and outside of moscow. the rest of them were locked in at home. for all 14 days of quarantine, doctors examined them twice a day. in addition, all the suspicious places in the capital were disinfected. at the same time, the authorities urgently began producing smallpox vaccines in quantities that would meet the needs of the entire population of the country. the epidemiological situation forced the soviet government to start mass immunization of the population as soon as possible. the main stage of primary vaccination was held from january 18 to february 1, 1960. during this time, 6,187,660 people were vaccinated. a total of 46 people became sick with smallpox that year in moscow, and three of them died. an outbreak of smallpox was fully localized by february 6, 1960. fortyfour days passed between the beginning of covid-19 and collective responsibility: a lesson from the smallpox outbreak in moscow in 1960 4 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 32 december 2020 the infection and the end of the outbreak. while the case of the smallpox infection in 1960 differs from the current pandemic in a key detail, that is, the availability of a vaccine, similarities can still be traced. in 2020, the state faced a highly contagious virus that claimed thousands of human lives. on both occasions, the state took various restrictive measures to prevent the spread of the disease. a brilliant result in the fight against the smallpox epidemic in 1960 was achieved through the restrictive measures imposed by the soviet government, the urgent comprehensive diversification of all medical resources and the creation of additional medical capacity, as well as the introduction of strict infection control not only in hospitals but also in the apartments of sick people. soviet doctors could not manage smallpox in time for the first patient, because there had been no cases of this disease since 1936 in the ussr. however, careful monitoring and quarantine, an epidemiological check-up, contact tracing, isolation and subsequent mass vaccination of patients turned the situation around and led to a victory over the epidemic. in 1960, the soviet authorities refused to inform the general public about the smallpox outbreak in moscow, which cannot be considered an appropriate measure for the fight against the pandemic in 2020. already at the beginning of the pandemic in april 2020, over 86% of the russian population had all the necessary information about the virus and its transmission (7). however, understanding how the infection spread did not prevent citizens from leaving the capital after the introduction of social distancing and self-isolation. this escape from the city's closed flats to the country contributed to the possible spread of infection from moscow, which was the center of the infection, to other regions and districts. another problem was the citizens' unwillingness to comply with the selfisolation regime after returning from abroad, where the pandemic was already raging. this made it difficult for epidemiologists to identify the outbreak of covid-19 and reduced the ability of state services to control its spread. to avoid the consequences of such irresponsible behavior or spontaneous and unconscious actions, in 1960 the soviet state assumed full responsibility for measures to combat the spread of the disease and save lives. by implementing a paternalistic model of relations, the state acted as “guardian”, assuming full responsibility for the outcome of an outbreak of a particularly dangerous infection. it proceeded on the assumption that the doctor knew better than the victim of infection what was good for his/her health. in this case, the opinion of citizens was not taken into consideration, since most people had little knowledge about the disease and its dangers, no knowledge about prophylaxis and treatment, and limited ability to choose an effective method of fighting it. but these government actions deprived citizens of their rights and made them victims of a policy of diktat. yet, this demonstration of power of the state machinery to enforce grigoryan yg., et al. 5 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 32 december 2020 quarantine also had the opposite effect. it deprived the population itself of the opportunity to demonstrate active citizenship, civic virtue, moral responsibility, and participation and concern for the public good. it extended mistrust, disrespect and inequality toward the very institution of the society as a community of socially responsible individuals whose personal well-being and personal values are inextricably linked to the values and well-being of others. in 2020, covid-19 has demonstrated the pivotal role of public values in governance (8). many states, including russia, have refused the toughest scenario in fighting the spread of the pandemic and shared responsibility for its spread with the society. the lack of a vaccine, high contagiousness of the virus, and the large number of asymptomatic infected people meant that social distance was crucial in combating the spread of the virus and preventing the collapse of the healthcare system. this could be achieved through cooperation and voluntary subordination. to accomplish this, citizens must demonstrate a high level of altruism, which is the desire and ability to sacrifice their values for the benefit of others or the society as a whole. but unfortunately, this is not what has happened. many people ignored the self-isolation requirements after returning from a covid-19 hotspot. many others refused to wear masks or maintain social distancing because of the inconveniences caused in their daily routine. finally, people refused to maintain isolation because they believed that the state had no right to restrict civil liberties. as a result, we have seen a sharp increase in the number of covid-19 patients, since such violations have triggered a new round of pandemic development (9). effective social distancing could also be achieved not through trust, but through coercion, for example high fines or threats of imprisonment for violators. this method has shown its effectiveness in china and other countries (10). in this case, however, it was inevitable that the state would disregard citizens' personal freedoms. consequently, in the absence of a vaccine and other effective means to prevent the spread of the disease, any government action to combat the pandemic turns into a search for the optimal balance between strategies to lower the rate of morbidity and mortality, and severe restrictive measures imposed by the government. according to this logic, the more people ignore social distancing measures, the more intolerant the government should be of those who violate the established rules of conduct. covid-19 has therefore posed a complicated ethical dilemma for the society in finding the optimal balance between individual impulses and freedoms, and the collective responsibility. should the society come to terms with restrictive measures during the epidemic? in an epidemic, are personal rights and freedoms as valuable as the lives of others? covid-19 and collective responsibility: a lesson from the smallpox outbreak in moscow in 1960 6 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 32 december 2020 it is the general belief that limitation or infringement of civil rights and freedoms cannot exist in democratic states, but that is not true. danielle s. allen believes that one of the harsh truths of democracy is that some people always give up something for others (11). it is no accident that people often find themselves in a state of disagreement with the political decisions of the state. what they will have to give up is certainly valuable to them, but they agree to give it up for something higher, that is, the common good. therefore, one of the harsh truths of democracy is that it requires sacrifices for the sake of others (12). the only way to deal effectively with this issue is to build a relationship based on trust among the citizens so that they can be sure that their sacrifice is reciprocated. social distancing measures will only be effective if each citizen realizes that he/she is responsible not only for himself/herself but also for others. individualism is a threat to human lives among members of the society as atomistic bearers of interests, preferences and desires who are expected not to seek to enter into social relations with one another during the covid-19 pandemic. if the world states cannot cope with the pandemic, the society should not stay aside. in the face of uncertainty, collective responsibility and its limitations remain the only way to defeat the disease for now. in addition to the elaborate ethical principles of autonomy, rights, freedom and well-being or welfare of the individual, public health ethics depends on the principles of virtue, reciprocity, justice, solidarity and collective responsibility (13). however, it has become increasingly clear that the society is not prepared to make such sacrifices. covid-19 has become a serious crisis of collective thinking about the basic values of democracy and solidarity. this is evidenced by the second wave of the pandemic and the steady increase in the number of victims of the epidemic. the smallpox epidemic in moscow in 1960 showed that a quick and effective response to the epidemic is associated with a restriction of civil rights and freedoms. in the case of covid-19, the state shares responsibility for fighting the pandemic with the society, and members of the society must be prepared to sacrifice some of their individual rights and freedoms for the lives of others. the priority of collective values, responsibility and solidarity can be the most effective weapons in the fight for survival. conflict of interests there is no conflict of interests to be declared. grigoryan yg., et al. 7 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 32 december 2020 references 1. who: coronavirus disease (covid-19). [cited 2020 december]; available from: https://covid19.who.int/ 2. lee lm, heilig cm, white a. ethical justification for conducting public health surveillance without patient consent. am j public health. 2012; 102(1): 38-44. 3. beauchamp tl, childress jf. principles of biomedical ethics, 7th ed. uk: oxford university press; 2012. 4. zhukovsky am. [successes of soviet medical virology]. [problems of virology]. 1977; 5: 517528. [in russian] 5. ivanova p. coronavirus lockdown is nothing new for some moscow residents [cited 2020 december]; available from: https://cn.reuters.com/article/instant-article/iduskbn21p1n3 6. baroian ov, serenko af. [an outbreak of smallpox in moscow during 1959-1960]. [zh mikrobiol epidemiol immunobiol]. 1961; 32: 72-9. [in russian] 7. anonymous. all-russian public opinion research centre (wciom). russians: there is enough information about the coronavirus [cited 2020 december]; available from: https://wciom.ru/analytical-reviews/analiticheskii-obzor/rossiyane-informaczii-o-koronavirusedostatochno [in russian] 8. yang k. unprecedented challenges, familiar paradoxes: covid-19 and governance in a new normal state of risks. public adm rev. 2020: 10.1111/puar.13248. 9. casciani d. covid quarantine breakers: 'it was selfish but i don't regret it' [cited 2020 december]; available from: https://www.bbc.com/news/uk-54346001 10. semenov av, pshenichnaya nyu. [born in wuhan: lessons from covid-19 epidemic in china]. [infection and immunity]. 2020; 10(2): 210-20. [in russian] 11. allen d. talking to strangers: anxieties of citizenship after brown v. board of education. usa: university of chicago press; 2006, p. 29. 12. mcivor dw, hooker j, atkins a, athanasiou a, shulman g. mourning work: death and democracy during a pandemic. contemporary political theory. 2020; https://doi.org/10.1057/s41296-020-00421-5 13. dawson a, verweij m, eds. ethics, prevention and public health. bull world health organ. 2008; 86(1): 77. ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ 1 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e original article volume 13 number 21 december 2020 copyright © 2020 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. rhazes’ pioneer viewpoints about psychiatry, neurology and neuroscience seyed mahmoud tabatabaei1*, amirhossein jafari-mehdiabad2 1.professor, department of psychiatry, roozbeh hospital, tehran university of medical sciences, tehran, iran; professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. 2.resident of psychiatry, roozbeh hospital, tehran university of medical sciences, tehran, iran. abstract after the emergence of islam and its advancement in the past three centuries in various countries and the muslims' acquaintance with civilizations emanating from the empires of iran, greece, and india, a civilization emerged that affected different aspects of people's lives in islamic lands and other countries. one of the components of this civilization was medical sciences that were collected and compiled by muslims using the resources of other civilizations and their own experiences and resources. rhazes (muhammad ibn zakaryya al-razi), who lived in the ninth century ad (fourth century ah), compiled a comprehensive textbook of medicine (named in arabic: al-hawi fi al-tibb) in all specialized medical disciplines in accordance with the latest achievements of his era. this book has been published in the contemporary period as a 25volume collection and contains knowledge and experiences from the medical resources of various civilizations and rhazes’ own knowledge and experiences. the first volume of this collection and some other volumes are devoted to the knowledge of neuroscience, psychiatry, and related diseases, illnesses, and disorders. in this review, we cite topics from "al-hawi" and other rhazes’ manuscripts related to the definition and description of diseases and disorders associated with the nervous system as well as psychiatry and neurology and compare them with modern medical sciences in a comparative manner. this is intended to make their importance and validity clear in terms of usability as part of medical history as well as for some medical research that requires historical and contextual information. keywords: rhazes; psychiatric disorders; neurological diseases; history of medicine. *corresponding author seyed mahmoud tabatabaei roozbeh hospital, south kargar ave., tehran, iran postal code : 13337-15914 tel : (+98) 21 55 41 22 22 email: smtabataba_md@yahoo.com received: 20 oct 2020 accepted: 1 nov 2020 published: 12 dec 2020 citation to this article: tabatabaei sm, jafari-mahdiabad a. rhazes’ pioneer viewpoints about psychiatry, neurology and neuroscience. j med ethics hist med. 2020; 13: 21. mailto:smtabataba_md@yahoo.com rhazes’ pioneer viewpoints about psychiatry, neurology and neuroscience 2 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 21 december 2020 introduction the emergence of islam and its advancement in different countries led to muslims' becoming acquainted with other civilizations, especially those emanating from the empires of persia, greece, and india. as a result, a civilization emerged that not only affected all aspects of people's lives (both material and spiritual) in the islamic caliphate but also spread to other countries. one of the most important branches of the islamic civilization was medical sciences, compiled by muslim scholars based on their own achievements as well as knowledge gained from other civilizations. rhazes (muhammad ibn zakaryya al-razi) was born in ray city (near tehran, iran) in 865 ad (251 ah). while working in the goldsmith profession in his early life, he learned the chemistry of his era. in the fourth decade of his life, he started began learning medicine. after learning the basics, he emigrated to baghdad, then the capital and scientific center of the islamic caliphate, and got involved in medical activities at "motazadi hospital” for several years. thereafter, he returned to ray city, where he headed the hospital for a while (1,2). he earned the nickname of "clinical physician" because of his earnest motivation and interest in taking care of patients and performing clinical activities (3). he compiled a comprehensive textbook of medicine (named in arabic: al-hawi fi altibb), which included all specialized medical disciplines in accordance with the latest achievements of his era. in the contemporary era, this book has been published as a 25volume collection and includes knowledge and experiences from the medical resources of various civilizations as well as rhazes’ own knowledge, clinical experiences, and theoretical achievements (4). in parallel with these activities, he has also studied and written numerous books in other sciences. his other famous and valuable medical works are "al-mansouri fi al-tibb" on somatic and organic diseases (5), "al-tibb al-ruhani" ("spiritual medicine") on mental health and standards for human ethics and behavior (6), "qesas va hekayat al-marazi" ("medical histories of patients"), a collection of medical records of several patients from diagnosis to treatment and their therapeutic outcome (7) ,"al-jadri va al-hasba" ("smallpox and measles") on smallpox and measles from symptomatology to treatment (8), and "mehnat al-tabib" ("evaluation and examination of physicians") on the evaluation of practitioners’ theoretical and clinical knowledge (9). it is worth noting that most prominent physicians and pharmacists of the past, such as ali bin abbas ahwazi (10), avicenna (11), abu rayḥ an al-biruni (12), ibn al-bitar (13), ashbili (14), jurjani (15) and aghili khorasani (16) have used razi’s books as reliable sources for their scientific and clinical activities. in his books, especially in al-hawi, after discussing a disease or disorder, rhazes also mentions the reason for naming it along with its causative factors, symptoms, differential diagnosis, and treatment plan from the perspective of the most prominent physicians such as hippocrates, galen, and other physicians of his era. after summing up, he also expresses tabatabaei s.m., et al. 3 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 21 december 2020 his own opinion, if different, giving the physician the chance to decide. as a result, it could be said that al-hawi includes all the authentic medical writings from hippocrates to rhazes (4). rhazes has, however, pointed out that all topics related to human anatomy in his manuscripts are taken from galen’s anatomy book (4,17), stressing that he had no distinctive personal experience in this regard (18). rhazes isolated himself in late life due to blindness caused by cataracts and died in ray city in 925 ad (313 ah) (1, 2, 19). in this review, we quote topics from the first volume of al-hawi and numerous other volumes devoted to psychiatry, neurology, neuroscience, and associating diseases, and try to compare them with modern medicine. method in this library research, we have carefully studied and compiled important topics related to psychiatry, neurology, and neuroscience from arabic original manuscripts of rhazes, especially al-hawi fi al-tibb, al-mansouri, and al-tibb al-ruhani. some of the works of galen and other physicians or thinkers of the early centuries of islamic civilization as well as some contemporary articles citing original sources of medical history have been carefully studied and compiled. in the following, we will make a comparative comparison of these works with modern medical knowledge to reveal their value and validity and the fact that rhazes has been a pioneer in some cases. general findings rhazes has emphasized on the evidencebased perspective in his studies and clinical experiences, particularly in the diagnosis and treatment of disorders. on the one hand, he has disapproved the influence of supranatural factors such as genies and the movement of the moon and stars on the onset of mental disorders. he has stressed that many mental and behavioral disorders are a direct or indirect cause of brain and nervous system damages, whereas others are caused by educational, social, or cultural factors. he believed certain psychological factors, such as suppressed basic needs, especially sexual ones, can also contribute to these disorder (4). also, he has explained some of the basic psychiatry and neuroscience terminologies such as delusion, hallucination, depression, madness, lethargy, catatonia, uniand bilateral facial palsy, migraine among others. he has also provided a primitive classification of psychiatric disorders and used cognitive psychotherapy for mental disorders such as obsessive-compulsive disorder. some of rhazes' achievements in neurology discipline the first volume of al-hawi, in 480 pages was published in 1990 (1369 ah) in octavo size and then translated into persian, was devoted to brain, neurological and mental diseases (20). some of the most interesting topics in this volume are: 1. a description of the anatomy of brain, spinal cord, cranial and spinal nerves, the rhazes’ pioneer viewpoints about psychiatry, neurology and neuroscience 4 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 21 december 2020 function of each nerve, the effects of trauma, inflammation or cutting the nerves. 2. stroke: causes, symptoms, complications, treatment and prognosis. 3. causes, symptoms and treatment of facial palsy (bell's palsy). the bilateral form of the disease, which has not been identified or described since hippocrates to rhazes, is one of rhazes' discoveries (3, 20, 21). 4. types of abnormal limb movements and corresponding diagnostic and therapeutic practices. 5. epilepsy, seizure, status epilepticus (3, 20). 6. types of headaches and their treatment (20). 7. diagnostic and therapeutic methods of some sleep disorders such as night terror and nightmare (20). 8. some of rhazes' achievements in psychiatry discipline 1classification of psychiatric disorders: rhazes classified mental disorders into two categories: a. based on impaired thinking and perception: a) impaired perception with healthy thinking. b) impaired thinking with healthy perception. c) concurrent impairment of perception and thinking (20). b. based on the persistence of mental disorder symptoms: a) permanent: it is caused by damage to the brain itself, its appearance is not sudden; it has a variety of primary and secondary symptoms. b) non-permanent: this type is a complication of another disease such as encephalitis or meningitis, pneumonia or pleurisies, severe fever, dehydration, and severe heat exhaustion, all of which can be accompanied with symptoms of mental disorder. the aforementioned classifications and corresponding treatment and prognosis were presented almost a thousand years before emil kraepelin, known by some psychiatry references as the pioneer in the classification of psychiatric disorders (22). 2. general information about mental disorders: rhazes believed that thinking, imagination and memory are powerful psyche tools. in line with the modern psychiatry references, he did not provide a definitive and accurate definition of human psyche but spoke in detail about mental health and mental disorders from different perspectives and dimensions. for example: a. he provided a comprehensive definition for delusion, hallucination, mania, melancholia, obsessivecompulsive disorder and several other mental disorders (3, 4, 20). b. his diagnostic criteria for certain anxiety disorders such as obsession, mood disorders such as depression and mania, and a variety of psychotic disorders are in line with that of contemporary psychiatry. for each disorder, he has developed a treatment tabatabaei s.m., et al. 5 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 21 december 2020 plan that fits the pathology and knowledge of his era. c. regarding the prognosis of mental disorders, he believed a mental disorder to be more benign when associated with a state of happiness and laughter than a state of sadness, depression, stupor, and/or aggression and violence. d. rhazes believed that hospitalization for patients with persistent delusions and mania is the most important step of the treatment (3). 3. melancholia and its types: in rhazes' viewpoint, melancholia is described as a mental disorder with symptoms such as derealization and delusion; other symptoms including hallucination, disturbed or irrelevant speech, increased or decreased activities, insomnia, aggression and assault are not required for the diagnose. he also presents another disease called mesenteric melancholia (hypochondriac), which is related to gastrointestinal diseases. the affected person has odd tenderness and extreme sensitivity to his/her internal organs. he may have stomach, liver or other abdominal diseases, or think the has lost these organs even when they are healthy. the other type of melancholia defined in alhawi involves patient's with extreme mental activity with thoughts or imaginations that he cannot resist and or be released from, causing constant pain and distress. he mentions this type of melancholia does not always require pharmacological treatment and can be treated through talking to the patient and eliminating the wrong thoughts. "a man came to me for an examination and asked me to treat him and relieve him from the black bile (melancholia) that he thought was infected with. i asked him, what do you see as a sign of this affliction and how do you feel? he said, i am caught up with an idea on where has the creator of the whole universe come from and how has he created all creatures that constantly harasses me and never sets me free. i convinced him that this thought occupies the minds of all wise people and should not be regarded as a melancholic thought. thereafter, the man become relaxed and recovered. this is while he previously thought he was in a state of madness, and his personal life and daily work was totally disturbed (20)”. 4. relationship between psychiatric disorders, gender and sexuality: al-hawi presents a disorder called "uterus stuffiness" that appears as epileptic seizures, aphonia, deafness, apathy, movement disorders among others in young to middle-aged girls who have been deprived of sexual relationships. this condition does not originate from a medical or neurological lesion. this phenomenon was known as "hysteria" in contemporary psychiatry until the end of the 20th century. while some psychoanalysts still consider it valid, it is replaced with "conversion & dissociation disorders" in modern classifications. 5. homosexuality: rhazes stated in a special treatise on homosexuality, "we have seen womanish men and mannish women. it has also been found that some people have a male rhazes’ pioneer viewpoints about psychiatry, neurology and neuroscience 6 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 21 december 2020 and female sexual organ both at the same time; being male or female are not the extreme borders in a gender. one of the overlooked issues in medicine is a disorder in which a man experiences sexual pleasure only through being sexually passive in a sexual relationship, and enjoys a female having sex with a man (23). 6. ethics & spirituality: while living in baghdad, rhazes wrote a short treatise on ethics and behavior to supplement the book al-mansouri that he had previously written at the request of colleagues and on the recommendation of then-ruler amir mansour. the manuscript was dedicated to somatic medicine. in parts of this book, he talks about motivations and their modifications and sublimation, reinforcing the psychic potency, emotions and excitements, various ways of relieving grief and anxiety and the effects of dipsomania. the book considers the human psyche as an independent system that influences and masters his physical aspect. part of the book reads, "many people are afraid of death, and to get rid of this phenomenon it is necessary to prove them that once the body is destroyed by death, the human psyche will not be destroyed." it also states, "indeed, one of the causes of depression is lack of things that a person loves (5, 6)." the latter phrase is identical to "loss of loved object" phenomenon. discussion a historical manuscript is considered scientifically valuable when its content is accepted by academicians and modern scientific communities. unfortunately, existing versions of rhazes' manuscripts contain many mistakes, vague words and phrases that are known as historical texts by the majority of contemporary scholars and academicians who are unfamiliar with rhazes' -era science and literature. regretfully, the non-qualified academicians who are not familiar with the general and specific conditions of research in the manuscripts of traditional medicine, either based on their taste or desire of a group of peers, rely on unfounded articles. they refute or substantiate the validity of ancient medical manuscripts and cultural heritage by publishing their work in the form of articles or books. the medical manuscripts of rhazes are a comprehensive collection of theories and experiences of the most prominent greek, indian and iranian physicians as well as his innovations. a detailed and unbiased study of rhazes manuscripts has important implications for the researchers as it shows that the medical knowledge has evolved since rhazes. also, he had questioned and criticized some theories of his most prominent earlier physicians such as galen who was considered a saint. rhazes evidence-based perspective has been crucial to the advancement of medical science as he emphasized that no general verdict should be issued based on limited diagnostic or therapeutic evidence. tabatabaei s.m., et al. 7 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 21 december 2020 conclusion from the findings presented in this article, one can infer rhazes’ accuracy and precision in the identification, diagnosis, differential diagnosis, pharmacological and nonpharmacological treatment of neurological and psychiatric disorders. most importantly, he considered physical and organic factors rather than supernatural ones in the emergence of diseases and disorders. this view is one of the important milestones in the history of medicine. as a result, it is recommended that rhazes' manuscripts be read carefully by researchers, in the hope of finding useful and valuable points. rhazes’ pioneer viewpoints about psychiatry, neurology and neuroscience 8 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 21 december 2020 references 1. najmabadi m. history of medicine in iran after islam. iran: tehran university press; 1975, p. 324-442. [in persian] 2. elgood c. a medical history of persia and the eastern caliphate from the earliest times until the year a.d. 1932, 1st ed. uk: cambridge university press; 1951. 3. tabatabaei sm. [kholseye ketabe al-hawi]. iran: mashhad university press; 2008, vol. 1, p. 97-108. [in persian] 4. rhazes m. [al-hawi alkabir fi al-tebb], 1st ed. india: [daerat al-maref al-osmanya]; 1956, vol. 1-25. [in arabic] 5. rhazes m. [al-mansoori fi al-tebb]. 1st ed. iran: tehran university press; 2009. [in arabic] 6. rhazes m. [al-tebb al-rohani]. 1st ed. iran: national committee of unesco press; 1962. [in arabic] 7. rhazes m. [qesas va hekayat al-marza]. iran: tehran university press; 1962. [in arabic] 8. rhazes m. [al-jodri va al-hosbah]. iran: tehran university press; 1962. [in arabic] 9. rhazes m. [mehnat al-tabib]. iran: tehran university pres; 1962. [in arabic] 10. alahwazi a. [kamel al-sena-ah al-tebbiah]. iran: institute of history and complementary medicine; 2002. [in arabic] 11. avicenna h. [al-qanon fi al-tebb]: manuscript & digital text. tehran, iran; 1880, chap. 10, p. 1037-1045-1056. [in arabic] 12. albirooni m. [saydanah]. iran: shaid beheshti university of medical sciences publications; 2008, vol.1, p. 54-82-115-216-366. [in persian] 13. ebn al-beitar. [al-jame lemofradat al-adwiah va al-aghdhiah]. egypt: boulagh publications; 1879. [in arabic] 14. eshbili a. [omdat al-tabib fi marefat al-nabat]. [dar al-gharb al eslami]. beirut, lebanon; 1995, vol.1-2. [ in arabic] 15. jorjani e. [zakhireh kharazmshahi]. iran: institute of iranian culture publications; 1977. [in persian] 16. aghili khorasani mh. [qarabadine kabir]. tehran, iran: mahmoudi library publication; 1971, p. 44-441. [in persian] 17. galen, p. handbook of anatomy. manuscript text. translated: honein ben isac. general number:809. library of goharshad mosque. mashhad, iran. [in arabic] 18. tabatabaei, sm, kalantar hormozi aj. anatomy in textbooks of traditional medicine. [pajouhesh dar pezeshki]. 2010; 34: 79-85. [in persian] 19. motazed k. [zakaryaie razi]. iran: development of iranian libraries company publication; 1992, p.15-34. [in persian] 20. tabatabaei sm. [al-hawi fi al-tebb], 1st ed. iran: al-hawi pharmacy company publication; 1992, vol. 1, p.129-53, 286-9, 293-8. [in persian] 21. sajadi mm, sajadi mrm tabatabaie sm. the history of facial palsy and spasm: hippocrates to razi. neurology. 2011; 77(2): 1748. 22. sadock bj, sadock v. synopsis of psychiatry: behavioral sciences/clinical psychiatry, 11th ed. usa: lippincott williams & wilkins; 2015. 23. rhazes m. [al-obnah]: manuscript text. iran: library of parliament: general number:31059. [in arabic] journal of medical ethics and history of medicine attachment styles as predictors of empathy in nursing students mohammadreza khodabakhsh department of psychology, allameh tabataba´i university, tehran, iran. *corresponding author: mohammadreza khodabakhsh address: faculty of psychology and education, dehkadeh olympic, tehran, iran. tel: (+98) 36 58 61 050 email: khodabakhsh@ut.ac.ir received: 12 may 2012 accepted: 14 nov 2012 published: 20 nov 2012 j med ethics hist med. 2012; 5:8. http://journals.tums.ac.ir/abs/22609 © 2012 mohammadreza khodabakhsh; licensee tehran univ. med. sci. abstract previous studies have traced a relationship between the attachment styles of nurses working as in healthcare teams and their empathy which is an essential characteristic required of people concerned with managing relationships, supporting social events, and improving the of nurse-patient relationships. since determining the effective variables in the quality of nurse-patient relationships in clinical settings is of paramount importance, current investigation is an effort to examine the relationship between attachment styles and empathy in nursing students. 260 university students (male = 130 and female = 130) were chosen as the sample of the study based upon specific inclusion criteria. all participants completed the attachment style questionnaire (asq) and the interpersonal reactivity index (iri). data was collected and analyzed using pearson correlation coefficient and regression analysis with spss (v.18). the results showed that secure and insecure attachment styles have significant positive and negative correlation with empathy respectively. based on the results of regression analysis, it was shown that secure attachment style is predicting 53% of the variance empathy variable, whereas insecure attachment styles are explaining up to 76% of the variance empathy variable collectively. the increase of attention to instructions that focus on empathetic relationships with patients and that are based upon the secure attachment style can result in positive changes in the area of nurse-patient relations and in increasing attention to medical ethics. findings are consistent with prediction derived from attachment theory and add to our understanding of relationship between attachment styles with empathy in nursing students. the meaning and limitations of this study and suggestions for further research are also discussed. keywords: attachment styles, empathy, personality, nurses. introduction attachment theory was essentially conceptual ized by bowlby (1-3), who believed that attach ment in infants is primarily a process of proximity seeking to a caring and protective caregiver (4). attachment is defined as ‘the tendency of human beings to make strong affectional bonds with special others’. attachment theory describes two aspects of attachment reflecting comfort with closeness (comfort) and anxiety over relationships (anxiety) (5, 6). individuals display forecasting models of cognitive-affective schema with high or low comfort and high or low anxiety; thus, these two aspects describe four attachment styles. these attachment styles have been recognized as secure, fearful, preoccupied, and dismissing, the latter three assessed as insecure styles (7). attachment styles of nursing students as caregivers, members of healthcare teams and future nurses are therefore considered to be a most important subject for studying. moreover, examination of attachment styles in nursing education and in nursing students as future j med ethics hist med 2012, 5:8 mohammadreza khodabakhsh page 2 of 7 (page number not for citation purposes) nurses can also offer valuable guidelines in order to provide mental health for nursing students. attachment style is recognized as an influential component in individual performance and might be related to improved nurse-patient relationship and patient outcomes. the nurse-patient relationship may be affected by nurses’ attachment styles and their reactions to patients’ attachment styles; the attachment styles of the nurses can also play a critical role in the kind of relationship that they develop with others. being aware of their own attachment styles and relational needs may help professional caregivers to be aware of their own contributions to their relationships with patients and to become more sensitively attuned to them (8). nursing students encounter stress associated with academic demand, clinical placements, and financial constraints. some researchers believe that secure attachment style may be a critical factor for better preparing nursing students for this demand ing and stressful profession. one of the issues investigated in the present study is the examination of the relationship between attachment styles and empathy. the central notion is that empathy is nurtured in the early rearing environment in relation to the quality of the early attachment relationships with a primary caregiver (9, 10). empathy has been defined in many ways, but it refers broadly to the reactions of an individual to the experiences of another (11). empathy is commonly described as consisting of perspective taking, empathic concern, and personal distress (11, 12). empathy is a basic capacity in individuals that contributes to the management of relationships, the supporting of communal activities, and group cohesion. this ability has an essential role in individuals' social life (13,14); in fact, empathy is the stimulating impetus of pro-social behaviours and those behaviours that lead to group cohesion (13-15). to appropriately express our empathy we need to possess social skills (13,16). empathy is an individual's strong emotional response to others' emotional reactions (13,17,18). on the other hand, empathy is the essential component for successful interpersonal performance (13,19) and plays a key role in the nurse-patient relationship because it promotes an understanding of the patient’s emo tional status and perception, and helps the nurse to effectively share or participate in the patient’s experience. the ability to identify and understand others’ emotions and to communicate one’s understanding of others’ emotions effectively to them is particularly applicable to clinical encoun ters between nurse and patient. the focus of the present study is examination of the relationship between attachment styles and empathy. the purposes of the present study are: 1) examination of the likely relationship between secure attach ment style and empathy and 2) examination of the likely relationship between insecure attachment styles and empathy. method participants and procedure the target population in the present correlation descriptive study included all nursing students inhabiting the dormitories of the tehran university of medical sciences, and the population under investigation was a convenient sample of 260 university students (130 females, 130 males). all participants were asked to complete the attachment style questionnaire (asq) and the interpersonal reactivity index (iri). after explaining the purposes of the study, the questionnaires were submitted to the participants. overall 98% of the participants completed the questionnaires. two psychological scales were translated into persian language and every effort was made to ensure that the translated version conveyed both the literal and the comprehensible meanings in persian. in order to examine the content validity the questionnaires were given to three phd students of the tehran university of medical sciences and afterwards the relevant comments were applied. there was no substantial change in the content of the items. to examine the test-retest reliability, 51 participants (31 females and 20 males) were asked to complete the questionnaires a second time, with a 12-day interval between measurements. findings support ed the content validity and test-retest reliability of the persian versions of both questionnaires. data was collected and analyzed using pearson correla tion coefficient and stepwise regression analysis with spss (v.18). measures attachment style questionnaire (asq): attachment style was determined by using a 40 item self-report measure of adult attachment dimensions and items scored on a six-point scale from 1 (totally disagree) to 6 (totally agree) and included five subscales derived from principal components analysis: confidence in themselves and others, discomfort with closeness, need for approval, preoccupation with relationships, and relationships as secondary (to achievement). items in each subscale were summed to obtain the subscale score (score range = 1–126). high scores indicated greater attachment relationship problems. the five scales of the asq have been shown to have adequate internal consistency, with cronbach’s alpha ranging from 0.76 to 0.84 and 10-week retest reliability coefficients ranging from 0.67 to 0.78 (5). the confidence subscale is a general measure of the security of attachment. the need for approval and the preoccupation with j med ethics hist med 2012, 5:8 mohammadreza khodabakhsh page 3 of 7 (page number not for citation purposes) relationships subscales assess the anxiety (about abandonment) dimension of the attachment style, whereas the discomfort with closeness and the relationships as secondary subscales pertain primarily to avoidance (of intimacy) dimension of the attachment style. the scoring method used in this study was similar to the original design. individuals scoring high on attachment-related anxiety endorsed statements such as “i find that others are reluctant to get as close as i would like” and “it’s important to me that others like me”. individuals scoring high on attachment-related avoidance endorsed statements such as “my relationships with others are generally superficial” and “achieving things is more important than building relationships”. the five subscales of the asq included: confidence (eight items) (e.g., “i feel confident that other people will be there for me when i need them”), discomfort with closeness (ten items) (e.g., “i worry about people getting too close”), need for approval (seven items) (e.g., “it’s important to me that others like me”), preoccupa tion with relationships (eight items) (e.g., “i worry a lot about my relationships”), and relationships as secondary (seven items) (e.g., “achieving things is more important than building relationships”. previous researchers have conducted their own factor analysis on the asq to determine the factor structure for their sample. the asq subscale scores have been used in other research studies and therefore were used for the purposes of the present study. the asq was selected because it possesses robust psychometric properties in terms of both validity and reliability (20). the psychometric properties of asq were verified with previous iranian samples (21). interpersonal reactivity index (iri) the interpersonal reactivity index (iri) is a multidimensional questionnaire of empathy (11). the iri is a 28-item measure of general empathic tendencies that assesses both cognitive and emotional components of empathy. items are evaluated on a 5-point likert scale ranging from 0 (does not describe me well) to 4 (describes me very well). this scale yields four subscales, each including seven items. items in each subscale are summed to obtain the subscale score (score range for each scale = 0–28), and a high score means higher perspective taking, fantasy, personal distress, and empathic concern respectively. perspective taking (pt) assesses attempts to take into consideration the point of view of others (e.g., “when i am upset at someone, i usually try to put myself in his shoes for a while”). fantasy (f) evaluates the propensity to identify with fictional characters (e.g., “when i watch a good movie, i can very easily put myself in the place of a leading character”). personal distress (pd) assesses ‘self oriented’ feelings and the tendency to feel anxious when confronted with negative situations (e.g., “being in a tense emotional situation scares me”). empathic concern (ec) measures “other-oriented” feelings of sympathy and concern for unfortunate others (e.g., “i often have delicate, concerned feelings for people less fortunate than me”). the iri was selected because it possesses robust psychometric properties in terms of both validity and reliability. the psychometric properties of iri were established with previous iranian samples (22). results table 1 indicates the statistics of the participants based on demographic variables. the mean age of the samples was 21.06 years, standard deviation 3.07 years. participants were 260 students enrolled at the tehran university of medical sciences. of this total, 130 (50%) were female and 130 (50%) were male. the majority who completed the questionnaires were married (82.70%) and the educational level was bachelor (71.15%). table 2 indicates the statistics of the participants on the basis of their scores on attachment styles, and empathy. the mean of the confidence sub scales, discomfort with closeness, relationships as secondary, need for approval and preoccupation with relationships was 30.20, 33.80, 15.14, 25.25 and 28.35 respectively. the mean of the perspec tive taking subscale, fantasy, personal distress and empathic concern was 26.30, 19.60, 14.80 and 24.80 respectively. table 3 indicates the pearson product-moment correlations between measures of attachment styles and empathy. the results of the correlation showed that secure and insecure attachment styles had significant positive and negative correlation with empathy respectively (see table 3). the highest positive correlation coefficient gained for confi dence pertained to empathic concern (r = 0.71, p < 0.01) and the highest negative correlation coeffi cient gained for avoidant attachment style pertained to perspective taking (r = -0.73, p < 0.01) and for anxiety attachment style it pertained to empathic concern (r = -0.73, p < 0.01). to investigate the unique contribution of secure and insecure attachment styles to empathy, regression analysis (stepwise) was performed. secure attachment style made a unique and significant contribution, and accounted for 53% of the variance empathy variable (f = 33.87, p < 0.01) (see table 4). avoidant attachment style and anxiety attachment style (insecure attachment) made unique and significant contribution, together explaining up to 76% of the variance empathy variable (f = 93.78, p < 0.01) (see table 4). j med ethics hist med 2012, 5:8 mohammadreza khodabakhsh page 4 of 7 (page number not for citation purposes) discussion the results of the present study indicated that secure attachment style has a positive relationship with empathy. this is consistent with the findings of previous studies (23-25) and can be interpreted on the basis of the following possibilities: accord ing to bartholomew and horowitz (7) individuals who develop a positive model of other people as potentially available, supportive and worthy of acceptance and support can be categorized as possessing a secure attachment style. individuals with a secure attachment style are supposed to have had early care giving experiences that were consistent, attentive and responsive, and they are liable to be most prosperous in forming supportive relationships with others. individuals with secure attachment style develop a sense of trust with caregivers who respond to them empathically and therefore develop the capacity to respond emotionally and empathically to others in later relationships. research has shown that lack of a secure attachment with mother can result in aggressive and hostile behaviors in later years that are not conducive to empathic engage ment (24). the results of previous studies indicated that the attachment history can predict medical students’ specialty preferences. for example, students with a secure attachment history are more likely to choose specialties that require more interaction with patients (26). a critical aspect in the developing of empathy during a nurse-patient encounter is effectively relating to the patient’s experience. nursing students need to imagine what it would feel like to be in the patient’s position and to be able to relate the patient’s condition to previous events in their own life. the initial component of empathy in clinical settings is the ability of active listening to the patient. it helps eliminating mental distraction during nurse-patient relationship, and the nurse should be attentive while the patient is speaking. eventually, nurse empathy fulfills the patient’s need to be understood and will impact therapeutic effectiveness. there are similarities between the mother-child attachment and the nurse-patient relationship. the child needs mother’s help and protection to survive dangerous situations, and therefore the attachment behavior (proximity seeking) intensifies when the child is in a stressful or painful situation. similarly, patients have a natural tendency toward affiliation with a caring figure (the clinician or nurse) to maintain their health during a time of pain and suffering. there fore, nurse-patient bonding is connected, though unconsciously, with the early attachment relation ship. recent literature in nursing education and psy chology has shown an increasing interest in the application of attachment to improve the nurse patient relationships in the clinical setting. the results of the present study indicated that insecure attachment styles have a negative relationship with empathy. this finding is consistent with the findings of previous researches (23-25, 27, 28) and can be interpreted on the basis of the following possibilities: the family environment early in life not only shapes the quality of later interpersonal relationships (29) but also nurtures the growth of the capacity for empathic engagement. insecure attachment styles involve at least one negative working model (of self or others). individuals with insecure attachment styles tend to experience more umbrage and to demonstrate more self-supportive avoidance of protective relationships. individuals with this attachment style have a so-called ‘fearful’ attachment style and exhibit an intense distrust of others and view themselves as unlovable and unworthy of care (7, 8). this negative working model of the world as arrogant and unlovable becomes an influential property of the child’s cognitive schema, serving essentially as an unconscious motivational power that significantly influences the individual’s interpersonal relationships and the capacity for empathic engagement (30). the results of previous studies indicated that attachment experiences can also influence the style of clinical practice in students. for example, clinical psychologists with an insecure attachment style who reported less empathic parental responses were more in need of support, and were more vulnerable to experience work-related stress such as job burnout, and were eventually susceptible to a variety of mental disorders (27). attachment styles may be a beneficial construct for examining the factors affecting adjustment and treatment response of patients. previous researches showed that insecure attachment styles were characterized by increased utilization of medical services. more recently, both nursing schools and the nursing literature authors are beginning to explore the role of attachment style and empathy in nursing education as a means to improve the nurse patient relationship in clinical settings. preoccupied attachment style can be viewed as a negative self model and positive other model. preoccupied attachment style reflects feelings of being unlova ble and unworthy of love about self, but positive views of others (31). several studies carried out in the field of nursing have suggested that attachment style has a critical impact on other important variables such as empathy. improving the quality of the nurse-patient relationship and reducing stress in clinical settings is one reason that secure attachment style and empathy have been identified as a characteristic of effective nursing performance. dismissive attach ment is a combination of high self-esteem and j med ethics hist med 2012, 5:8 mohammadreza khodabakhsh page 5 of 7 (page number not for citation purposes) negative views of others. dismissive individuals give great importance to autonomy and deny defensively the need for others and interpersonal relationships (8). insecure attachment styles may lead to ineffectual help-seeking behavior, which can in turn reduce potential social support to buffer stress. enhancing empathy skills in nursing students may help to cope with the cumbersome demands of the healthcare environment, which can be stressful and boring and can eventually lead to burnout in nurses. attachment theory suggests that individuals with insecure attachment style may have problems in interpersonal relationships and other domains of life. the results of the studies indicated that individuals with insecure attachment styles are more likely to lack social skills (32). specifically, individuals with insecure attachment styles have been reported to have behavior problems, emotion al difficulties, social incompetence (33), aggression (34), disability, depression, catastrophizing (35) and interpersonal dispositions, and have been described as introverted, cold, and emotionally inexpressive (36). empathy and secure attachment style in nurses and their ability to manage their emotions and understand those of their patients may potentially facilitate the nurse-patient relationship among nursing students. this study has significant implication for nurs ing students because nursing education may be more successful if nurse educators understand the attachment style of their students. this type of positive classroom environment will be beneficial for nursing students. nursing students who have secure attachment style are going to experience less difficulty in the clinical environment and are eventually going to launch positive relationships with patients and healthcare. further research may be required to examine the relationship of attach ment style and empathy with regard to nurse personalities. the present study needs to be replicated in dif ferent populations and needs more empirical support. in the meantime, the findings of the study should be interpreted with caution. furthermore, the cross-sectional design of the study and partici pants (i.e., a group of university students) exerts some limitations on the generalization of the findings. finally, the problems and limitations on the use of self-reporting instruments should not be overlooked. acknowledgement the author would like to acknowledge the gen erosity of nursing students who agreed to partici pate in this research. j med ethics hist med 2012, 5:8 mohammadreza khodabakhsh page 6 of 7 (page number not for citation purposes) table 1. demographic data of the nursing students demographic variables number (percent) sex: male/female 130/130 (50/50) marital status: married/single 45/215 (17.30/82.70) educational level: bachelor 185 (71.15) educational level: master 75 (28.85) table 2. subscales of the attachment style and empathy variable mean (sd) cconfidence scale 30.20(5.75) discomfort with closeness 33.80(6.37) relationships as secondary 15.14(5.56) need for approval 20.25(5.70) preoccupation with relationships 28.35(6.27) perspective taking 26.30(4.47) fantasy 19.60(5.70) personal distress 14.80(4.45) empathic concern 24.80(4.80) table 3. pearson product-moment correlations between subscales of attachment styles and empathy variable 1 2 3 4 5 6 7 1. asq confidence scale (secure attachment) 2. avoidant attachment style (insecure attachment) -0.43 3. anxiety attachment style (insecure attachment) -0.48 0.42 4. perspective taking 0.62 -0.73 -0.58 5. fantasy 0.58 -0.65 -0.64 0.32 6. personal distress 0.68 -0.72 -0.68 0.37 0.42 7. empathic concern 0.71 -0.67 -0.73 0.34 0.39 0.33 note: all these coefficients were significant at p < 0.01. table 4. regression analysis for empathy predicting variable adj.r2 df f se b β t enter asq confidence scale (secure attachment) 0.53 259 33.87 0.270 0.56 0.47 3.87 step 1 avoidant attachment style (insecure attachment) 0.68 258 110.5 4 0.282 0.75 0.36 4.70 step 2 avoidant attachment style (insecure attachment) anxiety attachment style (insecure attachment) 0.76 257 93.78 0.198 0.34 0.15 2.33 note: all these coefficients were significant at p < 0.01. j med ethics hist med 2012, 5:8 mohammadreza khodabakhsh page 7 of 7 (page number not for citation purposes) references 1. bowlby j. attachment and loss. new york: basic books; 1969, vol 1. 2. bowlby j. attachment and loss. new york: basic books; 1973, vol 2. 3. bowlby j. attachment and loss. london: 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clinical population of patients with episodic and chronic migraine. headache 2005; 45(5): 561–70. 36. cyranowski jm, bookwala j, feske u, et al. adult attachment profiles, interpersonal difficulties, and response to interpersonal psychotherapy in women with recurrent major depression. j soc clin psychol 2002; 21: 191–217. futile care fariba borhani 29-11-93 journal of medical ethics and history of medicine original article moral distress and perception of futile care in intensive care nurses fariba borhani1, somayeh mohammadi2, mostafa roshanzadeh3 1associate professor, medical ethics and law research center, shahid beheshti university of medical sciences, tehran, iran; 2msc in nursing, shahrekord university of medical sciences, shahrehkord, ira; 3mentor, surgical care research centre, birjand university of medical sciences, birjand, iran. corresponding author: mostafa roshanzadeh address: ghafare avenue, birjand university of medical sciences, birjand, iran email: mroshanzadeh62@gmail.com tel: 98 9397952522 fax: 98 56323925875 received: 07 jul 2014 accepted: 17 feb 2015 published: 23 feb 2015 j med ethics hist med, 2015, 8:2 © 2015 fariba borhani et al.; licensee tehran univ. med. sci. abstract special characteristics of care environments have always presented nurses with some challenges. one particular situation is futile care, which is frequently accompanied by countless moral and legal challenges. the dominant atmosphere in futile care may cause moral distress to nurses and lead to a sense of guilt, pain, suffering, job dissatisfaction, and eventually cause nurses to leave the job. this descriptive-analytical study attempted to investigate the relationship between futile care and moral distress in intensive care nurses. study subjects were 300 nurses in intensive care units in kerman, iran and were selected by convenience sampling based on inclusion criteria. study tools included corley’s 21-item questionnaire on moral distress and a researcher-made 17-item questionnaire on futile care. data analysis was performed using spss version 16 and suitable analytical and descriptive tests. the results showed a significantly positive relationship between moral distress and futile care (p = 0.03, r = 0.4). based on the obtained results, futile care can create conditions that may lead to moral distress in nurses and therefore strategies should be devised to prevent these conditions. moreover, distress in nurses should be identified by periodical counseling so that it can be managed more efficiently. keywords: moral distress, futile care, intensive care unit, nursing ethics mailto:mroshanzadeh62@gmail.com j med ethics hist med 8:2 feb, 2015 jmehm.tums.ac.ir fariba borhani et al. page 2 of 7 (page number not for citation purposes) introduction due to its humanistic nature, medicine and in particular the treatment and care process have always entailed moral problems and challenges (1). when a person is aware of the right moral action but feels unable to perform it, he/she experiences moral distress (2). when confronting moral distress, people worry about their moral integrity, which leads to increased stress as well as physical disorders like headaches and insomnia, or emotional symptoms like reduced self-confidence, anger and feelings of worthlessness (3). distress in nurses may have internal manifestations like job insecurity or lack of confidence, or external outcomes like decreased relationships with other health team members, reduced or non-existent organizational support, fear from legal actions, increased distress and its consequent unfavorable effects (4). moral distress and its negative impact on the treatment process can have certain undesirable outcomes. care providers may experience reduced moral sensitivity and become indifferent to ethical issues. moreover, in order to conquer moral distress, nurses may use different strategies, which can in turn lead to burnout (4). this may cause numerous problems for patients and health organizations. when nurses feel stressed, bored and dissatisfied with their jobs, they may consider quitting, which is clearly harmful for both patients and health care organizations (5). it should be noted that different factors contribute to moral distress such as organizational limitations (human forces or equipment), insufficient care and health service resources, and inappropriate requests and demands of patients and their families (6). one of the important causes of moral distress is futile care, which refers to a potentially purposeful treatment that has no effect on the quality of a patient’s life. in fact, technological advances in medicine often make it possible to prolong the life of patients who have little hope of recovery (7, 8). futile care is associated with numerous moral, legal, and medical challenges. from the moral point of view, futile care stands between usefulness and uselessness (9). on the other hand, health care systems should concentrate on treatment and should not be avoided merely due to poor prognosis (10). in terms of legal issues, everyone has a right to make decisions about their health and would benefit from treatment (11). limitations both in equipment, human, and financial resources cause health systems to be wary of futile care due to the high costs that naturally affect health systems, insurance companies and families (12). along with these challenges, nurses’ frequent contact with futile care leads to added moral distress. when faced with such situations, nurses feel unable to provide care for their patients and this endangers their ethical principles. nurses in one study stated that supporting end-of-life patients and providing futile care cause them to experience negative feelings such as powerlessness, hopelessness, anger, distress and guilt (13). ferrell believes that nurses confront a challenge both in the case of frequent, expanded and futile care, and lack thereof (7). nurses who have to provide futile care are faced with a dilemma: they know that the care is not effective but they must offer it. poor quality and futile care are among moral distress factors (14). if nurses feel that treatments are not only useless but may also increase the patients’ pain and affect their good death, they will be morally distressed (7). cases where the nurse has a prospect of failure, holds views opposing to those of the treatment team, and occupies a minor role within the system, are challenges to the nurse and determinants of futile care (14). studies have shown that futile care has different effects on nurses. meltzer and huckabay found that futile care is related to moral distress, tiredness, and exhaustion (8). additionally, observing and providing futile care puts nurses in distress and opposition (15). a survey of intensive care unit nurses showed that when treatment measures are replaced by palliative care, moral distress will be experienced (8, 16, 17). rice et al. also considered futile care a factor for increasing moral distress (18), and mobley et al. mentioned futile care in intensive care units as a significant source of moral distress (9). studies conducted in iran indicate that moral distress is a common phenomenon (19-21), although little research has been conducted on its relationship with futile care. global research shows that futile care is an important cause of moral distress in nurses (1517). these issues can potentially have negative effects on nurses, patients and health systems, and impede the achievement of health objectives. therefore, the present study was conducted to determine the relationship between moral distress and perception of futile care in intensive care nurses. method this was a cross-sectional, correlational study performed in 2013 aiming to investigate the relationship between moral distress and perception of futile care in nurses. study population and sampling study subjects included 300 nurses from kerman teaching hospitals who were selected by convenience sampling from icu, ccu, nicu, dialysis, and oncology wards of bahonar, shafa, and afzalipour hospitals. inclusion criteria were having a minimum bachelor’s degree and one year nursing experience in clinical wards of hospitals. the study proposal was approved by the ethics committee of shahid beheshti university of j med ethics hist med 8:2 feb, 2015 jmehm.tums.ac.ir fariba borhani et al. page 3 of 7 (page number not for citation purposes) medical sciences (proposal code: 1392-1-91-1189214435. ethical code: 92:145) and legal permissions were obtained prior to collection of data. study subjects were first provided with information on the questionnaire and the responses, and reminded that participation in the study was completely voluntary. furthermore, participants were asked not to write their names on the questionnaires and informed that their personal information would be confidential. research tool the applied tool was a questionnaire consisting of three parts: the first part included demographic information such as age, gender, years of service, and ward type. the second part was corley’s moral distress scale designed by corley et al. in 1995. the preliminary form of this questionnaire comprises 38 items (22), but in this study, the 21-item brief form developed by corley and hamrick in 2007 was used (23). the moral distress questionnaire was based on a 6-point likert scale including 6 options in the intensity and 6 in the frequency dimension. the options in the intensity dimension varied between not at all (0) and very much (5), and in the frequency dimension between never (0) and frequently (5) (23). the third part consisted of a researcher-made 17item questionnaire to evaluate the intensity and frequency of nurses’ perception of futile care situations and was designed based on corley’s moral distress scale and review of related texts. this questionnaire examined futile care situations with a focus on good death, pain and discomfort management, hasty withdrawal of treatment, effective communication with family members, disagreements among treatment team members, family members’ conflicts on treatment choices, and resource allocation. the responses to all three parts of the questionnaire were arranged based on a 6-point likert scale. the options in the intensity dimension varied between not at all (0) and very much (5), and in the frequency dimension between never (0) and frequently (5). corley’s moral distress questionnaire had already been translated into persian and its reliability and validity had been verified. borhani et al. had determined the validity (content validity index or cvi) of this questionnaire at 88%, and its reliability (cronbach’s alpha) at 93% (19). the futile care questionnaire was also studied in terms of reliability and validity. its validity (cvi) was determined by 10 experts on ethics at 82%, and its reliability (cronbach’s alpha) was shown to be 85% using internal correlation coefficient. after receiving ethical codes and permission to obtain the subjects’ written consent from the affiliated hospitals, the questionnaires were distributed among the nurses, and collected by the researcher after completion. this process took 35 days. there were a total number of 335 nurses of whom only 300 agreed to participate; the other 35 nurses refused to participate. data obtained from the questionnaires were registered in the spss version 16 software and analyzed using descriptive statistics (mean, standard deviation, frequency, frequency percentage) and inferential statistics (pearson’s correlation, independent t-test, one-way anova, etc.) to achieve the study objectives. results demographic characteristics of the study subjects included age, gender, ward and number of years in service. the age of participating nurses ranged from 25 to 44 (mean age = 32, sd = 3.1). eighty seven percent of the study subjects were female and 13 percent were male. the highest number of years in service was 25 and the lowest was 2 (mean = 14, sd = 4). the nurses’ ward types included icu, ccu, nicu, oncology, and dialysis (table 1). table 1ward type and gender of the nurses ward type no (%) icu 160 (53.33) ccu 53 (17.67) nicu 35 (11.66) oncology 32 (10.67) dialysis 20 (6.67) total 300 (100) gender male 39 (13) female 261 (87) total 300 (100) no: frequency; (%): the relative frequency intensity and frequency of moral distress and futile care the results revealed a mean moral distress intensity of 3.54 (sd=0.3) and a mean moral distress frequency of 3.11 (sd=0.6), and the total intensity and frequency ranged from 0 to 5. the average intensity of nurses’ perception of futile care was 3.2 (sd=0.46) and the average frequency was 3.7 (sd=1.2). total intensity and frequency ranged from 0 to 5. a review of the section on moral distress revealed that the highest average of intensity and frequency pertained to the item [my busy work schedule causes my job quality to be reduced] with a score of 2.28 (sd=0.4). the lowest average of intensity and frequency pertained to [i start resuscitation even when i am sure this will postpone patient’s death] at 1.09 (sd=0.6). j med ethics hist med 8:2 feb, 2015 jmehm.tums.ac.ir fariba borhani et al. page 4 of 7 (page number not for citation purposes) in the section on futile care, the highest average of intensity and frequency pertained to [i do life saving actions in spite of knowing that this only postpones death] with a score of 3.08 (sd = 0.7). the lowest average pertained to [i follow physician orders on treatments and tests for a patient who is in the final stage of life, even if they seem unnecessary] at 1.89 (sd=0.8). relationship between moral distress and nurses’ perception of futile care there was a significant correlation between the mean of total moral distress and the mean of total nurses’ perception of futile care (p = 0.03, r = 0.4). correlation between moral distress and nurses’ perception of futile care, and demographic characteristics there was a significant correlation between moral distress and age (p = 0.04, r = 0.3), and between moral distress and number of years in service (p = 0.04, r = 0.4). additionally, there was a significant correlation between moral distress and type of ward (p = 0.03) (table 2). a significant correlation was found between nurses’ perception of futile care and their age (p = 0.03, r = 0.4), and between their perception of futile care and number of years in service (p = 0.02, r = 0.5). moreover, a significant correlation existed between nurses’ perception of futile care and type of ward (p = 0.04) (table 2). table 2moral distress and futile care in terms of ward type work setting moral distress mean (sd) futile care mean (sd) icu 4.25 (0.25) 3.2 (0.76) ccu 3 (0.88) 2.6 (0.88) nicu 3.99 (0.5) 2.83 (0.66) oncology 2.6 (0.72) 3.2 (0.78) dialysis 2.8 (0.65) 2.71 (0.98) p value (0.03)* (0.04)* sd: standard deviation * (p value was significant) discussion the purpose of this research was to study the relationship between moral distress and nurses’ perception of futile care. our findings showed that there was a meaningful and positive relationship between the two, which has been confirmed by other studies as well. mobley et al. also studied moral distress and futile care in nurses, and reported a positive relationship between them. they found that moral distress and related conditions might increase nurses’ perception of futile care (9). in a study by mealer et al. on the conditions in intensive care units, the frequent involvement of nurses in futile care conditions was identified as a source of stress and distress (24). beckstrand et al. also considered end-of-life care as an important source of distress and stated that it may cause problems for nurses in various proportions (17). moreover, organ donation was regarded by rady and johnson as the only factor that may be effective in causing moral conflict among nurses (13). analysis of these results confirmed that futile care is a phenomenon contributing to moral distress in nurses, while the consequences and challenges can in turn affect its intensity and frequency. in other words, in addition to the futility or inutility of the care being offered, the legal, professional, and moral aspects of this phenomenon may increase the nurses’ stress and even make it unbearable. a review of the results showed that the highest average of intensity and frequency of moral distress pertained to [busy working hours decreased my job quality]. similarly, mccarthy and deady mentioned extended work pressure and shortage of work force in clinical settings as effective factors in moral distress (25). in her study on moral distress in intensive care nurses, corley identified the work pressure in these units as the most prevalent cause of moral distress (25). in most studies, high work pressure, both from intensity and frequency aspects, has been mentioned as the most important factor contributing to moral distress. in the present study, the lowest average of frequency and intensity of distress pertained to [i start resuscitation even when i am sure this will postpone patient’s death]. corley found that performing unnecessary actions that have no effect on a patient’s life was the main cause of moral distress (26). jameton also believed that taking unnecessary care was related to moral distress and that it could lead to problems like burnout if it happened frequently (27). based on these findings, moral distress induces various responses in nurses, and in different studies the causes for this phenomenon are shown to have different manifestations. in the section about nurses’ perception of futile care the highest average pertained to [i deliver life-saving care in spite of the fact that i know it may only postpone death]. mobley et al. found this item to be rather significant in their study as well (9). the highest frequency of futile care pertained to [even if it seems unnecessary, i follow physician orders on treatments and tests for patients]. in their study meltzer and huckabay showed that when nurses frequently have to tolerate conditions that they know would involve futile care, and through which the patient is denied an easy death, the condition itself will affect their perception (8). j med ethics hist med 8:2 feb, 2015 jmehm.tums.ac.ir fariba borhani et al. page 5 of 7 (page number not for citation purposes) our findings showed that the average of moral distress from both intensity and frequency aspects was at the medium level, while some other studies reported high levels of moral distress among nurses (18, 28, 29). these studies identified moral distress as an important phenomenon that may have different effects on nurses and patients. we were also able to find some other studies in iran that reported medium levels of moral distress (19, 21,30). the results showed that nurses’ perception of futile care was at a medium level from both frequency and intensity aspects, and that the average was higher in the former. based on the results from other studies, nurses’ perception of futile care differed from the intensity and frequency points of view, although it was at a medium level overall (15, 31, 32). in their study, meltzer and huckabay reported a medium level of moral distress in connection with delivering futile care (8). ferrell, however, found a high level of moral distress in nurses who provided futile care (7). it should be remembered that these studies have mostly examined futile care as a part of moral distress, and investigated its role in generating the latter. there was a significant and inverse relationship between moral distress and the parameters of age and number of years in service. these results indicate a decrease in moral distress with increasing age and service years. other studies have also revealed a significant correlation between the abovementioned parameters (7, 19, 28). research indicates that with increased age and years of service, nurses gain more experience and use effective defense mechanisms in facing ethical challenges, so they are less affected by the circumstances. additionally, nurses who have been on the job for a longer time prefer to work in easier environments and avoid ethical challenges. on the other hand, at the beginning of their service, nurses are not sufficiently experienced to face ethical challenges, and are often involved in and influenced by crisis and confusion. in assessing the relationship between moral distress and ward type, the highest level of distress was observed in icu nurses (28, 33). studies generally consider critical care units as having the highest degree of distress for nurses (7, 19, 28, 33), obviously due to the particularly acute conditions in these treatment settings that are associated with more complex ethical challenges. there was a significantly positive correlation between nurses’ perception of futile care, and age and tenure. our findings showed that nurses’ perception of futile care increased both in terms of intensity and frequency with age and tenure. other studies confirm the results of the current study (2, 23). one such study has been conducted by mobley et al., who maintained that with increased age and tenure individuals become more prone to futile care and its challenges (9). our study results are also confirmed by meltzer and huckabay, and also cummings who found that increased age and consequently repeated encounters with futile care result in psychological changes in individuals that will make them more vulnerable against the phenomenon (8, 34). based on the current study results a significant relationship existed between futile care and ward type. the highest intensity and frequency of perception of futile care pertained to nurses working in icu and oncology. meltzer and huckabay, and also dunwoody found the prevalence and intensity of this phenomenon to be higher among the nurses in icu than other units. they stated that icu nurses were more prone to circumstances that lead to futile care because of their frequent contact with patients suffering from chronic conditions (8, 32). mentioning that this phenomenon is more prevalent in icu, heland also declared that nurses delivering end-of-life care had a higher perception of futile care (35). conclusion the results from the present study showed that moral distress and futile care had a meaningful and positive relationship. this means that futile care is an important source of moral distress and its dangerous consequences. considering the nurses’ medium level of moral distress and perception of futile care more attention should be paid to strategies like teaching and applying positive adaptive mechanisms in order to reduce the effects of these phenomena on nurses. information and education can raise nurses’ awareness of these phenomena, and thus help them develop coping strategies and decrease any potential negative consequences by acquiring effective defense mechanisms. one limitation of this study was that it was conducted in a specific region in iran and on public hospital nurses. in order to reveal the other aspects of moral distress and perception of futile care in icu nurses, further studies should be performed in other regions as well as in private and specialized hospitals. acknowledgements we would like to express our gratitude to all nurses who participated in this study. the present study was based on a research plan approved in the department of medical ethics and the law research center of shahid beheshti university in tehran. j med ethics hist med 8:2 feb, 2015 jmehm.tums.ac.ir fariba borhani et al. page 6 of 7 (page number not for citation purposes) references 1. anonymous. american nurses association. code of ethics for nurses with interpretive statements. http://www.nursingworld.org/codeofethics (accessed in 2015) 2. jameton a. nursing practice: the ethical 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19(1): 25-31. moral conccept mohammad koshtegar 24-12-93 journal of medical ethics and history of medicine original article moral self-concept and moral sensitivity in iranian nurses fariba borhani1, mohammad keshtgar2*, abbas abbaszadeh3 1 associate professor, medical ethics and law research center, shahid beheshti university of medical sciences, tehran, iran; 2msc in nursing, nursing department, medical ethics and law research center, shahid beheshti university of medical sciences, tehran, iran; 3professor, department of medical-surgical nursing, school of nursing and midwifery, shahid beheshti university of medical sciences; and academy of medical sciences, tehran, iran. corresponding author: mohammad keshtegar address: medical ethics and law research center, no. 8, shams alley, tavanir, cross valieasr st, tehran, iran; p. o. box: 1516745811 email: m.keshtgar.ac@gmail.com tel: +989157467873 received: 05 apr 2014 accepted: 07 mar 2015 published: 04 apr 2015 j med ethics hist med, 2015, 8:4 © 2015 fariba borhani et al.; licensee tehran univ. med. sci. abstract nurses are often faced with serious situations that require high levels of legal and ethical knowledge, and should therefore be sensitive to the moral issues in their profession in the decision making process. some studies have investigated nurses’ moral self-concept as an effective factor in moral sensitivity, but there is not sufficient evidence to support this. the purpose of this study was to determine the correlation between moral sensitivity and moral self-concept in nurses employed in the teaching hospitals in zahedan, iran. this cross-sectional descriptive study aimed to study the relationship between moral self-concept and moral sensitivity in nurses employed in the teaching hospitals affiliated with zahedan university of medical sciences. chang’s moral self-concept questionnaire and lutzen’s moral sensitivity questionnaire were used for data collection. data analysis was performed using spss software version 17. a total of 188 nurses participated in this study. the results showed that there was a positive and significant relationship between moral self-concept and moral sensitivity (p < 0.05). based on our findings, an individual's attention to moral issues can lead to greater sensitivity and result in morally responsible behavior at the time of decision making. consequently, promotion of moral self-concept through personal effort or education can increase moral sensitivity, which in turn leads to behavioral manifestations of ethical knowledge. keywords: moral self-concept, moral sensitivity, moral decision making, nurse, iran mailto:m.keshtgar.ac@gmail.com j med ethics hist med 8:4 april, 2015 jmehm.tums.ac.ir fariba borhani et al. page 2 of 7 (page number not for citation purposes) introduction in the past two decades, opportunities resulting from developments in bioethics have been provided all around the world (1). the ever-increasing scientific progress has posed important moral questions to the human society that need to be answered. in medicine, there have been major developments in technology and treatment methods, creating progressively more complicated moral issues in patient care. nurses, who comprise a substantial group of health service providers, are naturally not excluded from this phenomenon (2). changes in nursing concepts and health needs, end of life care, increasing numbers of patients, changes in nursing values, improvements in medical technology, resource allocation, rising costs, population ageing, and greater attention to individual rights have caused new moral conflicts that nurses must face on a daily basis (3, 4). in order to solve these problems, nurses must gain skills and abilities in moral decision making (5, 6). the direct consequence will be improved quality of patient care along with scientifically aligned guidance for recipients of health care (7). to improve the moral decision making abilities and skills of nurses, they should first be aware of moral issues and pay them due attention, which can help increase their moral sensitivity. sensitivity and moral responsibility are two factors that can help nurses tell right from wrong, and are constantly and strongly challenged in the nursing profession. moral sensitivity can be defined as awareness of and attention to the existence of moral values in situations wrought with conflict, and an individual’s self-awareness concerning their role and function under the circumstances (8, 9). on the other hand, moral sensitivity also refers to the ability to recognize moral issues and to choose the best response (10). this means that moral sensitivity is not just related to an individual's sense of what is right, but also to their personal experience and the capacity to recognize the importance of the topic at hand (11, 12). a reduction in moral sensitivity and diminished attention to moral issues may lead nurses to underrate these issues in their busy and stressful professional lives. as moral sensitivity plays an important role in ethical decision making, the causes and effective factors need to be carefully investigated. some studies have identified nurses’ moral selfconcept as being a very important factor influencing moral sensitivity, but there is not enough evidence to support this (13). moral self-concept refers to an individual’s feelings, values and thoughts concerning moral issues (13). higher levels of moral integrity may be attained when an individual's moral interests and perceptions of moral dilemmas are explored. growth occurs as individuals try to find suitable moral solutions and make ethical decisions, not only because they recognize the importance of justice and altruism, but also because they perceive this to be the correct course of action (14). kim et al. believed that self-concept plays an important role in the development of moral sensitivity and subsequently in moral decision making (13). changes in moral self-concept cannot be obtained easily, as they require more powerful education systems, qualified educators, and an ethical health system (13). moral self-concept and moral sensitivity are influenced by the culture, customs and professional conditions in the society (15-17). there is a lack of studies investigating the relationship between moral self-concept and moral sensitivity, and we believe that these factors play an important role in moral decision making. therefore, the present study was conducted to investigate moral self-concept and moral sensitivity in nurses employed in teaching hospitals affiliated with zahedan university of medical sciences. zahedan is the capital of sistan and baloochestan province and is a city in southeast iran. method this was a descriptive, cross-sectional study, and the samples consisted of nurses employed in teaching hospitals located in zahedan city. sample size was calculated based on the results of a pilot study conducted by the researcher on 89 nurses in order to determine the statistical power of the study. subjects were chosen by simple random sampling using a chart of random digits. inclusion criteria consisted of having a minimum bachelor’s degree in nursing from an accredited domestic or international university, and having at least two years’ work experience in clinical settings. research objectives were explained to the participants and they were assured that participation was voluntary and the information would remain confidential. the study commenced after the necessary permits were obtained from the zahedan university of medical sciences, imam ali and social security hospitals. the questionnaire consisted of three sections: the first section contained 7 questions on the subjects’ demographic information, including gender, age, marital status, work experience, type of ward, and position. the second section was chang’s moral self-concept questionnaire (13), which consisted of 5 parts and 18 questions. chang’s questionnaire was translated from english into standard persian and then translated back into english, so that the two english versions could be compared with each other. the validity of this questionnaire was confirmed by 10 members of the nursing faculty of kerman university of medical sciences. in order to determine its reliability, it was distributed among 20 nurses, and the internal consistency was calculated to be 0.76 through cronbach’s alpha. the questionnaire j med ethics hist med 8:4 april, 2015 jmehm.tums.ac.ir fariba borhani et al. page 3 of 7 (page number not for citation purposes) used a likert scale with responses ranging from 1 (never) to 5 (always). the total scores of the participants varied between 18 and 90. the third section comprised the moral sensitivity questionnaire designed in 2005 by lutzen et al. in sweden (8). it contained 28 questions and was a likert type questionnaire with responses ranging from 1 (totally disagree) to 7 (totally agree). the participants’ total scores varied from a minimum of 28 to a maximum of 196 (18). in addition, this questionnaire contained six subscales including understanding the utilization of moral concepts in inter-personal relationships, improvement of patients’ autonomy, benevolence, experience of problems, moral struggles, and professional knowledge. the validity and reliability of this questionnaire were determined in the same manner as the self-concept questionnaire, and the internal consistency of this questionnaire was calculated to be 0.85 through cronbach’s alpha. the questionnaires were distributed on several consecutive days during three different shifts in imam ali and social security hospitals of zahedan city. the data were analyzed by spss software version 17, and descriptive and analytical tests such as one-way anova, pearson's correlation and t-test were used. results a total of 200 subjects participated in this study, and 12 variables were observed. the participating nurses were aged 32.19 years on average (sd = 5.77), and the mean of their work experience was 7.70 years (sd = 5.65). demographic features are shown in table 1. table 1demographic data ofstudy participants (n = 188). frequency (percent) gender male 21 (11.2) female 167 (88.8) marital status single 44 (23.4) married 144 (76.6) position nurse 131 (69.9) managers 57 (30.4) type of ward intensive care 59 (31.4) surgery 24 (12.8) internal 62 (33) emergency 19 (10.1) psychiatric 11 (5.9) office 13 (6.9) figure 1standardized means of moral sensitivity domains and moral self-concept as can be seen in figure 1, higher means in the various domains of moral sensitivity are related to an increased understanding of interpersonal relationships, while professional knowledge (rules) has the lowest mean. our findings showed that there was a positive and meaningful relationship between moral self-concept and moral sensitivity. moreover, a significant relationship was found across all domains of sensitivity except professional knowledge. this relationship is presented in table 2. table 2relationship between moral self-concept and moral sensitivity and its domains in nursing components r-correlation p value relationship 0.156 0.032* meaning 0.188 0.010** benevolence 0.234 0.001** autonomy 0.177 0.015* conflict 0.195 0.007** rules 0.072 0.327 moral sensitivity 0.268 0.0001** **correlation is significant at the 0.01 level *correlation is significant at the 0.05 level in the statistical analysis carried out through a pearson’s test, the results did not show a significant relationship between age and moral sensitivity or moral self-concept. nevertheless, a negative and j med ethics hist med 8:4 april, 2015 jmehm.tums.ac.ir fariba borhani et al. page 4 of 7 (page number not for citation purposes) significant relationship was found across the components of moral sensitivity in the factor ‘promoting patients’ independence’, and there was a positive and significant relationship between professional knowledge (rules) and increasing age (figure 2). figure 2the relationship between gender and moral sensitivity and its components, and moral self-concept the moral sensitivity of women and men was calculated by a t-test and a significant difference was found between the two groups in this respect, as women showed a higher average level of moral sensitivity. no significant difference was observed in applying moral concepts (meaning), benevolence, understanding of interpersonal relationships, and professional knowledge between men and women. furthermore, in all of the above-mentioned domains women obtained higher average scores, except for moral self-concept, where women and men did not demonstrate a significant difference. the results are presented in table 2. the study showed that a significant relationship existed between moral sensitivity and type of ward, but none between type of ward and self-concept. results are shown in detail in table 3. a bonferroni post-hoc test demonstrated that from the viewpoint of moral sensitivity and its domains, (except for professional knowledge) the psychiatric ward produced a significant difference from the other groups. as regards moral sensitivity and the remaining domains, the score was found to be high. on the other hand, no significant difference was found between moral self-concept and professional knowledge in any of the groups. table 3relationship between type of ward and moral self-concept and moral sensitivity components intensive care surgery internal medicine emergency psychiatric office p value relationship 5.16 (0.76) 5.14 (0.83) 5.18 (0.81) 5.20 (0.80) 6.45 (0.43) 4.98 (0.38) 0.001** meaning 4.97 (0.58) 4.93 (0.69) 5.10 (0.71) 4.67 (0.87) 5.53 (0.34) 5.10 (0.38) 0.033* benevolence 4.93 (0.73) 5.16 (0.68) 5.10 (0.61) 4.88 (0.52) 6.03 (0.44) 5.15 (0.80) 0.001** autonomy 3.80 (0.7) 4.02 (0.68) 3.94 (0.81) 3.92 (0.51) 4.65 (0.39) 3.53 (0.53) 0.004** conflict 3.54 (1.46) 3.59 (1.00) 3.80 (1.21) 4.40 (0.86) 5.18 (0.17) 3.12 (0.95) 0.001** rules 3.64 (0.97) 3.77 (0.79) 3.76 (0.94) 3.87 (0.87) 3.57 (0.74) 3.87 (1.17) 0.967 moral sensitivity 4.60 (0.41) 4.75 (0.39) 4.73 (0.40) 4.63 (0.43) 5.39 (0.40) 4.64 (0.28) 0.001** moral selfconcept 3.52 (0.34) 3.51 (0.41) 3.54 (0.34) 3.50 (0.22) 3.68 (0.14) 3.53 (0.24) 0.694 **correlation is significant at the 0.01 level *correlation is significant at the 0.05 level j med ethics hist med 8:4 april, 2015 jmehm.tums.ac.ir fariba borhani et al. page 5 of 7 (page number not for citation purposes) the relationship between work experience and other variables was investigated and no relationship was observed between work experience and moral sensitivity, or moral self-concept. nevertheless, in the domains of moral sensitivity, such as patients’ independence and professional knowledge, there was a significant difference. discussion the results of this study showed a positive and significant relationship between moral self-concept and moral sensitivity, and this was identical to results from a study conducted by kim et al. on nursing managers. these findings demonstrate that an individual's concern about morality can lead to greater sensitivity and result in moral behavior at the time of decision making. accordingly, every effort to improve nurses’ moral self-concept can lead to higher moral sensitivity and eventually better ethical conduct. finally, promotion of moral self-concept is possible through personal effort or education (13). in the present study, moral self-concept had a positive and significant relationship with all domains of moral sensitivity except for professional knowledge. it seems that unilateral development and clinical and practical skills and knowledge do not guarantee the development of moral self-concept in nurses, and other strategies are needed to develop nurses’ moral sensitivity and moral self-concept. in this research the degree of nurses' moral selfconcept was relatively high, with an average score of 3.52. the study by chang et al. also confirmed these results (13). we were unable to find similar studies on the level of nurses’ moral self-concept, although one study investigated moral improvement in nurses in which they attained a score of 3.23 (19). nevertheless, previous studies on nurses’ level of self-consciousness had produced lower scores. in cho and kang’s study (1984) the average score attained by students was 3.86, and in son's research (1996) the nurses’ score was 3.76 (20). the reason for nurses’ high moral self-concept may be that nursing is a basically moral career as ethics are the essence of care (21, 22). the moralistic nature of the nursing profession is both due to the content of this major and the students’ motivations. in other words, it is safe to assume that nurses are for the most part driven by strong moral motives, and even if they are not aware of it at the beginning, the recognition is obtained in the process of professional socialization. nurses’ moral self-concept develops in the course of their career and professional values will come to be of utmost importance. in addition, there is a high incidence of events that involve ethical considerations, and it is only expected that nurses will have higher levels of moral self-concept. among the questionnaire items related to professional moral self-concept, the highest score pertained to ‘i'm a person who maintains his/her honor’. in the study conducted on nursing managers in korea, the item ‘i have no feelings of pride and joy’ gained the highest score (13). maintaining dignity is an internal value that received the highest score in the present study due to individual and nonmaterial values, while in the case of korean nurses the external factors of self respect and honor may have been predominant. it is obvious that this perspective is influenced by cultural differences in the research environments. in our study the lowest score pertained to the item, ‘to surpass others i rely on unethical ways’ and in the korean study (13, 16), the lowest score was related to the item, ‘i want others to think that i am reliable’ (13). in this respect, the influence of internal and external values in the two cultures should not be overlooked. in other words, inappropriate conduct is generally judged according to one’s conscience, but in certain cultures external values such as the perceptions of other people are more important. although the technical skills of nursing are rather similar all around the world, the actual experience is not the same everywhere because cultures differ not only from country to country, but also from region to region. perceptions of morality can also vary in different areas. it appears that the above-mentioned differences in scores are related to cultural differences and as discussed previously, culture is a very important factor in moral issues (16, 23). in the present study no relationship was found between demographic features and moral selfconcept. in previous studies work experience and social relationships were effective factors in moral self-concept (13), but they did not appear to be relevant in our study. this means that in our study population the subject of moral self-concept is totally independent of demographic features. in the korean study, however, work experience and social communication were related to the level of education and also to moral self-concept, which indicates the effect of external values such as work experience and social relationships on nurses’ moral selfconcept in the korean culture.this may be due to the lower sample size in the present study than in theirs, or because their subjects were nursing managers while we carried out our study on nurses. the results of this study showed that the moral sensitivity of nurses was higher than average at 4.71 out of a possible 7. in another study conducted on 143 nurses in kerman this figure was 4.77 (24), and in a study by comrie, it was 4.95 (18). this level is far from ideal and certainly not appropriate in a career so intervowen with morality. therefore, suitable measures should be taken to increase nurses’ moral sensitivity and standards through the education system (21). in the domain of moral sensitivity, the highest score was related to understanding the dynamics of interpersonal relationships, and the lowest pertained to professional knowledge. in a study by abbaszadeh et al., the domain of professional j med ethics hist med 8:4 april, 2015 jmehm.tums.ac.ir fariba borhani et al. page 6 of 7 (page number not for citation purposes) knowledge had the highest score and the domain of problem experience and moral dilemmas the lowest. in another study conducted by comrie (18), applying moralistic concepts had the highest, and problem experience and moral struggles the lowest scores. moreover, there was no relationship between demographic features and the above-mentioned factors, which was similar to the results of the abbaszadeh et al. study (24). nevertheless, kim et al. found that at the age of 25 to 30, nurses had a higher moral sensitivity compared to those younger than 25 or older than 30. kim believed that around these ages nurses have a better understanding of nursing practices so they have greater sensitivity (25). furthermore, in a study by park, moral sensitivity was found to increase with age (26). on the other hand, a negative and significant relationship was observed between nurses’ ages and the domain of improvement in patients’ independence. this showed that older nurses emphasize less independence in patients and try to put patients’ requests in their later priorities. in the domain of professional knowledge there was a positive and meaningful relationship with age which was confirmed by the abbaszadeh et al. study (2011). these findings show that organized on-thejob training in clinical work settings probably leads to the development of professional knowledge in nurses, and this emphasizes the importance of training and further education for nurses. there was a significant relationship between gender and moral sensitivity in that women had higher levels of moral sensitivity than men. in the domains of understanding and managing interpersonal relationships, applying moralistic concepts, expression of benevolence, and professional knowledge, there was also a significant relationship with gender, with women obtaining higher averages in all of the aforementioned domains. it appears that gender is strongly related to moral sensitivity, or according to the gilligan studies, women exhibit care morality rather than equality morality. these two forms of morality are accompanied by justice morality, and woman have a greater tendency for care, rather than equality and justice. the most important form of morality in the nursing profession is care morality, and this was confirmed by current study results, and the women obtained higher scores overall (27-29). between the type of ward and moral sensitivity there was a meaningful relationship, with the psychiatric ward obtaining a higher than average score. other domains except for professional knowledge also showed a positive and meaningful relationship, and the department of psychological medicine obtained a higher than average score. our findings demonstrated that the nurses working in specialized departments had less moral sensitivity. in kim’s study lower moral sensitivity was observed in the icu department. this may be due to the fact that the nurses in these units face moral problems more frequently than other units which reduces their moral sensitivity (13). in contrast, there was a lower degree of stress in the department of psychological medicine in the imam ali hospital, and this may help explain the greater moral sensitivity that was observed. there was no meaningful relationship between work experience and moral sensitivity in the nurses in this study using a pearson’s correlation test. on the other hand, a negative relationship existed between work experience and improvement in patients’ independence, while there was a significant relationship between work experience and professional knowledge. these findings point to the relationship between patients’ independence and professional knowledge and age, and point to the correlation between these two domains and work experience, which may also result in increased professional knowledge. conclusion nurses often encounter serious situations in their medical practice that entail legal and moral outcomes, and must therefore be fully equipped for the decision making process. they should be sensitive to the ethical issues in their profession as this can help them to respect their patients’ rights, and also to manage problematic situations and create a difference between their professional and personal values. according to the findings of this study, moral self-concept is an effective factor in moral sensitivity, and therefore suitable planning for the development of the former should be a priority for nurses. furthermore, there is a need for more extensive studies in the field of moral self-concept and the factors contributing to it in order to evaluate the defects and find suitable solutions for emerging dilemmas. there were several limitations in this study including a lack of domestic and international resources on the topic of moral self-concept in nurses. another limitation was the sample size, and it is recommended that this study be repeated with larger samples. furthermore, nurses’ exhaustion and emotional preoccupations were among the undesirable factors that could have been removed through an explanation of the objectives of the study and combining participation with personal satisfaction. as previously stated in the introduction, moral self-concept and moral sensitivity fall under the influence of factors such as culture, traditions, and different professional conditions, and this highlights the necessity of repeating 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[in persian] 25. kim ys, park jw, you ma, seo ys, han ss. sensitivity to ethical issues confronted by korean hospital staff nurses. nurs ethics 2005; 12(6): 595-605. 26. park s. ethical values of doctor of nurse in hospital medical practice. nurs ethics 2002; 10: 657-79. 27. gilligan c. in a different voice: women's conceptions of self and of morality. harvard educ rev 1977; 47(4): 481-517. 28. gilligan c. in a different voice: psychological theory and women's development. harvard university press; 1982. 29. hoffman ml. empathy and moral development: implications for caring and justice. cambridge university press; 2001. medication error 3 101e seyyedeh roghayeh ehsani _2_.doc journal of medical ethics and history of medicine medication errors of nurses in the emergency department seyyedeh roghayeh ehsani1, mohammad ali cheraghi2, amir nejati3, amir salari4, ayeshe haji esmaeilpoor5, esmaeil mohammad nejad6 1 department of nursing, imam khomeini hospital complex, tehran university of medical sciences, tehran, iran; 2associate professor, department of nursing, faculty of nursing and midwifery, tehran university of medical sciences, tehran, iran; 3assistant professor, department of emergency medicine, imam khomeini hospital complex, tehran university of medical sciences, tehran, iran; 4phd student in disaster & emergency health, department of disaster public health, school of public health, tehran university of medical sciences, tehran, iran; 5department of medical surgery, faculty of nursing & midwifery, medical branch of islamic azad university, tehran, iran; 6phd candidate in nursing, international branch, shahid beheshti university of medical sciences, tehran, iran. corresponding author: esmaeil mohammad nejad address: floor, no. 9, kavusi alley, urmia st, south eskandari st, tehran, iran. email: asreno1358@yahoo.com tel: +98-2166936626 fax: +98-2166936626 received: 08 nov 2013 accepted: 11 nov 2013 published: 24 nov 2013 j med ethics hist med, 2013, 6:11 © 2013 esmaeil mohammad nejad et al.; license tehran univ. med. sci. abstract patient safety is one of the main concepts in the field of healthcare provision and a major component of health services quality. one of the important stages in promotion of the safety level of patients is identification of medication errors and their causes. medical errors such as medication errors are the most prevalent errors that threaten health and are a global problem. execution of medication orders is an important part of the treatment and care process and is regarded as the main part of the nurses’ performance. the purpose of this study was to explore the medication error reporting rate, error types and their causes among nurses in the emergency department. in this descriptive study, 94 nurses of the emergency department of imam khomeini hospital complex were selected based on census in 2010-2011. data collection tool was a researcher-made questionnaire consisting of two parts: demographic information, and types and causes of medication errors. after confirming content-face validity, reliability of the questionnaire was determined to be 0.91 using cronbach's alpha test. data analyses were performed by descriptive statistics and inferential statistics. spss-16 software was used in this study and p values less than 0.05 were considered significant. the mean age of the nurses was 27.7 ± 3.4 years, and their working experience was 7.3 ± 3.4 years. of participants 46.8% had committed medication errors in the past year, and the majority (69.04%) had committed the errors only once. thirty two nurses (72.7%) had not reported medication errors to head nurses or the nursing office. the most prevalent types of medication errors were related to infusion rates (33.3%) and administering two doses of medicine instead of one (23.8%). the most important causes of medication errors were shortage of nurses (47.6%) and lack of sufficient pharmacological information (30.9%). this study showed that the risk of medication errors among nurses is high and medication errors are a major problem of nursing in the emergency department. we recommend increasing the number of nurses, adjusting the workload of the nursing staff in the emergency department, retraining courses to improve the staff’s pharmacological information, modification of the education process, encouraging nurses to report medical errors and encouraging hospital managers to respond to errors in a constructive manner in order to enhance patient safety keywords: medication errors, nurse, patient safety, emergency department mailto:asreno1358@yahoo.com j med ethics hist med 6:11 nov, 2013 jmehm.tums.ac.ir esmaeil mohammad nejad et al. page 2 of 7 (page number not for citation purposes) introduction the main goals of care in health care systems are preservation and promotion of health (1). patient safety is one of the main concepts in the field of health care provision and a key factor in maintaining the quality of health care services (2). preservation of patient safety is a major concern in health care provision systems (3). according to valentin et al. one of the important stages of raising the safety level of patients is identification of medication errors and their causes (4). since the institute of medicine (iom) raised awareness about human errors in 2000, many attempts have been made to improve patient safety, such as epidemiological and etiological identification of medication errors (5). medication errors are among the most prevalent health errors threatening patients’ safety and are regarded as an index for determining patients’ safety in hospitals (6). these errors are one of the five medical errors classified by the national institute of general medical sciences (7). the first report related to medication errors was released in 1940 and attracted the attention of authorities (8). based on the conducted studies, thousands of people die in america due to these errors every year and financial expenses relating to medication side effects are near 77 million dollars in a year (9). studies indicate that medication errors increase hospitalization term by 2 days and increase cost to 2000 2500 dollars for each patient. most expenses are related to hospitalization due to inappropriate use of medicines, for example, drug side effects, failure to take appropriate medicine and inappropriate administration of medicine (10). most medication errors are committed by nurses (11,12). the reason is that nurses are the largest therapeutic team and most of them comply with the drug orders and 40% spend their time in hospitals administering medicine to patients (13,14). medication errors of nurses can lead to different problems such as unsuccessful and imperfect treatment, legal problems (15), increase of term and cost of hospitalization (16), damage to the professional reputation of nurses (17) and mistrust of patients and the society in the health care system (18). prevalent medication errors include administration at inappropriate times, committing errors in prescription of medicine, overprescribing, failure to follow the proper prescription, error in drug concentration, and giving medicine to the wrong patient due to improper identification of patients (19). among the important causes of medication errors are: a) personal reasons such as stress, fatigue, absentmindedness, error in administration of orders, reduced attention to details, lack of satisfaction with job and workplace, shortage of dutifulness or work consciousness and so on; b) predisposing causes such as shortage of educated personnel, excessive overtime, long working days, busy environment, provision of intensive care etc.; and c) reasons relating to knowledge and awareness such as lack of experience or knowledge about medications or patient’s condition, and incorrect mathematical calculations (20). although there are abundant advantages and ethical bases in elaboration and reports of nurses’ errors, it is very difficult to obtain accurate statistics of medication errors due to nurses’ protection against punishment, managerial laws regarding detection of errors, absence of an appropriate reporting and recording system, and shortage of information (21-23). one study conducted in england reported a medication error rate of about 15% and nurses were responsible for 56% of these errors (24). the study by simpson et al. showed that 71% of errors were due to imperfect prescriptions and 29% were due to dose calculation of medications, and the most prevalent types of errors were no administration, inappropriate medication, and medication at inappropriate time (25). in iran, a study by penjvini in sanandaj showed medicinal errors occurred for 16.7% of the nurses and the most common types of medicinal errors were omission of medicine and inappropriate dosage (26). overall, in the third world and developing countries, it is difficult to acquire accurate estimates due to absence of a proper recording and reporting system and shortage of research information, but experts speculate that the rate of these errors is high, and the increasing number of complaints against health care team in courts and to judicial authorities also confirms this (27). identifying the types of errors is the first step toward preventing them, and according to the findings of this paper, one can face the problem of medication errors as a nurse or trainer during professional activity. accordingly we aimed at conducting a study on medication errors and their causes in order to find out the number of recalled committed medication errors per nurse over the course of his/her nursing career, and the rate of medication errors reported to nurse managers using incident reports, in the nurses of the emergency department. method in this descriptive study, 94 nurses of the emergency department of imam khomeini hospital complex were selected based on census from 30 june, 2010, to 30 june, 2011. this complex is the largest educational and therapeutic center of the tehran university of medical sciences (tums) j med ethics hist med 6:11 nov, 2013 jmehm.tums.ac.ir esmaeil mohammad nejad et al. page 3 of 7 (page number not for citation purposes) which accommodates more than 1300 hospital beds and includes three independent hospitals and a joint emergency department for those three hospitals. the information gathering and data collection tool was the self made questionnaire prepared and adjusted by the researchers based on literature reviews and scientific papers (17, 28, 29). a questionnaire of two parts was prepared as follows: the first part aimed to collect the demographic information of the nurses (gender, age, level of education, work shifts, type of employment, and years of experience in nursing); the second part was related to the type and causes of medication errors. in this research, medication errors have been defined as ‘any medication administered or prepared in a way that deviates from the prescription chart, the manufacturer’s instructions and hospital policy which can be prevented and may cause injury to the patient’ (30). face and content validity of the questionnaire were assessed by previous studies, books and through asking 10 members of faculty of nursing of tums to comment on the questionnaire, and by considering their correctional comments. the reliability of the questionnaire was determined using cronbach's alpha test (r = 0.91). in order to comply with ethical considerations, the researchers explained the aim of the study to the study participants and then they were assured that the information will be confidential; also the questionnaire was anonymous and participation in the study was optional. inclusion criteria of nurses in this study was considered as physical and mental health, working in the emergency department for at least 6 months, and holding a bachelor’s degree or higher. the study protocol was approved by deputy of the research of the imam khomeini hospital complex. data analyses were performed by descriptive statistics (frequency, mean, median and standard deviation) and inferential statistics. spss software version 16 (spss inc., chicago, il, usa) was used for statistical analysis and p values less than 0.05 were considered significant. results all questionnaires were returned to the researchers after being completed. the average age of the studied nurses was 27.7 ± 3.4 years and their working experience was 7.3 ± 1.9 years. of participants 59 nurses (62.7%) were married, 82 nurses (87.2%) were female, and 42 nurses (46.8%) had committed medication errors in the past year. majority of the nurses (69.04%) had committed medication errors only once, and most (88.3%) held bachelor’s degree while the rest of them held higher degrees. the mean overtime of the study participants was 83.4 ± 43 hours per month and 54.2% of the nurses had fixed work shifts. the routine performance in ed is case method. according to the nurses’ comments, fortunately, no complication had arisen in most cases of medication errors (97.5%). the most prevalent type of medication error was related to errors in infusion rates, administration of two doses of medicine instead of one and omission of medicine. in table (1), types of medication errors have been reported. table 1. types of medication errors medication error types number percent omission of medicine 6 14.2 medication at inappropriate time 3 7.14 mistaken medication 5 11.9 administration of two doses of medicine instead of one 10 23.8 giving medicine of a patient to another patient 4 9.5 wrong infusion rate 14 33.3 the most prevalent causes of medication errors in organizational and human domain is a high patient -tonurse ratio in the ward, insufficient pharmacological knowledge, fatigue resulted from hard work, and use of abbreviated names (table 2). table 2. distribution of factors affecting the incidence of medicinal errors factors affecting medication errors number percent medical factors large variety of drugs in the ward 2 4.2 using abbreviated names 23 48.93 similarities among drug names 11 23.40 using some drugs in the rare cases 2 4.20 different medicinal dosages 9 19.14 managerial and human factors fatigue resulted from hard work 9 19.14 high patient -tonurse ratio 6 12.76 j med ethics hist med 6:11 nov, 2013 jmehm.tums.ac.ir esmaeil mohammad nejad et al. page 4 of 7 (page number not for citation purposes) insufficient education 2 4.2 insufficient pharmacological knowledge 13 27.65 false medicinal calculations 4 10.63 illegibility of patients records 7 14.89 illegibility of physicians’ prescriptions 4 8.51 the rate of under-reporting of medication errors by nurses was 72.7%. examples of the reported medication errors by nurses were presented in table 3. there was no statistically significant relationship between demographic specifications (age, gender, education) and job specifications (type of ward, work experience, monthly overtime) and medication errors committed by nurses (p > 0/05). table 3. examples of reported medication errors by nurses mistaken infusion rate of nitroglycerine and dopamine reconstituting antibiotics in dextrose 5% serum instead of normal saline giving nitrocontin tablet instead of warfarin giving 80 mg aspirin tablet instead of 325 mg aspirin tablet or vice versa preparing 10000 units heparin instead of 5000 units intradermal injection of insulin instead of subcutaneous injection venous injection of antibiotics such as cefazolin and ceftriaxone instead of venous infusion (microset) giving 6.4 mg nitrocontin tablet instead of 2.6 mg tablet discussion this study showed that half of the nurses committed medication errors. the extent of medication errors committed by nurses in different studies varied from 67% in stratton et al. study (31), 43% in the study by lisby et al. (32), 42.1% in the study by mrayyon et al. (7) to 10% in the study by koohestani et al. (17). the great difference in medicinal error rates in this study compared to similar findings in other countries can result from the negative reaction of colleagues, trainers and managers after giving reports (33), lack of medication monitoring, absence of a proper recording and reporting system (6), bad condition of patients, unpleasant physical conditions, noise and overcrowding (34). the results of this study showed that the most common errors were associated with wrong infusion rates and giving two doses of medicine instead of one. in a study in jordan, the most common types of medication errors were wrong patient and wrong dose (35). in a study on the incidence of medication errors among iranian nurses, nikpima et al. concluded that the most common medication errors were wrong dosage,medication omission and medication administration at inappropriate times (6). cheraghi et al. detected 64 nursing medication errors including mistaken infusion rates (44%), inappropriate dosage (23%) and wrong administration times (12%) (21). according to our findings, shortage of nursing staff, inadequate pharmacological knowledge and fatigue resulting from high workload were among the managerial and human factors associated with medication errors. hosseinzadeh et al. suggested the most important reasons for medication errors as shortages of nursing staff, nursing burn-out and high workload (36). al-shara observed that many medication errors were due to heavy workload (41.4%) and new staff (20.6%) (35). in contrast, stratton et al. reported that only 5% of the nursing staff considered lack of knowledge as an effective factor affecting the incidence of medication errors (31). in a study in united states, 42% of the nurses mentioned that there was no factor causing their error while 23.6% referred to carelessness and distraction of nurses, and 11.3% referred to long working hours as the factors causing medication errors (30). anoosheh et al. reported that 69 nurses and nursing managers believes that factors such as unsuitable work shifts, shortage of manpower, shortage of suitable equipment, performance of duties unrelated to the care role of nurses and lack of awareness caused working errors in nursing (37). carelessness of nurses during execution of drug orders is a very important subject which is affected by different factors such as fatigue caused by high work load. it seems that changes are required in the working conditions of nurses in order to reduce human errors (16). in different studies, inadequacy of job training and insufficient knowledge of the graduates are mentioned as the causes of medication errors (38). the results of this study showed that use of abbreviated names and similarities in drug names were among the medical factors associated with medication errors. micro et al. studied the process of drug prescription in internal wards for two years and mentioned that the most prevalent causes of medication errors were illegibility of drug orders in patient records (13.3%), error in preparation of drug (30%) and error in prescription of drugs (28.3%) (40). all of these errors are related to pharmacological information and many nursing researchers mention raising nurses’ pharmacological knowledge as a serious strategy for reducing medication errors, and conclude that updating the information of nurses and nursing students about j med ethics hist med 6:11 nov, 2013 jmehm.tums.ac.ir esmaeil mohammad nejad et al. page 5 of 7 (page number not for citation purposes) medicines and in particular new medicines can be an important factor in reducing medication errors (41). lack of pharmacological knowledge is one of the most important factors affecting medication errors, although the risks relating to medicines and their side effects are not limited to the nurses and many defects can be found during prescription, distribution and execution of orders (42). in this study, 72.7% of the nurses never reported these errors. the rate of reporting medication errors among nurses was far less than the medication errors they had made. a study conducted in jordan by mrayyan et al. revealed that 42.1% of the nurses had made at least one medication error in their career (7). in other studies, the number of medication errors reported by the nurses was less than the real value (43). although the disparity between the number of medication errors committed in the emergency department and their reporting rate is desirable to the authorities, it can be quite worrisome for the therapeutic system. report of medication errors can prevent potential harms to patients and is also regarded as a valuable information source for preventing similar medication errors in the future. the most important motivation of reporting medication errors should be protection of the health and safety of patients and prevention of potential harmful effects of medicines in patients (17). it is evident that the low rate of medication errors is desirable for authorities, but it should be noted that minimization of the gap between errors and their report should also be considered as an important matter. studies show that medication errors are one of the important problems in health care system and more importantly, prevention of these errors depends on their accurate report (37). in addition, these reports can be a way of better managing medication errors and preventing their emergence in the future. it should be noted that executive managers and trainers should not consider the negative undesirable results of these reports and punish the nurses, but they should try to remove the barriers of report and should ethically and legally compensate for the damages and side effects caused by nursing errors as far as possible (44). for this purpose, nurses should consider the principle of honesty as a virtue based on aristotle’s teachings and should be encouraged to report medication errors considering patient’s benefit, that is, perform an ethical task for maximization of benefits (45). although the confidentiality of demographic and information data was ensured and all identifiable data such as name and surname were eliminated, the participants may have provided incorrect answers to the questions as a result of fear of disclosure which can be considered as the limitation of our study. conclusion today, reducing medication errors and improving patient safety have become common topics of discussion in health care systems. despite increased attention to patient safety and the quality of health care services, medication errors are still frequent in the ed. this study showed that the risk of medication errors among nurses is high and medication errors are a major problem of nursing in the emergency department. the rate of reporting medication errors among nurses was far less than the medication errors they had made and this indicates a gap between the actual rate of medication errors and the reporting rate among nurses. we recommend increasing the number of nursing staff, adjusting the workload of the nurses in the emergency department and retraining courses aiming to improve nurses’ pharmacological information, and to modify the education process, encourage nurses to report medical errors and encourage hospital managers to respond to errors in a positive ethical and logical manner in order to enhance patient safety. acknowledgement this paper was enacted on 25 june 2010 under registration no. m/p/524 in the office of the research deputy of imam khomeini hospital complex of tums, and was completed on 7 july 2011 (letter no. m/p/673). we hereby appreciate all nurses participating in the present research who sincerely cooperated in obtaining the results. references 1. tol a, pourreza a, sharifirad g, mohebbi b, gazi z. the causes of not reporting medication errors from the viewpoints of nursing in baharlo hospital in 2010. hospital 2011; 9(1, 2):6-7. 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[in persian] jmehm-9-12_r1_.docx journal of medical ethics and history of medicine original article insurance companies’ point of view toward moral hazard incentives elahe khorasani1, mahmoud keyvanara2, manal etemadi3, somayeh asadi4, mahan mohammadi5, maryam barati5* 1phd candidate, department of pharmacoeconomics and pharmaceutical administration, school of pharmacy, tehran university of medical sciences, tehran, iran; school of pharmacy, isfahan university of medical sciences, isfahan, iran; 2associate professor, department of healthcare management, social determinants of health research center, school of management and medical informatics, isfahan university of medical sciences, isfahan, iran; 3phd candidate, department of health services management and health policy, health management and economics research center, iran university of medical sciences, tehran, iran; 4bsc, department of healthcare management, isfahan university of medical sciences, isfahan, iran; 5msc, department of healthcare management, isfahan university of medical sciences, isfahan, iran. corresponding author: maryam barati address: department of healthcare management, isfahan university of medical sciences, isfahan, iran. email: mbarati92@ymail.com tel: 98 09135562065 received: 28 nov 2015 accepted: 5 nov 2016 published: 15 nov 2016 j med ethics hist med, 2016, 9:12 © 2016 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract moral hazards are the result of an expansive range of factors mostly originating in the patients’ roles. the objective of the present study was to investigate patient incentives for moral hazards using the experiences of experts of basic iranian insurance organizations. this was a qualitative research. data were collected through semi-structured interviews. the study population included all experts of basic healthcare insurance agencies in the city of isfahan, iran, who were familiar with the topic of moral hazards. a total of 18 individuals were selected through purposive sampling and interviewed and some criteria such as data reliability and stability were considered. the anonymity of the interviewees was preserved. the data were transcribed, categorized, and then, analyzed through thematic analysis method. through thematic analysis, 2 main themes and 11 subthemes were extracted. the main themes included economic causes and moral-cultural causes affecting the phenomenon of moral hazards resulted from patients’ roles. each of these themes has some sub-themes. false expectations from insurance companies are rooted in the moral and cultural values of individuals. people with the insurance coverage make no sense if using another person insurance identification or requesting physicians for prescribing the medicines. these expectations will lead them to moral hazards. individuals with any insurance coverage should consider the rights of insurance agencies as third party payers and supportive organizations which disburden them from economical loads in the time of sickness. keywords: moral hazard, patients, insurance organizations mailto:mbarati92@ymail.com j med ethics hist med 9: 12 november, 2016 jmehm.tums.ac.ir maryam barati et al. page 2 of 7 introduction globally, 8% of countries’ gross domestic product (gdp) goes toward healthcare costs (1, 2). in most developing countries, about 5% to 10% of the costs of each government are allocated to the health sector (1, 3). in iran, about 7% of the gdp is allocated to the costs of the healthcare system (4). a consequence of the rapid growth in healthcare costs is the fact that annually more than 2% of households live below the poverty line. this growth in healthcare costs is because of the increased household demands for healthcare services which can be due to the asymmetric information about the status of individuals’ health (5). on the other hand, the need for healthcare and the costs of receiving services are basically related to the uncertainty of those who do not have enough knowledge about their sickness and the treatment costs. most often, catching a disease is something accidental (6). to provide fair healthcare services, and consequently, support households in the high costs of these services, insurance plans and projects are considered as important policies and coverage plans are established in different countries (7). insurance coverage mostly results in the excessive use of care services by insured individuals. individuals who are insured pay more attention to direct costs than to the total costs (6). some healthcare services are only utilized due to the existence of insurance coverage (8). excessive use means insured individuals purchase inpatient or outpatient services for example, and medicines at the point where the final cost and final benefit are not equal. the cost pooling made individuals to pay less for a service although it motivates them to use services which are not necessary and those that cost more than what they are worth (9-11). these changes in behaviors are due to increases in healthcare costs in a society. these phenomena of changes in behaviors resulting from insurance are defined as moral hazards (12-14). the lack of awareness about the severity or consequences of diseases can result in moral hazards for those who do not have any control over their treatment and their insurance coverage has no limitation in use of healthcare services (15). in general, two types of moral hazards can be distinguished; “provider moral hazard” and “consumer moral hazard” (6). provider moral hazard is explicated in the framework of induced demand. in fact, induced demand refers to referring or selling unnecessary services to clients of the health system and abusing the power of the imbalance between the providers information and the customers information. different economic and structural factors, behaviors of providers and consumers of services, and the asymmetry of information among them are effective on induced demand which causes use of services and goods with few benefits for the user (customer) (16-18). consumer moral hazard means that individuals enjoying insurance coverage utilize more care services than those who do not have any insurance because the perceived cost of receiving services is less than the real cost spent for the services (6). due to the significance of investigating the causes of moral hazard among patients, the objective of the present study was to investigate patient incentives for moral hazard using the experiences of experts of two basic iranian insurance agencies which can be summarized into a certain framework for policymakers of the health sector. method this qualitative study was conducted in 2014 using in depth interviews. the participants of the research included individuals who were aware of moral hazard aspects. the study population consisted of experts of two iranian basic healthcare insurance agencies in the city of isfahan, iran. the insurance agencies studied included the iran health insurance and the iranian social security organizations. in addition, insurance experts working in educational hospitals were involved in the study. the subjects were selected through purposive sampling method. in other words, those individuals were interviewed who had great knowledge of this field and valuable experiences. the selection of participants continued until reaching data saturation. accordingly, 18 verbal interviews were conducted. all interviews were recorded, and then, transcribed. the duration of each interview was between 30 and 90 minutes. to insure the validity and reliability of interviews, the triangulation technique that includes the use of interview guidelines and the confirmation of the framework of interviews by other researchers was used. the interviews were guided in order to prevent the influence of the researchers’ bias. frist, some interviews were experimentally conducted before starting the research phases. then, to approve the validity of the data collected from the interviews, they were analyzed in terms of the accuracy of data collection. to enhance reliability of findings, after extracting the data, the transcriptions of interviews were returned to some of the participants and their comments were applied. furthermore, the researchers tried to create a theoretical framework with high analytical precision. the conceptual coding method available in interviews contributed to the enrichment of data collection. criteria such as credibility of the data which is the validity of the study, trustworthiness which is the reliability, and provability which is the capability of final confirmation of the data were considered. the data analysis method was based on the thematic analysis method. stages of data analysis included data extraction, transcription, and storing in the computer and immersion, coding, reflexive remarks, marginal remarks, and memoing. in the first stage after each j med ethics hist med 9: 12 november, 2016 jmehm.tums.ac.ir maryam barati et al. page 3 of 7 interview, the text was transcribed, then, immediately typed and stored in the computer. in the next stage, the interview texts were examined and reviewed several times to understand and distinguish data. in the third stage, data were categorized into semantic units (code) in the form of sentences and paragraphs related to the main idea. semantic units were also reviewed several times. then, an appropriate code was inscribed for each semantic unit. accordingly, in each interview, subthemes were separated, and further reduced. finally, the main themes were recognized. reflective and marginal signs, ideas, and viewpoints emerging in the researcher’s mind were recorded during the interview and analysis. research ethical principles were also considered to gain the interviewees’ satisfaction. the participants were informed that interviews were being recorded for the purpose of easy transcription. anonymity of the interviewees was preserved and the participants were assured of information confidentiality. results the ideas of the participants indicated the important role of the patients in creating moral hazards. in the present qualitative research, 2 main themes and 11 subthemes were obtained. the main themes included economic causes and moral-cultural causes affecting moral hazards. economic causes the ideas of participants regarding patients in the domain of economic causes affecting moral hazards are summarized in the subthemes of poverty and economic pressures, the inability to pay for treatment, individuals' inclination to pay the lowest cost, and insurance coverage abuse. poverty and economic pressures participants presented factors related to patients such as poverty and destitution. [poverty, in my point of view, is the main factor] (interviewee number 2). [i think one cause is the destitution of the patients] (interviewee number 5). [among the insured people, the cause is financial needs] (interviewee number 14). [regarding the patients, the main cause is poverty. in this case poverty does not mean the ability to pay for household costs, but it means the amount someone wishes to pay for a service with or without insurance] (interviewee number 15). participants also referred to economic pressures. [realities should be stated; this problem occurs in our society due to economic pressures] (interviewee number 17). [however, in a society, with not enough discipline, rapidly increasing inflation, and an imbalanced income-expenses ratio, sure there will be a weakened morality] (interviewee number 7). chronic disease with high medical costs participants mentioned “the inability to pay treatment costs”, “insurance costs”, “the growing rate of out-of-pocket expenses”, “increase in catastrophic costs”, “admission fees”, and “the costs associated with chronic diseases” as factors affecting moral hazards. they also declared that [when people cannot afford their treatment costs, they will move toward moral hazards] (interviewee number 2). [in that case, they cannot pay for health insurance registration fees, so this may lead to using the insurance identification of others in hospitals] (interviewee number 2). [a quick look at the current out-of-pocket expenses rate shows the high probability of catastrophic costs for patients and occurrence of conditions which can destroy their lives or make it very hard to survive. this can be clearly observed in the cases of chemotherapy and special cases] (interviewee number 18). [well, you know, in any hospital admission, those with no insurance coverage face the high costs of treatment, so that would be an incentive to misuse the situation] (interviewee number 17). [in the case of patients with chronic diseases, such as those with thalassemia, they know how to abuse the system. for example, they are reimbursed by the health sector, and then, they take the bills to charities or the red crescent society] (interviewee number 6). inclination to pay the lowest cost a participant pointed to the willingness of most individuals to pay less and use governmental subsides as much as possible. [for example, insurance coverage is possible by only having an insurance card; so, there will be opportunities to commit crimes to have this advantage and pay less for the services received] (interviewee number 4). insurance coverage abuse some participants considered financial issues and insurance coverage abuse as the causes of moral hazard. [greed will cause some people to earn the most out of something” (interview 5). “i think the most important incentive is to earn money in this way] (interviewee number 6). moral-cultural causes the participants’ ideas indicated some extents of immoralities in patients’ behaviors; which were presented in the form of the subthemes of false attitudes and expectations of the insured individuals, the decline of spirituality in the society, and cultural poverty and unawareness of the insured. false attitudes and expectations of the insured examples of cases of wrong attitudes of the insured and their inappropriate expectations from the insurance organization were presenting unreal excuses to receive more services, considering any money received from insurance companies as a right, seeing the insurance agency as responsible for all treatment costs, receiving all kinds of services after paying insurance premium, receiving the maximum services without requiring them, getting money easily from the insurance organization and compensation without any relation to insurance, pretending to be sick to receive coverage, inadequate j med ethics hist med 9: 12 november, 2016 jmehm.tums.ac.ir maryam barati et al. page 4 of 7 understanding about the importance of id cards of others, and insisting to use the services of special centers with no contracts with the insurance company. [they ask physicians to prescribe 10 different medicines instead of 4 without needing them, because some drugs receive subsides after being prescribed by a physician] (interviewee number 4). [the insured persons consider it their right and claim that they have a legal right, because they pay insurance premium, and the insurance agency should pay all their costs. they have a health insurance card and pay insurance premium monthly; therefore, the cosmetic services that they perform should be paid for by the insurance company, while this is not in the insurance contract; so, this should not be a motivation for misusing the insurance] (interviewee number 12). [the definition considered by people for insurance is that they can get money as easily as possible from the insurance and this issue results in many damages or obtaining money due to many damages not under contract to the insurance] (interviewee number 7). [there are some cases in which people declare the events in a different way. for example, there has been a conflict, and he/she says that he/she has fallen or the event has occurred during work. it is not the responsibility of insurance agencies to pay for these issues. he/she was working and he/she has an employer who has to pursue the event. they want to present the reality in a different way and misuse the health insurance cards of other people] (interviewee number 2). [for example, the patient has had an accident and he has been insured late. he has another person’s health insurance card. when he refers here, it is not important for him that he does not own the health insurance card and says that it belongs to my family, there is no difference in ownership between me and my family] (interviewee number 2). [in some cases an insured person wants to use the services of all insurance centers, for example, hospitals and private institutes, while all centers do not have contracts with insurance agencies] (interviewee number 4). the decline of spirituality in the society a participant considered the decline of spirituality in the society as a factor in the occurrence of moral hazard and said: [spirituality has greatly decreased in the society, and a lot of people have no commitment to this issue morally, then, they claim that the government should provide insurance coverage for them] (interviewee number 18). [everyone thinks that if they can get some money from insurance agencies, even when it is illegal, they have done a good job and it is religiously legitimate] (interviewee number 7). cultural poverty and unawareness of the insured the participants presented cultural poverty and unawareness of the insured individuals as a cause of the occurrence of moral hazard. [this issue has emerged in our society due to individuals’ unawareness and their lack of high vision] (interviewee number 17). [now, when somebody, due to his or her unawareness of insurance laws and regulations, thinks that he or she can persuade physicians or authorities of hospitals, as well as insurance experts, by crying, this is cultural poverty] (interviewee number 16). [we have a number of patients who act illegally due to their unawareness, due to their cultural level. for example, they think that if the father of a family pays insurance premium, and all of his children, except for one of them, have health insurance cards, he can use the cards of others, or they have cards they have not used for a long time, so the wife believes that because her husband has paid insurance premium and she has not used it, at least her sister should use it] (interviewee number 15). a participant refers to patients’ unawareness of a good physician and declared that [we have problems in the issue of treatment and medicine. people think that if their physicians prescribe ampoules for them, they are proficient, but if they prescribe tablets, they are not] (interviewee number 15). [for example, if i refer to a physician and he prescribes that i should go home and rest up until i am healthy, i will never refer to that physician again. instead, i will refer to those physicians who prescribe drugs for, say, my runny nose. i claim that these physicians are proficient, because they make me healthy again, but a lot of diseases may not have therapeutic indications] (interviewee number 10). discussion participants believed that moral hazards are more likely to occur in patients of lower economic levels. homaie rad et al. and ebrahimnia et al., in their quantitative studies on the medical services of the armed forces indicated that with the decrease in income, moral hazard increases (19, 20). other similar studies indicated the positive correlation of income with moral hazards (21-23). these results are not consistent with the results of the present study. however, ashkzari, in his study, indicated that the low income of families is one of the causes of misuse of insurance (24). in this study, the unaffordability of treatment costs and coping with cost uncertainty were obtained as the main causes of moral hazards, especially in the case of chronic diseases with repetitive treatment costs, which may lead to misuse of insurance. koç, in his study, indicated that the rate of moral hazard in physicians who visit patients with chronic diseases is 2 times higher than others (25). these results are not consistent with the present study results. haddad and anbaji indicated that the more critical the health status of an individual is, the more likely he/she is to face moral hazards (26). these results are consistent with the results of the present study. j med ethics hist med 9: 12 november, 2016 jmehm.tums.ac.ir maryam barati et al. page 5 of 7 the participants of this study referred to insurance coverage abuses by some individuals. for instance, they may demand the physician to prescribe more drugs than needed, so they can sell them in the free market and receive extra money as an income source, which is an evident example of abuse of the insurance coverage (27). ghodoosi et al., in their research on physicians’ insurance frauds, showed that 1% of physicians and 0.8% of specialists, in 2010, committed fraud by drugs and services prescriptions only based on the patients’ demands (28). amani et al. indicated that 32% of the individuals referring to physicians ask them to prescribe drugs based on their opinion and not the physician’s diagnosis (29). in addition, in 26% of the cases, physicians act according to the patients demands (29). interviewees considered the tendency to pay the lowest costs as another cause of moral hazards. since individuals under insurance coverage have lower out-of-pocket expenses in case of receiving services, one important origin of moral hazard can be considered as the tendency to pay less. haddad and anbaji indicated that %1 increase in out-of-pocket expenses causes a 2.9% decrease in the costs of pharmaceutical and laboratory services (26). the participants believed that the individuals’ high expectation to use other people’s insurance cards indicates their attempt to ignore others’ rights in the society. ashkzari considers low level of commitment to the community as a cause of individuals’ misuse in the form of giving health insurance cards to others for use (24). in fact, the lack of moral commitment to the community and negligence of individuals’ rights are among the causes of moral misuse of the health insurance cards of others. the participants identified one of the causes of moral hazards as the tendency of the insured person to use centers which are not under contract with the insurance agency. meskarpour and kazemian referred to the tendency of the insured person to refer to health institutions not under contract with insurance agencies (30). this issue reduces the possibility of control and supervision of insurance agencies over insurance costs and the quality of provided care to the insured individuals (30). turning to a health center with no insurance contract, in which the possibility of insurance experts and supervisors, directly or indirectly, is not possible, increases the probability of moral hazards. insurance agencies should minimize the possibility of the occurrence of moral hazards in insured individuals in institutions not under contract with insurance agencies through the quantitative and qualitative development of centers under contract with insurance agencies. another issue considered as important by the participants was the decline of spirituality in the society. religious teachings consider moral deviations as indecent and discourage individuals from committing them. the fading and destruction of moral values in human communities provide the path for the occurrence of moral abnormalities and misuses. badamchi states that the role of religion in public behaviors has highly faded and only 31% of the subjects in his research believed in the intervention of religion in public behaviors (31). he believes that individuals keep those dimensions of religiosity which do not engender any intervention for their social interactions and overlook the other dimensions (31). in the present study, cultural poverty in the society has been considered as the root of many moral hazards in the insured individuals. visiting many physicians for receiving different drugs to treat the disease as soon as possible; is a result of iranian cultural belief in overusing drugs, which imposes considerable costs to the insurance industry. in fact, most individuals believe that the more a physician prescribes drugs, the better he is and their evaluation criterion for the selection and referral to physicians is their amount of prescribed drugs. hafezi et al. stated that the cause of individuals’ dissatisfaction with family physicians and their health team is that those referring to them are rural families and expect them to prescribe many drugs (32). factor affecting the creation of moral hazards from the point of view of participants can be divided into two groups of economic and moral-cultural causes. the false expectations of the insured individuals have roots in individuals’ moral and cultural values. for the insured person, the use of their own health insurance identification cards or that of others is indistinguishable and this issue requires training and powerful supervision as well as cultural construction in the society. demanding physicians to prescribe drugs and physicians being influenced by patients’ demands in the prescription of drugs are grounds for hazards in the insurance system which should be controlled through training physicians and supervising their prescriptions. insured individuals should observe the rights of insurance agencies as third party payers and supportive organizations which in cases of diseases can disburden them of the financial load in order that the money obtained from individuals’ 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[in persian] pts dignity mohammad ali cheraghi 25-1-94 journal of medical ethics and history of medicine original article patients’ lived experiences regarding maintaining dignity mohammad ali cheraghi1, arpi manookian2*, alireza nikbakht nasrabadi3 1associate professor, faculty of nursing and midwifery, tehran university of medical sciences, tehran, iran; 2assistant professor, faculty of nursing and midwifery, tehran university of medical sciences, tehran, iran ;3professor, faculty of nursing and midwifery, tehran university of medical sciences, tehran, iran. corresponding author: arpi manookian address: school of nursing and midwifery, tehran university of medical sciences, tohid sq., 1419733171, tehran, iran. email: manookianarpi@gmail.com tel: 98 21 66 92 71 71 fax: 98 21 66 90 42 52 received: 16 jul 2014 accepted: 04 apr 2015 published: 20 apr 2015 j med ethics hist med, 2015, 8:6 © 2015 mohammad ali cheraghi et al.; licensee tehran univ. med. sci. abstract preservation of dignity is frequently emphasized as a basic patient’s right in national and international nursing codes of ethics and is indeed the essence and core of nursing care. it is therefore essential to explore the concept based on patients’ lived experiences in order to maintain and respect their dignity and consequently improve the quality of health services and patient satisfaction. the present study aimed to discover the lived experiences of iranian patients regarding maintaining their dignity at the bedside. this qualitative study was conducted using an interpretive phenomenological approach. a total of 14 participants (9 women and 5 men) were purposefully selected, and data were collected through individual, semi-structured and deep interviews. the recorded interviews were transcribed and analyzed by the diekelman, allen and tanner approach. the findings of this study revealed three main themes and related subthemes regarding the meaning of preserving patients’ dignity. the first main theme was “exigency of preserving the innate human dignity” and comprised two subthemes: “respect for the intrinsic equality of all humans” and “treating the patient as a valued person, not an object”. the second theme was “service based on love and kindness” and included two subthemes: ‘being with the patient” and “inspiring the sense of being accepted and loved”. the third main theme emerged as “dignifying and transcendental professional service” and consisted of two subthemes: “professional commitment to uphold patients’ rights” and “enlightened practice”. this study revealed that the concept of maintaining patients’ dignity is related to health providers’ duty to preserve patients’ dignity and also their moral obligation to manifest the human love that is in their own as well as their patients’ nature. in conclusion, if nurses reflect on the transcendental nature of nursing care, they will value and prize their everyday bedside nursing practice and will utilize their capacities to be more human as well. keywords: human dignity, patient rights, qualitative research, hermeneutics, nursing ethics mailto:manookianarpi@gmail.com j med ethics hist med 8:6 apr, 2015 jmehm.tums.ac.ir mohammad ali cheraghi et al. page 2 of 7 (page number not for citation purposes) introduction questions regarding the nature of nursing or care are closely linked to ontological questions such as ‘what does it mean to be a person?’ this is why humanistic nursing theories, which have their roots in humanism, existentialism and phenomenological philosophy (1), claim to offer new insights to both patients and healthcare staff and explain the true meaning of humanity, health and nursing (2). from the humanistic point of view, dignity is an intrinsic and objective value that is inherent in every human being (3, 4), and proper nursing care has the potential to bring about further expression of human dignity (4, 5). in this respect, miller pointed out that care refers to responding to others’ needs by understanding and adopting their ends as one’s own and making an effort to cultivate and restore their agency (5-7). indeed, providing dignifying nursing care requires fulfilling all dimensions of patients’ physical, emotional, social, cultural and spiritual needs (8). in recent years, several quantitative and qualitative studies have been conducted on iranian patients’ dignity (9,10), but none has adopted a hermeneutic approach to address this phenomenon. the findings of these studies were similar to those of international research in terms of the factors contributing to preservation of patients’ dignity. these factors included: ensuring patient privacy, autonomy and involvement in care, considering patients’ intrapersonal features and beliefs, offering equal and fair treatment, establishing effective communication, providing adequate information and emotional support, and employing proper forms of address (711). many international and national nursing organizations consider the preservation of patients’ dignity to be the essence of nursing care (12-14), and “risk of compromising human dignity” has been listed as an important nursing diagnosis by the north american nursing diagnosis association (15). nevertheless, preservation of patients’ dignity at the bedside is still a concept not entirely understood. there is a shortage of hermeneutic research on iranian patients’ experiences in this respect, and the present study was therefore conducted to explore this phenomenon. the hermeneutic approach provides an opportunity to go beyond the popular pre-conceptions through interpretations and an in-depth understanding of the researched phenomenon (16, 17). in this regard, eriksson noted that regaining the hermeneutic aspect and acquiring a humanistic approach involves surpassing the immediate experiences and getting in touch with the essence of care (3). method this qualitative study was conducted using heideggerian hermeneutic phenomenology in order to interpret the lived experiences of patients regarding maintaining their dignity. the participants (9 women and 5 men) were purposefully selected from various governmental and non-governmental settings, primarily based on their abilities, their willingness to participate and their experiences regarding the topic of the research. inclusion criteria for study entry were being over 18 years of age, having the ability to communicate and speak in persian, willingness to share personal experiences, being oriented in time and place, having at least 48 hours of hospitalization experience. if the patients were ill weak or confused to the extent that would interfere with informed consent or participation in interviews, they were excluded. they were aged between 30 and 64, and had been hospitalized for a minimum of 2 and a maximum of 30 days. at the beginning of their selection process, they were provided with information about the research objective and ethical considerations. the data collection process, which took place between may and november 2012, was completed by the manookian, who was well acquainted with qualitative interviews. after making arrangements for the appointments, the interviewer visited each patient and created trustful conditions through effective communication, and informed them about the aim of the study and the interview process. the participants’ experiences regarding preservation of dignity were elicited using individual in-depth semi-structured interviews structured around the probing questions. they were asked to respond to questions such as: “what is your personal experience of dignified care?” “what does dignified care mean to you?” “what do you understand from the term ‘preserving patients’ dignity’?” and “can you describe situations when you came across a violation of patients’ dignity?” moreover, the participants received feedback, and thus verifying and additional data could be obtained during interviews. each interview took 20 to 60 minutes and was conducted at the participants’ preferred location. in 4 of the cases, more than one interview session was required to reach a comprehensive and deep understanding of the patients’ lived experiences. after each interview, the recordings were carefully listened to several times, immediately transcribed verbatim and analyzed in preparation for the next interview. data analysis the data were analyzed using the diekelmann, allen, and tanner method, which is a seven-step process based on heidggerian hermeneutic phenomenology. the analysis is typically conducted by an interpretive team and involves seven steps: (i) reading the interviews to obtain an overall understanding; (ii) writing interpretive summaries and coding for emerging themes; (iii) analyzing selected transcripts in groups to identify themes; (iv) returning to the transcribed text or the participants to clarify disagreements in interpretation, and writing a composite analysis for each text; (v) comparing and j med ethics hist med 8:6 apr, 2015 jmehm.tums.ac.ir mohammad ali cheraghi et al. page 3 of 7 (page number not for citation purposes) contrasting the texts to identify and describe shared practices and common meanings; (vi) identifying patterns that link the themes; and (vii) eliciting responses and suggestions on a final draft from the interpretive team and from others who are familiar with the content and methods of the study (18). in order to fulfill the above process, the transcribed texts were reviewed several times to gain a general understanding. then, an interpretive summary was written by all research team members for each interview, and attempts were made to extract hidden meanings. the extracted meaning units from each interview were compared with those from other interviews and were then categorized into subthemes. the process of interpretation was expanded repeatedly by writing and rewriting the transcripts. the research team members read their interpretations and related emerged themes aloud, and the similarities and differences of the interpretations were discussed until a consensus was reached. subsequently, the main themes and common features of the participants’ experiences were determined. in this way, the continuity of the movement from parts to whole and from whole to parts was observed (16). this interpretive cyclic process continued until the 14th interview where no new meanings emerged and the researchers were satisfied with the depth of their understanding regarding preservation of patients’ dignity at the bedside. several strategies as proposed by lincoln and guba (16, 19) were used to enhance the rigor of the findings. credibility of the findings was established through prolonged contact with the participants and continued engagement with the data during all phases of the research (9 months). credibility was also ensured through independent analyses conducted by each research team member, and by holding team sessions to reach comprehensive and deep interpretations. it should be noted that the credibility of the researchers was assured by choosing research team members who had sufficient qualifications and were experienced in phenomenological studies. to verify dependability and confirmability, detailed descriptions of the study including evidence and examples were used, so the readers would be able to confirm the findings. the transferability of the findings was assured by (a) offering exact instances and quotes of the participants to enable the readers to compare them with those in similar situations; and (b) providing sufficient contextual information, for instance by choosing participants from both sexes and various age ranges, as well as patients suffering from different medical problems, and from both governmental and non-governmental hospitals. ethical considerations this research was approved by the ethics review committee of tehran university of medical sciences (approval number 90/130/2691). participants were given written and verbal information about the purpose of the study and were asked to sign an informed consent. by clarifying the purpose of the study and providing full information on how the data would be used, the research team assured the study subjects that their participation in the study would not impact the quality of the care they received. moreover, all participants were provided with information about voluntariness of their participation and were assured that their identities would remain confidential during the analysis and reporting of the data to protect their privacy. ethical considerations were explained to the participants and verbal permission to record the interviews was taken before each interview. results the findings of the present study revealed that preservation of patients’ dignity involved the following themes: “exigency of preserving the innate human dignity”, “service based on love and kindness” and “dignifying and transcendental professional service”. exigency of preserving the innate human dignity the divine origin of the innate human dignity necessitates that all human beings respect each other. most of the participants placed great importance on “exigency of preserving the innate human dignity”, which consisted of two subthemes: “respect for the intrinsic equality of all humans” and “treating the patient as a valued person, not an object”. a 38-year-old man stated: [i asked them for a new and clean gown, but they ignored my request. i felt that their insensitive treatment of me was due to my social status, and that if i was a patient who came from a big city and had higher economic status, they would treat me in a more respectful way] (patient no. 1). a christian woman described her lived experience regarding the importance of equal treatment of patients and said: [the doctors and nurses didn’t care if i was christian or muslim. they were treating all patients equally] (patient no. 3). a dentistry student had an unpleasant experience during hospitalization and said: [the doctor didn’t even make eye contact with me while i was explaining my problem to him…. this made me feel ignored and devalued, as if i were an inanimate object] (patient no. 8). this theme indicates that people share many of the same human qualities, and preservation of patients’ dignity means to treat them equally, regardless of their gender, position, race and religion. the lived experiences of the participants in this study showed that they expected to be treated not as objects but as human beings who have inherent value. j med ethics hist med 8:6 apr, 2015 jmehm.tums.ac.ir mohammad ali cheraghi et al. page 4 of 7 (page number not for citation purposes) service based on love and kindness according to the findings of this study, preservation of patients’ dignity means having an effective relationship with the patient and providing compassionate care based on love and kindness. in the iranian context, preservation of patients’ dignity emerged as “service based on love and kindness” including two subthemes: “being with the patient” and “inspiring the sense of being accepted and loved”. the subtheme of “being with the patient” comprised two sub-subthemes: “compassion” and “altruism”. the participants pointed out that providing dignified care means being more sensitive to the patients’ holistic needs, especially emotional needs, trying to understand the patients’ feelings, making them feel listened to and supported, and meanwhile showing eagerness to help them to overcome the problems they encounter. some patients described how they expected their family members to be treated while attempting to express their lived experiences regarding preservation of patients’ dignity. a 39-year-old woman stated: [it’s a wonderful feeling when you need help and they are there promptly, and are eager to meet all your needs … you feel that they are like your close friends or sisters] (patient no. 4). the patients said that they felt valued and respected when they had a sense of being accepted and loved by the nurses. one patient stated: [they were treating me in such a way that i felt at home and felt like they were my children and had accepted my current state and were loving me in spite of the existing limitations…. their attitude conveys the massage that you are loved and not just someone who’s imposing an additional burden on them] (patient no. 7). generally speaking, providing dignified care involves empathic and compassionate treatment of the patient. in other words, being with the patient and allowing mutual human love to emerge is a basic requirement in the nursing practice. dignifying and transcendental professional service maintaining patients’ dignity is closely linked to nurses’ responsibility and accountability to provide professional care for patients in order to actualize the inherent values of the nursing profession. the third main theme consisted of two subthemes: “professional commitment to uphold patients’ rights” and “enlightened practice”. the participants pointed out that the health care staff has the responsibility and accountability to observe and advocate patients’ rights. they believed that the staff’s commitment to their professional values helps secure the patients’ rights and preserve their dignity. a 35-year-old woman hospitalized for ovarian cyst surgery noted the destructive impact of paternalistic behavior on patients’ dignity and stated: [when you’re hospitalized, some of the staff (not all of them) keep telling you that you are a patient and you should just accept what is going on. they don’t give you detailed information and don’t respond to your questions and complaints… you just have to keep quiet.… i believe that this is not in line with nursing values…. being informed of one’s own health status is a basic right of each patient] (patient no. 5). one of the hidden meanings of preserving patients’ dignity was extracted as “enlightened practice”. indeed, providing dignified care helps nurses to acquire a deeper insight into the value of their practice and highlights the significance of their professional values. such enlightenment, which is manifested through dignified care, will subsequently lead to a deeper understanding of the value of humanity and promote personal growth in this regard. a 43-year-old woman who was also a nurse hospitalized in a medical-surgical ward said: [to me, preserving patients’ dignity is possible when nurses’ self-awareness is raised through responding to patients' needs while providing care. if we reflect on the value of our everyday nursing practice, we will discover the core value of our profession, which is nothing but preserving patients’ dignity…. during my hospitalization one of my colleagues pulled the bed sheet i was lying on so carelessly that my urinary catheter was pulled out, and that caused terrible damage to my urinary tract... if she had thought about the value of care, she never would have acted in such a carless way] (patient no. 6). generally our findings emphasized the importance of recognizing and preserving patients’ dignity through providing professional nursing care and preparing the ground to actualize the core values of the nursing profession. discussion this study revealed that iranians have different notions of preserving patients’ dignity at the bedside. there have been numerous attempts in health and social care literature to define patients’ dignity preservation, but no explicit definition has been offered for this phenomenon so far. the reason might well be the subjectivity and complexity of this concept that leads to various perceptions of dignity preservation by different people (20-23). manookian et al. pointed out that human dignity is influenced by personal, cultural, social, religious, and spiritual constructs and contexts, and must therefore be interpreted based on people’s perspectives and lived experiences under specific circumstances (24). it is extremely important for healthcare professionals to comprehend the true meaning of maintaining patients’ dignity in order to provide effective and dignified care for patients, who have inherent worth endowed with divine blessing (20, 23, 25). the inherent value of human beings has been emphasized in a verse in the quran “and we have certainly honored the children of adam…” (26). j med ethics hist med 8:6 apr, 2015 jmehm.tums.ac.ir mohammad ali cheraghi et al. page 5 of 7 (page number not for citation purposes) in the present study, the first main theme emerged as “exigency of preserving the innate human dignity”. this is in line with numerous studies conducted in different contexts, which have highlighted the necessity of respecting each patient’s intrinsic worth as a core value of the nursing profession (22-29). it seems that the above-mentioned theme encompasses the concept of obligation as well. in this respect, nightingale’s valuable point of view regarding the nature of the nursing profession should be noted. she reminds us that we are accountable to god for respecting the dignity of each human being in this world (30, 31). in other words, the exigency of preserving patients’ dignity could be discussed from the ontological perspective. accordingly, it is absolutely essential to establish an appropriate relationship with patients and respond to their demands through caring for them and by attending to their individual needs. this will prepare the ground for recognizing and acknowledging the human worth of both patients and nurses, as well as their uniqueness and individuality. affirmation of this equal inner worth reminds us of our obligation to respond to each other’s needs through caring, which can lead to enhanced well-being and consequently promote dignity (5, 32). this ontological perspective can be extended to the second main theme of the present study, that is, “service based on love and kindness”. according to paterson and zderad’s humanistic nursing theory, nursing care, whose ultimate goal is to enhance people’s well-being, is a special kind of nurse-patient intersubjective transaction that offers the ground for personal development through the nurturing response of one person to another in need. this humanistic response occurs through the active presence of the nurse in time and space that is known as “being with the patient” (33, 34). through this authentic presence, mutual human love flows between the spirits of two human beings and actualizes the true meaning of nursing care. findings of the present study were in keeping with various research (8, 20-29, 35, 36) pointing to the significance of compassion and emotional support in maintaining and promoting patients’ dignity. indeed, caring is a human-to-human relationship and is therefore contingent on compassionate behavior (2) and emotional involvement as well as taking note of one’s own feelings, experiences, and reactions (37). olshansky pointed out that in nursing practice, it is essential to remember the fundamentals of service based on love and compassion and above all return to the art of caring, which tends to be marginalized nowadays (38). according to the participant’s lived experiences, the third theme was extracted as “dignifying and transcendental professional service”, which included two subthemes: “professional commitment to uphold patients’ rights” and “enlightened practice”. in this regard, heijkenskjöld et al. found that failure to dedicate personal time to patients, acting indifferently towards them and regarding them as objects who are not allowed to participate in their own care are instances of non-professional behavior that could compromise patients’ dignity (39). other studies have also shown that patients’ dignity will be compromised if nurses do not take professional responsibility to advocate patients’ rights. cases in point include paternalistic interactions with patients (11, 37), offering treatment in a matter-of-fact way (36), disregard for patients’ privacy (11, 21, 22, 27, 28) and their personal, religious and cultural values (25). “enlightened practice” was the second subtheme that emerged as a hidden meaning of preserving patients’ dignity based on the participants’ lived experiences. in this regard, providing dignified care offers an opportunity of self-reflection for the nurses to think about the values underlying their practice. buckley also found that treating patients with dignity could have a positive effect on caregivers since they affirm their own dignity through establishing the value of the care they provide (32). however, it seems that authentic care implies unconditional respect for others and fulfillment of their needs, which is nothing but the definition of humanity. whenever a nurse and a patient come together in a human-tohuman interaction, they both have the possibility to affect and be affected, that is, to become more human. indeed, acknowledgment of patients’ dignity provides the nurses with the opportunity to promote their self-awareness, personal growth and wisdom, which can in turn help them acquire further insight into their professional identities and healing capacities (31-34). watson called this a “caring moment”, whereby both the nurse and the patient feel a deep spiritual connection by transcending time and space, and each recognize their human dignity in the other and attempt to proceed on the caringhealing-loving journey (40). the present study was conducted to provide a deeper understanding of iranian patients’ experiences regarding maintaining their dignity and consequently their feelings and expectations. the findings may be used to develop practical guidelines and formulate more specific strategies in this regard. moreover, this study addressed a shortage of knowledge at the international level and could be applied worldwide and in diverse clinical settings, especially in contexts with a strong religious belief. conclusion preservation of patients’ dignity is a central phenomenon in nursing practice and nurses have a professional obligation to maintain and promote patients’ dignity. the present study explored the meaning of dignity preservation based on iranian patients’ lived experiences. the nurses’ obligation to preserve their patients’ dignity could be discussed on the grounds of the divine origin of the innate human j med ethics hist med 8:6 apr, 2015 jmehm.tums.ac.ir mohammad ali cheraghi et al. page 6 of 7 (page number not for citation purposes) dignity and the equality of the patient and the nurse. accordingly, acknowledging the equal inner worth of patients forms the basis for providing care based on love and kindness. indeed, through this type of care, mutual human love flows between the spirits of two human beings and actualizes the true meaning of nursing care. it seems that the current crisis in the nursing profession is due to a lack of centralization and reflection on some ontological concepts such as transcendental nursing care, which can promote dignifying care and at the same time prepare the ground for personal and professional growth. in other words, if nurses reflect on the transcendental nature of providing professional dignifying care for the patients, they will value and prize their everyday bedside nursing practice more and will better utilize their capacities to be more human as well. although the ministry of health and medical education of iran has emphasized the importance of implementing a professional code of ethics and respect for patients’ rights, there are still issues that need to be addressed in this regard. in addition to managerial and practical areas, the findings of this study may benefit nursing ethics education in undergraduate, postgraduate and continuing education programs. acknowledgment this article presents the findings of a research project entitled patients’ lived experiences regarding maintaining dignity, approved and funded by the international school of tehran 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caring. ethics of face and hand—an invitation to return to the heart and soul of nursing and our deep humanity. nurse adm q 2003; 27(3): 197–202. http://quran.com http://www.nightingaledeclaration.net/nightingale-not http://digitalcommons.mcmaster.ca/cgi/viewcontent.cgi?article=8470&context=opendissertations microsoft word 3 journal of medical ethics and history of medicine compassion in jewish, christian and secular nursing. a systematic comparison of a key concept of nursing (part i) silvia käppeli center for nursing research and development, university hospital zürich, switzerland *corresponding author: silvia käppeli address: center for nursing research and development, university hospital zürich, switzerland. tel: (+41) 44 25 53 954 telefax: (+41) 44 25 54 395 e-mail: silvia.kaeppeli@usz.ch received: 3 oct 2008 accepted: 15 nov 2008 published: 1 dec 2008 j med ethics hist med. 2008; 1:3. © 2008 silvia käppeli; licensee tehran univ. med. sci. abstract background the topos of the compassionate god is a dominant motive of the jewish and christian traditions. it is relevant for nursing because it asks the nurse to imitate god so as to become god‐like. also, to think that god suffers with the suffering believers is thought to give comfort to them. because in the western world the topos of the compassionate god represents the basis of the ethics of compassion/caring, this piece of basic research is important for clinical practice. this study explores to what extent jewish and christian nursing adhered to the biblical topos of the compassionate god at different periods and in different cultural contexts. method a mixed methods approach was used. it included variations of hermeneutical text analysis as used in historical, philosophical, theological, science of religion, and nursing research. results the analysis of the literary sources shows that the topos of the compassionate god was interpreted differently in different cultural contexts. however, at all times it directed religious and secular nursing. since the beginning of the 21 century it builds the core of “compassionate caring” as propagated by north american nursing science. conclusions the topos of the compassionate god laid the foundation of the tradition of the ethics of compassion in nursing. more research is required to learn whether it also plays a role in islamic nursing. keywords: compassion, caring, religious and secular nursing, nursing ethics. j med ethics hist med 2008, 1:3 silvia käppeli page 2 of 7 (page number not for citation purposes) introduction in this research project i investigated if and how the biblical topos 1 of the compassionate god was received in the spirituality, theologies, ideologies and theories of nursing during the 1 st through the 4 th century of the common era (ce) and in the 19 th and 20 th centuries. the topos of the compassionate god is one of several motifs of the jewish and christian traditions which give comfort to the suffering believers. to think that god suffers with them can help patients bear their misery. the scriptures of both religious communities contain many texts which give evidence for both, the need of suffering people for a compassionate god and for his continuing comfort (1). in the old testament (ot) a psalmist let god say: “when they call to me, i will answer them; i will be with them in trouble, i will rescue them and honor them. with long life i will satisfy them, and show them my salvation” (2: ps 91:15). in the beginning of the jewish and christian traditions the topos of the compassionate god served as a model for people who cared for the sick. jews and christians were asked to base their practice on this topos. those who adhered to it hoped to do justice to both the need of the suffering and to religious expectations. thesis the thesis for this research was that the biblical topos of the compassionate god provides the original model of compassionate nursing. it represents the core of today’s ethics of compassion and of caring in nursing. research questions the focus of this study lay on the history of compassion in nursing. in order to clarify the proposed thesis i investigated the following questions: 1. what substantive elements constitute the topos of the compassionate god in the old testa ment, in the christian new testament (nt) and in the jewish talmud? 2. can the topos be identified in later generations of jewish and christian texts (church fa thers/midrashim) 3. was the topos received in christian, jewish and secular nursing texts of the 19 th /20 th century? methodological approach this research is based on the assumption of a typological utilization of the tops of the 1 in this context “topos” can be compared to a theological construct; it can be an idea or become a dogma. compassionate god in nursing. “typological” means that an originally historical event – in this case the compassionate god as a spiritual reality for jews and christians – becomes a symbol or a paradigm which no longer is tied to the historical event. finally, the symbol is more important than the event which produced it. this process of transformation makes possible the transfer of past events (in this case the experience of god’s comfort to people in troubling situations) into the present or into the future and the generalization of a paradigmatic event (3). to investigate the history of a particular topos means to investigate its interpretation during various historical periods and in different societal contexts (4, 5). such research has to be transdisciplinary and methodologically pluralistic. it includes aspects of historical research (the analysis of the historical contexts of nursing (6), of philology (the clarification and interpretation of words and concepts such as “compassion”), of theology (the analysis of traditions of suffering) (7), aspects of the science of religion (the comparison of defined parts of christianity and judaism) (8, 9), of nursing science (the investigation of the consequences of compassion) (10) and of social research. this variety of perspectives required the utilization of all available sources. linguistic and hermeneutical problems a) compassion presupposes an experience of suffering, and any interpretation of compassion in a given text requires a qualitative and quantitative analysis of this underlying suffering and its context. this means that “compassion” remains a multifaceted and ambiguous concept. b) “compassion” is a comprehensive concept which includes the total of the experiences, expressions, activities of and interactions with the suffering. concepts such as compassion represent “worlds”. c) the rabbinical texts are of semitic origin, the christian texts follow greek tradition. hence in the rabbinical texts stories, in the christian texts rather abstract conceptualizations dominate. this raises the question of how to compare narrative descriptions with concepts. d) many new testament and talmudic texts do not describe extensively the qualities required of the carers but refer to an old testament text which has to be consulted for adequate interpretation. e) the variety of expressions containing aspects of compassion presented a serious problem as the following examples show (11, 12, 13): hebrew: chamal, rachamim, chesed, zeddaka, ahava j med ethics hist med 2008, 1:3 silvia käppeli page 3 of 7 (page number not for citation purposes) greek: sympaschein, sympatheo, splanchni zomai, oiktirein english: compassion, empathy, sympathy, caring german: mitgefühl, empathie, mitleid, mitleiden to discover the true meaning of these expressions in a given context a study of the texts in their original language was necessary. steps in the research process the investigation of the research questions required the following research steps: 1. analysis of old and new testament and talmud texts to establish the topos of the compassionate god 2. analysis of texts of the rabbis and of the church fathers from the 1 st through the 4 th century ce 3. analysis of the christian, jewish and secular nursing literature of the 19 th /20 th century (usa, german speaking countries) 4. comparative analysis of results according to the research questions selection of the research material the research material for the investigation of the first and the second research questions originates mainly in the eastern mediterranean world. the time of consolidation of rabbinic judaism and christianity were characterized by rich literary activity. the texts answering the third research question originate in the western world. during the 19 th and the 20 th centuries in the german speaking countries the protestant and catholic nursing orders as well as of jewish and secular schools of nursing started. this also applies to the american nursing scene. at the same time in both places humanita rian, social science, philosophical and new age approaches to nursing developed. i selected the research material according to two principles: a) terminological selection involving texts which contain the word compassion, b) subject related selection involving texts which imply compassion. the research material included jewish and christian sources (old testament, babylonian talmud, midrashim, new testament, church fathers) in their original languages and in various translations; secondary literature of scholars with expertise in the relevant substantive fields or language; modern texts (historical documents, reports, comments, diaries, biographical notes, rules of institutions, nursing literature). results the systematic hermeneutical analysis of the selected literature shows that the topos of the compassionate god forms the foundation of the ethics of compassion. it represents a dominant tradition of nursing since its documented beginnings. in this section i will present some of the literary evidence answering the research questions and supporting this thesis. what substantive elements constitute the topos of the compassionate god in the old testament, in the christian new testament and in the jewish talmud? the writings of the rabbinic and early christian texts are based on the old testament (ot). the following of these ot-reference texts illustrate god’s closeness to and compassion with his people. isaiah paraphrases god as follows: “for this says the high and lofty one who inhabits eternity, whose name is holy: i dwell in the high and holy place and also with those who are contrite and humble in spirit, to revive the heart of the contrite …” (2: isaiah 57:15-19). in another place isaiah says: “… it was … his presence that saved them (the israelites); in his love and in his pity he redeemed them; he lifted them up and carried them all the days of old” (2: isaiah 63:9). referring to the meaning of such texts, matthew, an evangelist of the christian new testament said: “this was to fulfill what had been spoken through the prophet isaiah: ‘he took our infirmities and bore our diseases’ “(2: mt 8:17). probably the clearest witness of the image of god, who gets involved actively in the fate and in the suffering of the (prosecuted) believers is hebrews (2: 4:15) the author of which states: “for we do not have a high priest (christ) who is unable to sympathize with our weaknesses, but we have one who in every respect has been tested as we are, yet without sin.” the most powerful nt-metaphor which teaches compassion to the christians is the parable of the good samaritan (2: lk 10:25-37). also the jewish talmud implies both god’s compassion and man’s obligation to imitate him. in the talmud rabbi chama ben chanina referred to the first and second ot-books of genesis and deuteronomium, when he addressed the members of his community: “’ye shall walk after the lord your god’ (2: dtn 13:5) … the meaning is, to walk after the attributes of the holy one, blessed be he … he visited the sick, for it is written: ‘and the lord appeared unto him (abraham) by the oaks of mamre’ (2: gen 18:1), so do thou also visit the sick…’” (14: bsota 14a/bned 40a). in another place the talmud teaches: “… and he will have mercy upon you and show mercy to you. who has compassion with his fellow human beings will be j med ethics hist med 2008, 1:3 silvia käppeli page 4 of 7 (page number not for citation purposes) shown mercy in heaven …” (14: bsab 151b). rabbi akiba referred to the psalms when he wrote: “not visiting a sick person equals shedding blood” (14: bned 40a). “who visits a sick person will be saved from the punishment of purgatory, because it is written (2: ps 41:2): ‘hail him who cares about the weak, in times of misfortune the lord will serve him’ and “weak” means a sick person. what is his reward in this world? the lord will protect him and keep him alive …” (14: bned 39b). many teachings about and descriptions of the compassionate god in the holy scriptures of both religions converge in a few elements that constitute the topos of the compassionate god: • he is existentially present near the suffering. • he is available for them. they can pray to him any time. • he is their advocate. • he is committed to their care. • he is actively involved in their suffering. • he is faithful and dependable. • he suffers himself because he is compassio nate. in their holy scriptures jews and christians are equally asked to imitate god’s attributes and acts. moreover they are promised a number of gratifications for their compliance. therefore believers of both creeds applied them in everyday life and in the care of the sick. can the topos of the compassionate god be identified in later generations of christian and jewish texts? the reception of the topos of the compassionate god, i.e. his presence with the suffering and his care could be identified in the writings (sermons, letters) of most church fathers who were active during the 1 st through the 4 th century ce in the region of the eastern mediterranean as the following examples show. the christian writer tertullian who lived in the 2 nd century ce wrote to a group of christian martyrs (198 ce): “above all, you blessed people, do not provide sorrow to the holy spirit who accompanied you to prison …” (15: letter to the martyrs, §§1-3). the intent of tertullian’s letter was to comfort the martyrs. the certainty of the presence of the holy spirit should enable them to transcend their pain. cyprian, bishop of cartago, who lived in the 3 rd century ce wrote to the prosecuted and suffering christians in rome: “i am suffering, brothers, i am suffering with you, and my personal well-being is no comfort to me, because if the flock gets injured the shepherd is even more afflicted. i am one with every single one of you. with every single one i share the burden of grief about the great loss. i am complaining with those who complain, i am crying with those who cry, i am feeling crushed with those crushed … in the shattered brothers compassion has also shattered myself” (16: letter to the inhabitants of rome, §3). from north africa cyprian paraphrases an nt-passage and uses the nt-metaphor of the shepherd and his flock to strengthen his bereaved companions in the distant community. basil the great (329-379 ce), bishop of caesarea in cappadocia, asked his colleagues for mercy: “… but now we ask you … to get dressed with mercy and compassion … you heard of our misery. as disciples of the apostle who teaches that the love of your neighbor equals the fulfillment of the law, you probably are not untouched … therefore we ask you to engage yourselves with eagerness … stop hesitating …” (17: letter to the bishops of italy and gallia, §§1f.) basil the great was one of the most excellent proponents of the care of the needy in the 4 th century ce. in this letter he asked his christian fellows to be compassionate with the people in his institution. he wrote: “who would have a heart as hard as a diamond, who would be as rough and without sensitivity as not to be shattered by the complaints which reach our ear from anywhere and which sound like one choir of the grieving. who would not be bent to the ground and destroyed by such indescribable sorrow?” (18: letter to the church of antiochia, §1). one of basils instructions which directly concerns nursing can be found in his sermon for the martyr julitta: “how could we show compassion and deep love … toward our neighbor? should we not cry when we meet people who suffer from serious disasters? should we not shed tears? but we must not believe that the one who cries aloud and complains with the suffering fulfils the law. i cannot praise a physician who instead of helping the sick allows himself to be contaminated by them … the same applies to the one who visits the mourning but who is not able to offer them anything reasonable or comfortable but instead meets them with inappropriate empathy. it is quite alright to mourn with those who suffer trials and tribulations. in this way you will become the confident of the suffering … but you are not allowed to be carried away by the suffering … this would mean to increase the misfortune rather than to soften it. don’t you see that the pain increases if fever is added to wounds and swelling? but a soft touch with your hand could sooth the pain? hence, don’t make worse the suffering by your own presence and don’t fall with those who fell. who wants to erect those lying on the ground has to stand higher than those who fell. who has fallen equally deep, also needs somebody to erect him. on the other hand it is right to have compassion with the events and to mourn silently about the misfortune of others and also to express the corresponding mood with one’s face and dignified earnest. it is not right when talking to the suffering to make reproaches as if one wanted to step on them with one’s feet. if you allow them to j med ethics hist med 2008, 1:3 silvia käppeli page 5 of 7 (page number not for citation purposes) complain and lament – this cannot harm – and in this way the pain will decrease soon and you find opportunity for tactful comforting” (18: 4th sermon for the martyr julitta, §§7f.) basil also borrows a metaphor of the nt-apostle paul when he asks his fellow bishops in a region where at that time the christians were less prosecuted to act on behalf of his own community in asia minor. with respect to his own community and the sick in his hospital basil sketched a sort of theology of caring. in this text basil explains the delicate balance between compassion and distancing with respect to the suffering of others in order for the compassio nate carer to remain therapeutic. in one of his sermons also gregor of nyssa expanded on the phenomenon of compassion in relation to the witnessing of suffering people: “… compassion is the opposite of toughness. the compassionate in his heart enters into a relation with the needy; through this he becomes like the broken minds of the suffering desire. in fact, compassion – if one conceptualises it – is a sort of sadness which the human being bears voluntarily because of the suffering of others” (19: 5th speech, chpt. 1). gregor of nyssa conceptualises compassion as a sort of identification of the observer with the suffering when he said: “because in the face of accidents of others we are being touched painfully… in the face of such events a certain painful state of participation develops in our soul …” (19: 5th speech, chpt. 4). his fellow bishop, gregor of nazianz, referred to the most prominent nt-models when he taught his community: “if we have to believe saint paul and jesus christ that love is the first and most important law, the major content of the law of the prophets, i declare the devotion to poverty, compassion with the suffering as the greatest love. because nothing is more specific to god than compassion…” (20: 14th speech, about the love for the poor, §5). and later on in his sermon he explained: “… even if you give little to the needy it is not little for someone who has nothing … if you have nothing to give to them, show your good intention. if you have nothing at all, give your tears. compassion that comes from the heart is a great comfort for someone who is miserable. true compassion is a great relieve in misery...” (20: 14th speech, about the love for the poor, §§27f.). gregor of nazianz identified love as gods most prominent feature and the most important to be imitated by the believers. unlike him bishop chrysostomos focused on compassion as the deepest human trait: “it is our nature to be moved by compassion and no other disposition is fixed as firmly as this. therefore one could ask why it roots as deeply as this in our nature so that we are moved to tears easily, … and that we are inclined towards compassion. compassion remains so deeply with us that we feel even with animals…” (21: 5th homilie, §4,). chrysostomos praises compassion as a christian virtue. all the texts quoted here show that the church fathers “celebrated” compassion with more or less direct reference to the compassionate god as a biblical virtue which cannot be renounced in the care of suffering people. similarly the jewish scriptures of the 1 st through the 4 th century (the midrashim) continue to refer to the topos of the compassionate god. the following midrashic confirmation by god of his compassion speaks for itself: “god said to moise: ‘don’t you realize that i am in trouble if the israelites are in trouble? from this you can see that: in the place in which i am talking with you, from the thorn bush, i participate in their suffering’” (22: shemr on ex 3:2). in judaism nursing is part of those works of charity (gemilut chasadim) which ought to be practiced spontaneously towards everybody in need. it involves not only material support but requires the whole person. holy texts such as the following encourage such actions. “the holy one, blessed be he, said: ‘who acts in the way of my works resembles me’” (23: tanchb bechuqqotai §56 on lev 27:1f.). this text tells the believers that by imitating god they will increasingly resemble his image. in the jewish tradition bikkur cholim, the visiting of the sick has special value among the prescribed works of charity. “visiting the sick” means nursing them, because it is unconceivable that one visits a sick person without comforting him, nursing him physically, sharing his suffering and without wishing him well or praying with him. the following examples from the rabbinical writings give an impression of the duties that go along with the visit of the sick: “who visits a sick person does not sit either on his bed or on a bench or on a chair. rather he wraps himself and sits on the floor. the almighty comforts him on his “bed of pain”” (14: bned 40a). this picture implies god’s presence with the sick rendering his bed in a holy place. it commands other visitors to prove their humbleness by staying on the lowest possible level. in another place a rabbi taught: “who visits a sick person takes off him the 60 th part of his illness” (14: bned 39b). this implies that sharing the burden of the sick reduces their suffering. rabbi levi said: “if you have nothing to give to the poor, comfort him with the words: ‘my soul wants to emanate because of you, because i have nothing to give to you’” (24: war 34:15 on 25:25). this midrash teaches that compassion, the spiritual touch of a fellow human being, is equally powerful as material gifts. also the mishna vividly illustrates how god expresses his compassion: “what expression does the divinity use when a human being suffers agony? my head is gone, my arm is gone! if god grieves so much over the bloodshed by the offenders, how much more over the blood of the pious…” (25: j med ethics hist med 2008, 1:3 silvia käppeli page 6 of 7 (page number not for citation purposes) msan vi). at the same time this is an illustration of god’s forgiveness vis-à-vis the sinners. similarly in the twin-parable of “the two who were beaten” (22: shemr 2:5) rabbi jannai said: “like those twins: when one of them suffers from a headache, then also the other! so, (if permitted) the holy one, blessed be he, said: ‘i will be with him in trouble’ (2: ps 91:15) and it is written: ‘in their entire affliction he was afflicted’.” “… like one who took a stick and beat two people. both were hit and experienced his pain. likewise misery and oppression of israel were obvious and known to the one who spoke and the earth became, as it is said: ‘… i know their sufferings’ (2: ex 3:7). this twin parable confirms god’s compassion with the israelites. the old testament confirms that wherever they are and whatever happens to them god is with them and suffers the same adversities. in another text rabban gamaliel said in the name of rabbi: “always, when you show compassion with the creatures, you will be shown mercy in heaven; if you do not show compassion with the creatures, you will not be shown mercy from heaven” (26: sifdev 13:18 §96). with this reference to god’s power of retaliation the believers are reminded to care about fellow human beings. rabbi akiba, a scholar who was teaching at the beginning of the 2 nd century in palestine made this even more explicit when he said: “everywhere, where the israelites were banned, the schekhina (god’s presence in the world) was with them. they were banned to egypt and the schekhina was with them, as it has been said: ‘i am being banned to the house of your father, as they were in egypt (2: 1sam 2:27). they were banned to babylon, the schekhina was with them, as it is said: ‘because of you i was sent to babylon (2: jes 43:14).’ they were banned to edom (rome), the schekhina was with them… and if they will return, the schekhina will be with them. as it is said: ‘and the eternal, your god, will return with your prisoners (2: dtn 30,3)” (27: mekhy on ex 12,41). rabbi akiba presents god as a companion of his people in exile. thanks to his presence the israelites retain their inner integrity and completeness. the quoted literary works teach that the eternal was compassionate not only towards the just and the pious israelites but also towards the sinners. his compassion therefore can be said to include his willingness for reconciliation and forgiving. also self-inflicted suffering is no reason for him not to be compassionate. the talmud thus states: “every day god cries about three kinds of human beings: about him who can preoccupy himself with the tora and does not do it; about him who cannot preoccupy himself with the tora but does it nevertheless and about the president of the community who behaves himself arrogant vis-à-vis his community” (14: bhag 5b). for both the suffering and the carers this example is important because they can be certain that even if they cause their suffering themselves they will not be abandoned by god and they can expect his compassion like all the others. conclusion of the first part of the study the analysis of the jewish and christian sources of the 1 st through the 4 th century ce show that their authors and editors picked up the topos of the compassionate god as presented in the ot. however, none of them includes all aspects of it. rather – depending on the purpose of a text (teaching, comforting, and asking for help) selected attributes appear. all of them more or less explicitly refer to the compassionate presence of god, the schekhina, the holy spirit, a saint or the authors themselves as their representatives. most of them ask the people addressed to imitate these characters through actively demonstrating their compassionate care towards their neighbors. the texts imply that compassion is not only an emotional gesture but involves caring acts. hence, it can be concluded that the scriptures of both religions start and consolidate a tradition of compassionate care in relation to the sick. in late antiquity the imitation of god’s mercy vis-à-vis the suffering was the strongest motivation of jewish and christian believers to nurse their sick. the topos presents itself as a religious motif of great variety, be it that the instructions for the carers simply refer to the requirements of the imitatio dei, be it that they describe in detail how to behave. j med ethics hist med 2008, 1:3 silvia käppeli page 7 of 7 (page number not for citation purposes) references 1. käppeli s. vom glaubenswerk zur pflegewissenschaft, geschichte des mit-leidens in der christlichen, jüdischen und freiberuflichen krankenpflege (the history of compassion in christian, jewish and secular nursing). bern: huber; 2004. 2. die bibel, einheitsübersetzung, altes und neues testament (the bible, unitary translation. old and new testament). stuttgart; 1998. 3. maier j. leiden und weisheit in der jüdischen mystik (suffering and wisdom in jewish mysticism). leiden und weisheit in der mystik. jaspert b. paderborn; 1992. 4. gadamer hg. wahrheit und methode (truth and method). tübingen; 1980. 5. steck oh. exegese des alten testaments 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____________________________________________________________________________________________________________________________________________ original article copyright © 2021 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e relationship between resilience and professional moral courage among nurses *corresponding author mehdi ajri-khameslou address: 1th floor, school of nursing and midwifery, shohada highway, ardabil, iran. postal code: 5615751147 tel: (+98) 91 48 39 69 94 email: ajri@arums.ac.ir received: 6 aug 2020 accepted: 16 jan 2021 published: 15 feb 2021 citation to this article: abdollahi r, iranpour s, ajri-khameslou m. relationship between resilience and professional moral courage among nurses. j med ethics hist med. 2021; 14: 3. reza abdollahi1, sohrab iranpour2, mehdi ajri-khameslou3* 1.researcher, department of medical and surgical nursing, school of nursing and midwifery, ardabil university of medical sciences, ardabil, iran; researcher, students research committee, school of nursing and midwifery, ardabil university of medical sciences, ardabil, iran. 2.assistant professor, social determinants of health research center, ardabil university of medical sciences, ardabil, iran; assistant professor, department of community medicine, school of medicine, ardabil university of medical sciences, ardabil, iran. 3.assistant professor, department of critical care nursing, school of nursing and midwifery, ardabil university of medical sciences, ardabil, iran. abstract nurses need to be resilient to be able to endure their working conditions, and their moral courage can affect their resilience. this work aimed at studying the relationship between resilience and professional moral courage among nurses working in hospitals. this descriptive cross-sectional study was conducted on 375 nurses working in teaching hospitals in the city of ardabil in iran in 2019. data was collected using the following questionnaires: a demographic questionnaire, sekerka et al. moral courage scale and davidson-connor resilience scale. the reliability of the davidson-connor resilience scale, and moral courage scale were found to be 89% and 85% using the test-retest method. the data were analyzed by pearson correlation coefficient, t-test, variance analysis, and linear regression using the spss software version 24. in participating nurses, mean scores were 6.35±0.5 for total moral courage (favorable) and 79.35±0.35 (moderate) for resilience, respectively. a positive and significant relationship was observed between resilience and professional moral courage (p<0.05, r=0.1). given the positive and significant relationship between resilience and professional moral courage, nurses require to have the high moral courage to enhance their resilience. determining factors affecting moral courage and resilience, as well as finding strategies and creating an appropriate moral climate can increase nurses' morally courageous behaviors and resilience. keywords: professional moral courage; resilience; nurses; moral development, economics. relationship between resilience and professional moral courage among nurses 2 j med ethics hist med. 2021(feb); 14: 3 jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e introduction nurses, the largest share of hospitals’ human resources in the healthcare system (1), often face complex problems due to their professional role (2). nursing is among occupations with high stress and high physical and mental workload (3, 4), and their workload was measured to be 62% in a study by holden et al. (5). enduring such conditions and properly performing nursing duties require resilience (6), as well adapting to challenges and threats and overcoming them (7). to manage professional problems, nurses should develop resilience to overcome negative experiences (8). another factor affecting resilience is moral difficulties in the healthcare system (9). advances in medical sciences have significantly affected clinical nursing work. cultural differences, end-of-life issues, organ donation, violence, medical errors, and workplace abuse increase moral conflicts in nurses (10, 11). as moral agents, nurses need moral courage, as an important component of moral competence, to properly manage moral problems and professional commitments. in the study by moosavi et al. the mean score of moral courage of nurses was found to be 63.72±5.91 (12). moral courage is a worthwhile virtue that help nurses make correct moral decisions at moral crossroads and upon observing unethical acts (13). in the study by oshio et al., a significant relationship was found between conscientiousness and resilience (14). resilience appears to be an essential factor in the nursing profession, and many factors could affect its development and enhancement (e.g., individual's personality and mentality traits). in the conceptual model by ebrahimi ghassemi et al., a positive correlation was found between resilience and moral courage among nursing students (15). few studies have been conducted on resilience-related issues and factors affecting it, including moral courage in clinical settings. the importance of these issues in the quality of nursing services, as well as their potential and widespread future effects on nurses, patients, and healthcare system, enhances the need to address such issues, and thus, this study aimed at addressing the relationship between resilience and professional moral courage of nurses working in teaching hospitals in the city of ardabil, iran, in 2019. materials and methods this descriptive cross-sectional study was conducted in five teaching hospitals (trauma center, a provincial pediatric center, maternity center, provincial ophthalmology and urology center, general hospital) in ardabil, iran, in 2019. from 1350 nurses working in these five hospitals, 422 were selected to participate using a two-stage sampling: first, sample size per hospital was determined based on the number of nurses in each hospital (140 in imam khomeini, 47 in imam reza, 94 in alavi, 78 in fatemi, and 63 in buali); second, convenience sampling was conducted in each hospital. participants were from all departments including internal medicine, surgery, urology, neurology, intensive care unit (icu), coronary care unit, and emergency department. the inclusion criteria were as follows: at least a bachelor's degree, no physical or mental diseases, and a abdollahi r., et al. 3 j med ethics hist med. 2021(feb); 14: 3 jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e minimum one year of work experience. data was collected using three questionnaires, and the participating nurses' response rate to these questionnaires was 96.5%: (i) a demographic questionnaire including gender, education level, age, years of work experience, marital status, organizational position, serving ward, managerial experience, income, type of employment, number of children, alma matter, and plans with benefits of productivity (e.g., iranian performancebased payment plan). (ii) connor-davidson 25-item resilience scale questionnaire with 5-point likert scale scoring: “totally incorrect” =0, “rarely correct” =1, “sometime correct” =2, “often correct” =3, and “always correct” =4. subjects with a score higher than 50 were considered resilient (14). in a previous study, the reliability of the connor-davison questionnaire using cronbach's alpha method was 0.89, and also the reliability coefficient of the test-retest method was 0.87 (16). the reliability of the scale for use in this study was estimated to be 89% using the test-retest method. (iii) professional moral courage 15-item questionnaire by sekerka et al. with five dimensions, including moral agency, multiple values, the endurance of threat, going beyond compliance, and moral goals. the dimension of moral agency concerns the individual's readiness and heart-felt desire to manage and resolve moral problems, and therefore the desire to conduct moral behaviors. the dimension of multiple values refers to the individual's ability to focus and combine personal values with professional and organizational values. the dimension of the endurance of threat refers to the individual's understanding and recognition of threats, pressures, and fears. the dimension of going beyond compliance refers to an individual who is first to conduct moral behaviors in the organization, prevent unethical acts, and attempt to enhance moral ideals. the dimension of moral goals indicates clarification and setting of goals considering respect, honesty, and other moral virtues. scoring was based on a 7point scale from “never” to “always”. the score range of each dimension was minimum 3 and maximum 21, and the total score was minimum 15 and maximum 105, respectively. for each dimension, a score was added for each dimension (3 questions) and the total was divided by three. for overall professional moral courage, the total scores for all items (15 questions) divided by 15 (17). the reliability of this scale was measured by connor among the nursing population; the overall moral courage scale showed good internal consistency, with a cronbach’s alpha coefficient of 0.853 (18). this questionnaire was translated into persian by mohammadi et al. and its validity was evaluated by 10 experts in the bioethics field; the cvi index was 81%, and its reliability was calculated using cronbach's alpha coefficient to be 0.85 (19). the reliability of the scale for use in the present study was calculated to be 85% using the test-retest method. informed consent was obtained from all participants, and the questionnaires were distributed among nurses during morning, relationship between resilience and professional moral courage among nurses 4 j med ethics hist med. 2021(feb); 14: 3 jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e evening, and night shifts. collected data kept confidential and anonymous, and that participants were free to leave the study at any stage. the sampling stage lasted four months starting from october 19, 2019, to december 14, 2019. this study was approved by the ethics committee of ardabil university of medical sciences (code: ir.arums.rec.1396.241). data were analyzed in spss-24 using descriptive (mean, standard deviation), inferential (pearson correlation coefficient, t-test, variance analysis, and linear regression) statistical tests; p<0.05 was taken as the significance level. result a total of 375 nurses with a mean age of 33.18±6.63 years, ranging from 35 to 45 years participated in the study. the majority of participants were women (83%), with less than five years of work experience (39.9%) and a mean of 2.33±0.68 years of work experience. moreover, most nurses (54.3%) used productivity plan benefits (table 1). table 1participants' distribution frequency data in terms of demographic details variable variable frequency percentage gender male 64 17 female 311 83 age 22-25 36 9.6 26-29 95 25.3 30-34 94 25 35-45 127 33.8 mean ± sd 33.18 ± 6.63 work history 1-5 150 39.9 6-9 75 19.9 10-14 84 22.3 15-30 65 17.3 mean ± sd 8.75 ± 5.98 working shift fixed morning 39 10.4 fixed afternoon 0 0 fixed night 4 1.1 rotating 332 88.3 qualification b.sc. 367 97.6 m.sc. 8 2.4 hospital imam khomeini 126 33.5 alavi 84 22.3 fatemi 70 18.6 imam reza 43 11.4 buali 52 13.8 productivity plan yes 204 54.3 no 171 45.5 the participating nurses' mean resilience score was 79.35±0.45, and based on the statistical analysis, of all demographic details, only mean resilience score had a abdollahi r., et al. 5 j med ethics hist med. 2021(feb); 14: 3 jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e significant relationship with productivity plan benefits (p<0.05, r=0.2), such that nurses with productivity plan benefits were more resilient (table 2). table 2-the relationship of demographic details with moral courage and resilience variable moral courage mean ± sd resilience mean ± sd gender male 6.23±0.54 77.70±11.28 female 6.33±0.49 79.69±8.48 p-value p=0.07* p=0.1* education b.sc. 6.35±0.50 79.69±8.48 m.sc. 6.19±0.54 79.33±9.08 p-value p=0.3* p=0.7* hospital imam khomeini 6.34±0.54 79.28±10.57 alavi 6.47±0.41 80.82±6.27 fatemi 6.21±0.64 77.60±9.10 imam reza 6.28±0.48 75.86±10.32 buali 6.38±0.43 82.42±5.67 p-value p=0.02** p=0.2** working shift fixed morning 6.28±0.53 79.25±9.07 fixed afternoon 6.32±0.44 80.34±5.53 fixed night 6.01±0.58 83.50±4.12 rotating 6.36±0.50 79.55±9.05 p-value p=0.2** p=0.2** work history 1-5 6.31±0.55 78.70±8.84 6-9 6.32±0.56 78.78±10.81 10-14 6.38±0.43 79.30±8.77 15-30 6.43±0.34 81.78±7.10 p-value p=0.03** p=0.1** age 22-25 6.10±0.79 77.16±8.14 26-29 6.39±0.41 79.08±8.33 30-34 6.26±0.60 78.43±11.41 35-45 6.23±0.36 80.34±7.84 p-value p=0.00** p=0.1** use of productivity plan yes 6.33±0.53 8.23±10.048 no 6.36±0.47 80.70±7.47 p-value p=0.6* p=0.00* *independent sample t-test **anova the mean moral courage score (6.35±0.50) was favorable; the highest mean moral courage score (1.34±0.58) was in the dimension of multiple values, and the lowest (1.26±0.33) in moral agency (table 3). relationship between resilience and professional moral courage among nurses 6 j med ethics hist med. 2021(feb); 14: 3 jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e table 3the relationship of resilience with moral courage and overall moral courage dimensions details moral courage mean ± sd resilience mean ± sd r p-value moral agency 1.26±0.33 79.35±0.45 0.1 0.00 multiple values 1.34±0.58 0.2 0.00 endurance of threat 1.33±0.55 0.1 0.00 going beyond compliance 1.27±0.27 0.2 0.00 moral goal 1.27±0.57 0.1 0.00 total moral courage 6.35±0.50 0.4 0.00 statistical analysis of data showed a positive and significant relationship between moral courage and participants' age (p<0.05, r=0.1), such that older nurses had greater moral courage. a positive and significant relationship between moral courage and the serving hospital was observed (p<0.03) (table 2). the pearson test results showed a positive and significant relationship between moral courage and resilience (p<0.05, r=0.4), such that subjects with higher moral courage had higher resilience. resilience also had significant and positive relationships with subscales of moral courage (moral agency, multiple values, the endurance of threat, going beyond compliance, and moral goals) (table 3). the linear regression analysis showed that resilience is significantly affected by both moral courage and productivity (p<0.05), such that moral courage affected resilience the most (0.45) and productivity the least (0.12) (table 4). these variables predicted 22% of the total variance of resilience. table 4prediction of nurses' resilience based on moral courage and use of productivity plan benefits details non-standard coefficient standard coefficient t p-value r2 moral courage 8.11 0.45 9.94 0.00 0.22 productivity plan 2.27 0.12 2.75 0.00 discussion this work studied the relationship between resilience and professional moral courage in nurses working in hospitals. nurses' mean resilience score was in moderate range, in line with the results by deldar et al. (20). as of the present study, in a study conducted by çam and büyükbayram, resilience was also reported to be moderate (21). unlike the present study, a study by mealer et al. reported high levels of resilience in nurses, especially in the intensive care unit (icus) (22); nurses work in different wards depending on their level of resilience, and resilient nurses tend to work and remain in icus. the present study’s participants were from all different wards, and the mean resilience score of the nurses was moderate, and no difference was observed in nurses’ resilience level from different wards. a study by gillespie et al. on operating room (or) nurses in australia reported a high abdollahi r., et al. 7 j med ethics hist med. 2021(feb); 14: 3 jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e level of resilience (23). the difference in the results can be attributed to the assessment of resilience according to various mental and behavioral characteristics in nurses as well as their different environmental and personal features. in the present study, a significant relationship was observed between resilience and having productivity plan benefits; nurses with such plan benefits had higher resilience because they had higher income, which resulted in higher resilience. this relationship can be attributed to iran’s economic conditions resulting from sanctions; higher income (e.g., through performance-based payment plan) increased resilience. however, resilience had no relationship with other demographic details, in line with the results of abdollahzadeh et al. (24). unlike the present study’s results, lee et al. reported that pediatric intensive care unit (picu) nurses with less than seven years of work experience had higher resilience (25). previous studies showed that other factors such as self-esteem, self-efficacy, and economic factors can affect nurses' resilience (14, 26). given iran’s economic sanctions, economic factors have largely affected nurses' resilience level, and using productivity plan benefits is an example of this effect. in the present study, no significant relationship was found between the mean score of resilience and participants' age. different results of the present work in iran when compared to other studies can be attributed to factors such as organizational support and lower workload for nurses in developed countries. participating nurses had favorable mean moral courage scores, in line with the study’s results by moosavi et al. conducted on nurses in tehran hospitals (12). mahdaviseresht et al. also reported a high mean moral courage score in nurses (27). however, nurses' mean moral courage score was moderate in a study by hanna et al. (28) and was poor in a study by gallagher (29). all these studies used the same tool and professional moral courage (pmc) questionnaire to collect data. the difference in moral courage level in these studies can be attributed to the effect of certain factors on moral courage, including ethical climate, nurses' age, organizational culture, managers' support, organization's support, and organization’s non-acceptance (12). further investigations are required to study the relationship of such factors with nurses' moral courage. in the present study, a positive and significant relationship was observed between nurses' age and moral courage, such that older nurses had greater moral courage, in line with the results by mahdaviseresht et al. (27). nejadsarvari et al. reported that physicians' moral sensitivity increases with age (30). individuals' information and awareness of a situation increase with age, and their capacity to recognize behaviors and the reasons behind them also develop with age, and hence older nurses can have greater moral courage in stressful situations. the highest mean score of moral courage relationship between resilience and professional moral courage among nurses 8 j med ethics hist med. 2021(feb); 14: 3 jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e was in the dimension of multiple values indicating the individual's ability to focus and combine personal values with professional and organizational values. moreover, the lowest mean score of moral courage was in the dimension of the moral agency relating to the individual's readiness and willingness to manage moral issues, and therefore the desire to conduct moral behavior. however, in a study by moosavi et al., the moral agency had the highest score and endurance of threat had the lowest score (12); the difference in results was due to variances in personality traits (e.g., individuals' different adaptation abilities, readiness to manage moral problems) and differences in nurses' working conditions (e.g., organizational support and various organizational atmosphere). high scores in multiple values can be beneficial in enabling nurses to match their values and ideals with those of the organization, thereby fulfilling organizational goals, which is quality care. moreover, the present study’s results showed a direct and significant relationship between resilience and moral courage as well as resilience and use of productivity plan benefits, such that 45% and 12% of changes in resilience are due to moral courage use of productivity plan benefits, respectively. generally, 22% of changes in resilience is due to these two variables. oshio et al. concluded that personality traits including neuroticism, extraversion, openness, agreeableness, and conscientiousness had a positive and significant relationship with resilience (14). nakaya et al. reported that personality factors affect resilience (31). bazrafshan et al. observed a significant relationship between nurses' conscientiousness and resilience (32). ebrahimi ghassemi et al. reported a significant and positive correlation between resilience and moral courage of nursing students (15). this finding can be explained as individuals with higher levels of moral courage have a reasonable understanding of their abilities due to features such as the endurance of threat, moral goals, and multiple values; therefore, they can manage stressors and have higher flexibility, leading to increased resilience in nurses. this study revealed a significant and positive relationship between moral courage and resilience. a shortcoming of this study, which limits the generalizability of the results, was sampling strategy, specifically in sampling from nurses of ardabil hospitals, and hence future studies in other settings are recommended. moreover, participants’ mental status when completing questionnaires could have affected the results, which were beyond the researcher's control. conclusion moral courage has an important role in improving resilience in nurses. considering the significant relationship between moral courage and resilience, enhancing nurses’ sense of accountability in managing patient problems and in reinforcing their role of patient support increases their courageous behaviors and their resilience. high levels of abdollahi r., et al. 9 j med ethics hist med. 2021(feb); 14: 3 jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e resilience in nurses enable them to use adaptive skills in coping with stress and help them productively endured hospitals’ stressful environment. resilience can be enhanced through constructive interactions with colleagues, and hence hospital managers should promote moral courage among nurses to increase their resilience. measures should be taken to promote moral courage in nurses, to improve the quality of nursing care. increasing nurses' awareness of moral principles leads to morally courageous behaviors in nurses and thus increases their resilience. given that moral courage increases with age, experienced nurses as coaches of newly-employed nurses can help improve courageous behaviors in them. this study also showed moderate levels of resilience in nurses, hence changes are required to enhance the levels. researchers, nursing managers, and planners should investigate other factors affecting resilience, and develop required strategies (e.g., creating a support network, promoting optimism, and providing role model benefits). furthermore, further studies are necessary to clarify the relationship between resilience and moral courage in nurses. acknowledgements this study was approved by ardabil university of medical sciences and was part of an m.sc. thesis. authors wish to thank participating nurses. conflicts of interests no potential conflict of interests was reported by the authors. relationship between resilience and professional moral courage among nurses 10 j med ethics hist med. 2021(feb); 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moral distress in ccu wards   zahra molazem1, nahid tavakol2, farkhondeh sharif3, sareh keshavarzi4 and soraya ghadakpour5 1 assistant professor, department of nursing, school of nursing and midwifery, shiraz university of medical sciences, shiraz, iran; 2 student research committee, shiraz university of medical sciences, shiraz, iran; 3 professor, department of nursing, school of nursing and midwifery, shiraz university of medical sciences, shiraz, iran; 4 assistant professor, department of bio statistics, school of medicine, shiraz university of medical sciences, shiraz, iran; 5 msc, department of nursing, school of nursing and midwifery, shiraz university of medical sciences, shiraz, iran.   corresponding author: zahra molazem address: department of nursing, school of nursing and midwifery, shiraz university of medical sciences, shiraz, iran p. o. box: 71936-13119. tel: +98 7116474254, fax: +98 711-6474252 e-mail: molazem@sums.ac.ir received: 09 jan 2013 accepted: 02 mar 2013 published: 06 apr 2013 j med ethics hist med, 2013, 6:5 http://journals.tums.ac.ir/abs/23424 © 2013 zahra molazem et al.; licensee tehran univ. med. sci. abstract complexity  of  health  care  has  caused  ethical  dilemmas  and  moral  distress  to  be  quite  unavoidable  for  nurses.  moral distress  is a major, highly prevalent problem in the nursing profession. the study aims to investigate the  effect of education based on the “4a model” on the rate of moral distress among the nurses working in cardiac  care units (ccu).   the  participants  consisted  of  60  nurses  working  in  cardiac  care  units  (ccu),  30  in  the  control  and  30  in  the  intervention group. those in the intervention group took part in the educational workshop about “moral distress”  and “4a model”. the moral distress questionnaire was completed by both study groups 1 and 2 months after the  intervention. after the intervention, the results of repeated measures analysis of variance revealed a significant  difference  in  the  moral  distress  mean  scores  between  the  intervention  and  the  control  groups  (p<0.001)  and  within  the  two  groups  (p<0.001).  moreover,  a  significant  difference  was  found  between  the  two  study  groups  regarding the mean score of moral distress 1 and 2 months after the intervention. the findings of the current study  revealed  a  decreasing  trend  in  the  moral  distress  mean  score  in  the  intervention  group,  while  there  was  an  increasing trend in the control group after the intervention.   it can be concluded that the “4a model” can be used for reducing moral distress and educational interventions can  reduce the rate of moral distress among nurses. authors of this study recommend that more studies with larger  sample sizes be conducted in different hospital wards as well.    keywords: moral distress, cardiac care units, education, nurse, 4a model j med ethics hist med 6:5 april, 2013 jmehm.tums.ac.ir zahra molazem et al. page 2 of 8 (page number not for citation purposes)     introduction complexity of health care has caused ethical dilemmas and moral distress to be quite unavoidable for nurses (1). moral distress is a major, highly prevalent problem in the nursing profession (2, 3). in fact, moral distress is defined as a painful feeling and a psychological disequilibrium felt by the nurses when they are not able to do what they believe to be right. in other words, in moral distress, the individuals know what is right, but organizational limitations prevent them from acting upon it (2). moral distress results from limited financial resources, a decrease in the patient to nurse ratio, and an increase in the severity of diseases (4, 5). moreover, evidence shows that complexity of the environment, high population of the patients, and the nature of the nurses’ professional role in critical care units (ccu) make them susceptible to moral distress (6, 7). the critical care nurses work in an environment where the patients are specifically faced with life-threatening problems; consequently, they are highly responsible for providing such patients with desirable services (8). in addition, due to the patients’ special conditions and the urgency of the medical measures, critical care nurses are more likely to encounter moral distress (9, 10). moral distress can lead to the feeling of inability, fatigue, job dissatisfaction, negative self-concept, anger, depression, isolation, guilt, anxiety, changing the department or the hospital, and even quitting the nursing profession. such nurses neglect the patients, cause them to feel unhappy and offended, and increase their pain as well as length of hospital stay, thus decreasing the care quality and patient satisfaction (1, 8, 11, 12). overall, moral distress can have negative effects on the patients, nurses, and the healthcare system (1315), so researchers have emphasized identification of moral distress in the healthcare system and are holding educational courses for reducing this phenomenon in nurses (3, 15-18). moral education can provide the foundation for empowering systemic responses to moral distress (3, 19). the studies conducted on moral distress have so far focused on western approaches; however, since the cultural context is quite effective in the creation of moral distress (15, 20), these studies are recommended to culturally take moral distress into account (21). in general, the growth of research conducted on moral distress shows the international attention to this phenomenon (3) . in iran, both quantitative (22-24) and qualitative studies (25) have been performed on this issue; nevertheless, while all these studies have emphasized the importance of educational interventions in reducing the nurses’ moral distress, no study has been carried out on the effect of educational intervention on the rate of moral distress. in the international contexts, few studies have been performed on this issue likewise and the researchers studying the effect of educational interventions on moral distress have stressed the necessity to perform more studies and interventions in this field (16, 26, 27). the american association of critical-care nursing (aacn) provided a model in 2004 entitled the “4a’s to rise above moral distress” that offers a framework for critical care nurses to identify and deal with moral distress. in review of articles, only beumer (2008) performed an interventional study by using the aacn's model on icu nurses (16). the present study aims to investigate the effect of education based on the “4a model” on the rate of moral distress among the nurses working in cardiac care units (ccu). method in this randomized controlled trial study, the intervention was performed through holding an educational workshop based on the “4a model” for the cardiac care units (ccu) nurses and a moral distress questionnaire was completed by both the intervention and the control groups before and after the intervention. the present study was conducted on 60 nurses working in cardiac care units (ccu) of shiraz heart center. the participants expressed their consent to take part in the study and after reaching the quorum, enrolled nurses were randomly assigned to the intervention (n=30) or the control group (n=30) with the use of a randomization list (random permuted blocks with length 4). the inclusion criteria of the study were having at least a bachelor degree in nursing, having at least 6 months of working experience (22) in cardiac care units, willingness to participate in the research, not suffering from anxiety disorders, and not using anti-anxiety drugs, based on self-report forms. in the present study, the researchers used corley’s moral distress scale (mds) whose reliability and validity were assessed in iran’s nursing community in 2008 (9). this questionnaire included 30 items with a 7-point likert scale, 1 and 7 representing the lowest and the highest levels of tension respectively. in addition, it consisted of 3 domains of “ignorance of the patient” (16 items), “patient’s decision making power” (8 items), and “practical-professional competency” (6 items). a researcher-made questionnaire including demographic information such as age, years of nursing experience, average working hours in a week, and marital status was also applied in this study. the 30 nurses in the intervention group took part in the educational workshop that was held in the conference hall of the heart center in two 4hour sessions during two consecutive weeks. at the beginning of the workshop, the intervention group was asked to avoid transferring the information j med ethics hist med 6:5 april, 2013 jmehm.tums.ac.ir zahra molazem et al. page 3 of 8 (page number not for citation purposes)     about the contents of the educational workshop to the other colleagues up to the end of the study, and then questions were posed regarding the concept of moral distress and the nurses revealed to have no information about this concept. after providing explanations about the concept of moral distress, the participants were asked about the situations that could result in this phenomenon and they stated the exact same instances resulting in moral distress as mentioned in most of the studies. next, the causes and symptoms of moral distress were mentioned and the participants discussed their experiences of this phenomenon. they said that before getting familiar with the concept of moral distress, they did not know what to name their feeling and considered it as an uncommon, unavoidable, and unsolvable feeling. when the participants asked about a way to eliminate or decrease the effect of moral distress, they were instructed to think about the strategies for reducing or eliminating this phenomenon in nurses and discuss them in the next session. in the second session, the nurses were asked about the strategies for reducing moral distress and they emphasized continuation of training courses, establishing ethical committees in the hospitals, and holding such workshops for the managers and head nurses. afterwards, the participants were presented with the aacn model, which consists of 4 stages of ask, affirm, assess, and act. in the first stage (ask), the nurse asks him/herself whether the stress he/she feels is a sign of moral distress or just a feeling of suffering. the aim of this stage is awareness of the existence of moral distress. in the second stage (affirm), the nurse makes sure about the existence of moral distress by sharing his/her feelings with others and promises to reduce it. in the third stage (assess), the nurse identifies the source of moral distress, which might be personal or environmental, estimates the intensity of his/her stress, and makes himself/herself ready for the act stage. in the last stage (act), the nurse both personally and professionally attempts to reduce moral distress and uses strategies in order to reach this goal. it is not uncommon for a nurse to regress to the previous stages; what is important, however, is that he/she enters the act stage and attempts to maintain his/her personal integrity (28). at this point, the participants were required to form 5-person groups and representatives were selected from each group to talk about the strategies used in cardiac care units as well as in ccus and exchange ideas. after that, each group’s representative explained his/her opinion to the others. the strategies for reducing moral distress were extracted from the articles and the stages of the model were also explained to the participants. finally, for the participants’ better understanding of the model stages, 5 volunteers performed a roleplay that was directed by one of the researchers, a professor of psychiatric nursing in shiraz university of medical sciences, shiraz, iran. in this roleplay, the participants suggested a situation creating moral distress in ccu and the “4a model” was performed for that situation. the participants stated that it was the first time that they felt someone was taking their feelings into account and requested further meetings to discuss their ethical dilemmas. they also asked for establishment of committees in hospitals so that the personnel could share and solve their ethical issues. after the intervention, the participants were informed that they could contact the researcher by phone in case they had any questions regarding the performance of the “4a model” or their feeling of moral distress. furthermore, the moral distress questionnaire was completed by both study groups before and 1 and 2 months after the intervention. ethical considerations the present study was approved by the ethics committee of shiraz university of medical sciences, shiraz, iran and the hospital authorities’ permission was sought as well. moreover, the participants signed the written informed consents for voluntarily taking part in the study before completing the questionnaires. questionnaires were anonymized and the participants’ information was collected privately by the researchers. statistical analysis the study data were analyzed using the spss statistical software (v. 15). cronbach's alpha coefficients of 0.898, 0.736, and 0.714 were obtained for internal consistency of the dimensions of ignorance of the patient, patient’s decision making ability and practical-professional competency, respectively. moreover, repeated measures analysis of variance was used in order to compute the mean scores and compare the moral distress mean scores before and one and two months after the intervention. in addition, in order to compare the two groups based on the demographic characteristics, i.e. age, years of nursing experience, marital status, and average working hours, chisquare test and independent sample t-test were used for the qualitative variables and the quantitative ones respectively. the changes in moral distress mean scores were compared between the two groups and based on different demographic variables such as age and marital status using twoway anova. results the present study was conducted on 60 nurses, 30 in the control and 30 in the intervention group. among the study participants, 2 were male and 58 were female and the two male subjects were in the intervention group. in the intervention group, j med ethics hist med 6:5 april, 2013 jmehm.tums.ac.ir zahra molazem et al. page 4 of 8 (page number not for citation purposes)     56.7% of the participants were single, while 56.7% of the control subjects were married. the mean age of the nurses in the intervention and control groups was 29.635.14 and 29.674.24 years respectively, and the mean working experience in the intervention and control groups was 5.534.42 and 5.673.05 years respectively. in addition, the intervention and control groups’ mean working hours were 47.8114.14 and 41.963.70 hours respectively. no difference was found between the two groups regarding the demographic variables and moral distress mean scores before the intervention; the results are presented in table 1. moreover, the results of the two-way anova revealed no significant relationship in the differences in mean of the moral distress score in the two groups based on demographic variables including age, marital status, years of nursing experience, and average working hours in a week. table 1. demographic characteristics of the study participants p value control (%) intervention (%) 0.894 30(100) 28(93.3) female gender 0(0) 2(6.7) male 0.979 18(66.6) 23(76.6) 20-30 age 9(33.3) 5(16.6) 31-40 0(0)* 2(6.6) 40+ 0.302 13(43.3) 17(56.7) single marital status 17(56.7) 13(43.3) married 0.895 (mean ±sd): 5.67±3.050) (mean ±sd): 5.539±4/426) years of nursing experience 0.246 (mean ±sd): 41.96±3.705) (mean ±sd): 47.81±14.40) average working hours in a week 30 30 total before the intervention, the two groups’ moral distress scores ranged from 2.30 to 7.50, and the moral distress mean score of the 60 participants was 4.571.03 out of 7. overall, 15 out of 30 items revealed >4 mean scores which shows the high rate of moral distress among the study participants. the study results revealed a decreasing trend in the intervention group’s moral distress mean score in that it had reduced from 4.441.24 before the intervention to 3.360.996 and 3.0481.25 one and two months after the intervention, respectively. on the other hand, the control group’s moral distress mean score showed an increasing trend, reaching from 4.7121.048 before the intervention to 5.2750.946 and 5.1831.153 one and two months after the intervention, respectively. after the intervention, the results of repeated measures analysis of variance revealed a significant difference in the moral distress mean scores between the intervention and the control groups (p<0.001) and within the two groups (p<0.001). furthermore, a significant difference was found between the two study groups regarding the mean score of moral distress 1 and 2 months after the intervention. similar results were also obtained regarding the domains of moral distress (figure 1 and table 2). table 2. moral distress in both groups during the study period group time group time after 2 month after 1 month pre intervention moral distress mean ± sd mean ± sd mean ± sd <0.001 <0.001 0.03 control intervention control interventi on control intervention 3.14±1.33 5.01±1.13 5.11±0.89 3.26±1.08 4.62±1.08 4.32±1.02 <0.001 <0.001 0.38 2.57±1.10 4.32±1.30 4.36±1.16 2.70±0.91 3.85±1.26 3.47±0.09 domain1* <0.001 <0.001 0.09 3.07±1.15 5.04±1.00 5.22±0.87 3.27±0.88 4.66±1.05 4.18±1.12 domain2** <0.001 <0.001 0.05 3.20±1.25 5.18±0.15 5.11±0.89 0.36±0.99 4.71±1.04 4.44±1.02 domain3 *** “ignorance of the patient”, ** “patient’s decision making power”, *** “practical-professional competency” j med ethics hist med 6:5 april, 2013 jmehm.tums.ac.ir zahra molazem et al. page 5 of 8 (page number not for citation purposes)     before the intervention, in “ignorance of the patient” domain, the two items “give only hemodynamic stabilizing medication intravenously during a code with no compression or intubation” and “carry out a work assignment in which i do not feel professionally competent” revealed the highest mean scores in both study groups. in the “patient’s decision making ability” domain, the statement “follow the family's wishes for the patient care when i do not agree with them” had the highest mean score. finally, in the “practicalprofessional competency” domain, the highest mean scores were related to the items “work in a situation where the number of staff is so low that care is inadequate”, “assist a physician who in your opinion is providing incompetent care”, and “work with ‘unsafe’ levels of nurse staff”. overall, the results of the study showed that the mean score of moral distress regarding the above-mentioned domains had decreased in the intervention group, while they increased in the control group 1 and 2 months after the intervention. moreover, a statistically significant difference was observed between the intervention and the control groups and within the two groups in this regard. discussion the findings of the current study showed a high mean score of moral distress among the participants before the intervention. several studies also reported high mean scores of moral distress among nurses (13, 22, 29-31). in this study, no significant relationship was found between the changes in moral distress mean scores and the demographic characteristics including age, marital status, years of nursing experience, and average working hours in a week, before and after the intervention, which is consistent with the findings of several studies conducted on the issue (18, 31, 32). however, some other studies have revealed a significant relationship between the rate of moral distress and the nurses’ level of education (33), age (34), and years of nursing experience (35). also, married nurses tended to experience moral distress more in comparison to single ones (9). the researchers who have revealed a negative relationship between moral distress and years of nursing experience point out that as the nurses get older, they have more experience of clinical conditions, develop adaptability mechanisms, and act better in moral distress creating situations (36, 37). furthermore, as to the absence of a relationship between moral distress and demographic variables, corley et al. believes that occupational stress, job dissatisfaction, and the role of nursing managers, colleagues, physicians and the ethical environment in creating moral distress are the other factors which need to be investigated (32). the study findings showed a significant difference between the moral distress mean scores in the two groups 1 and 2 months after the intervention. in fact, the rate of moral distress had changed in the two study groups so that the moral distress mean score had decreased in the intervention group, while it had increased in the control group, 1 and 2 months after the intervention. this shows the effect of the nurses’ training and awareness about this phenomenon on reducing their moral distress. similarly, beumer’s study (2008) showed positive outcomes of educational interventions revealing that educational workshops and continuous education were of great value in reducing the nurses’ moral distress (16). educational courses bring about an increase in the individuals’ ability to time 321 e st im at ed m ar gi na l m ea ns 5.50 5.00 4.50 4.00 3.50 3.00 control intervention groups figure 1: trend of moral distress mean in intervention and control groups j med ethics hist med 6:5 april, 2013 jmehm.tums.ac.ir zahra molazem et al. page 6 of 8 (page number not for citation purposes)     cope with moral distress and enrichment of healthcare environments through the use of effective strategies (38). on the other hand, the increasing trend of moral distress in the control group shows that in case moral distress is not recognized or diminished, its complexity and severity are enhanced, leading to irreversible effects over time. a large number of researchers have also mentioned the adverse effects of unresolved moral distress, including loss of self-esteem, change in interpersonal relationships, and psychological signs such as anger, fatigue, feeling of guilt, and lack of trust in others (11, 18, 37, 39) . these findings show the necessity of more consideration on the part of the managers of the healthcare systems in order to prevent the increasing trend of moral distress among critical care nurses. the results of the present study showed that before the intervention, the highest mean score in “ignorance of the patient” domain was related to the items “give only hemodynamic stabilizing medication intravenously during a code with no compression or intubation” and “carry out a work assignment in which i do not feel professionally competent”, which is in agreement with the results obtained in the study by merghati khoei et al. (9). it should be noted that these two items had the highest mean score among all the domains. these findings show that in cases where the patients’ rights are ignored due to the nurses’ lack of professional competence or the physicians’ incorrect orders, the critical care nurses experience the highest level of moral distress. in fact, the nurses experience moral distress when they feel that they cannot provide care in a proper, principlebased manner (2). in general, nursing competence and performance are moral principles (40). on the other hand, patient care offered by novice, inexperienced individuals highly affects the quality of care (25) and together with the feeling of being inefficient as a nurse and the inability to provide care for the patients will lead to moral distress (6, 33). thus, in iran, it is necessary to assess the nurses’ clinical competence upon employment and over time and focus on their educational needs for in-service training courses in order to enhance their capabilities and skills. also, considering the effectiveness of the educational workshop trainings in reducing the moral stress mean scores in the intervention group, such workshops need to be held for nurses in iran and in other clinical departments as well. considering "ignorance of the patient" domain, the item “carry out orders or institutional policies to discontinue treatment because the patient can no longer pay” revealed the highest mean score in the study conducted by abbas zadeh et al (2011) (22), while this statement was ranked the third in the present study. in the “patient’s decision making ability” domain, the highest mean score was related to the item “follow the family's wishes for the patient care when i do not agree with them”, which is in line with the studies by merghati khoei et al. (9) and corley et al. (32). zuzelo (2007) (41) has also stated that in case what the patients want is ignored because of their families’ requests or hospital requirements, the nurses will experience moral distress (41). furthermore, observing the patients suffering due to the physicians’, hospitals’, or families’ decisions is quite painful for the nurses. as patient advocates, when the nurses see that their attempts are fruitless and they have no power to modify the physicians’ decisions in the healthcare systems, they experience moral distress (8). in the “practical-professional competency” domain, the highest mean score was obtained in the items “work in a situation where the number of staff is so low that care is inadequate”, “assist the physician who in your opinion is providing incompetent care”, and “work with ‘unsafe’ levels of nurse staff”. in the study performed by merghati khoei et al. (9), the item “assist the physician who in your opinion is providing incompetent care” was consistent with the results of the present study. in addition, the item “work in a situation where the number of staff is so low that care is inadequate” showed the highest mean score in corley’s study (32). studies have shown that when, the nurses do not have enough time for providing patient care and cannot fulfill their professional duties due to the low number of staff, they feel exhausted, weak, and guilty (42, 43). lack of sufficient nurses results in the nurses’ stress, burnout, job dissatisfaction, and physical as well as mental illness which all lead to absenteeism from work, high turnover, and low-quality care (15, 44). moreover, delay in taking effective measures due to the physicians’ inability or their slow response in critical situations also results in the nurses’ moral distress (41). the findings of the current study revealed a decreasing trend in the moral distress mean score in the intervention group, while there was an increasing trend in the control group after the intervention. furthermore, a significant difference was observed in the moral distress mean score between the control and intervention groups and within the two groups over time, which shows the effectiveness of the educational interventions in reducing the rate of moral distress among the nurses under study. corley’s scale consists of 3 domains of “individual responsibility”, “not in the patient’s best interest”, and “deception” (32). the items which had the highest mean scores in corley’s study are quite different from those showing the highest mean scores in the present study; the highest mean scores were related to the items of “ignorance of the patient” domain in this study, while the items related to the “patient’s decision making ability” showed the highest mean scores in corley’s study j med ethics hist med 6:5 april, 2013 jmehm.tums.ac.ir zahra molazem et al. page 7 of 8 (page number not for citation purposes)     (32). according to merghati khoei et al. (9), these differences result from socio-cultural variations in different nursing communities as well as the policies and regulations of the hospitals and the nurses’ working environment. he also mentions the necessity of a cultural focus on this issue in new studies. one of the limitations of the present study was sampling from one hospital, which is, of course, the main heart disorders center in shiraz, and therefore the results cannot be generalized to all nurses. another limitation of the study was its small sample size, which was due to the nurses’ working in rotational shifts as well as their high workload. finally, researchers did not have adequate control over the exchange of information between the two groups as the study was conducted on both groups simultaneously. conclusion cardiac care unit nurses experience moral distress to a great extent which will increase in case no intervention is performed to tackle it. educational interventions are necessary for identification and reduction of moral distress and ethical education can improve the adaptability strategies. in fact, cardiac care unit nurses need to recognize moral distress in their working environment and be aware of its adverse effects on themselves as well as on patient care. overall, each institute should identify and utilize the mechanisms of controlling moral distress (2, 8, 15). the “4a model” can be used for reducing moral distress, and committees can be established in hospitals in order for the nurses to discuss and solve their ethical dilemmas. authors of this study recommend that more studies with larger sample sizes be conducted in different hospital wards in the future. acknowledgement this article is the result of a research proposal approved by the shiraz university of medical sciences and health-treatment services numbered 6106-91. we would like to hereby express our gratitude to all patients and their families who assisted us in performing this proposal. references 1. kälvemark s, höglund at, hansson mg, westerholm p, arnetz b. living with conflicts-ethical dilemmas and moral distress in the health care system. soc sci med 2004; 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associate professor, faculty of nursing & midwifery, tehran university of medical sciences, tehran, iran; 2 phd candidate in nursing, faculty of nursing & midwifery, tehran university of medical sciences, tehran, iran; 3 associate professor, endocrinology and metabolism research institute, tehran university of medical sciences, tehran, iran. corresponding author: fatemeh bahramnezhad address: school of nursing and midwifery, tehran university of medical sciences, east nosrat st, tohid sq, tehran 1419733171, iran. email: bahramnezhad@razi.tums.ac.ir tel: 98 9133974856 fax: 98 21 6405 received: 4 nov 2015 accepted: 24 jul 2016 published: 23 aug 2016 j med ethics hist med, 2016, 9:9 © 2016 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract one of the major advances in medicine has been the use of cardiopulmonary resuscitation (cpr) procedure since the 1960s in order to save human lives. this procedure has so far saved thousands of lives. although cpr has helped to save lives, in some cases, it prolongs the process of dying, suffering, and pain in patients. this study was conducted to explain the experience of iranian physicians regarding do not resuscitate order (dnr). this study was a directed qualitative content analysis which analyzed the perspective of 8 physicians on different aspects of dnr guidelines. semi-structured, in-depth interview was used to collect data (35 to 60 minutes). first, literature review of 6 main categories, including clinical, patient and family, moral, legal, religious, and economic aspects, was carried out through content analysis. at the end of each session, interviews were transcribed verbatim. then, the text was broken into the smallest meaningful unit (code) and the codes were classified into main categories. the codes were classified into 6 main categories, which were extracted from the literature. in the clinical domain 4 codes, in patient and family 3 codes, in moral domain 4 codes, in religious domain 3 codes, and in economic domain 1 code were extracted. according to the findings of this study, it can be said that iranian physicians approve the dnr order as it provides dying patients with a dignified death. however, they do not issue dnr order due to the lack of legal and religious support. nevertheless, if legislators and the iranian jurisprudence pass a bill in this regard, physicians with the help of clinical guidelines can issue dnr order for dying patients who require it. keywords: physician, dnr, religion, ethics, legal, iran, directed content analysis mailto:bahramnezhad@razi.tums.ac.ir j med ethics hist med 9: 9, august, 2016 jmehm.tums.ac.ir mohammadali cheraghi et al. page 2 of 9 introduction one of the major advances in medicine has been the use of cardiopulmonary resuscitation (cpr) procedure since the 1960s to save human lives. thus far, this procedure has saved thousands of lives (1). although cpr has helped to save lives, in some cases, it prolongs the process of dying, suffering, and pain for patients (2). prolongation of the dying process, in addition to the pain and suffering, has caused fundamental challenges for the patients' families and the health care system (3). the challenges in this regard include transference of patients to the hospital, hospitalization in the intensive care unit (icu), use of equipment and facilities, intensive care bed occupancy despite urgent need of these beds by other patients, experience of severe emotional trauma by the patients and their families, moral, legal, ethical, and religious involvement, and job burnout of health care providers for patients who have less than 5% chance of survival or in case of survival will have a low quality of life (qol) (1, 4, 5). prescription of antibiotics, intravenous feeding, mechanical ventilation, and other care measures, in addition to futile care, is associated with legal, moral, ethical, and emotional challenges for the patients, their families, the treatment team, and the community (3). the purpose of a do not resuscitate (dnr) order for dying patients, is in fact to provide conditions for a comfortable death and avoid futile care measures (6). the four key ethical principles of autonomy, beneficence, justice, and non-malfeasance are important in the care of all patients. moreover, they are in compliance with the clinical ethics of the josephson forum (principles of honesty, integrity, keeping promises, fairness, compassion, respect and reverence for others, responsible citizenship, justice, accountability, and responsibility) (7). the usefulness principle shows that health care providers should consider the benefits and advantages in providing care.failure to achieve this goal will result in conflict with the principle of beneficence (8). moreover, since the task of the treatment team is respecting patient autonomy and putting an end to patients’ pain and suffering, the principle of nonmalfeasance appears to be very important. a dying patient is weak and vulnerable, and it is important that the treatment team is committed to not harming the patient during care delivery. continuing treatments that prolong life, have not been requested by the patient, and likely are not benefiting him/her, and could harm the patient; therefore, they should be discontinued (9). despite numerous discussions in this regard in many countries, the dnr issue is not completely resolved and is assigned to the physicians (as the main authorities). physicians have moral and legal obligation to explain the patient's condition to him/her and his/her family (10). they should explain the prognosis of the disease and treatments which are futile and do not benefit the patient. physicians have a duty to talk to the patient and his/her family about imminent death or intolerable disability, benefits, and medical expenses. with the consent of the patient and his/her family to start palliative care, the physician should clearly discuss interventions that prolong life and are not beneficial to the patient (11). insufficient education in this field and religious and moral issues are reasons for opposing dnr. some physicians avoid talking to the patient for the fear that such a discussion with the patient may lead to the patient’s disappointment and his/her refusal of further treatment (12). however, the most important reason for the refusal of the treatment team to perform or issue dnr order is the lack of guidelines and legal support (13). in this regard, physicians and nurses believe that having a clear guideline and legal support can play a significant role in guiding these individuals and preventing many of the challenges associated with this issue (14). in iran, few studies have been conducted regarding dnr order. the authors did not find any qualitative study, which had explored this concept from different perspectives. decision about dnr in dying patients is a fundamental skill and includes many ethical, legal, and religious challenges. perhaps, by determining the perspectives of health care providers, especially physicians, who are responsible for making the final decision in this regard, the development of a guideline suited to the islamic society of iran will be possible. therefore, this study has been conducted to determine the perspectives of iranian physicians regarding dnr for dying patients. method this study is part of a dissertation for a phd degree in nursing and midwifery approved by tehran university of medical sciences, iran. the dissertation was developed in two phases. the first phase was literature review of the development of clinical dnr guidelines in dying patients. what is expressed in this paper is part of the second phase of the study (interviews with competent authorities regarding the guideline) and it is a directed content analysis. this paper has analyzed perspective of 8 iranian physicians on different aspects of the formulation of dnr guidelines through individual semi-structured in-depth interviews. at first, based on content analysis of literature review on 6 main categories, including clinical, patient and family, moral, legal, religious, and economic aspects, guiding questions were prepared for each point of view. it should be noted that, after each question, aspects were deeply studied with the help of exploratory questions (table 1). in this study, data collection was conducted through guided or theory-based content analysis described by hsieh and shannon(15), after collecting the data, the j med ethics hist med 9: 9, august, 2016 jmehm.tums.ac.ir mohammadali cheraghi et al. page 3 of 9 table 1interview questions based on the categories extracted from the literature review categories questions clinical view • what patient do you call a dying patient? • what are the medical symptoms of death? • have you ever ordered dnr for your patients? • what are the elements involved in cpr or dnr of dying patients? patients’ and their families’ views • does the family have permission to decide on cpr or dnr of their patient? • is the family or patient permitted to question such an order? • if a family disagrees with this order, what is the decision? • if in the present context a family has such a request from the medical staff, how should they react? moral view • based on the four ethical principles, what is the role of the patient and his/her family in this decision? • should they be satisfied? • is it necessary to consult with them? legal view • does the dnr have any legal position in iran? • can the legal guardian decide on this issue in iran? • if a patient has such a request, does the medical staff have immunity in case of implementation of such an order? • can such a decision be made based on a patient's will? economic view • do economic elements play any role in cpr or dnr of patients? religious view • from the religion point of view, what are the limitations and boundaries of dnr order? • does islam allow such an order? cpr= cardiopulmonary resuscitation directed content analysis was used. in the first phase, studies and guidelines about dnr and particularly the islamic and legal principles related to decisions about dnr were reviewed without time limitation. after reviewing the literature, six categories were extracted that were the basis for setting the interview guide and output codes resulted from the analysis were placed within the categories. each interview lasted between 35 and 60 minutes, and data were collected during february-april 2015. at the beginning of each interview, the purpose of the study and the individuals’ right to refuse to participate in the study at any time during the interview were explained to the participants. in addition, oral informed consents were obtained from the participants and they were assured of confidentiality of data. at this stage, one of the participants rejected the recording of his interview by the researcher, so his interview was conducted by taking notes. the transcription of interviews was implemented at the end of each session, and the transcripts were read several times in order to achieve a correct understanding. then, the text was broken into the smallest meaningful units (codes) and the codes were classified into six main categories, which were extracted from the literature. to ensure the credibility and acceptability of the data, the continuous involvement method with the research subject was used. in addition, the participants’ confirmation was used to verify the codes; the initial codes were checked by the interviewees before categorization. to provide the coding ability in the categories, peer check was used (by the advisor, consultant professors, and two phd students). results in this study, 8 iranian physicians (4 intensivists, 2 oncologists, 1 internist, and 1 neurologist) with the mean age of 46.12 ± 8.21 participated. a total of 300 codes were extracted from the interviews and, for a conceptual approximation to categories, were summarized in 15 codes and were placed in 6 categories. futile care, burnout, fear of the law, lack of a single protocol and, protection of human dignity were the codes extracted in content analysis of texts, but other codes were also extracted during interviews with iranian nurses. clinical view the clinical view consists of independence in responding, attention to evidence-based arguments, ability to communicate with clients, and observing morality that can be achieved following individualworking environment interactions and interpersonal communication. the following 4 codes appeared in this category. a) burnout burnout is associated with lack of energy and vitality, and leads to depersonalization, lack of personal status and individual progress, and poor job j med ethics hist med 9: 9, august, 2016 jmehm.tums.ac.ir mohammadali cheraghi et al. page 4 of 9 performance. this is an emotional, physical, and mental syndrome associated with a sense of low selfesteem. [i have been embarrassed by being a physician again and again, because when you cannot do anything for your patient and see his/her suffering, you feel guilty. every time, i say to myself, this time i will quit my job and go into business. i have lots of stress and a guilty conscience, so i feel depressed and absurd] (participant no. 3). b) stereotyped care stereotyped care means repeating care without combining theoretical and technical skills. most participants believed that, today, it is impossible to offer the same treatment and cares for all based on books and articles and that treatment must be tailored to individual circumstances. [we do not have the critical thinking skills in dealing with patients, we have studied a series of articles and think that we should act based on them step by step. we never think. for example, in resuscitation, we act in such a way as if the one who invented resuscitation has prescribed it for all. the person who was the inventor of resuscitation, had tattooed no dnr on his chest] (participant no. 1). c) futile care effort and care with unattainable goals in which a degree of success is impossible, both in physiological and qualitative terms, and success or survival of patients is unknown is called futile care. [i have already performed more than hundreds of cprs that were only for show and had no results. we have to do useless cprs, of course. in the health system of our country, many measures are useless, including many cprs. even in the best hospital settings with the best staff and facilities, the success rate of resuscitation is roughly 10% to 15%, but here we resuscitate all patients] (participant no. 6). d) lack of universal protocol protocols aim to improve health care quality by reducing the costs and variety of care. moreover, in the case of a variety of clinical evidence, they assist the healthcare team in the delivery of appropriate and effective care, and generate a clear understanding of decision-making models for competent authorities. all participants in this study believed that, since there is no certain protocol in this regard, every physician acts arbitrarily. [in the field of diabetes or brain death, we have certain protocols and fixed procedures, and they really work, but not for dnr, so everyone does whatever he/she wants. of course healthcare workers are careful not to fall into a trap. for example, some choose slow code, some do cpr for 45 minutes, some do not resuscitate at all, and just write that cpr was performed] (participant no. 2). patients’ and their families’ views the patient and his/her family are the most important elements in decisions on dnr order, and without their permission, decision-making in this regard is hampered. this approach consists of 3 categories. a) freedom of guilty conscience guilty conscience is a sense associated with anxiety that is created in the unconscious mind of a person concerning the action he/she could have taken. accordingly, the participants believed that the families resuscitate their patients until the last moment to escape from a guilty conscience. [i had a 75-year-old diabetic patient who had an accident. his gcs was 3 and he was hospitalized for 2 months, during which we had to resort to dialysis. i spoke with his son and explained that he has no way back, and if he comes back, he will die in the next few days, and his qol will be zero. he was crying so bitterly and said i know that it is useless. so far, i have borrowed 10 million tomans (irans currency), but i am afraid that i will feel guilty tomorrow, and i am afraid my children will do the same with me in the future] (participant no. 2). b) preservation of human dignity human dignity is a sense of respect, value, and physical and mental integrity of individuals, and is considered one of the basic principles of patient rights. in this regard, the participants believed that one of the reasons that families agree with dnr order is to preserve the dignity of their patients. [often, families ask us to end their patient’s life by any means possible. they say we do not want our patient to die in such misery. for example, one patient was an important person and had dignity, he was a university professor; it was not permissible or fair to him that his human dignity be questioned] (participant no. 5). c) lack of awareness of the family in fact, the inability to understand and experience events, thoughts and emotions evokes cognitive reaction conditions and accidents. participants in the study stated that families are not well informed about the disease process and prognosis; therefore, they try to save their patient until the last moment. [i had a patient with breast cancer who was not well at all. she was admitted to the icu and her family was not allowed to visit her. every time they asked personnel about the condition of their patient, personnel said trust in god, she will get well if god wills it. the family had sold their entire asset with the hope of recovery of their patient. when the patient died, her family was astonished. her husband repeatedly asked: why did you not tell me that my patient cannot survive? he said: if i had known, i would not allow her, myself, and my children to suffer so much] (participant no. 7). moral view in medicine, morality is a set of ethical principles that affect the values and clinical judgment of physicians. these principles include respect for autonomy, beneficence, justice, and nonmaleficence. in the moral view, 2 codes of protecting the j med ethics hist med 9: 9, august, 2016 jmehm.tums.ac.ir mohammadali cheraghi et al. page 5 of 9 independence of patients and reliance on religious beliefs appeared. a) protecting the independence of the patient every human being has the right to decide freely without being under pressure, and with sufficient information about the measures that need to be taken. most participants emphasized the independence of patients in decision-making and considered it as the most important moral principle. [one of the most important ethical principles in medicine is respect for autonomy of the patients. the patient should give the permission. i think that healthy individuals should decide what they want to happen after their death. for instance, his/her wish should be recorded in a form like organ donation, on a card or bracelet, or as a text on his/her driving license. you cannot decide about the asset of another person] (participant no. 3). b) reliance on beliefs morality is one of the main elements of human identity. the beliefs of the general population, social contract, and religious beliefs have led to the formation of morality. [the iranian people are emotional and have always struggled to keep their patients alive by every possible means. the opposite is also true. if they were asked to sacrifice and it meant the death of their beloved patient, they would do it.] (participant no. 6). legal view law is a set of instructions that is implemented by a set of institutions, acts as a mediator and facilitator of social bonds between people, and regulates human behavior. all participants in this study considered lack of legal support as the most important principle of non-compliance with dnr. [why should we get ourselves in trouble? when the medical council and forensic medicine do not support us, why should we seek trouble? you may provide thousands of scientific arguments and even moral arguments for not resuscitating the patient, but the law will not let you go. you cannot satisfy them. organ donation has been accepted only because of legal support and nothing else] (participant no. 8). religious views religion is a set of ideas, rules, and regulations that covers all insight-related, trend-related, and ethicsrelated principles of humanity. the following 4 codes were extracted from this view. a) religion equal to logic religion consists of ways, methods, and principles that contribute to the understanding of the issues of faith, and explains religious principles. however, logic is the knowledge by which to identify and present the right way of thinking and reasoning. in fact, in this code, participants believed that faith and reason both try to show individuals the right path. [divine religions are exactly equal to wisdom and reason. when reason says a patient will not survive and his/her survival will cause damage, religion says the same. religion is not opposed to logic. for example, euthanasia is logically hated and objected, and islam and other main religions have strictly forbidden it. thus, religion and logic are homogeneous] (participant no. 2). b) miracle miracle, in the public’s view, means surprising, unusual, and supernatural events. in divine religions, it is an extraordinary and supernatural event that occurs by the power of god or his envoys, and cannot be explained through natural rules of science. [i am not a religious person, but i believe the universe can do anything. the sound of a little baby may force the universe to raise his/her end stage mother. this cannot be denied. about 10-15 years ago, i saw a car fall off a cliff and all passengers die, except a 20 days old infant without even the smallest scratch. when we see these things, we feel doubtful about dnr] (participant no. 5). c) respect for the dying persons in the islamic perspective, when a person is about to die, his/her relatives have duties. [in fact, in religious terms, it is very rewarding. if we claim to be muslims, we should act like muslims. i have passed courses in the seminary for 2 to 3 years. there are lots of traditions and recommendations about dying persons. whenever i perform cpr for a dying patient, i remember them. i swear these useless cprs are not only non-rewarding, but a sin. we must respect dying individuals] (participant no. 3). economic view hospital costs, including medical and accommodation costs, is one of the factors affecting the process of treatment, and its role is very clear. a) lack of appropriate allocation of resources [sometimes the patient’s family does not continue the treatment, because they cannot pay the treatment costs. often, my colleagues do not give rare drugs to patients who clearly will not survive only for high expenses, whether the costs are covered by the family or the government. high expenses must be prevented, we must evaluate what and where to invest, and something the iranian people are unable to do] (participant no. 6). discussion participants’ interviews were coded and placed into the categories based on the categories extracted from content analysis of the literature review. in the clinical view, the 4 codes of futile care, burnout, protection of human dignity, and lack of single protocol were extracted. from the perspective of the participants of this study, resuscitation of patients who may not survive in qualitative and psychological terms may lead to staff burnout. in this regard, embriaco et al. estimated burnout in physicians in icus to be between 20% and 60% .the main causes of burnout in these j med ethics hist med 9: 9, august, 2016 jmehm.tums.ac.ir mohammadali cheraghi et al. page 6 of 9 physicians were workload, frequent communication with colleagues and patients’ families, and futile care (16). hamric and blackhall found that the main reason for burnout in physicians is moral challenges in the icu atmosphere(17) .physicians participating in the study believed that sometimes their efforts are not in line with their clinical commitments, have no benefit for their patients, and are considered futile (17). in this regard, wilkinson and savulescu believe that, although the decision to discontinue or not to start a medical treatment has excessive complexity and high load of value, physicians are morally responsible to stop treatments that are futile or not beneficial enough for patients (18). the stereotyped care code was consistent with the findings by brindley (3). this study emphasizes on performing cpr individually. cpr should be performed based on the patient's condition, the medical team agreement, and consent of the patient and his/her family, not based on theoretical findings in books and articles (3). o’neill et al. stated that care services have inferior quality in nursing houses and are not performed according to the patient's needs and desires, but are repetitive and routine (19). in this regard, papes et al. believe that routine intervention is a serious defect in nursing (20). they believe it should be replaced by patient-oriented care with an emphasis on maintaining the patient’s integrity and unique needs, along with the provision of specialized nursing process (20). the researcher did not find any studies on stereotyped care in medical treatment. huang et al. performed a study on a protocol for dnr in dying patients (21). their findings showed that patients with dnr order have lower rates of oxygen consumption, inotropic drugs, chest x-rays, dialysis, and antibiotics consumption, and the order reduces unnecessary and futile care in these patients (21). song et al. in a study on decisive factors in dnr among cancer patients in korean hospitals, found a significant relationship between the level of awareness in the family and acceptance of dnr (p <0.05) (22). downar et al., after 44 semi-structured interviews with dying patients, stated that patients with higher level of awareness are more likely to accept dnr (23). physicians who participated in the study believed that families accept dnr order to preserve the human dignity of their patients, and accept the order if they are recommended to do so. lee et al. performed a study on the protection of human dignity entitled "awareness and ethical attitudes toward dnr for cancer patients" (24). they concluded that 41.1% of cancer patients and their families accept dnr to maintain human dignity and ensure a dignified death in their patient (24). mularski et al. performed a study on the quality of death in the icu from the perspective of family members (25). they argued that the main reason for acceptance of the dnr order by family members was to ensure a dignified and peaceful death for the patients and protect their human dignity (25). on the code of freedom of guilty conscience in family members, the researchers did not find any studies. however, kelly believes that physicians and nurses feel guilty when ordering the slow code in cases where resuscitation is useless for patients (26). in medical procedures, different wishes and opinions are involved in decision making; thus, each one may have a level of autonomy. by the early twentieth century, medical practice was based on a sort of patriarchy. this means that physicians had the right to act as a father based on the medical condition of the patient, and perform treatments even if they were not accepted by the patients. however, today, the patient has autonomy, independence, freedom, and respect, which are considered the principles of medical ethics (27). the finding of this study showed that physicians pay special attention to the principle of patient autonomy. nevertheless, pellegrino (28) and rachels (29) argued that in western countries, respecting the principle of independence is largely accepted, whereas in other cultures, including that of middle eastern countries, sometimes the physician or the patient's relatives limit the patients’ independence. if dnr is requested by a patient, in order to respect the principle of patient independence, this must be accepted by the medical staff (30). curtis and burt conducted a study on informed consent and the dnr order (31). they found that some physicians prefer to implement dnr order without the informed consent of the patients due to lack of legal support. in many countries, even obtaining an informed consent from the patient is not considered a legal support for the physician (31). some physicians may insist on life prolongation measures for religious reasons. however, this is contrary to the principle of morality, and the physician must listen to the patient’s request, even though he/she may oppose it for religious reasons (32). also frost et al. believes that one of the main reasons that may prevent patients from accepting dnr is religious beliefs. people who have strong religious beliefs are less willing to accept dnr (33). according to pentz et al., the main reason for starting the debate on dnr is physicians’ beliefs (34). from the economic view, participants believed that millions of national capital is annually spent on useless resuscitations. karnik et al. believe that the influence of economic factors on decision-making about dnr is inappropriate, and financial problems should not have a role in decision-making in this issue (35). in the health system, resources are sometimes allocated based on patients’ demands, rather than their real needs, while the allocation of resources in j med ethics hist med 9: 9, august, 2016 jmehm.tums.ac.ir mohammadali cheraghi et al. page 7 of 9 the health system must cover the real needs of individuals. especially in recent years, in which the health reform plan has been implemented, the researcher believes that the fair and equitable allocation and distribution of health facilities is very important. therefore, planning for the use of health resources for preventive measures may be necessary. lack of access to competent individuals who had completed specialized courses was one of the limitations of the research. however, the researchers tried to study experts who met the criteria (clinical specialists in this field who had scientific publications on the subject). nevertheless, researchers often did not have access to these specialists. in addition, since this issue has moral challenges, the participants did not wish to speak in this regard in the early stages and preferred not to talk about their personal experiences. however, the researchers tried to solve this problem by assuring them of the confidentiality of the information. conclusion according to the results of the present study, it seems that physicians believed resuscitating some patients is useless and often resuscitating a patient who has no chance of survival compromises his/her dignity and creates many challenges for healthcare system. it seems that developing a clinical guideline with legal support can resolve many problems of the dnr order. in fact, developing an islamic-iranian guideline can prevent the implementation of futile and useless care. it is suggested that more research be conducted on this subject to determine the perspectives of other health care providers as well as lawyers, clerics, patients and their families in order to make an accurate decision about dnr order. acknowledgment this article is part of the research project number 9203-28-24249 approved by tehran university of medical sciences. the authors are grateful to the vice-president of research of the school of nursing and midwifery of tehran university of medical sciences, and the cancer institute of i.r iran and the cancer research center. conflict of interest the author(s) declare that they have no conflict of interests. j med ethics hist med 9: 9, august, 2016 jmehm.tums.ac.ir mohammadali cheraghi et al. page 8 of 9 references 1. park yr, kim ja, kim k. changes in how icu nurses perceive the dnr decision and their 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studies in ethics and rights, mumbai; 3mbbs and editor, indian journal of medical ethics; 4md and associate professor, kem hospital, mumbai; 5md, professor, d y patil medical college and research centre, mumbai; 6ma. and junior researcher, centre for studies in ethics and rights, mumbai corresponding author: rakhi ghoshal e-mail: rakhi.ghoshal@gmail.com  received: 06 sep 2012 accepted: 14 jan 2013 published: 23 jan 2013 j med ethics hist med, 2013, 6:2 http://journals.tums.ac.ir/abs/22985 © 2013 rakhi ghoshal et al.; licensee tehran univ. med. sci. abstract understanding  the  complexities  of  a  provider‐patient  relationship  is  considered  to  be  of  critical  importance  especially in medical ethics. it is important to understand this relation from the perspectives of all stakeholders.  this article derives from a qualitative study conducted across six obstetric care providing institutions in the cities of  mumbai and navi mumbai, india, over a period of 10 months. thirty obstetricians were interviewed in‐depth to  understand what they perceived as the most important aspect in developing a good provider‐patient relationship.   the study found that while most providers highlighted the point of communication as the most critical part of the  provider‐patient relationship, they admitted that they could not engage in communication with the patients for  various reasons. obstetric consultants and residents said that they were too overburdened to spend time com‐ municating with patients; providers working in public hospitals added that the lack of education of their patients  posed a hindrance in effective communication. however, providers practicing in private institutions explained that  they faced a challenge in communicating with patients because their patients came from educated families who  tended to trust the provider less and were generally more critical of the provider’s clinical judgement.   the article shows how provider‐patient communication exists as an idea among medical providers but is absent in  daily clinical practice. this gives rise to a discourse shaped around an absence. the authors conclude by decoding  the term ‘communication’ – they read the word against the context of its use in the interviews, and argue that for  the providers ‘communication’ was not  intended to be a trope towards setting up a dialogue‐based, egalitarian  provider‐patient relationship. providers used the word in lieu of ‘counselling’, ‘guiding’, ‘talking to’.   it concludes that, despite the providers’ insisting on the significance of communication and complaining about its  absence, what they desired in reality was not the possibility of a dialogue with the patient or a chance to be able to  share decision‐making power with the patient, but to be able to provide better instructions and chart out what  was best for them in a more detailed way.    keywords: communication, provider-patient, counselling, india rakhi ghoshal et al. j med ethics hist med 6:2 jmehm.tums.ac.ir january, 2013  page 2 of 8 (page number not for citation purposes)     introduction disbursal of medical care involves two people – the provider of care and the patient. of these two people at the two ends of the relation, one is sick, diseased, in pain and in need of care and intervention while the other is empowered with the skills and resources to alleviate the suffering. consequently a power-imbalanced relationship is often set up between these two (1-5). the nature of the relationship between the provider and his/her patient has been variously interrogated and critiqued for oppressing the voice and autonomy of the patient (6). generating consensus on the definition of an ethical provider-patient relationship is difficult, especially since ethics is context-based, contingent (7, 8), dynamic and changing in nature. within a modern, liberal framework, the emphasis has remained on the patient’s agency and autonomy (9). but contexts such as india and other parts of south asia call for a different paradigm to critically evaluate and understand the provider-patient relationship (10, 11), the argument being that the tenets of the liberal and individualistic framework do not necessarily apply to community based, postcolonial contexts. however, notwithstanding the differences between the western and eastern contexts, an emphasis on communication between the provider and the patient has remained strong in both (5, 12, 13). in fact, in india, especially in the media coverage, one keeps coming across grievances forwarded by patients, their relatives and also civil society organizations alleging that doctors are not communicating enough. the three critical purposes of communication identified are (i) creating a good interpersonal relationship, (ii) exchanging relevant and required information, and (iii) making treatment-related decisions (14). it is understandable that it might not always be practically possible for the patient to understand the criticalities of a medical situation and participate with equal and full knowledge; however, the nature of the dialogue expects that she be informed to the best of her cognitive and intellectual abilities so that she is maximum empowered to participate and can exercise a state of enhanced autonomy (9, 15). this is what mostly guides a society’s expectations from medical care providers. however, understanding what providers themselves expect from the provider-patient relation is also of significance, although this perspective is scarcely documented. having identified the lack of documentation of provider perceptions, the authors conducted a qualitative study among obstetric care providers across six care providing institutions in mumbai and navi mumbai, india. one of the objectives of this study was to understand what obstetric care providers perceived as the most important constituent of an ethical provider-patient relationship. the rationale of the study was that an in-depth and analytic documentation of provider perceptions would offer valuable insight – from an essentially insider’s view – into their perceptions and consequently aid in further informing the discipline of medical ethics, especially in contexts like india where perceptions of care-providers have been scarcely documented. method this article is based on the in-depth interviews of 30 obstetricians from the study sample. on an average an interview lasted for 60 minutes. a convenient method of sampling along with snowball method was used. the interview team consisted of three social science researchers. the following table (1) shows the range of institutions covered by the sample and it is evident that the study sought to include providers in high-end, tertiary care centres as well as those practicing in small, private individual set-ups often with limited or no emergency support. table 1: a profile of the obstetric care providing institutions in the study institutions owned by a private individual or a family with around 10 maternity beds 2 institutions owned by a registered charitable trust and run on the principle of cross-subsidy on a non-profit basis, with around 60 maternity beds 2 institutions owned by the state or the local civic body and offering free/subsidized maternity care services, with between 100-150 maternity beds 2 total institutions sampled 6 the rationale for choosing this wide range of institutions was two-fold: (i) the sample is a near representation of the different types of institutions that offer obstetric services in india, and (ii) the different sizes and structures of the set-ups were expected to shore up the differences in how institutional structures inform the day-to-day practice of obstetric care, day-to-day decision making and negotiations with authorities, and also to see how perceptions of emergency, criticality and ethics change with the context. the following table (2) shows designations of respondents and their hierarchy within medical practice at large. rakhi ghoshal et al. j med ethics hist med 6:2 jmehm.tums.ac.ir january, 2013  page 3 of 8 (page number not for citation purposes)     table 2: profile of respondents vis-à-vis their designation public/civic-run institutions private/non-profit institutions private individual owned maternity homes total professors/associate professors 5 4 9 resident doctors/post graduate medical students 7 5 12 obstetric consultants in non-teaching institutions 4 2 3 9 total 30 a broad idea of the relative positions of each category becomes important – especially the hierarchy between the professor/associate professor and the resident doctors – as the findings of the study will substantiate. the next table (3) shows a sex-disaggregation of the respondents. table 3: demographic profile of the providers: public healthcare sector private healthcare sector total male respondents 5 6 11 female respondents 9 10 19 however, since there was no difference in responses between the female and the male providers, data analysis has not been done based on the sex-identity of the respondents. there were differences between the public sector providers and the private sector providers, and the discussion focuses on that. a semi-structured questionnaire was used for the interviews. the first section of the questionnaire focused on basic biographical details of the respondent while the latter section probed the respondent on themes related to the study objectives. some of the themes included: issues providers have to deal with on a regular basis, perception of the practice of care in his/her institution, ethical decisions that need to be taken regarding having caesarean section deliveries, induction of labour, administering of epidurals, decisions and challenges of an emergency referral, and the ethics of the provider-patient relationship. this article is based on the providers’ deliberations on the final theme – their perception of an ethical provider-patient relationship. written informed consent was taken from the heads of all institutions and from the individual respondents. a separate written consent was taken from each respondent for audio-taping the interview; in the few cases where it was not permitted, hand written notes were maintained by one of the researchers on the interview team. each respondent was handed back a cd of the taped interview. identities of respondents were not shared with the institution management committees and all names were duly anonymised. data, collected over ten months (september 2010 – june 2011), was coded with the qualitative software coding tool weft qda. for the primary round of coding, broad codes were identified and marked, the cues for which were mostly taken from the questionnaire. in the next round the themes were further coded. in order to ensure privacy for the respondents and the six institutions, separate codes were developed. the study was cleared by the respective institutional ethics committees (iec) of each institution and by the consultant-owners of the smaller private maternity homes. it was also approved by the independent iec of the researching organization. results on the issue of what constituted the crux of an ethical provider-patient relationship, most frontline providers emphasized effective communication. it was explained that communication between the provider and the patient is of crucial importance. a healthy provider-patient relation draws its strength from communication. there was a general perception that a lot of untoward incidents – including the very common instance in india of relatives becoming chaotic and rowdy – can be tackled if sustained and healthy communication has been set in place with the patient and her relatives. “communication plays a very important role … when miscommunication happens, it can be corrected through [communication]. sometimes patient’s relatives create problems. but i think if we communicate properly, half of the problems are solved easily. so communication is important and administration support also plays important in such cases.” [associate professor in a trust-run private teaching hospital] some of the senior obstetricians – associate professors and professors – expressed that the young doctors of today often lack the skills in rakhi ghoshal et al. j med ethics hist med 6:2 jmehm.tums.ac.ir january, 2013  page 4 of 8 (page number not for citation purposes)     communicating with patients and they do not appreciate its importance either. however, communication is an aspect that should not be ignored by young medical students. “they [providers] should be trained to how to talk to patients, how to behave with patients, on giving them information, [residents should learn] to talk in different ways … the tone, the language, all are very important.” [head of the department of a public teaching hospital] however, when the researchers spoke with the residents, it emerged that most residents placed a premium on communication. a fact unique to the department of obstetrics-gynaecology was that patients were not seen only at the time of admission but over a span of several months, thereby allowing providers the time to develop a bond with the patient, get acquainted with her family history and her non-obstetric medical history. for some residents, this particular feature of the speciality had a special appeal. they realised that for sealing this bond with the patient, communication was the cement. “i should be able to develop a good relation [with the patient], the wave length of the patient should match with the doctor’s. it is not only about nine months and then delivering and going. sometimes she may be requiring some contraceptive advice … she might want to have some information about something sexual intercourse with her husband. all these things can be taken care of better if the patient has developed that kind of comfort level with the doctor. if i give her that space and that much time, probably she will open up. it will help her as well as me.” [senior resident in a public hospital] but despite this insistence on the importance of communication, when it came to the reality of daily practice, a gap emerged. after emphasizing the importance of communication, providers went on to explain why they were not able to focus on communication in daily practice. communication impeded: workload and overcrowding as in several other countries, teaching hospitals in india offer free or subsidized treatment and service to patients. however, after the 1990s (which marked the globalization phase), the healthcare sector got broadly divided into the private and the public; the private is mostly a forprofit sector where the patient’s purchasing power decides the quality and coverage of medical treatment/intervention she will receive. the public healthcare sector, though gradually diminishing in scope and coverage, continues to provide free or subsidized services. nevertheless, with the state also promoting private investors in the healthcare market, the quality of public hospitals have kept deteriorating for lack of funds and other required resources. this has also led to a division among the patient population – the affluent and economically affording ones avail of the private sector service and the public sector is accessed by the poor who have little or no purchasing power. this does not mean that public hospitals in india are sparsely populated; with over half the country’s population thriving below the poverty line, the public healthcare sector – despite its poor resources and low quality – is crowded with patients. the obstetric wards in public tertiary hospitals – in the study sample – saw around 12 to 15 deliveries a day on an average. providers working in public hospitals echoed the importance of communication with patients, but added that the large volume of patients did not allow them the time for it. a professor-consultant at a teaching hospital said that there were several reasons why providers could not spend time with patients as desired – “the work load is too much high … the patient volume is high in the hospital … infrastructure provided is also not very good” – pointing to the detrimental combination of workload and poor resources. another provider in this hospital complained that the out-patientdepartments (opd) are always chock-a-bloc with patients: “an opd is an opd, no matter which hospital. some of us see 100 patients in one slot [of three hours]. it’s crazy! how will you talk [to patients]?” residents too shared this view: “workload is a lot over here. as i have said patients from all over the city and even the country come over here. people from other states are told that [this] is a good hospital, and we do not have a right to refuse any patient. whichever state the patient comes from, in whatever state and wherever, we have to take the patient. so that way the work load is more, […] it being a tertiary institute and having other faculties like medicine, blood bank and everything else. work load increase because of that.” [senior resident in a public teaching hospital] most senior consultants in public hospitals complained about the crowd they have to deal with on a daily basis, along with poor infrastructure. yet their stress on the desirability of provider-patient communication underlined the importance medical providers attach to it. when we asked them how this issue could then be addressed, they said that residents should take up this duty: “residents should communicate [with patients] anyway. they are residential. they are residents, they are here,” said the head of the department in the public teaching hospital. the point that in general, over the past couple of decades the overall standard of medical graduates in india has deteriorated was especially emphasised by consultant-professors in rakhi ghoshal et al. j med ethics hist med 6:2 jmehm.tums.ac.ir january, 2013  page 5 of 8 (page number not for citation purposes)     teaching medical hospitals. it was mentioned that residents are now more detached from patients than they used to be in earlier generations. as the head of the department of the public teaching hospital said, “the present generation of young doctors … it is deteriorating. […] the doctors who are coming out of medical colleges are turning out worse and worse, knowledge, skills, attitude”. the suggestion that residents should spend more time communicating with patients came in as a double-edged solution to the problems of the existing lack of provider-patient communication and to enhance the communication skills of residents in general. providers were of the opinion that a lot of violence perpetrated by relatives at the hospitals can be avoided if a prior good relation has been set up with the patient, and so they did not want to compromise on this aspect of a good provider-patient relation. “we should teach [our juniors] how to talk to the patients, how to respect their feelings. if the patients are asking the same question again and again how to tackle the patients. we write in english so there should be somebody to explain the patients what to do. the doctors should write the prescription and the other person should take up the work of explaining it to the patients. to talk in the patients' language is important. then the patients would be happy.” [head of the department of a teaching hospital] communication impeded: residents are too busy residents are certified medical graduates pursuing a specialised postgraduation. the residents interviewed in the study were either in their second or their third/final year of postgraduation. attending to patients in the opds and the wards, treating patients, assisting seniors in surgeries and conducting some surgeries form part of their syllabus. technically the residents are on-call or on emergency duties round the week. they often did not get time to even take a bath a day or have a meal at leisure. also, given their positions on the lower rungs of departmental hierarchy, negotiating between mandated training and outsourced pressures from seniors was a tough call. in talking of her experiences as a resident in a tertiary level public teaching hospital, a resident shared: “it was a bit difficult in the first six months. two to three times i thought that i should leave and go as i cannot handle the pressure. the work load is a lot […] especially in gynaecology department as we do not have any fixed time. they can call you at any time of the day or night. you could keep working three days or four days. you could not to go to your room to sleep.” [senior resident in a public teaching hospital] added to these impediments was the lack of cooperation from the hospital class-iv staff 1 . residents thus often ended up doing the “running around” (going to the blood bank to get a matching blood type, taking the patient for a sonography, etc.) in order to save time. a senior resident said: “i never interact with servants. it is difficult making people work. we at times yell at them, blackmail them and … maybe just do the work ourselves.” another resident asked rhetorically, having described a typical day at work, “where is the time to talk to a patient?” in this context, where residents were always on a mode of hurrying and running around, their priority became clinically treating each patient, and ensuring that there was no mortality. doing anything beyond this was a luxury in terms of time, which they could ill afford. consequently, notwithstanding the importance accorded to communication, in reality it failed to exist as part of normative practice. with both consultants and residents saying that it was not possible for them to expend time or energy on communication, there was an impasse. communication impeded: lack of patients’ education according to public hospital providers, the lack of education of patients added to the hurdles in communication. patients who came to the public hospitals were poor, mostly uneducated and even illiterate. women who came in for check-ups did not often remember the date of their previous menses, a lot of them did not understand the importance of antenatal check-ups and came to the hospital straight away for delivery, at times with a malformed foetus that could well have been screened earlier. adding to this was the fact that in so many households in india, till date, the woman – despite being the one requiring the medical intervention – has not much say, and decisions are made for her, usually by the husband or mother-inlaw. explaining the exasperation that such encounters bring on, a consultant said: “i tell her [the patient], ‘you tell me now, what have you understood?’ half the time i realize they have not understood only! either they were not listening or after telling everything they ask me to tell it to their husbands. … i know these indian women usually don’t take decisions, our society doesn’t let the indian women to take decision and she is brought up in such a way. […] it’s then better that i directly tell her husband what the problem is.” [professor in a public teaching hospital]                                                              1 class-iv staff, also known as group-d staff includes the employees of the institution who are responsible for tasks such as maintaining of files, docketing of letters, serving food to the patients, helping with stretchers, taking patients for getting tests done, getting matching blood samples back to the ward, etc. rakhi ghoshal et al. j med ethics hist med 6:2 jmehm.tums.ac.ir january, 2013  page 6 of 8 (page number not for citation purposes)     another senior consultant in a public tertiary hospital said: “see, counselling fails when the ideas and beliefs are very strong … and illiteracy adds to the problem. medical literacy is low. see, the patients who come here to this hospital, they are not that educated. they come from socially backward families. they have no understanding of what has happened.” [consultant in a public hospital] public hospital providers held the view that more education would solve the problem since patients would then come having some basic idea about their body, about their pregnancies and about possible obstetric complications. communication would also be easier with educated patients, especially when providers do not have much time on their hands. however, private sector providers, who mostly have patients from urban, affluent, educated backgrounds, had a counterpoised view on this issue. for them, education could at times add to barriers in effective provider-patient communication. communication impeded: ‘too-much’ access to information most patients accessing the private obstetric institutions were tech-savvy and intellectually equipped to look up the internet, go through online medical literature and reasonably comprehend it. they also were more inclined towards consulting more than one provider and come to certain conclusions on their own. and when these independently formed ‘ideas’ became a tool to question the provider’s decision and judgement, it caused much discomfort for the latter. “initially people did not have access to medical literature, would come to us and believe what we said. now situation has become like this that patients have become literate but are half literate. no non-medical person will have complete picture about medical illness. they receive half or distorted information. […] their knowledge is half baked. they read up on the internet which only provides a brief account or summary of the disease, if they try to go into details they will not understand. if they have doubts they should consult with the doctor!” [head of department, private tertiary hospital] a middle-level consultant added: “too much of education becomes a problem. reading up some stuff on the internet will not help at all.” from the perspective of these providers, ‘too much education’ and ‘easy access to information’ were creating a situation where the patient was becoming more autonomous than either desired or preferred. it was empowering the patient in a way that was not desired by providers. this meant such patients would ask more questions, be satisfied less easily, take up a lot more time, and want the provider to be more accountable. it also implied that such patients would trust the provider much less and remain more skeptical of his clinical and diagnostic skills as compared to those who were uneducated, had no access to medical information and so were bound to trust what the provider said. in india, even though medicine gets understood, deployed and practiced as an empirical, evidence-based and objective science, subjective and nondocumentable aspects like the patient’s trust and faith in the provider and in his judgement, remain critical for a successful practice of medicine. as a departmental head in a private hospital added: “once you come to a doctor you must come with full faith, there can be difference of opinions but when you have full faith you can take decisions.” provider-patient communication: decoding ‘communication’ having documented (i) providers’ perception of an ethical provider-patient relationship, and (ii) the reasons why no provider could actually communicate with patients, this section will analyze the term ‘communication’ in the context of its use by these providers. it is important to mention here that all interviews with doctors and residents were conducted in english. occasionally regional phrases were used in some sentences, but the quotes that were analyzed for this research article include no english translation. the word ‘communication’ was used by providers themselves during the interviews. during a close reading of the contexts in which the term/concept of ‘communication’ was evoked by the providers, it emerged that the term was being used interchangeably with the terms ‘counselling’, ‘guiding’ and ‘talking’. in describing situations that impede communication, in describing how providers would want to communicate in an ideal situation, it emerged that communication implied a mode of instructing patients. instructions for when to come for the next antenatal check-up, what routine tests to undergo, when to get admitted for delivery, how to take medication, what to do in case some obstetric emergency arose while the patient was at home. providers told them what was good for them, since these women, especially those in the public hospitals, were believed to be clueless about their own physical well-being and to have no understanding of their bodies. “when i see a patient in an outpatient clinic i tell her everything about the treatment, about the problems, about the requirements. usually she will have no clear idea of what’s best for her. […] counselling i will have to do.” [consultant in a public teaching hospital] in order to accommodate the volume of patients in public hospitals, patients (especially those who rakhi ghoshal et al. j med ethics hist med 6:2 jmehm.tums.ac.ir january, 2013  page 7 of 8 (page number not for citation purposes)     came in for their antenatal check-up) were often addressed together in groups of eight or 10. “counselling is very important, […] but we cannot afford to give so much time to a patient in the opd. one to one counseling is not possible. suppose i have to counsel a patient about contraceptives or sterilization … what i do in the opd is to gather maybe a group of patients tell them what to do.” [senior resident in a public teaching hospital] when the researchers were asked if a patient is allowed to ask any specific question during these group sessions, the resident said that she can if she wants to, “but they do not.” discussion providers in the study stressed on the ethical importance of developing a relation with the patient that is based primarily on communication. they also explained why they were not able to attain such a relation. reasons included issues related to lack of infrastructure and of other resources, problems of overwork, volume of patients, lack of education of patients and also at times the patients’ access to easy information on clinical issues. an analysis of the context in which providers used the word ‘communication’ led the researchers to argue that it was used synonymously with counselling, talking and instructing. this peculiar usage of the word is important, since, as the researchers argue, it throws light on the nature of the provider-patient relation that providers want to develop. theories in philosophy explain communication between two people as a dialogic, two-way mode of exchange of information, views and decisions. consequently, communication is expected to bring about a balance in power and knowledge between the two people involved. it is also supposed to have both these people alternate their roles as listener and speaker (17, 18). counselling, on the other hand, is usually a one-way flow of instruction, guidance, suggestion and help (19). in the counselling model, there is a knower and a known. the knower is the one with access to more knowledge, who wields more power. in comparison the person who is the known lacks in knowledge that pertains to her state of being, her illness, her body, and so has less control of the situation. the knower is expected to be sympathetic and concerned about the well-being of the known, and to decide the right and correct course of action for the latter (17). the british association for counselling and psychotherapy described the process of counselling as “an interaction in which one person offers another person time, attention and respect, with the intention of helping that person explore, discover and clarify ways of living more successfully and towards greater well-being”. so in counselling, the patient – who plays the role of the known – is bereft of decision-making capacities and power over her body. what the authors show is that when providers used the term communication, they were not talking about a power-balanced, egalitarian relation with the patient, where the agency and authority for decision-making was to be shared with the patient. the providers were actually talking about counselling; it was an expression of regret over the fact that they could not afford more time and resources to better instruct the patients. the providers wanted to satisfactorily guide patients on their problems, course of treatment, clinical dangers, prognosis, antenatal and postnatal care, contraception and sterilization. the article showed that, despite providers’ insisting on communication and complaining about its absence, what they desired in reality was not the possibility of a dialogue with the patient or a chance to be able to share decision-making power with the patient, but to be able to provide better instructions and chart out what was best for her in a more detailed way. clinical decisions were made either between providers or between the provider and the hospital management. “decision-making is a discreet event” (16) and neither patients nor their relatives were allowed to be part of the discretionary process. in the existing frame of things, the best interest of the patient was expected to be known only by the provider. conclusion understanding providers’ perceptions of the coordinates of an ethical provider-patient relation is critical in mapping the holistic picture of providerpatient interface. while patients’ perceptions of the relationship have been studied, mapping the providers’ perceptions in the indian context has rarely been done and more such studies need to be conducted. this qualitative study represents the perceptions of a section of providers who practice obstetrics in hospitals in urban india. it is intuitively felt that perceptions of providers – of the same issue – would be very different in a rural context. a limitation of the study is that even within the urban space, the sample did not include tertiary superspeciality corporate hospitals. this particular category of care providing institution has come to shape india’s healthcare sector in a major way, especially over the last two decade. the study did seek permission from some of these hospitals for access, but permission was not granted by any of them. the authors have concluded from informal sources that the dynamics of clinical practice and of care would have shored up yet another dimension to the ethics of provider-patient relationship in the corporate multispeciality hospitals. a second limitation is that despite all intentions and even attempts, the researchers failed to go back for a second interview with some respondents. this was rakhi ghoshal et al. j med ethics hist med 6:2 jmehm.tums.ac.ir january, 2013  page 8 of 8 (page number not for citation purposes)     largely because of the tight schedules of the respondents who, though keen, could not spare the required time for a second round of interview. the researchers are of the opinion that certain issues might have been even better analysed with further interaction with respondents. however, this also opens up scope for further research into this area of enquiry. acknowledgement the authors want to acknowledge nobhojit roy, sundari ravindran, aditi iyer, helen sheehan, emma pitchforth and fatima castello for their suggestions at various stages of the study and during the writing of this research article. they would also like to acknowledge the wellcome trust, u.k for funding the study. references 1. szasz t, hollender mh. the basic models of the doctor-patient relationship. in: henderson g, king n, et al, eds. the social medicine reader. university of north carolina: duke university; 2000, pp. 278-286. 2. balachandran s. patient autonomy, advocacy and the critical care nurse. issues med ethics 2001; 9(3): 82-3. 3. portmann j. physician-patient relationship: like marriage, no romance. west j med 2000; 173(4): 279-82. 4. fochsen g, deshpande k, thorson a. power-imbalance and consumerism in the doctor-patient relationship: health care providers’ experiences of patient encounters in a rural district in india. qual health res 2006; 16(9): 1236-51. 5. ganesh k. patient-doctor relationship: changing perspectives and medical litigations. indian j urol 2009; 25(3): 356-60. 6. kalantri sp. informed consent in public hospitals. issues med ethics 2000; 8(4): 116-7. 7. christakis na. ethics are local: engaging cross-cultural variation in the ethics for clinical research. soc sci med 1992; 35(9): 1079-91. 8. anonymous. the relativity of ethics in philosophy of nature. http://physicalspace.wordpress.com/2009/03/19/the-relativityof-ethics/ (accessed in 2012) 9. chin jj. doctor-patient relationship: from medical paternalism to enhanced autonomy. singapore med j 2002; 43(3): 15255. 10. chattopadhyay s, raymond dv. bioethics concerns are global, bioethics is western. eubios j asian int bioeth 2008; 18(4): 106-9. 11. have ht, gordijn b. travelling bioethics. med health care philos 2011; 14(1): 1-3. 12. pandya sk. doctor-patient relationship: the importance of the patient’s perceptions. j postgrad med 2001; 47: 3-7. 13. swaminath g. doctor-patient communication: patient perception. indian j psychiatr 2007; 49: 150-3. 14. ong lm, de haes jc, hoos am, lammes fb. doctor-patient communication: a review of literature. soc sci med 1995; 40(7): 903-18. 15. quill t, brody h. physician recommendations and patient autonomy: finding a balance between physician power and patient choice. ann intern med 1996; 125: 763-9. 16. lakshmi k. the ‘intractable’ patient: managing context, illness, healthcare. in: zachariah a, srivatsan r, tharu s, eds. towards a critical medical practice: reflections on the dilemmas of medical culture today. hyderabad: orient blackswan; 2010, pp. 226-45. 17. moitra s. feminist thought: androcentrism, communication, objectivity. kolkata: munshiram manoharlal publishers pvt ltd; 2002. 18. das a. towards a politics of the [im]possible: the body in third world feminisms. london: anthem press; 2010. 19. feltham c. what is counselling. london: sage publications; 1995. ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ original article copyright © 2021 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e nurses' attitudes toward caring for terminally ill neonates and their families in iran: a cross-sectional study *corresponding author marjan kouhnavard address: no.62, children’s medical center, gahrib st., tehran, iran. postal code: 1419733151 tel: (+98) 21 66 92 09 83 email: mkouhnavard@razi.tums.ac.ir received: 29 jul 2020 accepted: 1 feb 2021 published: 16 feb 2021 citation to this article: kadivar m, mardani-hamooleh m, kouhnavard m, sayarifard a. nurses' attitudes toward caring for terminally ill neonates and their families in iran: a cross-sectional study. j med ethics hist med. 2021; 14: 4. maliheh kadivar1, marjan mardani-hamooleh2, marjan kouhnavard3*, azadeh sayarifard4 1.professor, department of pediatrics, nursing and midwifery care research center, children’s medical center, tehran university of medical sciences, tehran, iran. 2.associate professor, nursing care research center, department of psychiatric nursing, iran university of medical sciences, tehran, iran. 3.researcher, department of pediatrics, children’s medical center, tehran university of medical sciences, tehran, iran. 4.associate professor, center for academic and health policy, tehran university of medical sciences, tehran, iran. abstract providing care for terminally ill neonates is an important issue in nicus. this research aimed to determine nurses’ attitudes toward providing care for terminally ill neonates and their families. a total of 138 nurses working in neonatal intensive care units (nicus) affiliated to tehran university of medical sciences participated in this cross-sectional study via convenience sampling in 2019. the data collection tool was the frommelt attitudes toward caring for terminally ill persons and their families scale. the nurses in this study had the most positive attitudes toward the items “nursing care should include the family of the terminally ill patient, too” (4.2 ± 0.6) and “the care provider can prepare the patient or his/her family for death” (4.1 ± 0.7). the nurses had the least positive attitude toward the item “the time spent on caring for terminally ill patients creates a sense of frustration in me” (1.06 ± 1). the mean score of the attitudes of nicu nurses toward caring for terminally ill neonates and their families indicates the necessity of improving this attitude. keywords: end-of-life care; family; terminal care; neonate; nurse; nicu. nurses’ attitude toward caring for terminally ill neonates and their families in iran: a cross-sectional study 2 j med ethics hist med. 2021(feb); 14: 4 jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e introduction the development of neonatal intensive care units (nicus) has caused new problems for the caring staff working in these wards. one of these problems is related to the provision of advanced care for neonates with poor prognoses (1). accordingly, one of these advanced care modalities is end-of-life care provided for terminally ill neonates (2). this type of care is considered standard practice in nicus (3). while providing therapeutic interventions for terminally ill neonates, caregivers suffer from the pain neonates might feel (4). therefore, some countries like france have regulated rules to avoid performing therapeutic interventions in the late stages of life to respect human dignity and decrease the neonates’ discomfort. it seems that these rules help care providers to make therapeutic decisions in the late stages of patients’ lives. however, these rules can pose certain ethical challenges; for example, there is a probability of survival of neonates with brain tumors following a period of maintenance therapy (5). it can be stated that decision-making about life prolonging treatments for neonates hospitalized in nicus has led to a conflict among care providers, which makes it difficult to decide about neonates’ lives (6). in this regard, some studies have emphasized the necessity of paying attention to end-of-life care for terminally ill neonates. according to iranian nurses working in nicus, the most important obstacles to providing end-of-life care for neonates are inadequate resources and equipment, inappropriate individual and social attitudes, and defective organizational culture (7). jordanian nurses, on the other hand, consider legal constraints as one of the obstacles to making decisions about neonates' end of life (3). the results of a study conducted in korea suggested that the factors affecting these decisions are related to the clinical conditions of terminally ill neonates (8). the findings of a national survey in belgium showed that 90-100% of nurses are willing to withdraw from providing end-of-life care for terminally ill neonates (9). in addition, the results of a study performed in the us suggested that while providing end-of-life care for neonates, nurses experience moral distress that threatens their professional progress (10). furthermore, the results of a study performed in vietnam suggested that 40% of the nurses respect the children’s families’ beliefs about continuing maintenance treatments, and 72% of them believe that these treatments should be stopped by families (11). according to a study in canada, the factors affecting nurses' decision-making about the life of terminally ill neonates include the patients’ condition (90%), the families’ desire (81%), the disease characteristics (74%), and acceptance of death (36%) (12). when the applied treatments are not effective on the neonates hospitalized in nicus, the most important choice will be palliative care (pc) (13). pc has been used for neonates hospitalized in nicus for more than 30 years (14). in order to provide pc in nicus, the health care team should be familiar with this type of care, and they kadivar m., et al. 3 j med ethics hist med. 2021(feb); 14: 4 jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e should have the required support to be able to offer professional consultation in difficult conditions (15). however, the results of a study in brazil showed that only 20% of the neonates hospitalized in nicus received pc (16). the family members of the neonates hospitalized in nicus also need spiritual care, because they suffer from emotional and spiritual problems such as depression and anxiety on account of their neonates’ hospitalization (17). neonatal death is one of the most unpleasant incidents for families (18). the stated facts highlight the necessity of paying attention to the provision of spiritual care for these families. nevertheless, pc specialists do not usually provide consultation for neonates in life threatening conditions and their families (19). furthermore, it is possible to provide pc for neonates and their families even before birth, and this type of prenatal care provides the families with support and postpartum consult (20). provision of pc for terminally ill neonates has not been defined clearly (21). regarding terminally ill neonates, nicu nurses might face ethical challenges associated with end-of-life decisions including end-of-life care, cardiopulmonary resuscitation, and medical futility. in addition, the important issue that makes ethical decision-making difficult in the case of neonates is that they are not independent individuals. thus, considerations about neonates' and their families' rights in making decisions lead to moral distress in nurses. other issues that increase nurses' distress regarding ethical decision-making about end-of-life-care are uncertainty about treatment results and neonates' poor prognoses (22). with regard to the importance of this issue, the present study aimed to determine the nurses’ attitudes toward providing care for terminally ill neonates and their families. methods this descriptive cross-sectional study was performed in the first six months of 2019. the research was performed in children’s medical center, bahrami, and arash hospitals affiliated to tehran university of medical sciences (tums). the population included all the nurses working in the nicus of the mentioned centers. with a significance level of 95% and test power of 80%, 145 nurses were selected as the samples by convenience sampling. the inclusion criteria were: at least one year of work experience and full-time employment in the nicus of the abovementioned centers. it should be added that after the distribution of the questionnaires, they were filled by 138 nurses, all of whom were women (the response rate was 98.7%). data were collected using a demographic characteristics questionnaire for measuring the variables of age, marital status, working record, education level, working shifts, economic status, and background of participation in pc courses. also, the attitudes toward caring for terminally ill persons and their families scale was used as another tool. this scale has been designed by frommelt (1991) and used for terminally ill patients of any age (23). the scale nurses’ attitude toward caring for terminally ill neonates and their families in iran: a cross-sectional study 4 j med ethics hist med. 2021(feb); 14: 4 jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e consists of 30 items, 15 of which are expressed in a positive manner (1, 2, 4, 10, 12, 16, 17, 19, 20, 21, 22, 23, 24, 26, and 29) and emphasize the nurses’ attitudes toward the role of families in caring for terminally ill patients; the remaining 15 items are expressed in a negative manner (3, 5, 6, 7, 8, 9, 11, 13, 14, 15, 18, 25, 27, 28, and 30) and are related to the nurses’ fear and stress in caring for terminally ill patients. the items are scored based on the likert scale (completely disagree, disagree, no idea, agree, and completely agree), and the overall scores range between 30 and 150. the positive items are scored from 1 to 5 and the negative items from 5 to 1, with higher scores indicating a more positive attitude to caring for terminally ill patients and their families. in iran, the reliability of the scale for use in nicus was evaluated and reported to be 0.7 using cronbach’s alpha coefficient (24). in this study, validity was evaluated based on content validity. for this purpose, the persian and english versions of the tool were reviewed by 7 expert nursing professors and their opinions were applied to modify the tool. total reliability of the tool was obtained as 0.84 based on cronbach’s alpha coefficient. data analysis data analysis was done by descriptive statistics (frequency, percentage, mean, and standard deviation) and inferential statistics (independent t-test, and anova) in spss 16; p-value ˂ 0.05 was considered as the significance level. ethical considerations the present study was conducted after receiving permission from the research ethics committee of tums (ethics code: ir.tums.fnm.rec.1396.3239). also, it was supported by the nursing and midwifery care research center, tums; under project no. 96-02-99-34966. the researcher explained the research goals to the nurses, and the nurses were reminded that participation in the study was optional and their information would be kept private. then, the researcher started data collection by referring to the wards in which the nurses worked in morning and evening shifts. the time required to answer the questionnaire was determined to be 15 minutes and the whole process of data collection lasted for 4 months. result according to table 1, among the demographic characteristics, age and previous participation in pc courses were significantly related to the nurses’ attitudes toward providing care for terminally ill neonates and their families (p ˂ 0.05). the nurses had the most positive attitudes toward the items “nursing care should include the family of the terminally ill patient, too” (4.2 ± 0.6), “the care provider can prepare the patient or his/her family for death” (4.1 ± 0.7), and “the family should be involved in physical caring for the terminally ill patient” (3.9 ± 1.02). the nurses’ least positive attitude was related to the item “the time spent on caring for terminally ill patients creates a sense of kadivar m., et al. 5 j med ethics hist med. 2021(feb); 14: 4 jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e frustration in me” (1.06 ± 1). table 2 presents the mean of the nurses’ answers to each item based on the 1-5 score range. the total score of the nurses’ attitudes was reported to be 97.07 ± 8.93. table 1frequency distribution of the demographic characteristics of the participants table 2nurses’ attitudes toward caring for terminally ill neonates and their families no item mean ± standard deviation 1 caring for terminally ill patients is a valuable experience. 2.1 ± 0.8 2 death is not the worst thing that may happen to a patient. 1.7 ± 0.7 3 it is unpleasant for me to talk to the family of a terminally ill patient about death. 2.25 ± 0.8 4 nursing care for the patient’s family continues until the end of their grief period. 2.4 ± 0.76 5 i don’t want to be assigned the responsibility of caring for terminally ill patients. 2.96 ± 1.8 6 the nurse is not the one to talk to the family of a terminally ill patient about death. 2.32 ± 0.88 7 the time spent on caring for terminally ill patients creates a sense of frustration in me. 1.06 ± 1 8 it is unpleasant for me to see frustration in the family of terminally ill patients. 2.4 ± 1.01 9 it is so difficult to closely communicate with the family of a terminally ill patient. 2.34 ± 0.9 10 sometimes, the family of a terminally ill patient welcomes the death. 1.91 ± 0.8 11 when the family asks the nurse, “is our patient about to die?” the best thing to do is talk about a happy subject. 2 ± 0.01 12 the family should be involved in physical caring for the terminally ill patient. 3.9 ± 1.02 13 i hope the patient dies when i am not on my shift. 1.94 ± 0.7 test results percentage number demographic data f = 0.322 *p = 0.001 29.1 41 less than 30 age (years) 61.6 85 30 40 9.3 12 more than 40 t = 0.644 p = 0.326 56.5 78 single marital status 43.5 60 married f = 0.662 p = 0.552 10.9 15 less than 5 job experience, (years) 71 98 5 10 18.1 25 more than 10 t = 1.122 p = 0.342 93.5 129 bachelor’s degree education level 6.5 9 master’s degree t=1.224 p=0.162 20.3 28 fixed shift work 79.7 110 rotational t = 0.724 *p = 0.001 29 40 yes previous participation in pc courses 71 98 no f = 0.128 p = 0.426 23.2 32 good economic status 46.4 64 moderate 30.4 42 weak nurses’ attitude toward caring for terminally ill neonates and their families in iran: a cross-sectional study 6 j med ethics hist med. 2021(feb); 14: 4 jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e no item mean ± standard deviation 14 i am afraid of having a friendly relationship with the family of a terminally ill patient. 2.11 ± 0.8 15 when the patient dies, i want to leave the place. 2.08 ± 0.8 16 the family needs emotional support to be able to accept the changes in the patient’s condition. 2.94 ± 1 17 families should note that helping the terminally ill patient is the best action in the remaining days of his/her life. 2.87 ± 1.1 18 the family of a terminally ill patient should not be allowed to make decisions about physical care. 2.93 ± 1.1 19 the family should provide normal conditions for the patient as far as possible. 2.25 ± 0.8 20 it is helpful for the family of a terminally ill patient to express their emotions. 2.99 ± 1.1 21 nursing care should include the family of the terminally ill patient, too. 4.2 ± 0.6 22 the care providers should let the family of a terminally ill patient have flexible visiting times. 3.88 ± 0.77 23 the family of a terminally ill patient should be the ones to make decisions. 3.22 ± 1.88 24 narcotic addiction should not be the nurse’s concern in the case of terminally ill patients. 2.82 ± 1.1 25 it upsets me to enter the room of a terminally ill patient and see him/her crying. 2.94 ± 1 26 the family of a terminally ill patient should receive honest answers about the patient’s condition. 3.87 ± 1 27 the care providers are not responsible for training the families about death and dying. 2.48 ± 1 28 the continuous presence of family members of terminally ill patients interferes with care. 1.87 ± 1 29 the care provider can prepare the patient or the family for death. 4.1 ± 0.7 30 nurses should avoid getting close to terminally ill patients or their families. 2.45 ± 1.06 discussion in the present study, the most positive attitude of the nurses to caring for terminally ill neonates and their families was related to the item “nursing care should include the family of the terminally ill patient, too”. a study conducted on chinese nurses demonstrated that most of the subjects had a positive attitude toward paying attention to the families of these patients (25). according to the results of a qualitative study in iran about caring for terminally ill patients, it is important to avoid harming them and respect their cultural and religious beliefs, as well as the patients’ and their families’ dignity (26). the results of a qualitative study in saudi arabia also showed that nurses working in nicus had the experience of providing end-of-life care while respecting the neonates’ families, and that this respect remained the same even after the neonate’s death (18). according to the islamic and cultural doctrine, family institution is considered vulnerable in iran, and therefore the nurses in this study observed this and considered the families in caring for neonates. the second priority in the nurses’ viewpoint was the item “the care provider can prepare the patient or the family for death”. in this regard, a qualitative study in iran suggested that the families of neonates hospitalized in kadivar m., et al. 7 j med ethics hist med. 2021(feb); 14: 4 jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e nicus want the nurses to provide them with information about their neonates’ disease, and in this way, they can get prepared for the patients’ death (27). the results of a study in australia suggested that the nurses working in nicus try to prepare the parents of terminally ill patients for their death (28). in consistence with this finding, the results of a systematic review showed that preparing the asian parents of neonates hospitalized in nicus for their death is affected by the families’ religious and cultural beliefs (29). accordingly, it is important for nurses to provide the families with the necessary information to prepare them for their neonates’ death while considering their cultural and religious beliefs. the third priority in the nurses’ attitudes toward providing care for neonates and their families was related to the item “the family should be involved in physical caring for the terminally ill patient”. according to the findings of a qualitative study in brazil, nicu nurses consider care provision for neonates a service that should be offered while respecting the family’s values, and one in which the families should preferably participate (30). these findings emphasize the necessity of the families’ participation in providing physical care for terminally ill neonates. also, they suggest the importance of family-centered care in nicus, which should be developed in iran. in iran, mothers can stay with their neonates in nicus and take part in the physical care of the neonates to encourage parental collaboration through family-centered care. however, this opportunity is not provided for fathers or grandparents (31). as a result, since the mother is the only one participating in the physical care of her neonate, cooperation of other family members might be limited. in this study, the least positive attitude was related to the item “the time spent on caring for terminally ill patients creates a sense of frustration in me”. in this regard, the results of a systematic review showed that while providing care for neonates hospitalized in nicus, nurses have a feeling of professional incompetence that can lead to their frustration in long term (32). it seems that the nurses participating in this study did not feel that end-of-life care was accompanied by a sense of frustration, so their attitude was not affected. in general, the total score of the nurses’ attitudes to providing care for neonates and their families was 97.07 ± 8.93. with regard to the scores range (30 150), it seems that promotion of the scores requires holding pc and end-of-life care training courses. in this regard, the findings of a qualitative study in brazil showed that nurses working in nicus claimed they had not received adequate training about pc for neonates and therefore needed support (30). according to taiwanese nurses, the factors affecting their attitude about caring for terminally ill neonates included lack of relevant training courses and pc guidelines (33). moreover, the results of studies performed in iran show that although clinical care staff members believe in the positive effects of spiritual care on patients, they have not received adequate training in these areas nurses’ attitude toward caring for terminally ill neonates and their families in iran: a cross-sectional study 8 j med ethics hist med. 2021(feb); 14: 4 jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e (34). the most important challenge in providing end-of-life care for children is lack of spiritual and mental support by the caring staff (35). as spiritual care is a part of pc, it is obvious that nurses should receive relevant training to acquire the necessary skills for providing optimal care to neonates and their families. among the demographic characteristics, age and the experience of participating in pc courses had a significant relationship with the nurses’ attitudes toward providing care for terminally ill neonates and their families. in other words, older nurses and those who had an experience of participating in pc courses had a more positive attitude toward providing care for terminally ill neonates and their families. the results of another study in iran suggested that the performance of the nurses working in nicus is affected by their age (35). the results of a study in taiwan suggested that providing pc for neonates hospitalized in nicus by clinical specialists is affected by age and relevant training (36). a study in china showed that nurses who had the experience of participating in courses on death-related issues had a more positive attitude toward caring for terminally ill patients (25). one limitation of this study was that nonrandom sampling decreased the generalizability of the findings. moreover, this study only investigated the nurses’ attitudes, and it is suggested to investigate the doctors’ attitudes about caring for terminally ill neonates and their families in future studies. conclusion since the scores obtained through the tool used in this study ranged from 30 to 150, it seems that nurses' attitude toward the investigated issue was at a moderate level. it seems that age has a positive effect on the nurses’ attitudes toward the studied issue. taking pc training courses can promote positive attitudes in nurses by improving their knowledge of the subject. it is suggested to provide the nurses working in nicus with end-of-life and pc training courses, as they can promote the nurses’ attitude about caring for terminally ill neonates and their families. furthermore, it is recommended to develop a pediatric pc curriculum for nurses, since it will lead to improvement of the nurses’ knowledge, attitude and skill in the field of the studied issue. also, as mentioned previously in the introduction section, nurses working in nicus experience moral distress regarding making ethical decisions about end-of-life care for terminally ill neonates. therefore, it is necessary to provide nurses with training programs on ethical decision-making in nicus in order to decrease their moral distress. acknowledgements the researchers are thankful to all of the nurses who participated in the present study. conflicts of interests none declared. kadivar m., et al. 9 j med ethics hist med. 2021(feb); 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https://www.ncbi.nlm.nih.gov/pubmed/?term=peng%20nh%5bauthor%5d&cauthor=true&cauthor_uid=30036114 https://www.ncbi.nlm.nih.gov/pubmed/?term=liu%20hf%5bauthor%5d&cauthor=true&cauthor_uid=30036114 https://www.ncbi.nlm.nih.gov/pubmed/?term=wang%20tm%5bauthor%5d&cauthor=true&cauthor_uid=30036114 https://www.ncbi.nlm.nih.gov/pubmed/?term=chang%20yc%5bauthor%5d&cauthor=true&cauthor_uid=30036114 https://www.ncbi.nlm.nih.gov/pubmed/?term=lee%20hy%5bauthor%5d&cauthor=true&cauthor_uid=30036114 https://www.ncbi.nlm.nih.gov/pubmed/?term=liang%20hf%5bauthor%5d&cauthor=true&cauthor_uid=30036114 https://www.ncbi.nlm.nih.gov/pubmed/?term=evaluation+of+comfort+and+confidence+of+neonatal+clinicians+in+providing+palliative+care. ____________________________________________________________________________________________________________________________________________ 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____________________________________________________________________________________________________________________________________________ 1 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e original article volume 13 number 18 november 2020 copyright © 2020 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. psychometric properties of persian version of the research misconduct questionnaire (prmq) *corresponding author bita mesgarpour no. 21, west fatemi st., national institute for medical research development (nimad), tehran, iran. tel: (+98) 21 66 93 80 37 email: mesgarpour@research.ac.ir received: 27 may 2020 accepted: 1 oct 2020 published: 10 nov 2020 citation to this article: shamsoddin e, janani l, ghamari k, kabiri p, shamsi gooshki e, mesgarpour b. psychometric properties of persian version of the research misconduct questionnaire (prmq). j med ethics hist med. 2020; 13: 18. erfan shamsoddin1, leila janani2, kiandokht ghamari1, payam kabiri3, ehsan shamsi gooshki4, bita mesgarpour 5* 1.research assistant, national institute for medical research development (nimad), tehran, iran. 2.associate professor, department of biostatistics, school of public health, iran university of medical sciences, tehran, iran. 3.senior research fellow, department of biostatistics and epidemiology, school of public health, tehran university of medical sciences, tehran, iran. 4.assistant professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran; department of medical ethics, school of medicine, tehran university of medical sciences, tehran, iran. 5.assistant professor, national institute for medical research development (nimad), tehran, iran. abstract assessment of scientific misconduct is considered to be an increasingly important topic in medical sciences. providing a definition for scientific research misconduct and proposing practical methods for evaluating and measuring it in various fields of medicine discipline are required. this study aimed at assessing the psychometric properties of scientific research misconductrevised (smq-r) and publication pressure questionnaires (ppq). after translation and merging of these two questionnaires, the validity of the translated draft was evaluated by 11-member expert panel using content validity index (cvi) and content validity ratio (cvr). reliability of the final questionnaire, completed by 100 participants randomly chosen from medical academic members, was assessed by calculating cronbach’s alpha coefficient. the final version was named persian research misconduct questionnaire (prmq) and consisted of 63 question items. the item-level content validity indices of 61 questions were above 0.79, and reliability assessment showed that 6 out of 7 subscales had alpha values higher than 0.6. hence, prmq can be considered an acceptable, valid and reliable tool to measure research misconduct in biomedical sciences researches in iran. keywords: biomedical research; psychometrics; scientific misconduct; research misconduct; surveys; questionnaires; translation. psychometric properties of persian version of the … 2 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 18 november 2020 introduction what gets measured gets accomplished and improved because measurement, as performance indicator, provides information for decision-making to manage outcomes and improve results. similarly, measurement means and tools in research misconduct follow the same rule. commission’s report on research integrity in the united states in 1995 defined research misconduct as offenses involving misappropriation, interference, and misrepresentation (1). despite sensitivity to scientific misconduct in all scientific fields, misconduct is especially significant in medical sciences because of misconduct’s destructive consequences (2-4). such misconducts not only can disturb the public health status of different individuals including the patients, but also can impose extensive financial costs on healthcare systems (3, 5, 6). some studies suggest that the rate of serious misconduct types (e.g. data fabrication) is often lower than that of other types (7-13). pupovac et al. conducted a survey in 2016 to assess research misconduct in the croatian scientific community on 237 researchers where 3.8%, 9.3%, 3.8%, and 25.3% admitted plagiarism, data falsification, data fabrication, and violation of authorship rules, respectively (14). in 2014, roberts and favs measured the prevalence of research misconduct in academics of the united kingdom where more than 68% of the respondents admitted committing inappropriate co-authorship (8). hence, measuring research misconduct is a critical issue in medical sciences that need to be addressed appropriately. surveys and questionnaires are among the most popular tools in assessing research misconduct in medical sciences. in 1997, rankin and esteves developed scientific misconduct questionnaire (smq) to address ethical problems and scientific wrongdoings in medicine (15). eight years later, broome et al. revised the smq to accommodate the changes occurred in medical sciences. they developed 68 closed-choice items and 12 open-ended items in the revised version, called scientific misconduct questionnaire-revised (smq-r), and used it in national surveys after assessing its psychometric characteristics (16, 17). furthermore, the 14-item publication pressure questionnaire (ppq) developed by tijdink et al. in 2014 was highly cited, which ppq mainly emphasized on the considerable impact of different academic communities on scientific productivity (18). several studies aimed at assessing and measuring scientific misconduct in iran. khadem-rezaiyan and dadgarmoghaddam conducted a cross-sectional study using a 4item questionnaire to evaluate the prevalence of major types of research misconducts in iran in 2015 (19). hadji et al. in 2016 studied the prevalence of various publication misconduct among iranian authors in the medical field using a 5-item questionnaire (20). review of current literature suggests that further means and tools are required to comprehensively inspect research misconduct among the iranian medical researchers (19-23). in this study, smq-r was translated from english to persian because of its comprehensive approach in addressing topics related to research misconduct: perception of workplace environment, prevalence of scientific misconduct, awareness and beliefs about misconduct, reporting of research shamsoddin e., et al. 3 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 18 november 2020 misconduct, and behavioral influences of research misconduct. academic organizations in iran impose pressure on students and faculty members to publish more articles, and ppq covers various aspects of publication pressure. hence, ppq was also translated from english to persian in this study. several studies discussed policies imposing such pressure in iran, showing the fundamental importance and necessity of formulating appropriate regulations in this regard (23-25). the contributions of this work are the translation of smq-r and ppq to persian, merging them, and evaluation of psychometric properties of the persian version. method translation of smq-r and ppq to persian this study was focused on quality assessment of smq-r and ppq’s translated version. to ensure credibility, steps involved in this study was reassessed according to streiner and kottner’s protocol (26). figure 1 demonstrates the methodology of this study in a workflow diagram. initially, permissions for translation of the questionnaires were obtained through email from the developers of the original ppq and smq-rz. two authors of this study, who were acquainted with academic writing style with acceptable english language skills, independently translated the questionnaires. these two drafts were integrated and revised in a meeting involving the authors and a methodologist. in addition, three meetings were held to develop the preliminary draft in the forward translation process. furthermore, to evaluate the translated version’s conceptualization and relevancy, two peer academic researchers (native persian speaking academic staff with a competent knowledge of english language) independently translated the persian version back to english. figure 1development workflow of persian research misconduct questionnaire (prmq) psychometric properties of persian version of the … 4 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 18 november 2020 validity assessment after the forward and backward translation procedures, an expert committee was formed to further assess the preliminary prmq’s semantic, grammatical, and lexical accuracy. the committee consisted of the following members: forward translation authors (two authors), backward translation authors (two peer academic researchers), a methodologist, and two independent colleague researchers. moreover, face validity of the tool was qualitatively evaluated in a meeting to ensure that the questions cover the intended topics and measures the phenomenon to be measured. pilot test cognitive debriefing was conducted as follows: (i) selecting several volunteers from the academic staff of medical universities, (ii) asking them to complete the preliminary prmq questionnaires, and (iii) requesting them to leave comments regarding modifications that make the questionnaire more coherent. fifty-four participants were selected from vice-chancellors of medical universities from all-around iran, which attended a meeting held in the city of rasht in 2019. the volunteers were asked to complete consent forms covering the following topics: (i) their autonomy in participation; (ii) their participation did not cause any harms, (iii) no compensations or rewards were provided for participation, and (iv) maintaining confidentiality of the participants’ information and answers. after responding to the questionnaire’s items, the participants were enquired about their understanding of items and their thoughts regarding their answers. this process ensured that this adapted and localized prmq functions properly when applied in the target discipline. moreover, the committee panel evaluated participants’ answers to the preliminary prmq. content validity assessment the content validity assessment was conducted in two stages. initially, an expert panel was formed consisting of 11 independent scientists from different disciplines of medical sciences including epidemiology, social medicine, basic sciences and clinical sciences. the inclusion criteria for the expert panel were their experience in research conduct and research management, indicative of dexterity in their specific research disciplines. information about the study and its goals was provided to the expert panel members, and their answers to the questions were assured to be kept confidential and anonymous. waltz and bausell’s index was used to calculate content validity index (cvi), and lawshe’s index was utilized to assess the content validity ratio (cvr) (27, 28). the expert panel members were requested to specify whether an item is “relevant” (cvi test), “clear” (cvi test), “simple” (cvi test), “essential” (cvr test), “useful but not essential” (cvr test), and “not necessary” (cvr test). to do so, the experts were requested to score each item of the questionnaire from 1 to 4 indicative of the degree of relevance, clarity, or simplicity: shamsoddin e., et al. 5 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 18 november 2020 1 (strongly disagree), 2 (disagree), 3 (agree) or 4 (strongly agree). additionally, the members were asked to rank each item from 1 to 3 depending on the degree of its necessity: 1 (not necessary), 2 (useful but not essential), or 3 (essential). in calculating item-level-cvi index (i-cvi), an approved item had a score of 3 or 4 from all expert panel members. total cvi was the sum of cvis of all items, and a scale-levelcvi (s-cvi) was the ratio of the total cvi to the total number of items. for any item with cvi and cvr lower than 0.79 and 0.59 respectively, the expert committee decided whether to include the item in the final questionnaire or not. the thresholds were not set as absolute cut-off points. instead, they guided the expert committee to discuss their viewpoints regarding the contribution of each item in quantification of research misconduct. since many preliminary prmq’s items were not valid based on opinions of the committee, a second round of content validity analysis was run for the final prmq with the same committee one month after this first assessment. reliability assessment the final version of prmq was sent to 100 participants randomly chosen from medical academic members in iran in 2019. cronbach’s alpha test was used to analyze the internal consistency of prmq. statistical analysis gathering and cleaning of the raw data was performed using microsoft excel (2017). then, statistical analyses on the data were done using ibm spss statistics for windows, version 24 (ibm corp., armonk, n.y., usa). results translation the comparisons showed that some items of the first draft of prmq needed to be removed, revised, re-worded, or reemphasized. in the “demographic information” subscale, questions 6, 7, 9, 10, 11, 12, 13, 17, and 18 were repetitive, and hence removed. in addition, question 8, “do you hold certification in clinical research?”, was replaced with “what is your current hindex?”. in the “prevalence of scientific misconduct” subscale, item 35, “international protocol violations related to procedures” was replaced with “data fabrication”. content validity assessment the preliminary prmq with 82 items was evaluated by the expert panel. to assess content validity, cvis were calculated representing the relevance, clarity, and simplicity of all items of prmq except items related to the demographic information. the s-cvis of relevancy, clarity, and simplicity were 0.797, 0.791, and 0.794, respectively. table 1 demonstrates the detailed results of content validity assessment. psychometric properties of persian version of the … 6 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 18 november 2020 table 1final prmq’s content validity results q# description i-cvi-r i-cvi-c i-cvi-s cvr 11 researcher competitiveness 0.91 0.91 0.91 0.63 12 pressure on researchers to obtain tenure 1.00 1.00 1.00 1 13 pressure on researcher to obtain external funding 1.00 1.00 1.00 0.81 14 severity of penalties for scientific misconduct 0.91 0.91 0.91 1 15 chances of getting caught for scientific misconduct if it occurs 1.00 1.00 1.00 0.81 16 researchers' understanding of rules and procedures related to scientific misconduct 1.00 1.00 1.00 1 17 your own understanding of rules and procedures related to scientific misconduct 1.00 1.00 1.00 0.81 18 other research staff's understanding of rules and procedures related to scientific misconduct 1.00 0.91 0.91 0.63 19 researchers' support of rules and procedures related to scientific misconduct 0.91 0.91 0.91 0.63 20 research coordinators' support of rules and procedures related to scientific misconduct 1.00 1.00 0.82 1 21 other research staff's support of rules and procedures related to scientific misconduct 1.00 1.00 1.00 0.63 q# description i-cvi-r i-cvi-c i-cvi-s cvr 22 the effectiveness of your organization's rules and procedures for reducing scientific misconduct 0.91 0.91 0.91 1 23 plagiarism 0.91 0.82 0.91 0.81 24 falsifying data 0.82 1.00 1.00 0.81 25 data fabrication 0.91 0.91 0.91 1 26 intentional protocol violations related to subject enrollment 1.00 0.92 0.91 1 27 coercion of potential subjects 0.91 0.91 0.82 0.81 28 selective dropping of data from "outlier" cases 0.91 0.91 0.91 0.63 29 disagreements about authorship 1.00 0.82 1.00 0.81 30 pressures from study sponsor to engage in unethical practices 1.00 0.91 0.91 0.63 31 in your work environment, how often have you been aware that a researcher engaged in scientific misconduct during the past year? 1.00 0.91 1.00 0.81 32 in your work environment, how often have you been aware that a research coordinator or the other personnel engaged in scientific misconduct during the past year? 1.00 0.91 0.82 1 q# description i-cvi-r i-cvi-c i-cvi-s cvr 33 how did you learn about the instances of scientific misconduct you are aware of (check all that apply)? 0.82 0.91 0.82 1 shamsoddin e., et al. 7 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 18 november 2020 34 what do you think a typical research coordinator in your area would do if they knew a principal or co-researcher violated accepted rules for research integrity on a research project or assignment? 0.91 0.82 0.82 0.63 35 what do you think a typical research coordinator in your area would do if they knew a research team member or a staff member violated accepted rules for research integrity on a research project or assignment? 0.91 0.82 0.91 0.81 36 if someone engaged in scientific misconduct and was reported to your institutional authorities, how likely do you think it is that they would be disciplined? 0.91 0.91 0.91 0.63 37 i am concerned about the amount of misconduct 1.00 0.91 1.00 0.63 38 i think the responsibility for the scientific integrity of a study lies with the principal researcher only 0.91 0.91 0.91 1 q# description i-cvi-r i-cvi-c i-cvi-s cvr 39 all professional education programs should include information about standards of research ethics 0.82 0.82 0.91 0.63 40 i feel uncomfortable talking with research coordinators and other research personnel about their ethical behavior 0.82 0.82 0.91 1 41 dishonesty and misrepresentation of data is common in society and doesn't really hurt anybody 0.73 0.91 1.00 1 42 pressure for tenure. 0.82 1.00 0.91 0.63 43 pressure for external funding 1.00 0.91 0.91 0.81 44 need for recognition 0.82 0.91 0.82 0.81 45 need for publication 1.00 1.00 0.91 1 46 unclear definitions of misconduct 1.00 0.91 1.00 0.81 47 insufficient censure for misconduct 0.91 0.91 0.91 0.63 48 financial conflict of interest 0.82 0.91 0.82 0.81 49 number of protocols research coordinator is responsible for 0.91 0.82 0.91 1 50 without publication pressure, your scientific output would be of higher quality 0.91 0.91 0.91 0.63 51 your scientific publications contribute to better (future) medical care 0.91 0.91 0.91 1 q# description i-cvi-r i-cvi-c i-cvi-s cvr 52 you experience your colleagues’ assessment of you on the basis of your publications as stressful 1.00 0.82 0.91 0.81 53 you experience the publication criteria formulated by your university for your appointment or re-appointment as professor as 1.00 1.00 0.82 0.63 psychometric properties of persian version of the … 8 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 18 november 2020 a stimulus 54 publication pressure puts pressure on relationships with fellow researchers 0.91 0.91 0.91 1 55 you suspect that publication pressure leads some colleagues (whether intentionally or not) to color data 1.00 0.91 0.91 0.63 56 the validity of medical world literature is increased by the publication pressure in scientific centers 0.91 0.82 1.00 0.81 57 publication pressure leads to serious worldwide doubts about the validity of research results 1.00 0.91 0.82 1 58 in your opinion, the pressure to publish scientific articles has become too high 0.91 0.91 1.00 0.81 59 the competitive scientific climate stimulates me to publish more 0.91 0.82 0.82 0.63 60 your colleagues judge you mainly on the basis of your publications. 0.91 0.91 0.91 1 q# description i-cvi-r i-cvi-c i-cvi-s cvr 61 fellow scientists maintain their clinical and teaching skills well, despite publication pressure 1.00 0.91 0.91 1 62 you cannot confide innovative research proposals to your colleagues 0.73 0.73 0.64 0.81 63 publication pressure harms science 0.91 0.91 0.91 0.63 prmq: persian research misconduct questionnaire q#: question number in the final prmq i-cvi-r: item-level content validity index for relevancy i-cvi-c: item-level content validity index for clarity i-cvi-s: item-level content validity index for simplicity cvr: content validity ratio in the “prevalence of scientific misconduct” subscale, questions 37 and 39 were omitted due to i-cvis lower than cutoff points. moreover, in the “behavioral influences on scientific misconduct” subscale, questions 60 to 67 were removed. moreover, the section “actual experiences with scientific misconduct” was eliminated to reduce structural heterogeneity within the prmq and raise its comprehensibility level. the final prmq, available at https://forms.gle/lgp85pqvfqjbxzcua, consisting of 63 items, was elicited from the preliminary version. from these 63 questions, 10 were about demographic information, and the validity of all subscales except the demographic information were rechecked. after changing some words for several items to make them more fluent and comprehensible, content validity was re-assessed by the panel through an online survey. scale-level content validity indices were 0.929, 0.909, and 0.912 for relevancy, clarity, and simplicity of the items, respectively. shamsoddin e., et al. 9 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 18 november 2020 reliability assessment in this step, the participants were 71 males and 29 females with age ranged between 33 to 64 and a mean of 47.97 years (sd = 7.43). from education level perspective, 81% had a doctoral degree and 19% held a master’s degree or a clinical specialty degree. additionally, the median of the participants’ h-indices was 13. ninety-one percent of the respondents replied “high” or “very high” to the item enquiring about the rate of research misconduct in their workplaces. table 2 depicts the results of reliability assessment. table 2final prmq’s reliability assessment results section item numbers cronbach’s alpha perception of workplace environment 12 0.648 prevalence of scientific misconduct 8 0.877 awareness of research misconduct 3* 0.786 reporting research misconduct 3 0.743 beliefs about research misconduct 5** behavioral influences 8 0.612 publication pressure 14*** 0.807 * since an item in this subscale has multiple response option format, two out of a three items were considered in reliability assessment. ** this section did was not considered a distinct subscale because the items measured distinct constructs. hence, we did not report an alpha coefficient for this section. *** all items in this section assembled to be a unified construct, and only one alpha coefficient was reported for all. discussion the prevalence of research misconducts by iranian researchers in the field of medicine has been expressed by several medical journals (21). other studies also emphasized on the high rate of scientific misconduct in iran's health system, which is due to the policies of this system regarding medical research and misleading orientations stimulating misconduct in medical research (19, 24, 29). hence, this work aimed at translating, assessing, and validating the psychometric properties of the smq-r and ppq as valid and reliable tools to be used in researches in persian. translating these two from english into persian required cultural and conceptual adaptations achieved by several amendments to the translated and merged drafts. a pilot test involving cognitive debriefing was run to ensure that the persian version covered the intended topics equivalent to the english version. to validate preliminary prmq, consisting of 82 items, both qualitative and quantitative methods were employed to approve face validity and content validity. a large number of participants were needed to assess the construct validity of prmq considering its relatively high number of questions, and hence construct validity was not assessed in this work and left for in future studies. psychometric properties of persian version of the … 10 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 18 november 2020 all changes made to the preliminary prmq were such that they had minimal impact on the integration of smq-r and ppq. amendments to the preliminary prmq included deleting of 19 items and rewording of several items. in the final prmq, all items except two had i-cvis greater than 0.79. one of these two items was the last question in the “attitudes and beliefs about scientific misconduct” section with the following description: “dishonesty and misrepresentation of data is common in society and does not really hurt anybody.” another item having i-cvi of 0.73 was in the “publication pressure” section with the following description: “i cannot confide innovative research proposals to my colleagues.” the expert panel found these two items irrelevant; however, since both cases can have many interpretations, they were not removed from the final prmq. the item-level and scale-level content validity indices were indicative of significant changes in the final prmq compared to the preliminary prmq, showing the efficiency of the translation and the proofreading procedures. in the preliminary prmq, most items were considered not “necessary”. on the contrary, in the final prmq, given that cvrs were all above 0.59, all items were essential sub-constructs according to the expert panel. two subscales, “perceptions of workplace environment” and “behavioral influences”, both depicted alpha value between 0.6 and 0.7, or an acceptable threshold. two other sections, of the smq-r, “awareness of misconduct” and “reporting research misconduct”, showed a higher internal consistency with alpha value between 0.7 and 0.8. another section of smqr, “prevalence of scientific misconduct”, and all items of the ppq showed alpha value between 0.8 and 0.9, or an excellent score. only one subscale in the smq-r showed inconsistent results, “attitudes and beliefs about scientific misconduct” section. this inconsistency was in accordance with the findings of broome et al. stating that items of this subscale measured separate constructs, and hence a meaningful consistency as a whole was not achievable for this section (16). khajedaluee et al. conducted a study in 2019 in iran resulted in the development and psychometric assessment of a 75-item questionnaire consisting of three distinct questionnaires: smq-r, attitude towards plagiarism questionnaire, as well as positive and negative attitude and subjective norms towards plagiarism questionnaire. this study, similar to our work, considered smq-r to be baseline. content validity was measured using cvis and cvrs, and reliability was assessed using cronbach’s alpha coefficient. their results showed acceptable cvis (above 0.79) and cvrs (above 0.75) for all the items, and overall alpha was 0.77 (30). in the last stage of our study, 69% and 22% of 100 participants reported “high” and “very high” rates of misconduct in their workplaces, respectively. only 9% of 100 participants reported “low” rate, highlighting the importance of measuring misconduct as well as developing or reinforcing regulations for researches by medical science academics. in a survey conducted by okonta and rossouw, 68.9% of 132 researchers from nigeria admitted committing at least eight listed forms of research misconduct, and shamsoddin e., et al. 11 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 18 november 2020 42% of these researchers had falsified data or committed plagiarism (31). another national survey by saberi-karimian et al. in 2018 reported that 43% of academics engaged in at least one misconduct over the past three years (23). our results, in line with these findings, highlighted the prevalence of research misconducts. our questionnaire tool can help future research in assessing the extent of scientific misconduct in medical sciences researches. using this tool, medical universities, academic centers, and institutions can measure misconducts to develop or reinforce regulations for their future researches. conclusion persian research misconduct questionnaire (prmq), persian version of research misconduct questionnaire, can be a valid and reliable tool in assessing research misconducts in the medical sciences. this tool can be approved and utilized by healthcare’s policy-making officials and managers as well as regulatory officers to measure research misconducts in the affiliated departments and centers. acknowledgements authors are grateful to prof. broome for and dr. tijdink for their permission to translate smq-r and ppq questionnaires. authors are also thankful to the colleagues and participants who helped in assessing the translated questionnaires. conflict of interests the authors declare no source of funding that supported this work and no competing interests during this study. psychometric properties of persian version of the … 12 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 18 november 2020 references 1. us department of health and human services. integrity and misconduct in research. 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bioeth. 2013; 13(3): 10.1111/j.14718847.2012.00339. x. microsoft word 4 journal of medical ethics and history of medicine compassion in jewish, christian and secular nursing. a systematic comparison of a key concept of nursing part ii the reception of the topos of the compassionate god in jewish, christian and secular nursing texts of the 19 th through the 20 th centuries in the german speaking world and in north american nursing science silvia käppeli center for nursing research and development, university hospital zürich, switzerland *corresponding author: silvia käppeli address: center for nursing research and development, university hospital zürich, switzerland. tel: (+41) 44 25 53 954 telefax: (+41) 44 25 54 395 e-mail: silvia.kaeppeli@usz.ch received: 3 oct 2008 accepted: 15 nov 2008 published: 1 dec 2008 j med ethics hist med. 2008; 1:4. © 2008 silvia käppeli; licensee tehran univ. med. sci. introduction the major thesis of this research is that the biblical topos of the compassionate god was the original model of compassionate nursing and that this topos represents the core of the ethics of compassion and of caring in nursing today. the analysis of the literary sources of the first four centuries ce supports this assumption for the eastern mediterranean area, i.e. the birthplace of jewish and christian nursing (see first part of this article). works of love and compassion on behalf of the suffering and the sick were one of their main features, and distinguished them from the polytheistic greek and roman culture. in the course of this period “the church” and “the synagogue” became the controlling institutions of nursing. they contributed to their consolidation. this is not the case for modern and post-modern nursing. since the enlightenment these are no longer determined by religious institutions. secular societal movements and the rising of the medical and social sciences became increasingly influential for nursing. hence, the values inherent in the topos of the compassionate god (existential presence, availability, advocacy, commitment, active involvement, faithfulness) and its meaning for nurses and patients were challenged. in this second part of the article the results of the investigation of the 3 rd research question is presented. to this purpose, literary sources of selected exemplary christian, jewish and secular nursing institutions in the german speaking countries and in north america were investigated. the methodological principles applied to the ancient texts (see first part of this article) were also used for the analysis and interpretation of the modern and post-modern ones. these documents were treated as samples. text analysis and j med ethics hist med 2008, 1:4 silvia käppeli page 2 of 8 (page number not for citation purposes) interpretation were used to find out whether or not the imitation of the topos of the compassionate god or the tradition of compassionate nursing were continued. was the topos of the compassionate god received in christian, jewish and secular nursing texts of the 19 th /20 th century? the third research question asked for the investigation of whether or not modern and post modern nursing received the topos of the compassionate god. it could be anticipated that the sources of the catholic and protestant nursing orders as well as of jewish nursing would contain actualizations of the biblical values inherent in this topos. however, it was less clear how this tradition would be dealt with in secular approaches to nursing because by definition, their intention was to be different from the religious. because of this, it was particularly interesting to find out how they re contextualized the traditional values’ system. compassionate nursing in the spirituality of the diaconate of kaiserswerth the protestant order of the deaconesses of kaiserswerth (germany) was founded in 1836 by pastor fliedner and his wife. it was the first diaconate in german speaking europe (1). the original rule of this institution (2) was derived from the new testament evangelist mark (2: mk 8:34) where jesus is quoted to say: “if any want to become my followers, let them deny themselves and take up their cross and follow me”. this is a reference to the imitation of jesus, the incarnation of god the compassionate. another rule states that in this institution nursing is being practiced as a work of love for the lord of mercy and that “souls” who choose this “holy occupation” contain a priori the necessary features such as compassion (3). the deaconesses had to serve in obedience to god, thankful for the love of jesus christ, and trusting in the help of the holy spirit. another biblical foundation of the diaconate is mt 25:40 (4): “and the king will answer them: truly i tell you, just as you did it (charity) to one of the least of these who are members of my family, you did it to me.” this implies the new testament teaching of jesus christ’s presence in every human being, i.e. in every patient. in nursing them they nurse him, which means that nursing is a holy service (4). fliedner also referred his deaconesses to phoebe, the servant of the community of kenchreä, who is mentioned in the nt-letter to the romans (4: 16:1) (3). 1 furthermore he emphasized that nursing unfolds its full meaning and significance in the care 1 jahresbericht über die diakonissenanstalt zu kaiserswerth 1836-1850, §3, 1ff. in taubert 1994, 49). of the dying where the nurse’s love and compassionate care comforts patients most (5). compassionate nursing in the spirituality of the diaconate of bethany the diaconate of bethany was founded 1874 in germany by the methodist church. in zürich, switzerland, it started in 1887 (6). also the deaconesses of bethany were asked to imitate jesus christ’s total devotion to the human beings, in particular his bearing of all their suffering. because christ sacrificed his life for them, the deaconesses had to be prepared to “put their lives on his altar”, i.e. to sacrifice their own lives or “to pawn” them. according to the nt-letter to the romans (4: 14:8) “if we live, we live to the lord, and if we die, we die to the lord; so then whether we live or die, we are the lord’s”. because he gave his life for the needy the deaconesses should sacrifice their own lives for him. jesus christ served as role model of the deaconesses. unlike the “ordinary” nurse the deaconess – as disciple of jesus christ – had to deny herself. to pastor rexroth, the founder of this institution, it was “the privilege of the deaconesses to … practice the idea of holy service” in its purest nature. he said: “somebody who nurses has to be able to put himself into the situation of a patient with all her sensitivity … with sacrificing love, christian mercy, selflessness and full dedication …” i.e. compassionately (6). in 1981 the order confirmed its original value system, i.e. that the church of christ has to testify god’s love for the human beings in words and deeds. the diaconate is perceived as the visible implementation of this idea. in particular it is perceived to “… include the service for christ, for one’s neighbor and for each other” (7). in many places amongst the rules of the order of bethany the work of the deaconesses is said to be founded in the imitation of god’s compassion, self dedication and self-sacrifice. the rules explicitly ask the individual deaconess to exceed her role model with respect to these virtues. the search for values pertinent to the topos of the compassionate god in the protestant nursing orders proved fruitful. already the written intent of both, to revitalize the biblical idea of the diaconate, basically implies the continuation of that value system. in addition, even though the compassio nate god is not mentioned explicitly, the instructions of the deaconesses clearly show that they were asked, eagerly to imitate his ways of being and acting. the deaconesses’ work is perceived to be both religious and secular which also brings them near their role in early christianity. until today this ethos is leading the clinical practice of both the religious sisters and the nurses of the two orders. in contrast to the j med ethics hist med 2008, 1:4 silvia käppeli page 3 of 8 (page number not for citation purposes) church fathers who associated compassionate care and the service to the sick with the spiritual enhancement of the cares, both pastors fliedner and rexroth – authors of the rules of these protestant orders – called for the deaconesses’ personal self-denial. however, they were confident that the compassionate god not only had to be imitated but also that he gave the nurses the strength to do so (8). compassionate nursing in the spirituality of the hospital sisters of lucerne the catholic order of the hospital sisters of lucerne was founded in beaune, burgundy, france in 1443. the original rule of the order gives evidence for the compassion of its founders nicolas rolin and his wife. they are reported to have been “… touched by the great misery in burgundy” at that time (9). the presently stated creed of the hospital sisters includes the following passage: “… the sisters …want to reply to god’s call to imitate his love for the poor and the miserable. in brotherly community ... they dedicate themselves compassionately to the service of the poor and sick, whom they accompany on the way to cure or to the threshold of death” (9). similarly it is said that the sisters should carry out their work with humility and dedication and in doing so they gain the kingdom of god” (9). in 1830 the order started in lucerne, switzer land. in 1956 the rules of the hospital sisters were revised. in this modernized version the sisters call themselves “god’s assistants”. the edition of the rules of 1970 quotes the apostle paul’s metaphor of the “new” and the “old” man. here the sisters are asked to strip the “old man” and to get dressed with the new one. the unification with jesus christ in his self-sacrifice for humanity is said to be the sisters’ goal in life. after the last council of the vatican in 1962-1965 the sisters explicitly stated that the imitation of christ is the foundation of their rule. based on this they actualized their conception of nursing again in 1979. there they stated: “if the hospital sisters want to renew their spirituality, they cannot restrict themselves to activities of modern nursing techniques” (9). nursing involves the care of an interpersonal relationship …, i.e. the art to be near the people, to express affection, care, friendship and solidarity for them.” in their charisma of 1982 they stated: “vis-à-vis the actual, one-sided expectations of achievement and growth, power and profit we advocate our sense for friendship, security, for compassion and grief, for encounter and understanding.” in 1992 they reformulated the cornerstones of their work: “practicing and deepening god’s philanthropy, openness and availability for the people in need, empathy with the joys and troubles of human beings …” the documentation of this catholic order shows a continuous and successful actualization of the core of their traditional value system, i.e. to imitate god’s love and compassion for the suffering. this involves important aspects of the topos of the compassionate god: presence and dedication. for the sisters the ideal relationship between themselves and their patients is based on solidarity, a modern concept of fidelity. moreover they stress their conscious delimitation of their spirituality from economically founded approaches to nursing. in accordance with the rules of the two diaconates theirs also asks the sisters to practice in the confidence that god will support both the sick and themselves. compassionate nursing in the spirituality of modern jewish nursing in judaism the care of the sick is considered to be everybody’s religious duty. therefore in europe professional jewish nursing started only at the beginning of the 20 th century. because of this and because of the prosecution of the jews during the second world war, very few documents about jewish nursing in germany and austria are available. in switzerland jewish women were integrated in secular schools of nursing where they were free to practice their creed. hence no particular rules were necessary. to gain insight into the continuation of the ethos of compassion in jewish nursing for this research it was necessary to consult a variety of sources. one was a plate mounted on the wall of a jewish home for the blind and deaf-mute in vienna in 1873. it states: “… in thankful recognition of this work of philanthropy … may it be witness to future generations of the warm compassion of the founder for his suffering human fellows, and honor his name forever” (10). the anniversary journal from 1912 of the society for the visit of the sick (chevra bikkur cholim) in another austrian town contains the following statement: “we do not want gratification when we commit ourselves to such heroic work, rather we want to be aware of the fact that we fulfill a holy duty vis-à-vis of god … as they have been handed down by the fathers” (11). a jewish physician who fought for formal nursing education for jewish women in germany emphasized in an article that such education ought to be comprehensive and adhere to the jewish tradition. “the technical education is necessary, but techniques alone are not good enough. those who value nursing as manual performance can perhaps educate jewish wardens but never jewish nurses. we have to emphasize that our nurses have to be inspired by the spirit of judaism” (12). in another place feldmann wrote: “the main motif of nursing is and remains the sanctification of god, in that explicit jewish sense that the sanctification has to j med ethics hist med 2008, 1:4 silvia käppeli page 4 of 8 (page number not for citation purposes) take place through and in the daily work, by conscientious fulfillment of all duties … in the sense of our fathers and by works of charity to all human beings (13). furthermore a 1960 document of the jewish women’s organization of zürich states with direct reference to the talmud: “the world rests upon three things: holy teaching, holy service and charity. the first two are mainly carried out by men. but the third, upon which the world rests, is mainly a matter of us women … the exercise of alms and charity. our sages teach. in three ways gemilut chasdim is greater than zeddaka: we do not just give money, but our women commit themselves with their whole person to assure success to our efforts” (14). these texts were written at quite different times and with quite different purposes. they do not explicitly mention the features of the compassionate god or his acts. however they address the care of the sick, and all of them quote “the fathers”, i.e. holy authorities such as moise or abraham, who fulfilled god’s law in exemplary way. this reference to the fathers implies faithfulness to their teachings all of which are based on the old testament. in terms of the topos of the compassionate god this means that the tradition of compassion is continued. feldmann’s distinction between wardens and nurses reminds the reader of the text of the diaconate of bethany which also distinguish between secular nurses and religiously motivated deaconesses. at the same time this difference shows that the care of the sick simultaneously could be understood as a secular and a religious duty. compassionate nursing in the framework of secular nursing in the second half of the 19 th century parallel to confessionally-oriented nursing secular nursing developed. it’s ideal type was the “red cross nurse” of the turn of the 19 th to the 20 th century (15). protagonists of secular nursing did not see themselves as imitators of god. on the contrary, they defined themselves anthropocentric and had an orientation towards a secular ethos: philanthro py. their goal was the achievement of the good rather than of the holy. and they made clear that doing good should be regulated in terms of working hours, and should be paid. nevertheless, many documents of this movement imply that the ethical tradition of compassion continued (15). for example at the beginning of the 20 th century a night nurse praised her duty as follows: “the well-being and the aches of the sick are partially in our hands; we can be saviors of his health but also destroyers of it, if in our duty we are not guided by true love for men. is it not the most wonderful, delightful experience for a nurse to be able to give a charitable service to them when others rest? the most unknown person ceases to be a foreigner, you live and care for him, you love him (16). this passage on the one hand reflects the value of heroism which dominated the european turn of the century and which was combined with philanthro py. also it shows the overlap of this with traditional nursing values: love, charity and care. a director of a school of nursing in a degree ceremony expanded on the compassionate relationship that develops between patient and nurse: “if … a gifted nurse enters the room of the sick it is as if – from the first moment – invisible threads extended between her and him. she is in contact with him; she feels into his soul and into his body and knows what he needs. and again, the sick person himself feels that the nurse feels in his sense, that without his initiative she gives him all he needs and this takes off him all his sorrows and problems, he knows that he is in professional hands, in motherly care, and wonderful calmness overcomes him” (16). in this speech the intimate relationship between nurse and patient is conceptualized within a framework of motherhood, rather than of a religious act which is typical for a historical period during which motherhood was one of the few accepted roles of middle class women. in the literature of the forties a leading nurse emphasized the importance of thinking and acting in the place of the patient (17) and of getting in his “world of thoughts and feelings” (16). a nursing officer of an operation theatre wrote in 1909: “the tasks which we have to fulfill conscientiously must not kill our human participation in the suffering of our neighbors. … i know from experience what comfort we can spend and what thankfulness we often earn when we show our patients in the operation theatre that we do not only want to help but also be compassionate” (16: 142f.). here, at the beginning of the evolution of technical nursing the humane aspect of nursing is presented as complementary component. in these examples compassion is no longer expressed by this term. rather it is implied by words such as “caring”, “taking off the burden”, “participating” and “charity motivated by love” etc.. the examples show that the values previously derived from religion were now contained in the humanitarian ethos and stood in the service of middle-class gender ideologies, of nationalism and patriotism. previously, to work hard without expecting gratefulness or pay was a religious ideal. now this service was presented as an inner necessity of women or as a principle of motherhood. when before self-sacrifice, selflessness, faithfulness to the duties and submission under god and the clergy were required by the church, it was now required in the service of the physicians, the family or the state. hence, the break with religious nursing took place only in institutional and financial matters but not with j med ethics hist med 2008, 1:4 silvia käppeli page 5 of 8 (page number not for citation purposes) respect to nursing’s value system. the mental situation of nursing remained essentially unchanged, but now was presented in the frame of a humanitarian ethos. interestingly, modern jewish nursing never required self-sacrifice and subordination of their nurses but instead, solid education and assertiveness. from the middle of the 20 th century the secular nursing movement started to dominate the religious approaches. the confessional nursing institutions found themselves in crisis. at the same time and until today, nurses practice on the basis of religious motivations. in a recent study carried out in switzerland 40% of the secular nurses confirmed that they want to nurse patients – amongst other reasons – because of religious or spiritual motives (18). research on the effects of dying on practicing nurses they confirmed in many versions how they feel or suffer with the dying and their families (19). compassion in north-american academic nursing from the beginning of the seventies of the 20 th century, nursing education in the german speaking countries started to import north american nursing approaches and it relies on them until today. for this reason i felt challenged in this research to investigate the position of compassion in these approaches. the selection of the literature according to the two principles mentioned above led to texts about “compassion” and even more about “caring”. the literature analysis showed that there are as many definitions and descriptions of these concepts as authors. sometimes “compassion” and “caring” are dealt with synonymously. also, in american nursing science compassion only recently and to a very limited extent became a subject of research. if the american literature deals with “compassion” systematically within the framework of ethical analyses these reflections often are not written by nurse scientists but by medical ethicists or clergymen. for example, nouwen wrote about compassion: “it hurts to enter into the places of pain, to share the brokenness, fear, confusion and anguish. compassion challenges us to cry out with those in misery and to mourn with those who suffer loneliness, to weep with those in tears. compassion requires us to be weak with the weak, vulnerable with the vulnerable and powerless with the powerless. compassion means full immersion in the condition of being human” (20: 13). donley describes the sharing of someone else’s suffering as an act of spirituality (21). to her the spiritual response of the carer is compassionate accompani ment, a search for meaning in the suffering, and action to remove the suffering. dougherty and purtilo proposed the following definition: “compassion is the ability and willingness to enter deep enough into the suffering of a human being in order to experience how he suffers, and the resulting will to remove suffering or to comfort the suffering if nothing else is possible” (22). father smith stated that “common to all religious traditions is an acknowledgement of the primary place in human life of compassion and solidarity … a truly compassionate health care giver will bring to the encounter with patients a habit of trusting and believing …(23). reich maintained that a compassionate human being tolerates that something troublesome happens to him because it happens to somebody else without necessarily identifying with it (24). the significance of compassion in american academic nursing in the american nursing literature four main foci can be identified in relation to the discourse of compassion: the discussion about what compassion is; the controversy about the therapeutic value of compassion; the discussion about compassion as a basis for a caring relationship and the debate about the significance of compassion in the process of professionalization. the discussion about what compassion is: structurally compassion is presented as human trait, moral responsibility, type of interpersonal relation, basis and essence of a nursing relationship or as a nursing method. the statements related to the therapeutic value of compassion are rather unspecific (25) and mostly consist of speculations or individual experiences that are generalized (26). so far, nursing has no means to measure the therapeutic effectiveness of compassion (e.g. how it influences pathologies or healing processes). instead, it relies on descriptive evidence of patients’ experience of compassionate nursing. summarizing such anecdotal observations of the “therapeutic” value of compassion reported in professional articles leads to the following results. compassionate nursing is said to lead to a closer and more attentive nurse-patients relationship, to a more exact assessment of the patients’ vulnerability, to better hermeneutical understanding of patients, to a more careful selection of nursing interventions, to a greater motivation to help and less compromises on the part of the nurses (27). hence compassion should lead to an identifiable quality of care which is distinct from that resulting from distancing nurse behavior. therefore it seems to have a protective effect on patients. donley (21) recognizes the outcome of compassionate nursing in the covenant relationship between nurse and patient. its main features are the mutual promise to availability, advocacy, commitment and dependability in striving to achieve agreed goals. for leveille gaul (28) compassion is a condition for a helping j med ethics hist med 2008, 1:4 silvia käppeli page 6 of 8 (page number not for citation purposes) dialogue and at the same time increases the consideration of the particularity of a patient when decisions have to be taken. unfortunately, in the analyzed literature there is no indication as to in what situations compassion can be contra-indicated although the comprehensive research works of janice morse and colleagues about suffering enduring imply several (29). most texts about compassion in nursing converge in the conclusion that compassion leads to compassionate care (25) and that care without compassion cannot be called care (30). for roach (27) the impulse to care that grows out of compassion is especially crucial for nursing in a technological context or in a reductionist health care system because it preserves the dignity of both nurses and patients. a compassionate approach to care contrasts the value of affect neutrality basically leading medical practice. loewy (31) emphasizes that compassion influences the behavior of nurses and therefore has to be paired with reason when decisions are taken. if in the american nursing literature compas sion is presented as the basis of morally responsible nursing, i.e. of a caring relationship this often takes place in a theological frame of reference. this argumentation follows the new testament metaphor of the good samaritan (32) which is a consequence of the topos of the compassionate god. it is an actualization of the biblical covenant relationship between god and men. however, also secular nurse scientists advo cate nurses’ obligation to compassionate care. hildegard peplau and joyce travelbee (33, 34) explain the compassionate quality of therapeutic relationships with principles of humanistic nursing speaking of a “human-to-human” relationship. based on her intercultural research madeleine leininger (35) concludes that in any helping act compassion is part of normal human behavior. it is the opposite of an attitude which favors egocentric behavior. another secular interpretation of the human inclination to compassion and care originates in the philosophical tradition of sympatheia (36). it explains interpersonal understanding and empathy through the historically, culturally and socially shared horizon of meanings and through the human sharing of some crucial experiences such as suffering and compassion. phenomenology calls this “inter subjectivity” (37). martha rogers (38) interprets compassion as interpersonal relatedness of nurse and patient within a common energy field. when jean watson (39) in her new age approach to nursing proposes compassionate nursing she goes as far as to say: “the person has one basic striving: to actualize the real self, thereby developing the spiritual essence of the self, and in the highest sense, to become god-like” (i.e. compassionate). all approaches advocating compassionate nursing have in common the awareness that both caring and the omission of caring have consequences for both participants in the nurse patient relationship. thomasma and kushner (40) state that compassionate care requires of the nurse a generous management of rules and regulations such as working contracts. this may mean that she has to bear the conflicts which are brought about through covenant partnership. however, according to verena tschudin (41) the satisfaction resulting from such a relationship gives the nurse the courage and energy to protect and preserve the dignity and rights of patients on a continuous basis. the debate about the significance of compassion in the process of professionalization in nursing appears in sharp contrast to the enthusiastic though speculative presentation of the therapeutic value of compassionate caring. while in the clinical context compassion is seen as a virtue and strength related to the professionalization of nursing it is presented as a weakness. the concept of compassion is said to be too unspecific and useless in distinguishing nursing from other health professions (42). this author also worries that cultivating compassion to become the crucial feature of the nursing profession will undermine all scientific and political efforts to professionalize nursing. the significance attributed to compassion in clinical nursing also contrasts the way, in which it is presented in the nursing literature. many articles are expression of frustration, disappointments or of nostalgia and idealized traditions. an analysis of the categories and titles under which compassion is presented in the literature are: editorials, stories (a day in the life of a nurse), soapbox, feature, end piece, reflexions (a christmas story). they are placed at the very beginning or at the end of scientific journals. conclusions the research presented in this article (part 1 and 2) investigated what substantive elements constitute the topos of the compassionate god in the primary jewish and christian sources, how it was received in nursing in the 1 st through the 4 th century ce and how it was received in jewish, christian and secular nursing in the 19 th and 20 th centuries. the results show that throughout these periods “compassion” was an important feature of nursing care and until the end of the 20 th century remained a defining feature of nursing’s professional tradition. the original theological topos of the compassionate god involved existential presence, availability, advocacy, commitment, active involvement, and faithfulness. the biblical topos is bound to remain unchanged. however, the analysis of the literary sources show various interpretations and actualizations of this value system in ancient j med ethics hist med 2008, 1:4 silvia käppeli page 7 of 8 (page number not for citation purposes) and modern judaism and christianity and even more in secular approaches to nursing. both religious and secular interpretations start from the premise of a universal relatedness of all human being as the basis of compassion and of the obligation to help each other. all recognize the overarching gratification for compassionate care in the perfection of self. in the theoretical framework of religion this means imitation of god, i.e. the progressive sanctification of self and the approaching of the essence of the icona dei. in the framework of humanistic psychology and new age theories it means self-actualization and approaching a state of healing and wholeness. also in post-modern nursing these values became the constituents of the construct “caring” with compassion being its core. all authors acknowledge a notion of transcendence in relation to compassion. it manifests itself for example in the question why the suffering of a person should motivate anyone to relieve him. all interpretations speculate about the therapeutic value of compassionate nursing care. the almost universal advocacy of the concept of compassion within nursing shows that throughout history religious and secular nursing leaders succeeded to translate this value system into a distinct relationship between patients and carers: the covenant relationship. this seems especially crucial in times when caring is not the most prominent feature of a society because it ascertains patients’ safety and well-being. an important detail of this research shows that whether or not compassion is motivated by religious (theocentric) or a secular (anthropocen tric) argument is irrelevant for its effectiveness. both, doing “the good” or doing “the holy” can be constitutive for the solidarity with the suffering as well as for the preservation and restitution of their lives. more research is required to clarify whether or not the topos of the compassionate god plays a role in nursing in the context of the third monotheistic religion, islam. j med ethics hist med 2008, 1:4 silvia käppeli page 8 of 8 (page number 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((12.11.2008)) ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ original article copyright © 2021 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e the ethical obligation to provide care to patients diagnosed with brain death until the end stages based on grounded theory *corresponding author zahra sadat manzari address: school of nursing and midwifery, ibne-sina st., doktora crossing, mashhad, iran tel: (+98) 51 38 59 80 19 email: manzariz@mums.ac.ir received: 13 oct 2020 accepted: 20 jan 2021 published: 15 feb 2021 citation to this article: yazdimoghaddam h, manzari zs, heydari a, mohammadi e. the ethical obligation to provide care to patients diagnosed with brain death until the end stages based on grounded theory. j med ethics hist med. 2021; 14: 2. hamideh yazdimoghaddam 1, zahra sadat manzari2*, abbas heydari3, eesa mohammadi4 1.assistant professor, non-communicable diseases research center, operating room department, faculty of paramedics, sabzevar university of medical sciences, sabzevar, iran. 2.associate professor, nursing and midwifery care research center, school of nursing and midwifery, mashhad university of medical sciences, mashhad, iran. 3.professor, nursing and midwifery care research center, school of nursing and midwifery, mashhad university of medical sciences, mashhad, iran. 4.professor, department of nursing, faculty of medical sciences, tarbiat modares university, tehran, iran. abstract nurses are faced with tremendous pressure when providing brain-dead patients with care. there is limited guidance for nurses on the care of these patients. the present study aimed to report the experiences of nurses regarding the care of patients diagnosed with brain death. semi-structured interviews were conducted with 31 nurses and other stakeholders, and the observations and field notes were analyzed using continuous and comparative analysis based on grounded theory. the qualitative analysis of the data resulted in extraction of six final categories, including 'facing increased tensions and conflicts', 'organ donation: a distinct care element', 'inconsistency of care management', 'effective care requirements', 'challenges, rights and duty requirements', and 'moral obligation to provide holistic care until the last minute'. data analysis identified 'challenges, rights and duty requirements' as the main issue and showed that the nurses managed this issue using the strategy of 'moral obligation to provide holistic care until the last minute' as the core variable. according to the results, it is recommended that the healthcare system (especially hospital management) take supportive action for nurses in various fields of care of brain-dead patients to resolve educational, moral and legal challenges. keywords: brain death; nurses; advance care planning; tissue donors; grounded theory. the ethical obligation to provide care to patients diagnosed with brain death … 2 j med ethics hist med. 2021(feb); 14: 2 jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e introduction care provision is the essence of the nursing profession, an important aspect of which is the care of dying patients (1). brain death refers to the irreversible loss of all brain functions, particularly the brainstem (2). according to statistics more than 10 % of deaths are due to brain death (3) .in iran, brain death is a major consequence of road accidents with a mortality rate that is significantly higher than the global and regional average. according to the iranian society of organ donation report, 5,000 8,000 potential brain deaths have been reported in 2017, with 2,500-4,000 cases identified as possible organ donors (4). the care process of brain-dead patients involves several challenges. numerous studies have focused on the challenges and ambiguities that nurses encounter in the care of brain-dead patients (5 6), reporting issues such as uncertainty about the concept of brain death (7 11), problems about care and communication with the patients' families (12 16), religious, ethical, and cultural challenges regarding the acceptance of brain death and organ donation (4, 17 19), inadequate knowledge (20 22), and lack of mental preparation for the care of potential organ donors (9, 16). while the care process of the brain dead patient remains unclear, the understanding and exploration of this process is essential to the maintenance of body organs for donation. in this regard, special attention must be paid to the actual experience of nurses under such challenging circumstances. in the present study, the grounded theory was used to determine nurses’ experiences in the care process of patients diagnosed with brain death. methods it is clear that selection of proper research methodologies depends on the phenomenon under investigation. the grounded theory could be used effectively to discover social processes and comprehend the conditions leading to them, as well as the causative agents of the conditions (23). this qualitative research was conducted based on the grounded theory. data collection started in march 2014 and gradually continued until data saturation in 2017. sampling was performed via in-depth, semi-structured interviews with 31 participants, including 18 nurses, three family members of the patients, three physicians, and other stakeholders (head nurses, shift supervisors, organ donation committee coordinators, and head of the donation committee in khorasan razavi province, iran). the participants were recruited from among the nurses (36% male and 64% male) working in hospitals affiliated to universities of medical sciences in mashhad, neyshabur and sabzevar in khorasan razavi, iran. the mean age of the participants was 31.84 .in addition, two complementary interviews were conducted until theoretical saturation in november 2017. the interview began with an open and general question: "could you describe the care of brain-dead patients that you have actually experienced in the icu (intensive care unit)?" based on the obtained responses, other questions were asked. the duration of the interviews was 45 yazdimoghaddam, h., et al. 3 j med ethics hist med. 2021(feb); 14: 2 jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e 90 minutes. after obtaining the permission of the participants, the researcher recorded the interviews and occasionally took notes. the time and place of the interviews were agreed upon by consulting the participants, and the interviews were conducted individually in a quiet environment. all the interviews were directed by the same researcher (first authors) and the recorded interviews were immediately transcribed word-by-word and reviewed repeatedly. data analysis was initiated with the first interview. data analysis was performed using the corbin and strauss approach (2008), and included examination of the concepts, context, process and consequences, and finally the integration of categories to build the theoretical framework (23). the emphasis of the analysis was on the formation of concepts based on the data obtained in each stage of data analysis. coding and analysis were used to form a concept from the beginning of data collection. at this stage of the analysis, the primary classification of similar codes was also performed, and a primary subcategory was formed. in the open-coding process, the researcher aimed to discover the main issue to determine its solution based on the participants’ viewpoints (23). for this purpose, the researcher could identify the factors that constituted the context of the study phenomenon through enquiry (who, what, where, when, and why). after data analysis and development of the categories and the main issue, the process was analyzed in order to obtain strategies and consequences. the researcher tried to integrate the categories into the paradigm by creating a story line, doing diagrams and rereading memos with the intention of discovering the core variable and developing a theory. the researcher recorded the observations of the nurses regarding care provision for patients diagnosed with brain death in order to collect objective data. data reliability the quality of the present study was assessed based on the criteria proposed by corbin and strauss (2008) (23). to this end, the researcher used long-term follow-up, continuous member check, search for negative items, integration, peer debriefing and a survey by researchers who were familiar with qualitative studies in order to ensure the reliability of the data. for this purpose, the interview transcripts and extracted codes were presented to the participants to obtain their confirmation and complementary comments. in addition, the interview transcripts, the initial codes and the categories were reviewed by a coresearcher and two professors with ample experience in the field of qualitative research. theoretical sampling (i.e., interviews with diverse individuals in terms of age, gender, employment status, work experience and workplace) verified data transferability. moreover, the duration of the study was three years. at all stages, the researcher tried to present the findings to healthcare providers of various educational and clinical positions (especially nurses) in the most meaningful manner. the ethical obligation to provide care to patients diagnosed with brain death … 4 j med ethics hist med. 2021(feb); 14: 2 jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e ethical and research approvals the study was approved by the ethical committee of our institution, mashhad university of medical sciences, iran. (code: ir.mums.rec.1394.58). in accordance with national regulations, written informed consent was obtained from each enrolled subject. the participants were informed about the ethical considerations of the study prior to the interviews and assured of confidentiality. participation was voluntary, and subjects were assured that their statements would not be disclosed to anyone, except the researcher. result the qualitative analysis of the interview data, observations and field notes led to the extraction of 1,270 initial codes, 12 subcategories, and 6 final categories. the six categories extracted from data analysis included 'challenges, rights and duty requirements', 'facing increased tensions and conflicts', 'organ donation: a distinct care element', 'inconsistency of care management', 'effective care requirements’, and 'moral obligation to provide holistic care until the last minute'. the findings will be presented according to the analysis as context, process or strategy, and consequences, to guide the reader. the main issue: challenges, rights and duty requirements the majority of the participants emphasized two issues in every situation: ‘the tension of keeping the organ donor alive until donation ' and 'fear of punishment and failure'. these phenomena were indicative of the main issue in the viewpoint of the participants since all the nurses were stressed about keeping the organ donor alive through all the care stages. in non-candidate patients, despite the lack of survival stress, the nurses still believed that they should take care of the patients until the last minute. the tension of keeping the organ donor alive until donation: this category indicated that nurses deal with stresses such as keeping the patient alive and maintaining the health of donation organs during the care of these patients. these concerns add to the difficulty and sensitivity of care due to changes in the conditions of the patients. below are some of the statements made by the participants in this regard. “all the team members were trying to keep the organ donor alive, and the family of the patient gave their consent for donation, which is why the care of the patient was extremely sensitive. suddenly tachycardia occurred, and the patient’s blood pressure decreased…. in other words, all parts of the patient’s body must be meticulously monitored until the last moments before donation….” [participant no. 7] “my concern is to keep the organ donor alive, especially the body organs. that is why i closely monitor the patient and will immediately notify the attending physician in case of problems…. despite all this monitoring to the last minute, there is still the stress of keeping the patient alive until donation….” [participant no. 5] the comments above demonstrate the dimensions of 'obligation to keep the organ donor alive', which was repeatedly pointed yazdimoghaddam, h., et al. 5 j med ethics hist med. 2021(feb); 14: 2 jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e out by the nurses as the main issue in the care of organ donors. fear of punishment and failure: this category indicated nurses’ concerns regarding the care of brain-dead patients, such as fear of insufficient time, inability to maintain the health of organ donors, and loss of the organs. understandably, the nurses were faced with the feeling of guilt in the care of non-candidate patients “it is true that some brain-dead patients are non-candidates, but as human beings, they have the right to receive care. i would feel guilty if the ward was crowded and i was unable to care for these patients….” [participant no. 3] according to the nurses, caring for noncandidate patients was perceived as futile by physicians and even the healthcare system. meanwhile, most nurses felt guilty after inefficient care, discontinuation of medications, and weaning of patients from the ventilator. “some say you should not take care of noncandidate patients... there is no such thing in our culture. i have never been able to not care for non-candidate patients because i would feel guilty.” [participant no. 1] the mentioned issues highlighted the dimensions of 'duty requirements to maintain the health of organ donors' and 'right requirements to care for a noncandidate patient’. the concepts of these categories were grouped together as they seemed to relate to each other. finally, the main issue of 'challenges, rights and duty requirements' was extracted. context: inconsistency of care management after determining the main issue, the subcategory of 'inconsistency of care management' was extracted and explained as the context for the 'challenges, rights and duty requirements’. the context (in which nurses are confronted with the care process of brain-dead patients) consists of two categories: 'defects in the efficient healthcare system' and 'perceived conflicts in the acceptance of the situation'. defects in the efficient healthcare system the healthcare system emphasizes the importance of care provision to brain-dead patients and increasing the rate of donations. however, there has been no planning to increase the quality of care and maintain the health of potential donation organs, which causes tension in nurses . “the organ donor was about to be transferred to the transplant center during my shift. at the same time, i had a critically ill patient and had to take care of the two of them simultaneously, so i was constantly stressed about keeping the organ donor healthy until donation.” [participant no. 8] “i still do not know how to care for organ donors. i do not even know which organs must be properly monitored and what laboratory tests must be quickly performed. but the head nurse does not pay attention to my lack of training on the care of brain-dead patients.” [participant no. 14] perceived conflicts in the acceptance of the situation the ethical obligation to provide care to patients diagnosed with brain death … 6 j med ethics hist med. 2021(feb); 14: 2 jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e nurses experience conflicts from the moment they encounter brain-dead patients to the confirmation of brain death and transfer of the organ donor to the transplant center, and even afterwards. these conflicts are mainly caused by the 'duality of emotions about organ donation' and 'doubts and conflicts between physicians and nurses in understanding the treatment and care'. in addition, nurses have the fear of punishment and failure. “if a brain-dead patient does not meet the donation criteria, i am never sure the diagnosis is correct; i would feel guilty if i did not care for these patients and discontinued dopamine and other drugs....” [participant no. 2] “several other patients could have a new life if the organs of brain-dead patients are donated. therefore, i am very sensitive about their care and constantly stressed whether they live or die until donation.” [participant no. 15] an example of the recorded observations is as follows: “the organ donor was supposed to be transferred to the operating room for donation in half an hour. the attending nurse was extremely stressed during this time and meticulously cared for the organ donor. her level of stress was totally understandable....” [participant no. 2] strategies: success and tranquility despite physical and mental exhaustion the extracted categories were indicative of the challenges faced by nurses in the care process of brain-dead patients. in this process, nurses use the following strategies to eliminate the main issue: 'diligent care efforts to successfully carry out the donation', 'conscientious care', 'care provision while keeping human and emotional considerations in mind, 'moral commitment to provide care even when death is imminent', and 'organ donation: the most distinctive element in life-saving care’. consequence: success and tranquility despite physical and mental exhaustion consequences of these strategies were classified into two categories of 'threat to physical and mental health' and 'internal satisfaction and spiritual self-control following proper care'. it may be concluded that these strategies can lead to tranquility despite physical and mental exhaustion. integration of categories in line with moving from mere description toward theorization, the researcher constantly attempted to develop a storyline based on the core variable, and the final category and subcategories were the basis for the theoretical structure. all the interactions were focused on 'challenges, rights and duty requirements’, and nurses used 'moral commitment to holistic care until the last minute' to deal with this main concern. this strategy emerged from the listed categories as the core variables with the required criteria, ultimately leading to "success and tranquility despite physical and mental exhaustion”. other categories emerging from analysis of the results appear below. the concept of 'facing increased tensions and conflicts' indicated the circumstances that nurses were faced with, including the tension of the initial care, the hopelessness yazdimoghaddam, h., et al. 7 j med ethics hist med. 2021(feb); 14: 2 jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e following confirmation of brain death, and dealing with the emotions of the families of the patients in the care process. therefore, a major challenge for nurses is to overcome these stresses so that they can care for the brain-dead patient. the concept of 'organ donation: a distinct care element' affects how nurses care for brain-dead patients as an intervening factor. organ donation strengthens motivation for care, and conversely, when donation is not an option, nurses’ desire to care for a noncandidate patient diminishes. 'effective care requirements' are intervening conditions in the care process pertaining to the 'challenges, rights and duty requirements'. targeted communication between the healthcare team and the patients’ relatives also plays a key role in the provision of care to organ donors. therefore, nurses need adequate knowledge to provide effective care to brain-dead patients (table1). table 1concepts/categories developed from the data at the integration stage subcategory category final category the tension of keeping the organ donor alive until donation challenges in patients’ rights and duty requirements facing increased tensions and conflicts fear of punishment and failure the tension of giving bad news to the family turbulent confrontation with successive chains of stress the stressful experience of the first care difficulty in dealing with the family’s feelings sense of lack of support in care the stress of being blamed by the family disappointment and sadness following confirmation of brain death the physical distress caused by stressful care threat to physical and mental health success and tranquility despite physical and mental exhaustion the psychological distress and family problems of nurses following stressful care satisfaction with the life-giving care internal satisfaction and spiritual self-control following proper care success and satisfaction the tranquility following careful and human care paying attention to the passing of life and the gift of life moral development conscientious care care based on ethical and conscientious values moral commitment to holistic care until the last moment moral commitment to provide care even when death is imminent the effect of patient status and characteristics on the care provider care provision while keeping human and emotional considerations in mind nurses' emotional distress following care respecting the rituals for dying patients being less sensitive to non-candidate patients’ care futile care of non-candidate patients organ donation: a distinct care element feeling uselessness of care when donation is not an option giving life: an incentive for increased effort to receive the family’s consent for donation organ donation serving as a motivation booster and giving meaning to care organ donation: the stimulus and result of careful care organ donation: the most distinctive element in life-saving care duality of emotions about organ donation perceived conflicts in the acceptance of the situation inconsistency of care management doubts and conflicts between physicians and nurses in understanding the treatment and care defects in efficient organizational management defects in the efficient and targeted healthcare system ineffective and non-targeted structure of care facilitating communication with the family in deciding about donation the effect of multifaceted carecentered communications on the donation process effective care requirements the role of communication with patients in understanding care effective care as a result of teamwork nurses’ need for education in order to provide effective care the necessity for adequate knowledge and skill in providing care nurses’ need for sufficient knowledge and skill in order to provide proper care the necessity of impartiality and full support of the family the ethical obligation to provide care to patients diagnosed with brain death … 8 j med ethics hist med. 2021(feb); 14: 2 jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e theory of moral commitment to holistic care until the last moment the theory developed after analyzing the data from this study explains that nurses face increasing stress and conflicts in the care of brain-dead patients, and the main issue of the 'challenges, rights and duty requirements’ is formed by the inconsistency of care management. nurses lack sufficient understanding about the concept of brain death and experience conflicts about organ donation. they face interventional measures (e.g., donation), which affect the care of brain-dead patients, so they have to dedicate all their efforts to finishing the task through 'moral commitment to holistic care until the last moment'. the consequence of this ethical and moral commitment to care is success and tranquility despite physical and mental exhaustion. in fact, in the face of these problems, nurses attempt to provide holistic care until the last moment to gain inner tranquility (figure 1). figure 1 the theory of "moral obligation to provide holistic care until the last minute" yazdimoghaddam, h., et al. 9 j med ethics hist med. 2021(feb); 14: 2 jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e discussion in this qualitative research, we evaluated the nursing care of patients diagnosed with brain death using the grounded theory approach, reaching the theory of 'moral commitment to holistic care until the last moment'. therefore, the results were assessed by focusing on this core variable in order to solve the main issue (challenges, rights and duty requirements). while no study has pointed out this core variable and categories specifically. simonsson et al. assessed the icu nursing experience of caring for potential donors. the nurses stated that the organ donation process is emotionally challenging, supporting the patient’s family is a difficult and demanding duty, a complex and multidimensional process should have a high level of liability, and respectful care must be provided based on respect for the potential organ donor (6). forsberg et al. showed that nursing care strives to preserve respect for the organ donor and relatives within an atmosphere of tranquility (24). these studies have paid special attention to precise care provision and respecting organ donors as live patients, as well as their relatives, which is consistent with the subcategory of the core variable in the present study. in studies that were mainly focused on the experiences of nurses in the care of braindead patients, the only concept assessed was the tension of keeping the patient alive until donation, and nurses’ experiences in the care of non-candidate brain-dead patients and the related concerns were not evaluated. for example, in the study by salehi et al. nurses’ experiences showed the sensitivity of the care of organ donors due to its role in maintaining the health of the donation organs, which was described as an "excruciating task" (21). this is congruent with the category of 'tension of keeping the donation organs alive until donation' as one of the dimensions of the main issue in the present study. vijayalakshmi et al. recommend continuing training to enhance nursing knowledge and skills, as well as sensitivity to social, cultural, moral and religious issues, and support in the area of organ donation (9), which is in line with the main issue of the present study. this consistency is indicative of the importance of organ donation as part of the icu culture, and shows that nurses carry out their responsibilities for the health of vital organs regardless of geographical boundaries. maintaining physiological performance is possible by focusing on keeping the organs alive for reutilization while providing care to organ donors (25). different studies have shown the significance of the care of organ donors as the most important aspect of the nursing care of patients before transfer to the operating room for donation (9, 16). keshtkaran et al. showed the lack of trust in diagnosis and verification of brain death as a "halo of ambiguity and doubt", so that nurses did not announce the brain death of patients and hoped for their cure. such the ethical obligation to provide care to patients diagnosed with brain death … 10 j med ethics hist med. 2021(feb); 14: 2 jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e doubts make nurses uncomfortable and reinforce denial in the families of patients (8). victorino aimed to evaluate the care management of organ donors by nurses when the latter had doubts about the diagnosis of brain death due to different cultures and beliefs (19). these findings are consistent with the concept of the main issue and context in the present research. one of the stressful factors was the tension of giving bad news to the family. in a research, yousefi et al. extracted concepts such as shock, hope for recovery, unknown process, conflict of opinions, and conflict of opinions (26). according to foresberg, et al. communication with patients’ families was very difficult for the nurses and could be associated with emotional reactions due to their sensitive emotional state (24). the concept of 'defects in the efficient care system' was another underlying contextual factor for the main issue of the present study. in sweden, the rate of organ donation has been on the rise since 2001, which shows the improvement of the organizational structure (27). in 2017, the actual donation rates in iran were 900-1,000 based on the statistics, while 7-10 patients on the transplant waiting list are reported to die daily (4). therefore, it could be inferred that the organizational management is still faulty, and high-quality care must be provided to donors so that the organs can be maintained in good condition. a review of the studies showed that the care of braindead patients and interaction with their families imposed tremendous pressure on nurses, resulting in cognitive dissonance (21). under such circumstances, nurses become frustrated and inefficient due to the stressful care of brain-dead patients, which leads to the decreased quality of patient care (5). therefore, nurses consider the care of brain-dead patients as a big challenge (21). our findings presented the consequence of 'internal satisfaction and spiritual selfcontrol following meticulous care', which showed the excellence of the nurses caring for brain-dead patients in various personal and spiritual aspects. in addition to the aspects of the patient care process by nurses, the theory used in our research also considered the experiences of the other stakeholders involved in the care process. limitation the limitation of this study was that nurses’ statements had to be translated from the original language of the interviews into english. conclusion the results of the grounded theory confirmed that nurses felt a moral commitment to care for organ donors and non-candidate patients despite all tensions, so that holistic and careful care could be provided until the last moment. nurses tried to complete the care of potential organ donors meticulously based on ethical and conscientious values and regardless of the patient's prognosis, and even despite the futility of care of brain-dead patients. according to the results, nurses faced many yazdimoghaddam, h., et al. 11 j med ethics hist med. 2021(feb); 14: 2 jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e ambiguities regarding the ethical and legal aspects of brain death, and providing care to organ donors caused them a lot of tension, leading to their gradual mental and physical exhaustion. therefore, “moral commitment to holistic care until the last moment” was the main strategy of nurses and the turning point of the study in the multidimensional process of caring for the brain-dead patient to overcome the phenomenon of “challenges in patients’ rights and duty requirements". acknowledgements hereby, we extend our gratitude to all the participants who patiently recounted their experiences. this study was part of a phd dissertation approved by the school of nursing and midwifery in mashhad university of medical sciences, iran (code: 931512) conflict of interests none declared the ethical obligation to provide care to patients diagnosed with brain death … 12 j med ethics hist med. 2021(feb); 14: 2 jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e references 1. alligood mr. nursing theory e-book: utilization & application, 5th. usa: elsevier health sciences; 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11(3): 129-42. 26. yousefi h, roshani a, nazari f. experiences of the families concerning organ donation of a family member with brain death. iran j nurs midwifery res. 2014; 19(3): 323-30. 27. gómez m, pérez b, manyalich m, editors. international registry in organ donation and transplantation2013. transplant proc; 2014 ;46(4): 1044-8. ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ original article copyright © 2021 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e developing and validating an instrument to measure: the medical professionalism climate in clinical settings *corresponding author zahra shahvari address: azad university complex of gachsaran, school of nursing and midwifery, first floor, department of midwifery, ferdousy blvd., gachsaran, iran. postal code: 75 81 86 38 76 tel: (+98) 074 32 33 533 email: shahvari@iaug.ac.ir received: 20 jan 2021 accepted: 1 aug 2021 published: 3 nov 2021 citation to this article: asghari f, shahvari z, ebadi a, alipour f, samadi s, bahreini m, amini h. developing and validating an instrument to measure: the medical professionalism climate in clinical settings. j med ethics hist med. 2021; 14: 11. fariba asghari1, zahra shahvari2*, abbas ebadi3, fateme alipour4, shahram samadi5, maryam bahreini6, homayoun amini7 1.professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. 2.assistant professor, school of nursing and midwifery, islamic azad university of ghachsaran, ghachsaran, iran. 3.professor, behavioral sciences research center, life style institute, nursing faculty, baqiyatallah university of medical sciences, tehran, iran. 4.associate professor, eye research center, farabi hospital, tehran university of medical sciences, tehran, iran. 5.associate professor, department of anesthesia and intensive care, imam khomeini hospital complex, tehran university of medical sciences, tehran, iran. 6.associate professor, department of emergency medicine, school of medicine, tehran university of medical sciences, tehran, iran. 7.professor, department of psychiatry, roozbeh hospital, school of medicine, tehran university of medical sciences, tehran, iran. abstract this study was conducted to develop and validate an instrument to measure the medical professionalism climate in clinical settings. the item pool was developed based on the tehran university of medical sciences guideline for professional conduct. the items were distributed between two questionnaires, one for health-care providers and the other for patients. to assess the construct validity of the questionnaires, 350 health-care providers and 88 patients were enrolled in the study. the reliability of the questionnaires was evaluated by calculating cronbach’s alpha and icc. at first a 74-item pool was generated. after assessing and confirming face and content validity, 41 items remained in the final version of the scale. exploratory factor analysis revealed the three factors of “personal behavior”, “collegiality” and “respect for patient autonomy” in a 25item questionnaire for service providers and a single factor of “professional behavior” in a 6-item questionnaire for patients. the three factors explained 51.775% of the variance for service providers’ questionnaire and the single factor explained 63.9% of the variance for patients’ questionnaire. the findings demonstrated that from the viewpoints of patients and service providers, this instrument could be applied to assess the medical professionalism climate in hospital clinical settings. keywords: professionalism; clinical setting; questionnaire; validation. developing and validating an instrument to measure: the medical … 2 j med ethics hist med. 2021(november); 14: 11. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e introduction professionalism is fundamental in maintaining the public trust in medical professions (1). medical professionalism regulates health-care providers’ behavior in their interactions with patients, other healthcare providers, and the health-care organization. in the past two decades, professionalism has been recognized as an essential medical competency and is now included in the undergraduate and postgraduate curricula (2-4). professionalism has also received increasing attention in iran over the past decade. professionalism is currently defined as a core competency for graduate medical education, and its position is being recognized as an integral part of the formal curricula in iran. in 2013, tehran university of medical sciences (tums) developed a framework for professionalism based on a project. the framework consisted of six domains (altruism, honor and integrity, respect, responsibility, justice and excellence), and was used to formulate a guideline for professional conduct in medical practice (5). this guideline serves to direct training and the assessment activities related to professionalism for students and faculty members. the hospital setting has an important role in shaping students’ professional behavior. the students’ professional identity is developed more effectively through socialization in clinical settings than formal education (6). relationships, processes and policies of the hospital setting are important parts of the informal and hidden curriculum of medical education that can facilitate or hinder the formation of professional identity in students. for example, the unprofessional behavior of attending physicians could alter the attitude of trainees and staff. professional practice can hardly take place in an unprofessional environment. there are reports of the deterrent role of the hidden curriculum in developing professional identity and enhancing professionalism, and the importance of corrective interventions (7 9). kalet et al. assessed the formation of professional identity in medical school graduates through different steps of professional formation: independent operator, team-oriented idealist, selfdefining professional and self-transforming professional. they found that medical students can end up with various results during medical school training with regard to professional identity (10). according to goldie, professional identity is more efficiently influenced by hidden curricula, professional role models, feedback from others, and integration into social networks in the medical environment than formal teaching measures (11). for evaluation of the effectiveness of any corrective interventions, it is very important to assess the professionalism climate in clinical settings. in addition, the development and application of questionnaires at the beginning of professionalism enhancement programs could encourage the involved people (residents, faculty members and staff) to adhere to professional codes and improve the current situation (12,13). professionalism asghari f., et al. 3 j med ethics hist med. 2021(november); 14: 11. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e is a culture-sensitive concept and any tool for measuring its constructs in the clinical setting should reflect the cultural context (14). as the first step, we need to provide a definition for professionalism climate. this can be described as the employees’ perceptions of organizational practices in the health-care facility that reinforce professional behavior and discourage unprofessional behavior. on the other hand, the organization’s ethical climate refers to the employee beliefs about the organizational atmosphere and shows (a) whether and how ethical decisions are made, or (b) whether conditions facilitating ethical decision-making and ethical reflection exist (15). although different instruments have been developed to evaluate some aspects of professionalism in hospital settings, no single tool does all at once. some instruments have focused on the organizational climate or cultural differences, and have evaluated the social capital among health-care providers and leadership in the hospital setting (15, 16). some other tools have measured a number of professional behavior outcomes (for example patient safety or patientcenteredness of services) in clinical settings (17-19). some instruments have only investigated the professionalism climate from the viewpoints of certain groups (1620). quaintance et al. developed an instrument for the assessment of the professionalism climate in clinical settings from the viewpoint of students (20), but did not include the viewpoints of faculty members and other hospital staff. olson also proposed a tool for the assessment of ethical climate in the clinical setting from the nurses’ perspective (15). in this study we aimed to develop a comprehensive tool for the assessment of different aspects of professionalism climate from different viewpoints. methods the current instrument development study aimed to develop and validate a questionnaire to measure the climate of professionalism in clinical settings in iran. the study was conducted in two phases: phase i: item generation the researchers generated an item pool through developing a detailed list of examples of professional conduct based on the “guideline for professional conduct in medical practice” developed by tums (5) and review of the literature. the items were generated deductively. in this phase, a comprehensive literature review was performed on published literature dating from 2010 to 2017 indexed in medlib, iran medex, magiran, sid, irandoc, medline, ebsco and proquest. this phase was designed to complete the items based on the existing literature. articles could enter the study if: 1) they had been written in the english language, and 2) they contained the words “professional behavior”, “professional attributes” or “professional climate”, and “assessment”, “instrument” or “tool” in the developing and validating an instrument to measure: the medical … 4 j med ethics hist med. 2021(november); 14: 11. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e title or abstract. considering the main attributes of professionalism, the appropriate phrases were extracted from literature. the items were reviewed, and duplicates and overlaps were merged. then, five experts were asked to review the items and add any other relevant or necessary items. it should be added that the experts were attending physicians and had knowledge of professionalism or published papers on the subject. the primary item pool included 91 items, which were reduced to 74 after deleting duplicates and overlaps. as patients are a rich resource for evaluation of professionalism in the clinical setting, the experts allocated some of the items to patients, and the structure and wording of the items were changed so that they could be easier for the patients to read and understand. phase ii: validation in this phase, the psychometric properties of the scale, such as its face, content and construct validity (exploratory approach), as well as its reliability were evaluated. the process of evaluating the psychometric properties of the scale was as follows: a) face and content validity, b) factorial (construct) validity, and c) reliability. the draft of the instrument included two separate questionnaires, one for receiving the viewpoints of the patients and one for obtaining the viewpoints of service providers, including physicians, nurses, other care providers, and residents across the university hospitals. a) face and content validity the content validity of the questionnaire was assessed three times. each time, a content validity assessment questionnaire was sent to 20 experts who had knowledge, information and published papers in professionalism through google forms. the experts were medical ethicists or attending physicians of various clinical departments of tums. also, all experts were familiar with medical professionalism in the iranian context. in the first round, the experts were requested to rate the items as necessary, useful but unnecessary, or unnecessary. then, the content validity ratio (cvr) was calculated based on the critical values for lawshe’s content validity ratio (21). out of 11 experts, at least 9 had to vote an item as necessary. the experts also were asked to provide their comments for adding new items and completing the item pool. in the second round, all items, including the new and modified ones, were returned to the experts to determine the cvr. in the third round, the content validity index (cvi) was calculated through evaluation of each item’s relevance to the concept of professionalism using a 4-point likert scale (1 = irrelevant, 2 = relatively relevant, 3 = acceptably relevant, and 4 = totally relevant). moreover, they were asked to modify the items that were not relevant to the concept of professionalism. cvi was calculated for each item and items with cvis below 0.79 were deleted. cvi was asghari f., et al. 5 j med ethics hist med. 2021(november); 14: 11. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e calculated by dividing the number of experts who gave each item a score of 3 or 4 by the total number of experts participating in the panel. the face validity of the questionnaire was assessed by receiving the viewpoints of 20 experts, and also through conducting interviews with a sample of the final scale responders (including 14 faculty members, 10 residents and 15 nurses for the service providers’ questionnaire, and 10 patients for the patients’ questionnaire). the responders were requested to read the items aloud and share their comprehension with the researcher in order to assess the difficulty and ambiguity of the items. finally, their comments for simplification and clarification of the items were collected. for scoring, we formed an expert panel consisting of 4 experts in instrument designing and 4 experts in professionalism to determine the proper likert scale. the items were divided into two groups, one with a five-point likert scale of “never” to “almost always”, and the other with a fivepoint likert scale of “very little” to “very much”. the likert options for each item were given scores between 1 and 5 based on the item’s accordance with expected professional behaviors (reverse items were scored reversely). accordingly, the total score of each questionnaire was calculated by adding up the scores of all items. b) factorial validity for evaluation of the construct validity of the instrument, we used exploratory factor analysis (22, 23). the questionnaires were completed by the staff and patients of a hospital affiliated with tums. service providers’ questionnaire: subjects were selected through convenient proportional to size sampling according to the different levels of service providers. the inclusion criteria were at least one year’s work experience and at least 6 months’ experience in the ward of interest. therefore, medical students did not meet the inclusion criteria due to short-term rotations in each ward. three hundred and 95 service providers were enrolled, considering 5 to 10 subjects for each item (24), and there were a total of 41 items in the service providers’ questionnaire. overall, 365 questionnaires were completed: 210 out of 220 nurses (response rate = 96%), 70 out of 85 residents (response rate = 82.3%), and 70 out of 90 faculty members (response rate = 78%). fifteen questionnaires were excluded due to the responders’ inattention in answering the questions, so the final analysis was done on 350 subjects. patients’ questionnaire: the inclusion criteria were hospitalization for at least three days in the ward and complete alertness. eighty-eight patients were chosen to participate in the study using systematic random sampling. six questionnaires were excluded due to missing data. the kmo index of sampling adequacy and the bartlett’s test of sphericity for confirming the fitness of the factor analysis model were applied. the kaiser criteria and a scree plot with a minimum factor load of 0.4 were employed to maintain the items in the developing and validating an instrument to measure: the medical … 6 j med ethics hist med. 2021(november); 14: 11. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e extracted factors. since some items were loaded in more than one factor, we changed the rotation to non-orthogonal rotation (direct oblimin) (25). c) reliability cronbach's alpha coefficient of internal consistency was calculated to assess the scale reliability. in order to detect at least 80.0% power of the test, minimum sample size was set at 207 (26). cronbach's alpha coefficient was calculated on the factorial validity sample (n = 365). also, the relative reliability of the instrument was measured by test-retest at an interval of two weeks, and the intraclass correlation coefficient was calculated. the test-retest was done on 30 nurses for the service providers’ questionnaire and 40 patients for the patients’ questionnaire. result the primary item pool included 91 items, which were reduced to 74 after deleting duplicates and overlaps. of these items, nine pertained to the patients’ and 65 to the service providers’ questionnaires. validating the questionnaires a) validity content and face validity: the changes in the questionnaire item numbers in different stages of content and face validity assessment are presented in table 1. table 1the changes in the patients’ and service providers ’questionnaires in the validation process patients’ questionnaire service providers’ questionnaire validation process total modified removed added initial number of items total modified removed added initial number of items 10 0 1 0 11 46 9 21 2 65 first round content validity 9 0 1 0 10 46 6 0 0 46 second round 7 5 2 9 47 17 0 1 46 face validity 6 0 1 0 7 41 0 6 0 47 third round content validity 6 0 6 30 11 41 construct validity (exploratory factor analysis) the mean cvi was 0.945 and 0.921 for service providers’ and patients’ questionnaire, respectively. factorial validity/service providers’ questionnaire: homogeneity of the questions was confirmed before conducting exploratory factor analysis. the kmo value was 0.925, which confirmed sampling adequacy. the high significance of the bartlett’s test (p < 001) showed an acceptable correlation among variables for factor analysis. the scree plot showed a three-factor structure of the scale. considering a minimum factor load of 0.4, fifteen items were eliminated. factor analysis revealed three factors: “personal behavior” (15 items), “collegiality” (7 items), and “respect for patient autonomy” (3 items). these three factors explained 51.775% of the variance: 36.642% for asghari f., et al. 7 j med ethics hist med. 2021(november); 14: 11. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e “personal behavior”, 8.395% for “collegiality” and 6.738% for “patient autonomy”. all explained variances are presented in table 2. table 2the three-factor structure of the service providers’ questionnaire items component factor loading my colleagues in this ward: factor 1 factor 2 factor 3 1. make sure the patients are provided with complete information and care continuity is maintained during patient transfer or shift change. 0.837 2. do their duties in a timely manner. 0.793 3. observe the university dress code. 0.761 4. wear their identification badges in plain sight. 0.701 5. provide patients with sufficient medical information and seek their consent. 0.680 6. share patients’ information only with the treatment team, the patient, or his/her companion(s), and observe data confidentiality. 0.673 7. give the necessary instructions to patients and their companions. 0.673 8. take the necessary steps to correct any medical errors that may have occurred. 0.614 9. have a respectful behavior towards one another. 0.607 10. pay attention to updating their knowledge and skills. 0.602 11. are careful not to waste hospital resources and facilities. 0.598 12. seek help if they lack sufficient knowledge or skills in a matter. 0.576 13. resolve disputes with colleagues in a friendly manner with respect for dignity of the involved people. 0.547 14. pay attention to the system’s shortcomings and give feedback to superiors. 0.515 15. are careful not to waste the time of colleagues, patients and their companions. 0.474 16. welcome constructive feedback. 0.837 17. professional behavior is encouraged in this ward. -0.805 18. make certain that there is a good balance between educational and treatment activities. -0.778 19. make sure that the educational and administrative rules are observed. -0.738 20. take all the necessary measures to promote effective team work among members of the treatment team. -0.738 21. ensure that if there is an error, respectful feedback is given to the person at fault. -0.736 22. do everything they can so that patients’ complaints are used for correcting processes and improving services. -0.701 23. for research purpose do not impose a risk or a cost on the patient.. 0.847 24. respect patient's beliefs. 0.704 25. for education do not impose a risk or a cost on the patient. 0.657 initial eigenvalues 9.161 2.099 1.684 explained variance (%) 36.642 8.395 6.738 cumulative variance (%) 36.642 45.038 51.775 patients’ questionnaire: homogeneity was confirmed in the related questions. the kmo value of 0.853 showed data adequacy for statistical analysis. the high significance of the bartlett’s test (p < 001) confirmed a sufficient correlation between variables for factor analysis. finally, the scree plot showed a one-factor structure for this scale. in factor analysis of patients’ data, all items were loaded under a factor with an eigenvalue of 3.78 that explained 63.9% of developing and validating an instrument to measure: the medical … 8 j med ethics hist med. 2021(november); 14: 11. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e the variance. all items had a factor loading above 0.4 and none was eliminated in factor analysis. the highest and lowest factor loading was related to “they took care of me with sympathy and compassion” (0.786) and “they paid attention to my comfort when i was resting” (0.429), respectively (table 3). table 3. the one-factor structure of the patients’ questionnaire factor loading item 0.614 1. they treated me respectfully and politely 0.643 2. they answered my questions with patience 0.633 3. they gave adequate explanations before any procedure 0.786 4. they took care of me with sympathy and compassion 0.681 5. they took care of my tasks in a timely manner 0.429 6. they paid attention to my comfort when i was resting 63.9 explained variance (%) b) reliability service providers’ questionnaire: in the final questionnaire, the cronbach’s alpha coefficients for factor 1, factor 2 and factor 3 were 0.787, 0.815 and 0.888, respectively. the intraclass correlation coefficient (icc) of the final scale was 0.816 at a significance level of 0.001. patients’ questionnaire: the cronbach’s alpha coefficient and icc were 0.616 and 0.60 at a significance level of 0.001. c) further evidence for validity we assessed between group differences (nurses’ vs. physicians and residents) using anova. there was a significant difference [f(2,362) =9.683, p=000] between the nurses, residents, and faculty members. post hoc comparisons using the tukey hsd test indicated that the mean score given by residents (m=66.5, sd=14.5) was significantly lower than that given by nurses (m = 74.4, sd = 13.5) and faculty members (m = 73.8, sd = 11.5). however, the scores given by nurses did not significantly differ from those given by faculty members. discussion in this study, we designed an instrument for measuring the professionalism climate in hospital settings. this instrument can be used by hospital managers and help caregivers and patients express their viewpoints on health-care workers’ adherence to each item. the instrument consists of two parts. the first part is the service providers’ questionnaire, which contains 25 items including three factors of “personal behavior” (15 items), “collegiality” (7 items), and “respect for patient autonomy” (3 items) (table 2). the second part is a 9item patients’ questionnaire containing only one factor. in another scale 7 dimensions were considered: self-interest, company profit, friendship/the interest of the team, social responsibility, personal morality, rules, and laws (professional codes) (27). quaintance et al. assessed medical professionalism based on dimensions such as respect/caring/compassion, duty/service, altruism, honesty / integrity, accountability/ responsibility, and excellence. they asghari f., et al. 9 j med ethics hist med. 2021(november); 14: 11. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e evaluated the extent of teaching and also acting in accordance with principles of professionalism in their environment. the instrument they used helped them assess and simultaneously upgrade the level of teaching professionalism in their setting (20). wangsaturak and mcaleer tried to develop an instrument to evaluate the different aspects of the medical education climates. in their instrument, some items about the institutional environment and practices of colleagues and teachers were related to the topics of medical professionalism including altruism, honor, integrity and excellence (28). in this study, we assessed professionalism climate, and not ethical climate. ethical climate has been described as maximized self-interest and collective interests and adherence to universally accepted ethical principles. in this description patients seem to be ignored. respect for patient autonomy is highlighted in our scale in the iranian context. collegiality and flexible interprofessional collaborative relationships (29) are other important attributes of professionalism. in order to foster proper collaboration between nurses and physicians, it is essential to improve workplace civility to provide high-quality services (30) factor analysis showed that the items in the service providers’ questionnaire explained an acceptable percentage of the instrument variance for evaluation of the professionalism climate in clinical setting. personal behavior and environment are two major factors in levels of change in the onion model (31). evaluation of the professionalism climate is of major significance, because in a non-professional climate, the behavior of individuals who lack adequate knowledge and the right attitude will deviate from professional norms (13). it could be stated that the climate of professionalism represents hidden curriculum management. the students’ professional identities are influenced by the context in which they are formed, so they may be affected by collective professional values (32); therefore, the climate and context of professional interactions are very important. this instrument can measure the prevailing practice of professionalism in interaction with patients, self (excellence), colleagues, and hospital management. this questionnaire can help identify clinical settings that foster professionalism and those that require improvement, as well as enable us to follow the changes in different settings over time. furthermore, it can detect the differences among settings or improvements over time. the length of the instrument seems suitable for busy hospital staff to fill out. the items of the questionnaire are not related to a certain person’s behavior, and the respondents should consider the behavior and interactions of all the staff in the ward to answer the questions; therefore, people can complete the questionnaire honestly without being worried about stigmatizing a person. this questionnaire is self-administered and honesty in completing it depends on the personnel’s trust in the confidentiality of the developing and validating an instrument to measure: the medical … 10 j med ethics hist med. 2021(november); 14: 11. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e responses. in comparison with olson’s questionnaire that only measures the climate of professionalism from the nurses’ perspective (15), our questionnaire considers the viewpoints of all service providers as well as patients. we believe the viewpoints of the patients could be used as a complementary resource in the assessment of professionalism, and therefore some items of the questionnaire are related to patients, which is one advantage of our instrument. this helps researchers employ the viewpoints of both health-care providers and recipients to assess the climate of professionalism in clinical settings. the instrument designed by thrush et al. assesses medical professionalism in the learning environment in 11 items, but it only measures the personal behavior of faculty members and residents, and medical students are the only assessors (12). in our instrument, however, professionalism is assessed from the perspectives of all parties whose professional behavior forms the climate of professionalism. analysis of variance indicated that the residents gave lower scores to the professionalism climate of the hospital than nurses and faculty members, but this does not mean that residents are stricter at evaluating the professionalism climate compared with nurses and professors. the difference between residents’ estimation of the professionalism climate and faculty members’ or nurses’ cannot support further validity of our tools. this difference might be due to the lower exposure of residents to the ward atmosphere and increased sensitivity to its flaws. we recommend further research in this regard to evaluate the factors truly correlated with participants’ perspective of the professionalism climate. our instrument provides a direct observation in clinical settings. direct observation creates a sense of safety while learning, and, since observation is bidirectional, it allows trainees to observe supervisors’ illustrating corrections (33). in spite of the mentioned advantages, our study had some limitations. for instance, many respondents may not have the patience to complete the questionnaire, although it can provide additional information for feedback. the current questionnaire is an interim step between the original raw material and the creation of a "short-form" test. we did not assess the correlation between the results of the service providers’ and patients’ questionnaires, which warrants other studies with appropriate sample size. also, we did not assess the validity and applicability of the instrument in outpatient wards. other studies are required to show whether this questionnaire can be applied in outpatient settings. moreover, the present study did not offer any cut-off points for acceptability of the climate of professionalism in clinical settings. among the inclusion criteria was at least 6 months of experience in the ward; since medical students spend less than 6 months in each ward, only residents were considered eligible in the measurement of the professionalism climate. more studies asghari f., et al. 11 j med ethics hist med. 2021(november); 14: 11. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e are needed to determine the minimum required length of stay in the ward for assessment of professionalism climate. reliability of the patient questionnaire was also not quite satisfactory. this might be due to the patients’ change of mind about the professional practice in the ward after two weeks. professionalism is understood to be a complex concept, as it is likely to mean different things in different contexts, locations and cultures (34). since the questionnaire items are based on an iranian medical professional code of conduct (5), the instrument may not be completely applicable in other countries and could therefore benefit from some modifications. conclusion we designed a valid, and reliable instrument for the assessment of the professionalism climate in clinical settings. this questionnaire can be used to evaluate hospital clinical settings in terms of adherence to professionalism, determine areas requiring improvement, and assess the effectiveness of interventions aimed at enhanced collegiality and personal behavior. ethical considerations this study was a research project approved by tums, aimed at designing and validating a questionnaire to assess professional behavior in clinical settings. the protocol of the study was approved by the ethics committee of tums under code number 95-01-74-318. conflicts of interests the authors declared no potential conflict of interests. acknowledgements researchers would like to appreciate the sincere cooperation of all physicians and nurses who participated in this research. developing and validating an instrument to measure: the medical … 12 j med ethics hist med. 2021(november); 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26(1): 1869393. 34. jha v, mclean m, gibbs tj, sandars j. medical professionalism across cultures: a challenge for medicine and medical education. med teach. 2015; 37(1): 74-80. ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ 1 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e original article volume 13 (suppl.) number 23 december 2020 copyright © 2020 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. nurses' perception of ethical challenges in caring for patients with covid-19: a qualitative analysis nasrin rezaee1, marjan mardani-hamooleh2*, maryam seraji3 1.associate professor, community nursing research center, department of psychiatric nursing, zahedan university of medical sciences, zahedan, iran. 2.associate professor, nursing care research center, department of psychiatric nursing, iran university of medical sciences, tehran, iran. 3.assistant professor, department of health education & health promotion, zahedan university of medical sciences, zahedan, iran. abstract nurses face several challenges in providing care for patients with coronavirus disease in 2019 (covid-19). the study aimed to explain the nurses' perception of ethical challenges in this regard. the qualitative study was carried out using a content analysis method. individual and semi-structured interviews were conducted with 24 nurses. inductive content analysis was used to categorize the data. nurses' narratives indicated that ethical challenges in caring for patients with covid-19 included threats to professional values and the absence of a holistic covid-19 care approach. the first category was subcategorized into the risk of declining quality of patient care and a stigmatized public image about covid-19 care. the second category was divided into poor spiritual care, poor compassionate care, and lack of family-centered care. health care managers must develop protocols for nurses that address these issues to alleviate the ethical challenges of covid-19 care. keywords: coronavirus; covid-19; nursing ethics; ethical challenges; qualitative study. *corresponding author marjan mardani-hamooleh vanak sq., zafar st., tehran, iran. postal box: 1996713883 tel: (+98) 21 43 65 18 14 email: mardanihamoole.m@iums.ac.ir received: 21 oct 2020 accepted: 1 dec 2020 published: 19 dec 2020 citation to this article: rezaee n, mardani-hamooleh m, seraji m. nurses' perception of ethical challenges in caring for patients with covid-19: a qualitative analysis. j med ethics hist med. 2020; 13(suppl.): 23. nurses’ perception of ethical challenges in caring for patients with covid-19: a qualitative analysis 2 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 23 december 2020 introduction the year 2020 may be considered as the "year of corona" (1). the coronavirus disease 2019 (covid-19) is considered a challenge for the health systems around the world (2, 3). the challenge of caring for covid-19 patients (4) has imposed a substantial burden on health care (5, 6). nurses are the key stakeholders in the development and implementation of policies on patient care standards during the covid-19 pandemic (7). they are in the front-line of covid-19 care (8,9). as a result, nurses are affected in various ways (10). they experience moral distress and long working hours while caring for patients with covid-19 (11). they may also experience discomfort, fatigue, and feeling of helplessness (12). covid-19 engages nurses in a complex situation in which they face several problems (13), mainly as providing clinical care to a patient in an infectious environment (14) can cause severe stress (15). besides, they face challenges due to the short distance between hospital beds (16). nurses are also at risk of skin injuries and pressure sores on their faces because of the long-term use of protective equipment needed to take care of covid-19 patients (17). due to certain ethical challenges, they sometimes compromise the safety of themselves, their colleagues, patients, and their families as they consider the patient's interests as their priority (18). several international studies have been conducted on caring for patients with covid-19, the problems caused by providing care to patients during the pandemic. studies in china have shown that apart from feeling fatigued due to overwork, nurses experience emotional fatigue (16) and suffer from stress while caring for high-risk infectious patients (16). in taiwan, the problems linked with taking care of covid19 patients led to uncertainty in care (20). an iranian study showed that nurses providing care to covid-19 patients experience stress, anxiety, and lack of organizational support (21). a study in turkey stated that the caregivers experience burnout due to exposure to the disease and death of patients and were also deprived of social support (22). furthermore, the experience of health workers about home care in new york showed that nurses felt being at risk while taking care of patients in times of such crisis. (23). a review article suggested that caring for patients with covid-19 and generally providing care to these patients during the pandemic, in addition to some psychological challenges such as fatigue, stress, and burnout, was accompanied by some ethical challenges such as insecurity in care, lack of organizational and social support for nurses, and injustice and marginalization for healthcare workers. however, the perception of iranian nurses of the ethical challenges in caring for covid-19 patients has not yet been explored. given that the nurses' perception of ethical challenges in caring for covid-19 patients can be a context-based concept, it is more effective to explore and understand these challenges using a qualitative approach. therefore, the present study evaluates the nurses' perception using their narratives in a natural setting to identify rezaee n., et al. 3 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 23 december 2020 their understanding of ethical challenges in caring for patients with covid-19. method the qualitative study was conducted using the content analysis approach. content analysis is a technique for analyzing written, spoken, or visual messages on a concept. in inductive content analysis, the available information about a concept is limited and the concept under study is explored from the data context via categories and names (24). the research setting was two educational and medical centers affiliated to zahedan university of medical sciences (zaums), in which patients with covid-19 were treated and cared for. the participants were nurses working in covid-19 intensive care units and were selected by maximum variation in terms of age, gender, education, work experience, history of caring for covid-19 patients, and the ward they worked in. the participants were selected using purposeful sampling and the sampling process continued until data saturation was achieved. the inclusion criteria were full-time employment in the covid-19 wards and having at least one month of experience in caring for covid-19 patients. the participants were 24 nurses, mainly women (15 participants), aged between 27 and 49 years. most participants had a bachelor's degree (18 participants), and the remaining a master's degree. their nursing experience ranged from 4 to16 years and they worked with covid-19 patients between 1 to 5 months. most nurses worked in general wards (14 participants) whereas others were from the covid-19 intensive care units (table 1). table 1characteristics of the participants participant age (years) gender education work setting nursing work experience (years) experience related to covid-19 care (months) 1 47 female bachelor's degree intensive care unit 10 3 2 38 male bachelor's degree general ward 8 4 3 30 female bachelor's degree intensive care unit 6 2 4 37 male master's degree general ward 5 3 5 49 female bachelor's degree general ward 16 4 6 36 male bachelor's degree general ward 12 2 7 42 male bachelor's degree general ward 13 3 nurses’ perception of ethical challenges in caring for patients with covid-19: a qualitative analysis 4 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 23 december 2020 participant age (years) gender education work setting nursing work experience (years) experience related to covid-19 care (months) 8 29 female master's degree general ward 4 1 9 47 male bachelor's degree intensive care unit 16 5 10 40 male bachelor's degree general ward 8 2 11 30 female master's degree general ward 12 4 12 39 male bachelor's degree general ward 8 3 13 29 female bachelor's degree intensive care unit 5 4 14 42 female bachelor's degree general ward 14 5 15 40 male bachelor's degree general ward 12 2 16 49 female bachelor's degree intensive care unit 14 1 17 34 female bachelor's degree intensive care unit 13 4 18 47 female bachelor's degree intensive care unit 11 4 19 33 female bachelor's degree general ward 10 4 20 41 male bachelor's degree intensive care unit 12 1 21 49 female master's degree intensive care unit 15 1 22 31 female bachelor's degree general ward 9 2 23 43 female master's degree general ward 14 4 24 27 female master's degree general ward 4 4 after sending the letter of introduction, the researcher made the required arrangements with the head nurses to introduce the qualified nurses. then, the researcher recorded the nurses’ phone numbers with their permission. given the restrictions caused by the covid-19 pandemic, such as controlling the entry of people into inpatient wards to prevent the transmission of the virus as well as the high workload of nurses, it was not possible to conduct face-to-face interviews with the nurses in their workplace. therefore, the interviews were conducted using whatsapp mobile software in the form rezaee n., et al. 5 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 23 december 2020 of video calls (21 nurses) and voice calls (3 nurses). the semi-structured interviews were conducted individually and lasted between 30 and 45 minutes. data were collected between september and october 2020. all nurses were interviewed once and a total of 24 interviews were conducted. the interviews were conducted at the times that the participants were not at work. the main interview questions were, how would you describe caring for people with covid-19? what are the ethical challenges of providing care in your opinion? data collection and analysis were performed simultaneously. the collected data were analyzed using the approach proposed by graneheim and lundman (2004) (25). for this purpose, each interview was recorded and then typed and converted into text. then, the texts were reviewed several times to extract meaning units. the related codes were then extracted from the meaning units. the codes were then placed in relevant subcategories based on their similarities and differences. finally, the subcategories were merged into categories. trustworthiness to check the rigor of the findings, the credibility, dependability, confirmability, and transferability criteria were used (25). to ensure the credibility of the findings, there was a constant engagement with the subject and data. the members of the research team expressed their opinions about data collection and analysis. the findings were shared with some of the participants and experts with a ph.d. degree in nursing. to check the dependability of the findings, an external reviewer who was familiar with both the clinical setting and qualitative research was asked to review and confirm the results. to ensure the confirmability of the findings, all procedures taken to conduct the study were recorded and a report of the research process was provided. finally, to check the transferability of the findings, the results were shared with 2 nurses who were not participants but had a history of caring for covid-19 patients. ethical considerations to comply with the requirements for ethical considerations, a permit to conduct the study was obtained from the research ethics committee of the zahedan university of medical sciences (zaums) (ethics code: ir.zaums.rec.1399.263). after informing the participants about the objectives of the study, the interviews were recorded with their consent. the participants were assured that the information will remain confidential and that they could withdraw from the study at any time. results the analysis of the nurses’ narratives indicated that the ethical challenges in caring for patients with covid-19 included threats to professional values and the absence of a holistic covid-19 care approach. the threats to professional values were subcategorized into the risk of declining nurses’ perception of ethical challenges in caring for patients with covid-19: a qualitative analysis 6 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 23 december 2020 quality of patient care and a stigmatized public image about covid-19 care. the absence of a holistic approach to covid-19 care was divided into subcategories such as poor spiritual care, poor compassionate care, and lack of family-centered care (table 2). table 2 results of data analysis categories subcategories the threats to professional values the risk of declining quality of patient care a stigmatized public image about covid-19 care the absence of a holistic covid-19 care approach poor spiritual care poor compassionate care lack of family-centered care a. threats to professional values the participants believed that the threats to the nursing professional values pose an ethical challenge to caring for covid-19 patients. they perceived this ethical challenge in the form of declining patient care quality and a stigmatized public image about covid-19 care. a.1.the risk of declining quality of care the participants stated that for reasons such as nursing shortage or fatigue due to consecutive shifts, they are not at the patient's bedside at the time of need. as a result, responsibility and accountability in caring for patients are threatened: “declining sense of responsibility and accountability in patient care is really painful ... these problems are caused by factors such as the limited number of nurses or fatigue due to consecutive shifts. i have to tell you that under these challenging conditions, we cannot be at the patient's bedside when he/she needs us; although, this is part of our nursing duties.” [participant no. 5] besides, the participants believed that inadequate competence along with lack of experience and clinical skills leads to insufficient and unsafe patient care. poor quality care with an increased possibility of errors ultimately leads to the death of the patient. “caring for covid-19 patients requires experienced nurses and any inadequacy in caring for these patients leads to the violation of their rights. for example, when a lowskilled nurse works in the covid-19 intensive care unit, the patient is provided with incorrect or poor-quality care”. [participant no. 16] “the presence of unskilled nurses in the icu itself is a big moral problem ... a nurse with insufficient skills needs time to learn, and patients may die during this time”. [participant no. 9] a.2. a stigmatized public image about covid-19 care according to the nurses, after providing care to covid-19 patients, their professional dignity has been endangered by family, friends, and relatives. this ultimately leads to a threat to their social respect by the community: “it's interesting that my father asks me to get rezaee n., et al. 7 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 23 december 2020 away from these patients and recommends me to leave my job. he asks me if i am short in money that i have to care for these dying patients in the deathward. he says i would lose my life. for these stigmata, all my colleagues want to change their workplace and go to another ward”. [participant no. 22] “in the community, we have been stigmatized as corona-infected nurses, and we are known by this name among friends and relatives. neighbors think that i have been infected with coronavirus because of working with covid patients, so our family is also regarded as a corona-infected family. i think there has been a kind of cultural sensitivity towards nursing”. [participant no. 11] b. the absence of a holistic covid-19 care approach the participants believed that issues such as poor spiritual or compassionate care, and lack of family-centered care could lead to the absence of a holistic covid-19 care approach. b.1. poor spiritual care according to the nurses, there is a lack of spiritual care in treating covid-19 patients, which may lead to spiritual distress in patients: “the patients in this ward are in dire need of spiritual care, which unfortunately is not available right now, and that is why covid19 patients suffer from spiritual distress”. [participant no. 24] this is while the spiritual care shows the patients the path of life, enabling them to continue living and having spiritual vitality. “our patients know they are on the verge of death because of covid-19. well, there is a lack of spiritual care here ... spiritual care shows the patient the path of life and tells him/her that even if covid is the end of life, this is fate, and death is part of it that has come to an end”. [participant no. 18] “i believe that if we could provide spiritual care to the patients, they could continue to live more peacefully ... if the nurse can provide spiritual care to the patient, he/she will be spiritually refreshed and empowered”. [participant no. 2] b.2. poor compassionate care according to the nurses, empathy and compassion-focused care as well as listening to patients with covid-19 are missing due to time restrictions. besides, for this reason, there is no mutual sense in caring for the patients and understanding them at the moment: “our nurses give mainly physical care to the patients and have no time to offer empathy and/or compassion-focused care ... i dare say that listening to the patient meets their needs and meeting these needs means offering good care to the patient”. [participant no. 10] “when there is no mutual understanding of caring for these patients, i think caring for a patient becomes problematic. in the current situation, because of our workload, we really nurses’ perception of ethical challenges in caring for patients with covid-19: a qualitative analysis 8 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 23 december 2020 cannot understand the patient and put ourselves in their shoes. this is missing in covid-19 intensive care units”. [participant no. 3] the nurses stated that the sudden outbreak of covid-19 has prevented them from receiving the necessary training on compassion-focused care: “because covid came suddenly, our colleagues never received the necessary training on compassion-focused care for patients, and that is why we have many problems in providing this type of care”. [participant no. 14] b.3. lack of family-centered care the nurses considered the lack of familycentered care for patients with covid-19 as an ethical challenge. lack of family-centered care means that there is no system to support and follow up families, especially at the time of patient discharge: “when patients are discharged, the family is very worried about relapse. for example, if there is a problem with their patient, as they are no longer in the hospital, who is in charge of providing support to them? morally, it is not clear who is in charge of supporting the families after discharge. one reason is perhaps there is no family-centered care at all, and we do not have a system to follow up and support families”. [participant no. 19] the moral challenge of not having familycentered care also deprives the family of saying farewell to the patient at the end of life. besides, the family is abandoned after the patient's death, and the health system fails to manage their grief: “when the patient is at the end of life, there should be a possibility for the family to say goodbye. i do not know what to say. this moral problem torments me when the family comes to ask about the patient’s condition and we have to say that he/she has died as there is no possibility of the family members seeing the patient wearing the protective equipment, and being with him/her at the time of death”. [participant no. 1] “after the death of the patient, the family is abandoned, especially because no mourning ceremony can be held in the current situation. the family has no chance of holding any mourning ceremonies and there is a possibility that the family goes through an abnormal lamentation. it's not clear when the disease disappears. but the fact that our burial and mourning ceremonies have changed is a big challenge. what can be done to manage the mourning of these families, and this is a vague issue”. [participant no. 23] discussion the present study explored the nurses' perception of ethical challenges in caring for patients with covid-19. the results showed that these challenges included threats to professional values and a lack of a holistic covid-19 care approach. according to the nurses participating in this study, the professional values governing rezaee n., et al. 9 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 23 december 2020 nursing are threatened in the form of declining quality of patient care and a stigmatized public image about covid-19 care. in other words, these threats range from workplace to community factors. they added that the low level of responsibility and accountability in caring for the covid-19 patients, which is due to the insufficient number of nurses and them being fatigue from work pressure, results in failure for timely bedside attention to the patients. besides, the employment of inexperienced and unskilled people leads to poor quality, inadequate, unsafe, and error-prone care for these patients. ultimately, this may cause a violation of the patient's rights and even their death. according to the results of a chinese study, caring for patients with covid-19 placed nurses under pressure that led to a decline in their professional performance (14). therefore, hospital managers should employ sufficient nursing staff in terms of quantity and quality to prevent the risk of any decline in the quality of covid-19 patient care. while employing more nurses, their experience and skills should also be considered to guarantee quality care. besides, the studied nurses stated that caring for a patient with covid-19 posed a threat to the professional dignity and social respect for the nursing profession from family, friends, relatives, and the community as a whole. the nurses believed that such threats were due to the cultural sensitivity to nursing. metaphors such as the "death ward" equivalent to the covid-19 ward, the provision of care for "dying" instead of the patients with covid19, the "corona-infected nurse" and the "corona-infected family” indicated that providing care for the covid-19 patients was accompanied by stigma. since stigma has cultural roots, it can be suggested that the nurses participating in the present study viewed this type of care with a stigmatized public image. similarly, existing research has shown that healthcare workers in africa experienced a similar stigma while providing care for covid-19 patients (26). therefore, to overcome this moral challenge, a culturebased education must be provided for the community. anti-stigma education is necessary to teach people that taking care of a patient with covid-19 is the same as caring for other illnesses and that the nurse is responsible to provide the required care to the patients. these training programs can help result in the de-stigmatization of the topic. the nurses also stated that one of the ethical challenges was the absence of a holistic covid-19 care approach, which included poor spiritual care, poor compassionate care, and lack of family-centered care. the nurses acknowledged that spiritual care could lead to the patient's spiritual vitality. lack of this type of care, on the other hand, can cause spiritual distress to the patients. for patients with covid-19, however, spiritual care is considered a vital component of their health management that helps them cope with illness and suffering (27). given the significance of the issue, it is necessary to provide spiritual care in addition to physical care to provide holistic care for these patients. according to the nurses, spiritual care can help show the nurses’ perception of ethical challenges in caring for patients with covid-19: a qualitative analysis 10 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 23 december 2020 path of life to covid-19 patients and allow them to continue living. the nurses stated that compassion-focused care was not provided for patients with covid-19 due to time restrictions and substantial workload. according to the researchers, caregivers do not have enough time to communicate constructively with the patients when providing care to covid-19 patients so there is no compassion and empathy in their relationship (28). however, for covid-19 patients, humanistic care based on mutual understanding between the nurse and the patient is necessary (29). in other words, providing optimal care for these patients requires empathy, which only occurs through an effective sense of empathy by the patient (30). according to the nurses, the sudden outbreak of covid-19 has prevented them from receiving the necessary training on compassion-focused care. this highlights the need for compassion-focused education for nurses caring for patients with covid-19. due to the high prevalence of covid disease, it is not possible to provide this type of training in person, and thus online courses by the psychologists and psychiatric nurses would be useful. according to the nurses, the lack of familycentered care for patients with covid-19 is a moral challenge. it can be argued that they considered these ethical challenges not only for the patients themselves but also for their families. it should be noted that when patients with covid-19 are discharged from the hospital, they face certain health-related challenges. to this end, a model has been developed for older adults to help them return to the community. families are also considered in this model. the components of this model include improving the patient's cooperation with the treatment team, managing the relapse symptoms, training family caregivers, cooperating with social services, and improving the continuity of care (31). the nurses in the present study acknowledged that the family has no chance of saying farewell to patients with covid-19 if they die. this highlights the need to provide family-centered care in these cases. in this regard, and to alleviate the suffering of the families at the time of death and to offer the opportunity of a good farewell to the patients, healthcare professionals provide daily video conferencing in spain between the patients and their families. this close communication allows families to see their patients and improves the connection between professionals, patients, and their families (32). on the other hand, lack of familycentered care also causes ambiguity for nurses about family mourning after the patient's death. the nurses believed that since families do not follow the normal mourning and burial rites, they may lament abnormally. however, it is not clear how the health system should act in managing family mourning. according to previous studies, when covid-19 patients die, the burial and mourning ceremonies are important to their families. since mourning ceremonies are held for these patients without customary social etiquette, their survivors may develop prolonged grief disorder (33). therefore, to rezaee n., et al. 11 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 23 december 2020 resolve the ethical challenge of the lack of family-centered care for patients with covid-19, the health system must take effective measures. for example, these measures could include supporting families with an educational approach to raise their awareness of symptom management by physicians and nurses. furthermore, teamwork with the participation of psychologists is needed to support families. since it is not currently possible to say goodbye to the patients in the covid-19 intensive care units, this teamwork becomes more important to prevent morbid mourning for families. the participant recruitment approach and the nature of the qualitative study limited the ability to generalize the presented findings. conclusion to address the ethical challenges of nurses in caring for covid-19 patients, the professional values of nursing should be considered by healthcare managers. this can be accomplished by employing highly experienced nurses to care for patients with covid-19 as these nurses can provide safe and error-free care. the ethical challenges that threaten the nurses' professional dignity and social respect were generally cultural in origin. to address these challenges, nursing professionals and professors must provide cultural education fitting the cultural context of the community to the public through the media, such as television, so as not to tarnish the nursing profession. besides, this study found that the lack of a holistic covid-19 care protocol is another challenge for nurses. in this regard, an ethics-based model for covid-19 care should be developed, according to which, in addition to routine care, concepts such as spiritual, compassionate, and family-centered care is considered and provided by nurses. it is also essential that comprehensive training courses on compassionate care are organized and held for nurses providing care for covid-19 patients. it must be acknowledged that one of the requirements in caring for these patients is family-centered care, which needs to be taken into account by healthcare policymakers. nurses’ perception of ethical challenges in caring for patients with covid-19: a qualitative analysis 12 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 23 december 2020 references 1. hermes c, ochmann t. 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the transitional care needs of older adults with covid-19. j aging soc policy. 2020; 32(4-5): 387-95. 32. estella á. compassionate communication and end-of-life care for critically ill patients with sars-cov-2 infection. j clin ethics. 2020; 31(2): 191-3. 33. goveas js, shear mk. grief and the covid-19 pandemic in older adults. am j geriatr psychiatry. 2020; 28(10): 1119-25 pts rights -2sanaz azamin 23720-8-94.docx journal of medical ethics and history of medicine original article development of a scale for the evaluation of patients’ rights prerequisites at educational hospitals in iran: a study using the delphi technique sanaz aazami¹, mosayeb mozafari*¹ 1 department of nursing, faculty of nursing and midwifery, ilam university of medical science, ilam, iran corresponding author: mosayeb mozafari address: department of nursing, faculty of nursing and midwifery, ilam university of medical science, banganjab, ilam, iran email: mozafaric@yahoo.com tel/fax: 00988432227123 received: 21 feb 2015 accepted: 5 jul 2015 published: 14 nov 2015 j med ethics hist med, 2015, 8:12 © 2015 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract the patients’ rights status is one of the essential elements in defining norms related to the concept of clinical governance system. in addition, the patients’ rights status is an important index for quality of care offered in the health care system. however, the lack of a coherent instrument makes it difficult to evaluate patients’ rights status in hospitals and clinics. the aim of this study was to develop an instrument for the evaluation of patients’ rights prerequisites at educational hospitals in iran. this study was conducted using the modified delphi technique. in this study, 36 experts in the fields of law, medicine, and professional ethics were participated. the panel of experts participated in 3 rounds. first, experts were asked to judge some preidentified items, and then, excluded items were judged again in the second round. at the end of the third round, all of the agreed items were included in the final list to form an evaluative scale on practice of patients’ rights. experts were asked to judge a total 171 items in 3 rounds. around 31% (n = 53) of items obtained the panel’s approval to be included in the final version of the scale. the experts’ opinions were collected using face-to-face interviews and electronic email during a 6-month period of data collection from october 2013 to february 2014. this study developed a 53-item scale for evaluation of patients’ rights prerequisites in educational hospitals in iran. this scale was developed in 7 areas of commitments including university education, research, supervision, process management, physical structure, organizational policy, and human resources management. this study developed an evaluative scale to assess the practice of patients’ rights in educational hospitals. the items in the final version of this scale were obtained from a consensus of experts and the instrument can be used to evaluate the context and prerequisites for practice of patients’ rights in iranian educational hospitals. keywords: patients’ rights, delphi technique, questionnaire design mailto:mozafaric@yahoo.com j med ethics hist med 8:12 november, 2015 jmehm.tums.ac.ir sanaz aazami et al. page 2 of 11 (page number not for citation purposes) introduction the promotion of patients’ rights is among the priorities of healthcare providers and is considered as an indicator of the health state in every community (1). in addition, patients’ rights status is an important index for quality of care offered in the health care system. iranian comprehensive patients’ bill of rights has been framed in 5 chapters and 37 articles including values, visions, and one explanatory note. the topics of these 5 chapters are receiving appropriate care, right to obtain sufficient amount of desired information, right to an unrestricted decision on receiving health-care services, right of privacy and confidentiality, and right to access an efficient complaint system in articles number 14, 4, 7, 9, and 3, respectively (2). the results of previous studies show that realization of patients’ bill of rights requires the provision of commitments, infrastructure, and constructive implementation (3). in other words, existence of such a charter independently does not guarantee development and practice of patient’s right. the world health organization (who) also believes that the sole existence of the charter will not lead to optimization of patients’ rights. patients’ rights will be effectively practiced in presence of appropriate policies, collaboration, and public awareness, community empowerment along with development of economic, social, and cultural indices (4). establishment of the patients' bill of rights content entails several important prerequisites which can be achieved by intrasectional and intersectional collaboration (5). therefore, some experts and researchers believe that developing instruments to evaluate adherence to patients’ rights is one of the prerequisites for observing the contents of patients’ bill of rights (2). however, lack of a coherent instrument makes it difficult to evaluate patients’ rights status and it is not enough to rely on the content of the patients’ bill of rights for developing such instruments. in addition, optimizing patients’ bill of rights requires the preparation of preconditions in several fields such as management of organization, structure, human resource, and organizational process. therefore, it is necessary to consider not only the content of the patients’ bill of rights, but also, the mentioned preconditions before developing an instrument to evaluate adherence to the patients’ bill of rights. we were not able to find a valid and reliable instrument which can assess observance to patients’ rights in iran. furthermore, patients’ rights are important indices in the clinical governance system, and organizational excellence and quality improvement which encouraged us to develop a questionnaire for assessment of patients’ rights in iran. thereby, we designed this study in two stages. the first stage included assessment of the commitments for establishing patients’ rights in iranian educational hospitals which has been published elsewhere (3). within the first stage, 7 areas of commitments were recognized using the delphi technique including university education, research, supervision, processes management, physical structure, organizational policy, and management of human resource. in addition, each and every area was composed of several administrative recommendations which are directed toward establishment and maintenance of patient rights. within the second stage, which is the current study, authors developed a scale with 7 subscales for evaluating the requirements of patients’ rights practice at educational hospitals in iran. the scale was developed based on the 7 recognized areas and experts’ opinions in each area. delphi technique the delphi technique is a subjective-intuitive systematic method of forecasting for collating judgments from a panel of experts on a subject (6). the rand corporation (santa monica, california, usa) developed the delphi technique in the 1950’s during an operational research. the delphi technique gathers the knowledge of experts on a subject during a structured group communication process in which decisions are made in several rounds until a consensus emerges (7-9). common surveys try to answer “what is?”, whereas, the delphi technique attempts to address “what could/ should be?” (8). despite several modifications in the delphi technique, it is still a valuable method of collating expert’s judgments using an interactive structured process which eventually leads to consensus on a subject. the aim of this technique is to achieve consensus on a subject among a panel of experts in which a series of anonymous questionnaires is administrated in several rounds and feedback is obtained in each round (10). homogeneous and independent experts are asked to professionally judge a special topic over a wide geographical area using a questionnaire administrated in several rounds and continued until consensus emerges (610). the results of each round is reviewed and edited in the next round. there are several benefits to the delphi technique which result in the prioritization of this method over focused group approaches. factors which affect the expert’s opinion in the focused group approaches consist of personal interaction of experts, time limitation, and group dynamics and needs. however, in the delphi technique, there are no time and location limitations, experts are blinded to each other’s identity, and therefore, the experts face no limitation in expressing their opinions. furthermore, the results derived from the delphi technique can be interpreted using statistical methods (8, 9, 11). methods this study was conducted using the modified delphi technique in which data were collected through facej med ethics hist med 8:12 november, 2015 jmehm.tums.ac.ir sanaz aazami et al. page 3 of 11 (page number not for citation purposes) to-face interviews and electronic mail during a period of 6 months from october 2013 to march 2014. the ethics committee of the ilam university of medical sciences, iran, approved this study. the present study was performed in 3 rounds of the delphi technique. initially, we prepared appropriate questions for this study. the main question in this study was: “what should be placed in an evaluative scale to measure practice of the patients’ rights?” in the next step, the primary version of the scale was developed in 7 areas based on the results derived from the first stage (3). the primary version of the scale was evaluated and edited by 5 experts (3 experts in medical ethics, 1 physician who was head of a hospital, and 1 nurse who conduct research in patients’ right issues). corrections suggested by experts were applied and content of the scale were revised and prepared for the first round of the delphi technique with 95 items. finally, experts were identified and included in the panel of experts based on their qualifications and experiences in the relevant scientific and academic fields. the initial list of experts was composed of 45 professionals. it included 6 phd holders in the field of management, particularly quality management, 9 in ethics and medical ethics, 6 in islamic ethics (clergy men), and 8 clinical specialists who were at least assistant professors. this list also included 5 clinical nurses who had worked for at least 15 years, 8 managers and heads of medium and large hospitals with more than 300 beds (4 physicians and the rest non-physicians), and 3 hospital architects. upon identifying the panel of experts, we sent an invitation letter along with a prepared booklet to each of them. the prepared booklet contained a summary of the delphi technique, patients’ bill of rights, and objectives of the current study. out of the 45 invited experts, 3 refused to participate in the study and we did not receive any response from 6 of them. therefore, 36 professions (15 females and 21 males) were included in our study. the panelists were informed that this study included 3 rounds and they are required to participate in all of the rounds. the panelists were asked to rate each version of the scale on a 7-item likert type scale ranging from 1 (strongly agree) to 7 (strongly disagree). furthermore, the opinion of the panelists was asked for any correction, deletion, or suggestion of a new version of the items. upon receiving all of the comments from the first round, we calculated mean, frequency, and percentage of agreement on each version. then, we constructed the new version of the scale according to the agreement rate and suggestions from experts. this new version of the scale was sent to the experts along with necessary requirements. we asked panelists to rate the scale again and this continued until the third round in which we finalized the scale according to the established criteria. regarding the instruction to approve an item, it should be noted that experts reported their agreement in answers ranging from 1 to 7 representing strongly agree, moderately agree, somewhat agree, neutral, somewhat disagree, moderately disagree, and strongly disagree. the criteria for approving an item was obtaining at least 70% response rate of “strongly agree” by the experts. on the other hand, the criteria to reject the item was obtaining at least 70% response rate of “strongly disagree” by experts. eventually, in the case that responses fall between these two criteria, the item is labeled as not approved and is included in the next round of the delphi method. this process will continue until a consensus is reached on approval or denial of an item. this approach has been frequently used in the delphi method studies to decrease risk of low level of agreement between experts (6-11). this study was conducted through face-to-face interviews and electronic mail. scoring the scale was scored using the scoring system of the european foundation for quality management (efqm) excellent model (named radar logic) (12). this is due to the fact that we aim to develop a scale for assessing patients’ rights practice in health care organizations. besides, the efqm model has widely been used by iranian researchers (13). this study was scored according to the radar (results, approach, deployment, assessment, and review) method of the efqm excellent model. approach means what an organization plans to reach and the reason it implies. deployment consists of 2 parts of approach implementation and systematic implementation of the approaches. implementation refers to carrying out and practice of the plan and systematic utilization of the approach. assessment and review imply approach measurements, learning, and improvement of their performance. measurement includes regular assessment of the effectiveness of this approach and building it through focusing on technique rather than on quantitative values. training refers to the training activities performed in order to identify and use the best practices within and outside the organization. improvement is the outcome expected from measurement and training. therefore, these two activities can be used in identifying, prioritizing, planning, and implementing improvements (14). each of the radar elements obtained a score between 0-100% in every round of the study and the average score obtained from the 3 rounds composed the overall score of each element. principles and guidelines for the degree of evidences are described in the efqm model (13) which has been used in several studies (11, 12). the evidences are categorized based on the model guidelines that contain 5 classifications. these classifications are comprehensive evidence (86-100%), clear evidence j med ethics hist med 8:12 november, 2015 jmehm.tums.ac.ir sanaz aazami et al. page 4 of 11 (page number not for citation purposes) (61-85%), good evidence (36-60%), little evidence (11-35%), and lack of evidence (0-10%). results all of the 36 experts that agreed to participate in the current study were engaged in the 3 rounds of this study. the experts in this study consisted of 15 females and 21 males. in terms of educational attainments, 15 of them hold phd certificates; 5 in management (particularly quality management), and 4 in nursing, and 6 were clinical specialists. moreover, 7 of them were specialists in ethics and medical ethics, 5 were clergy men and experts in islamic ethics, 7 were managers of medium and large hospitals (4 physicians and the rest non-physicians), and 2 were architects. tables 1 and 2 show the detail of the performance of the 3 rounds of the delphi technique. within the first round, experts strongly agreed on 33 items out of 95 which were included in the final version of the scale. in addition, there were 25 items which received suggestions and comments mainly from research and organizational fields and to a lower degree from human resources and provisional fields. some of the suggestions and comments include edition of items, grammar editing and revising the content. thus, 5 items where added and 25 were modified which resulted in the inclusion of 46 items in the second round. however, after applying corrections received from the experts, an overlap was observed between 2 items. therefore, one of them was excluded from the study and a total 45 items were included in the second round. table1results of round 1 to 3 of the delphi technique t otal h um an resources p hysical structures o rganizatio nal policy p rovision processes m anagem ent r esearch e ducation rounds criterion 95 12 10 10 9 21 18 15 items entered into 1 st round first round 33 4 6 3 5 6 4 5 approved items 16 2 1 1 2 3 4 3 disapproves items 25 2 3 5 2 4 5 4 modified items 5 2 0 1 0 1 0 1 added items 21 4 0 1 0 8 5 3 rejected items 45 6 4 7 4 8 9 7 items entered into 2nd round 11 1 0 2 1 3 2 2 approved items second round 19 2 2 2 2 3 5 3 disapproved items 10 2 1 2 1 1 2 1 modified items 2 1 1 0 0 0 0 0 added items 5 1 1 1 0 1 0 1 rejected items 31 5 4 4 3 4 7 4 items entered into 3rd round 9 2 1 0 0 2 1 1 approved items third round 22 3 3 4 1 2 6 3 disapproved items 53 7 7 5 8 11 7 8 final scale table 2agreement percentage in the first and final rounds on suggested phrases criterion approved items in the 1st round (%) approved items in all three rounds (%) human resources 33.0 30.5 physical structures 60.0 38.9 organizational policy 30.0 23.8 provision 55.6 50.0 process management 28.6 33.4 research 22.3 20.6 education 33.0 30.8 total 34.73 31.0 j med ethics hist med 8:12 november, 2015 jmehm.tums.ac.ir sanaz aazami et al. page 5 of 11 (page number not for citation purposes) within the second round of this study, 45 items were judged by the experts, 11 of which obtained at least 70% agreement and were included in the final version of the scale. in this round, 2 items were added by experts, 10 items were edited, 5 items were rejected, and 19 items did not obtain the minimum agreement rate and were included in the third round for further investigation. out of the 31 items that were included in the third round, only 9 items obtained the minimum agreement rate. finally, the scale for evaluation of patients' rights prerequisite in educational hospitals was developed with a total of 53 items (attachment 1). discussion this study was aimed at developing a persian version of a scale for evaluation of patients’ rights prerequisite using the opinion and judgment of experts. to the best of our knowledge, the developed scale in this study is the first scale exclusively designed to measure patients’ rights observance in iranian educational hospitals based on experts’ opinions. albeit, we are aware of one existing persian questionnaire for measuring patients’ rights observance (15), but it has some shortcomings. for example, this scale is general, is mixed with other areas (e.g. clinical governance), and the scoring depends on the evaluator’s interpretation. this questionnaire is part of a book on accreditation of hospitals and clinical governance-related issues. the items are scattered in different parts of this book and are not able to capture a clear profile of patients’ rights and infrastructure in a hospital. in addition, the literature does not show any evidence of using this questionnaire as an instrument to measure patients’ rights. there are also some scales which have been constructed based on physicians’, nurses’, and patients’ points of view (16-18) and no organizational requirement has been considered in such questionnaires. these limitations illustrate that we must elaborate the discussion by showing that criterion and items in the scale are reflective of prerequisites for patients’ rights provision. the scale that we developed in this study has an important feature that distinguishes it from other scales. this is due to the fact that we employed an established approach to developing this scale. the approach has been adopted from the efqm excellent model and guarantees that the obtained score is a function of the established and continuous processes in organizations (12). the results of our study showed that the developed scale was composed of 53 items in 7 areas including education, research, provision, process management, physical structure, organizational policy, and human resource management. assessment of the items in the final version of our developed scale revealed that consensus was reached among experts on issues that play an important role in patients’ rights. some of these issues are formation of an ethical decisionmaking committee (second article of organizational policy subscale), ethical committee in research, and dissemination of ethical consideration among researchers (research items), assessment of violence cases, complaint processing system, and timely response from the patients’ complaint processing system (item 1, 7, and 8 from the provision subscale). sarbaz and kimiafar (19) have suggested that supervisors and technical assistants in hospitals may control the practice of patients’ rights (19). in addition, kagoya et al (20) recommended the formation of a governance committee in hospitals to control the observance of patients’ rights (20). establishment of an informal committee to voice patients’ complaints in educational hospitals enables matters to be resolved immediately while avoiding the need for litigation and official disciplinary processes. moreover, these informal committees could rely on ethical approaches to resolve patients’ complaints rather than formal disciplinary proceedings (21). the decisions and advices of commissioners’ are remarkably important for health professionals in some countries such as new zealand (22). among health care professionals and even the public in new zealand, commissioner’s decisions outweigh judiciary resolutions (23). moreover, reports from the province of quebec, canada, have shown that more than 98% of health care professionals accept decisions made by informal committees (24). successful use of the informal committee has been reported in several countries such as norway, united kingdom, finland, and hungary (25-28). in germany, at least 149 clinical ethics committees and 86 behavioral counseling institutions have been established to maintain patients’ right practice in more than 77 hospitals since 2005 (29). in 2007, another 29 educational hospitals were added to the mentioned list (30). these evidences show that the role of informal committees in resolving patients’ complaints could be less expedient and systematic in comparison to formal multidisciplinary proceedings. non-judiciary and fair treatment of patients’ complaints may facilitate the acceptance of informal committees’ decisions by patients and caregivers. furthermore, parsapour et al. recommended establishing an organized patient compliant system in health centers as a way to improve patients' rights status (31). in order to improve the function of informal committees in regulation of health care services, it is necessary to provide more information and latitude for the committees. additionally, it would be beneficial to introduce and enforce patients’ rights to health care institutions, public, and governments (26). with regards to the educational area, there was a consensus among professionals on the need for introduction of patients’ rights in orientation j med ethics hist med 8:12 november, 2015 jmehm.tums.ac.ir sanaz aazami et al. page 6 of 11 (page number not for citation purposes) meetings of new staff, continuity of education among staff, revision and development of a patientcentered syllabus, and evaluation of students according to their adherence to patients’ bill of rights. sarbaz and kimiafar (19) considered education as a way to affect health care professionals’ attitudes and eventually increase their adherence to patients’ rights (19). these authors also believed that patients’ rights should be the main focus of medical education along with teaching support and communication skills to students. continuous education programs, patient education, and developing protocols for observing patients' rights are suggested for the establishment of patients' rights practice in health centers. parsapour et al. revealed that supplementary education is needed to inform health-care workers about patients’ rights issues, particularly, patients’ access to clinical information and decision-making (31). according to results of the qualitative study by kagoya et al (20) patients’ knowledge about their rights was correlated with employment status, educational level, and number of referrals to hospital (20). in addition, knowledge of staff about patients' rights correlated with educational level and years of experience as a nurse (20). our study showed a consensus among panelists about the role of public education on patients’ awareness about their own rights. these findings are consistent with that of the studies by dadkhah et al. (32) and ansari et al. (33) that showed a positive significant correlation between educational level and patients’ knowledge about their own rights. these researchers believe that media can play an important role in promoting public sensitivity to patients' rights issues. according to the majority of researches, patients with higher educational level have more expectations regarding their rights (1). in this vein, kagoya et al (20) suggested the establishment of a patients' rights guideline in hospitals and other health care organizations, mass media awareness about patient rights, and legal advocacy for patients who suffered from violence (20). the current study showed that criteria such as human resources, process management, and physical aspects of organization are other issues that obtained consensus among panelists. these key areas are the main aspects of any organization especially health care organizations. kagoya et al (20) revealed that organizational barriers to practicing patients’ rights are financial constraint, shortage of the human resources such as physicians and nurses, lack of communication channels to spread information on patients’ rights, and lack of communication skills (20). furthermore, kagoya et al (20) found that 81.5% of patients and 69.4% of health workers were not aware of the patients’ rights charter in uganda (20). they found that 36.5% of patients experience violation of their right, while 79% of them never demand their own right (20). in addition, the results of the study by ducinskiene et al (34) in litiwani showed that 56% of patients were aware of their own rights (34). bǘken and bǘken (35) revealed that infrastructure and management problems are the most important causes of lack of appropriate patients’ rights practice in turkey . urlich et al (36) assessed 600 studies that link the characteristics of the physical environment of hospitals to patient and staff outcomes . their findings showed that there is a significant linkage between physical environment and several outcomes including staff stress and effectiveness, patient and family stress, effectiveness in delivering care, patient safety, quality of care, and reducing costs (36). these outcomes are representative of human and patients’ rights. the authors emphasized the use of evidence-based practice in designing hospitals to ensure patients’ rights practice. an italian study investigated spatial factors in designing hospitals which influence the right to health (37). the mentioned italian study indicated that spatial configuration of hospital spaces influence behavioral model of communication and relationship between patients and health-care staff which, evidently, are the key elements in the right to health. the authors declare that studying spatial configuration in hospitals is an effective instrument for policy makers in decision-making toward increasing quality of care and provision of patients’ rights. there are several elements in designing a hospital including easy access to spaces, location of wards, and horizontal linkage between cores, entrance, and connection areas. among the spatial factors, the integration core of the public and staff are the two most important cores. furthermore, it has been shown that patients’ privacy and dignity is not respected due to lack of adequate physical space especially in critical care units, staff’s low awareness of patients’ rights, shortage of same-gender care providers (38), and infrastructure limitations (39). these findings show that practice of patients’ rights depends on organizations and their resources including human resources and other infrastructures. therefore, improvement of organizational resources provides an avenue for better practice of patients’ rights. the results of the current study show that experts’ decisions were directed toward those main elements that play an important role in maintenance and practice of patient's rights. basic actions such as resolution of patients’ bill of rights, development of measurement instruments, and awareness of the public and health care workers are required to effectively practice patients’ rights. awareness of patients of their own rights can lead to some advantages. examples of these advantages include increased quality of health care services, decreased costs, prompt recovery, decreased length of stay in hospitals, lower risk of physical and spiritual damages, and more importantly, increased dignity of j med ethics hist med 8:12 november, 2015 jmehm.tums.ac.ir sanaz aazami et al. page 7 of 11 (page number not for citation purposes) patients through their participation in decisionmaking (40). the concept of “human rights in patient care” has been extended and referred to human rights principles in the provision of care (41). applying human rights in the process of patient care requires several measures including policies, laws, course of action to protect human rights in the process of care, and education of health-care providers and patients on human rights principles (41). the most helpful intervention for promoting these rights would be to inform people, alongside educating healthcare providers, about patients’ rights issues (1). moreover, establishment of informal committees in hospitals is necessary to voice patients’ complaints and to effectively practice patients’ rights. this is to ensure patients demand their own rights even in the presence of some barriers including low education, language differences, low socio-economic status, feeling of inferiority toward health workers, and tendency to receive free services (26, 27). on the other hand, the main focus of hospitals is to fulfill patients’ needs rather than promote patients’ rights. in addition, human resources shortage and time limitations restrict the extent of information shared between health care providers and patients. this is in contradiction of professionals’ principles. therefore, it is necessary to observe the practice of patients’ rights through informal committees that are independent of hospitals (24, 27). conclusion in conclusion, our study developed an evaluative scale to assess the practice of patients' rights in which the scoring method was adopted based on the excellent fundation quality management (efqm) model. this scale was constructed as a result of consensus that emerged among experts in the field of medical ethics in the iranian health system. therefore, this scale can be used as a valid instrument to evaluate prerequisites of patients’ rights and process in iranian educational hospitals. furthermore, hospital managers and stockholders may also benefit from this scale by assessing the status of patients’ rights prerequisites and apply the findings. acknowledgment we would like to thank the ilam university of medical sciences for supporting this study. we would like to extend our sincere gratitude and appreciation for all of the hard work and dedication provided by the panel of experts in this study. competing interest the authors declare that there is no conflict of interest for this study. funding this study was funded by the ilam university of medical sciences under grant number 908107. j med ethics hist med 8:12 november, 2015 jmehm.tums.ac.ir sanaz aazami et al. page 8 of 11 (page number not for citation purposes) references 1. joolaee s, hajibabaee f. patient rights in iran: a review article. nurs ethics 2012; 19(1): 45-57. 2. parsapoor a, bagheri a, larijani b. patient rights in iran. j med ethics hist med 2009; 27: 39-47. 3. mozafari m, mousavi-moghaddam sr, jafari agh. surveying the prerequisites for establishing patient's rights charter in health centers of iran-a delphi study. j clin nurs midwif 2013; 2(3): 74-85. 4. anonymous. who. patients’ rights and citizens’ empowerment: through visions to reality. copenhagen, denmark: world health organization; 1999. 5. hooshmand a, joolaee s, mehrdad n, bahrani n. nurses’ information and their view points about 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[in persian] 39. joolaee s, nikbakht nasrabadi a, parsa yekta z. the view of patients and patients’ companions regarding patients’ rights: a phenomenological research. hayat 2004; 10(4): 5-20.[in persian] 40. mastaneh z, mouseli l. patients’ awareness of their rights: insight from a developing country. int j health policy manag 2013; 1(2): 143-6. 41. cohen j, ezer t. human rights in patient care: a theoretical and practical framework. health hum rights 2013; 15(2): 7-19. http://www.ombudsman.org.uk/__data/assets/pdf_file/0013/4144/impact-study.pdf j med ethics hist med 8:12 november, 2015 jmehm.tums.ac.ir sanaz aazami et al. page 10 of 11 (page number not for citation purposes) attachment 1patients’ rights prerequisite scale* items a pproach im plem entation e valuation 0-100% education 1is there a compiled program for professors teaching patient rights? 2have the issues related to patient rights been included in the orientation program for new staff? 3is there a continuous education program on patient rights in the organizational setting? 4has the patient rights module been included in the curriculum of medical schools? 5had the revised curriculum been based on patient rights? 6have the activities for improving knowledge, attitude, and practice of students about patient rights been anticipated in the revised curriculum? 7is there any evidence regarding efforts for public education? 8does clinical evaluation of students emphasize practicing patient rights? research 1has the research ethics committee been established at the organizational level? 2is there an established policy in research to ensure patient rights are respected? 3are researchers being notified about instructions on protecting confidentiality of the participants’ information? 4are the researchers being notified about instructions on how to maintain the physical privacy of the study participants? 5does the ethics committee inform researchers on the codified legislation designed for human studies? 6are the researchers being notified about instruction on maintaining the participants' authority in decision making? 7are the researchers being notified about instructions on how to avoid conflict of interest in the study? process management 1have the processes of patient care been clearly described? 2have the processes of patient care been exposed to patients? 3do health care providers fulfill patient care according to the described processes? 4is the confidentiality of patient information maintained during the process of admission, treatment, care, and discharge? 5are the key processes of patient care performed according to the standards and the codified legislations (e.g. the patient rights charter)? -consent form -acquittal form -scheduling appointments -complaints -account clearance -delivering the medical record summary to patients -admission -discharge -patient's discharge with personal written consent form -dying patient 6is the patient rights charter recognized at the organizational level? 7are patients informed of the outlines of the patient rights charter upon their admission? 8is there a central unit to facilitate the patients' communication? 9do health care providers have an identity card? 10is there a system for monitoring and regular evaluation of patient's satisfaction? 11is the patient visiting system performed regularly? j med ethics hist med 8:12 november, 2015 jmehm.tums.ac.ir sanaz aazami et al. page 11 of 11 (page number not for citation purposes) items a pproach im plem entation e valuation policy 1does the strategic plan comprise the issues related to patient rights? 2have the ethics committees been established and deployed? 3has the compliance with shariah law been formally established? 4has the unit for quality improvement been established in the centers? 5-do the centers comply with the decisions made by the quality improvement unit? human resource 1is there any evidence on educating patient rights in human resources development programs? 2is there a coherent program for improving staff’s communication skills? 3is the ratio of staff to patient enough? 4does the staff evaluation system consider issues related to patient rights? 5is there a compiled program to ensure that promotional opportunities are equally distributed? 6is there a system for evaluation of staff satisfaction? 7is there a program to teach clinical staff how to make an ethical decision? physical environment 1are the diagnosis and curative procedures performed at the standard settings? 2-are the toilets run at the defined standard levels? 3are the buildings easily accessed via the public transport system? 4are the buildings easily accessed by children, elderly, pregnant ladies, and handicapped individuals? 5-are the signs adequate and illustrative? 6-are the centers equipped with facilities such as bank, atm, or cafeteria? 7-has the caring environment been designed to maintain clients' privacy? provision 1are there appropriate channels to contact top level managers (suggestion box, contact line, internet, and etc.)? 2is there a system for regular evaluation and monitoring of patient satisfaction? 3does the ethics committee constantly and regularly monitor human studies? 4is there a system for evaluation and improvement of processes in patient care? 5is there regular report and record on actions maintaining patient rights observance? 6does the committee regarding patient issues (e.g. infection control, morbidity, and mortality) hold meetings regularly? 7is there any deadline for responses to patients' complaints? 8is there a system to track and assess violence in hospitals? *the original version of this questionnaire was developed in the persian language. the current english version was translated using backward-forward translation by panels of bilingual experts. authors who are interested in using the persian version of this scale may contact the corresponding author. 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____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ 1 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e original article volume 13 (suppl.) number 33 december 2020 copyright © 2020 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. observance of patients’ rights by physicians and nurses from the covid-19 patients’ perspective *corresponding author mohsen kamali abhar school of nursing, next to alghadir hospital, parastar blvd., abhar, zanjan, iran. tel: (+98) 24 35 27 94 12 email: mkamali@zums.ac.ir received: 15 nov 2020 accepted: 16 dec 2020 published: 30 dec 2020 citation to this article: kamali m, mousavi sk. observance of patients’ rights by physicians and nurses from the covid-19 patients’ perspective. j med ethics hist med. 2020; 13(suppl.): 33. mohsen kamali*, seyed kazem mousavi researcher, department of nursing, abhar school of nursing, zanjan university of medical sciences, zanjan, iran. abstract observance of patients' rights is a significant indicator in evaluating the quality of healthcare services. the covid-19 pandemic has become a global crisis and affected the interactions between healthcare providers and patients. this study examined the covid19 patients’ viewpoint about the observance of their rights by physicians and nurses. this study is a descriptive cross-sectional work of research conducted on the covid-19 patients in zanjan province, iran, in september 2020. the subjects were selected through convenience sampling, and data was collected using a twosection questionnaire consisting of a demographic characteristics survey and a likert-type scale for evaluating patients' rights observance. the validity and reliability of the questionnaire were found to be acceptable, and the collected data was analyzed in spss v.26 using descriptive statistics, independent t-test, and anova test. the mean score of observance of patients' rights was 69.60±7.36, representing a moderate level. the highest and lowest scores for the observance of patients' rights were related to the dimensions of courteous communication and responsibility, respectively. a significant relationship was found between the observance of patients’ rights and their marital status, health insurance, and education level (p<0.05). this study showed that the observance of the covid-19 patients' rights has not been affected by the social agitation caused by this disease. keywords: patient's rights; physicians; nurses; covid-19. observance of patients’ rights by physicians and nurses from … 2 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 33 december 2020 introduction patients are one of the most vulnerable groups suffering not only from physical health issues but also from mental and emotional stress. hence, the foundation of medical and nursing care is based on respect for patients’ self-esteem and identity (1, 2). an efficient healthcare system involves active interactions and satisfactory relationships between medical and healthcare team and patients (3). courteous communication, respect for patients’ privacy, responsibility, and attention to the cultural values are the primary components of cooperative relationships in healthcare systems (4). in every society, the principle of respect for patients' rights is vital from a medical ethics perspective (5). the patient's rights charter is a framework to defend patients’ rights in emergency situations and to satisfy their needs without discrimination in a respectful environment (6, 7), as well as to promote communication between patients and healthcare providers (4, 8, 9). the first serious step in establishing the concept of patient rights was the universal declaration of human rights (udhr) where in its article 2, intrinsic dignity and equal rights are an indispensable part of human rights based on freedom, justice, and peace around the world (10). thus, patients' rights, including patients' physical, psychological, spiritual, and social needs, are expected to be observed by healthcare providers (11), and oncoming ethical controversies in medical care has challenged fulfilling patients' rights (11 ,12). advances in medical technology have led to many new ethical challenges requiring legal instructions to protect care recipients' human dignity (13). as in other countries, the patients' rights charter in iran has been developed while carefully considering religious and cultural issues incorporated in all the articles of the charter (14, 15). according to parsapoor et al., along with political laws, educating the general public and professionals is required to ensure that patients' rights are properly respected in the healthcare system (15). when people are exposed to psychological stress, their cognitive, behavioral, and support resources have a fundamental role in controlling their adaptation and emotional reactions, such as fear, anxiety, and panic. under the psychological stress of an illness, personal and social resources are known as influential factors that can positively or negatively affect treatment results (16, 17). emphasis on patients' rights in healthcare is especially important for patients with a special disease. these patients are more vulnerable in terms of physical, mental, and social problems (18). according to alrabiaah et al., the perceived stress of a special disease can affect interactions between patients and healthcare providers (e.g. physicians and nurses) (19). kord et al. reported that acquired immune deficiency syndrome (aids) patients, as individuals with a special disease, expect healthcare providers to observe their rights equally and without discrimination, and treat them as other patients (20). near the end of 2019, the outbreak of a new viral disease, called covid-19, was kamali m., et al. 3 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 33 december 2020 reported in the city of wuhan, china (21). due to its rapid transmission, the covid-19 pandemic became a global health crisis in all countries within a few months (22). healthcare workers and their family members have been among the most vulnerable populations in this pandemic and have suffered from psychological tensions due to the fear of getting infected (23). social anxiety arising from the quick spread of covid-19 affected the relationships and interactions between healthcare providers and the covid-19 patients. therefore, this study aims to assess the observance of patients’ rights by physicians and nurses from the viewpoint of the covid-19 patients hospitalized in zanjan province, iran. method this study is a cross-sectional work of research conducted on the covid-19 patients admitted to one of the hospitals in september 2020 in zanjan province of iran. the subjects were selected through convenience sampling from the covid-19 patients. the total number of known patients with covid-19 admitted and hospitalized in 11 public hospitals during the study was 342. after obtaining permission from the research department and ethics committee of zanjan university of medical sciences and making arrangements with the hospitals' managers, the researchers explained the objectives of the study to the participants and assured them of the confidentiality of their information. to ensure maximum accuracy in data collection, the researchers were present at the patients' bedsides in full compliance with health protocols, including the use of gowns, gloves, masks, and shields, and orally interviewed the patients and completed the questionnaires. the researchers assured the patients that their responses would have no effect on their treatment plans and that they were orally interviewed just to prevent virus spread. then, as a further precaution, the researchers took photos of the completed questionnaires and then discarded all the paper questionnaires. the participants' informed consent, having been hospitalized for more than one day, and being in stable physical and mental conditions as verified by a physician were the inclusion criteria of this study. the subjects were selected via convenience sampling, and the duration of access to the samples and data collection was between one to three visits to the hospitals. data was collected through a two-section questionnaire consisted of a demographic characteristics survey and a likert-type scale for measuring compliance with the patients' rights charter–the scale was designed and tested in the ph.d. thesis of parsapoor in 2014. demographic characteristics included age, gender, marital status, education level, economic status, health insurance, history of hospitalization, and length of hospital stay. the patients' rights charter questionnaire consisted of 70 questions scored on a likert scale from 1 (non-observance) to 5 (complete observance) for every item. this observance of patients’ rights by physicians and nurses from … 4 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 33 december 2020 questionnaire measured observance of the patients' rights in nine dimensions using the following weight coefficients: (i) courteous communication (weight: 2.5); (ii) justice (weight: 9.2); (iii) privacy (weight: 4.4); (iv) responsibility (weight: 15.8); (v) patient's welfare and comfort (weight: 3.1); (vi) quality of services from a scientific point of view (weight: 25.6); (vii) patients’ interest (weight: 16.3); (viii) access to information (weight: 10.9); and, (ix) respect for patients’ choices (weight: 12.2). dimension’s weight represented its impact on the respondent’s total score for the observance of patients' rights, and hence the dimensions with the highest and the lowest weights had the most and the least impacts on the total score, respectively. the total score range of the observance scale is between 20 and 100 based on every dimension's weight. respondents’ scores were interpreted as follows: low observance (20 to 51), moderate observance (51.01 to 76), and high observance (76.01 to 100). as for courteous communication, based on the dimension’s weight, low, moderate, and high observance were indicated, respectively, by the following scores: 0.5 to 1.27, 1.28 to 1.90, and 1.91 to 2.5. as for justice, based on the dimension’s weight, low, moderate, and high observance were indicated by the following scores, respectively: 1.84 to 4.69, 4.70 to 6.99, and 7 to 9.2. as for privacy, based on the dimension’s weight, low, moderate, and high observance levels were indicated by the following scores, respectively: 0.88 to 2.24, 2.25 to 3.34, and 3.35 to 4.4. as for responsibility, based on the dimension’s weight, low, moderate, and high observance levels were indicated by the following scores, respectively: 3.16 to 8.05, 8.06 to 12, and 12.01 to 15.8. as for the patients’ welfare and comfort, based on the dimension’s weight, low, moderate, and high observance were indicated by the following scores, respectively: 0.62 to 1.58, 1.59 to 2.35, and 2.36 to 3.1. as for the quality of service from a scientific point of view, based on the dimension’s weight, low, moderate, and high observance were indicated by the following scores, respectively: 5.12 to 13.05, 13.06 to 19.45, and 19.46 to 25.6. as for patients’ interests with five questions, based on the dimension’s weight, low, moderate, and high observance levels were indicated by the following scores, respectively: 3.26 to 8.31, 8.32 to 12.38, and 12.39 to 16.3. as for patients’ access to information, based on the dimension’s weight, low, moderate, and high observance levels were indicated by the following scores, respectively: 2.18 to 5.55, 5.56 to 8.28, 8.29 to 10.9. finally, as for respect for patients’ choices with eight questions, based on the dimension’s weight, low, moderate, and high observance levels were indicated by the following scores respectively: 2.42 to 6.20, 6.21 to 9.22 and, 9.23 to 12.2. the dimensions of the patients' rights charter, the number of questions in each dimension as well as their score ranges and weights are listed in table 1. the reliability, internal consistency, and kamali m., et al. 5 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 33 december 2020 validity of this questionnaire were tested in parsapoor’s ph.d. thesis, and the results were within acceptable limits. parsapoor used the intra-class correlation (icc) and cronbach’s alpha indexes to assess the questionnaire's reliability and internal consistency. total icc was 0.87 and the cronbach's alpha was 0.91, showing that the reliability and internal consistency of this questionnaire were satisfactory. parsapoor evaluated the questionnaire's validity by measuring the relevance and clarity of its items. the questionnaire's total relevance and clarity were found to be, respectively, 97.2 and 90.2, indicating that the tool was suitable for evaluating the observance of patients' rights. the relevance and clarity of the items were assessed by experts in the field of patients’ rights, cooperative patients who had been informed of the study’s objectives, and an experienced methodologist (24). the collected data was analyzed in spss v.26 using descriptive statistics, independent ttest, and anova test. table 1observance level of patients’ rights in various dimensions of patients’ rights categorization of scores score range weight number of questions lowest score highest score standard deviation mean dimensions of patients' rights low: 0.5 – 1.27 0.5 – 2.5 2.5 11 0.85 2.5 0.32 2.10 courteous communication moderate: 1.28 – 1.90 high: 1.91 – 2.5 low: 1.84 – 4.69 1.84 – 9.2 9.2 4 3.07 9.2 1.52 6.76 justice moderate: 4.70 – 6.99 high: 7 – 9.2 low: 0.88 – 2.24 0.88 – 4.4 4.4 5 1.32 4.4 0.71 3.01 privacy moderate: 2.25 – 3.34 high: 3.35 – 4.4 low: 3.16 – 8.05 3.16 – 15.8 15.8 3 4.74 15.8 2.81 9.95 responsibility moderate: 8.06 12 high: 12.01 – 15.8 low: 0.62 – 1.58 0.62 – 3.1 3.1 15 1.15 2.92 0.3 1.91 patients’ welfare and comfort moderate: 1.59 – 2.35 high: 2.36 – 3.1 low: 5.12 – 13.05 5.12 – 25.6 25.6 7 10.24 24.75 3.98 18.67 quality of service moderate: 13.06 – 19.45 high: 19.46 – 25.6 low: 3.26 – 8.31 3.26 – 16.3 16.3 5 4.08 16.3 3.2 11.09 patients’ interests moderate: 8.32 – 12.38 high: 12.39 – 16.3 low: 2.18 – 5.55 2.18 – 10.9 10.9 12 6.10 10.68 0.96 9.07 access to information moderate: 5.56 – 8.28 high: 8.29 – 10.9 low: 2.42 – 6.20 2.42 – 12.2 12.2 8 4.15 10.03 1 6.99 respect for patients’ choices moderate: 6.21 – 9.22 high: 9.23 – 12.2 low: 20 – 51 20-100 100 70 46.60 87.88 7.36 69.60 total observance score moderate: 51.01 76 high: 76.01 100 observance of patients’ rights by physicians and nurses from … 6 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 33 december 2020 results all covid-19 patients admitted to one of the hospitals of zanjan province were selected for data collection. among these patients, 54 patients had been taken to intensive care units (icus) and were unable to respond to the researchers’ questions due to their unstable conditions. thirteen patients were unwilling to participate and were, therefore, excluded. eventually, 275 questionnaires were completed and analyzed. analysis of the demographic characteristics showed that the participants' mean age was 58.25±10.2 years. most of the participants were female (70.9%), married (82.2%), and had primary school education (64%). in terms of economic status, 52.7%, 37.4 %, and 9.9% described their status as middle, low, and high, respectively. moreover, 82.9% had health insurance and 71.3% had a history of hospitalization. additionally, the participants' average length of hospital stay at the time of this study was 4.65±1.86 days. the mean score for the observance of patients' rights by physicians and nurses from the covid-19 patients’ perspective was found to be 69.60 with a standard deviation of 7.36, indicating moderate observance. moreover, the dimension of courteous communication had the highest score (2.10 ± 0.32), while the dimension of responsibility had the lowest score (9.95 ± 2.81); courteous communication and responsibility were the most and the least observed dimensions of the patients' rights charter, respectively. the mean scores, standard deviations, the highest and the lowest scores, and score ranges are shown in table 1. according to table 1, in addition to courteous communication, the dimensions of justice, quality of service from a scientific point of view, and access to information were reported to be highly observed. the participants evaluated the dimensions of privacy, patients’ welfare and comfort, patients’ interests, and respect for patients’ choices as moderately observed. only the dimension of responsibility was reported to be poorly observed. moreover, the researchers examined the relationship between the subjects’ demographic variables, namely age, gender, marital status, education level, economic status, health insurance, history of hospitalization, and length of hospital stay, as well as their total mean scores for the observance of patients' rights. table 2 shows the frequency and percentage of the demographic variables, and the mean and standard deviation of the patients’ total scores for the observance of patients’ rights along with the results of the statistical tests used to investigate the relationship between the participants’ demographic variables and their scores. kamali m., et al. 7 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 33 december 2020 table 2mean score and standard deviation of the patients' rights observance in terms of demographic characteristics variables variable frequency (percentage) mean and standard deviation for observance of patients' rights statistical test p-value gender man 91 (33.1%) 69.90±7.73 independent t-test 0.62 woman 184 (66.9%) 69.45±7.17 marital status single 8 (2.9%) 69.90±8.73 anova 0.001 married 226 (82.2%) 70.71±5.89 divorced 17 (6.2%) 60.94±10.26 widowed 24 (8.7%) 65.16±11.01 education level illiterate 87 (20.7%) 70.66±6.55 anova 0.005 primary school 176 (64%) 70.92±6.07 high school/ diploma 28 (10.2%) 68.40±8.21 college 14 (5.1%) 60.26±8.77 economic status good 27 (9.8%) 71.19±5.99 anova 0.063 moderate 146 (53.1%) 70.81±4.79 bad 102(37.1%) 69.38±5.97 health insurance yes 228 (82.9%) 70.85±6.23 independent t-test 0.005 no 47 (17.1%) 63.55±9.25 history of hospitalization yes 196 (71.3%) 69.69±6.75 independent t-test 0.73 no 79 (28.7%) 69.39±8.72 table 2 shows that the total score for the observance of patients' rights does not correlate with gender, economic status, or history of hospitalization. however, with regard to the impact of patients’ marital status on how they estimate the observance of their rights, the analysis of variance (anova) test results showed a statistically significant relationship between the two (pvalue<0.05). the results of the post hoc test of least significant difference (lsd), after equality of variances, had been ensured via levene’s test, determined that the mean score of the married patients was significantly higher than those of the divorced and widowed patients. moreover, the mean observance score of the single patients was significantly higher than that of the divorced patients (p-value<0.05). observance of patients’ rights by physicians and nurses from … 8 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 33 december 2020 table 3the lsd post hoc test’s results for the mean differences between the participants based on marital status and education level variable groups mean difference p-value marital status single married -0.80 0.74 divorced 8.96 0.00 widowed 4.74 0.09 married single 0.8 0.74 divorced 9.76 0.00 widowed 5.54 0.00 divorced single -8.96 0.00 married -9.76 0.00 widowed -4.22 0.54 widowed single -4.74 0.09 married -5.54 0.00 divorced 4.22 0.54 education level illiterate primary -0.26 0.80 high school/ diploma 2.26 0.14 college 10.40 0.00 primary illiterate 0.26 0.54 high school/ diploma 2.52 0.06 college 10.66 0.00 high school/ diploma illiterate -2.26 0.14 primary -2.52 0.06 college 8.13 0.00 college illiterate -10.40 0.00 primary -10.66 0.00 high school/ diploma -8.13 0.00 the results showed a statistically significant relationship between the participants' total mean scores for the observance of patients’ rights and their education level (pvalue<0.05). the post hoc test results for identifying differences between the groups showed that only the mean observance score of the patients with a college degree was significantly lower than that of patients with other education levels (p-value<0.05). the lsd post hoc test’s results for identifying possible differences between the participants’ observance of patients’ rights scores based on their marital status and education level are shown in table 3. the results also showed a statistical difference between the total mean scores of the patients' rights observance and their health insurance. the independent t-test’s results showed that the patients with health kamali m., et al. 9 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 33 december 2020 insurance evaluated the observance of patients’ rights more highly than the patients without health insurance, and the difference was statistically significant (p-value<0.05). to examine the relationship between the variables of age and length of hospital stay, the pearson's correlation test was used. the results showed no significant relationship between the patients' mean scores for the observance of patients’ rights and their age or length of hospital stay (table 4). table 4pearson’s correlation coefficients between mean scores for observance of patients’ rights and their age and length of hospital stay variable correlation coefficient p-value age 0.038 0.53 length of hospital stay 0.034 0.57 discussion this study’s results show that the observance level of patients' rights from the covid-19 patients’ viewpoint is moderate, whereas many other studies reported different results. the results of the study by sheikhbardsiri et al. consistent with the present study’s results, showed that the observance level of patients' rights in emergency wards from the patients’ viewpoint is moderate (43.10 ±15.05) (24). similarly, zandiyeh et al. reported that the observance level of patients' rights is average (50.2) (25). however, ghaljeh et al. reported the mean and standard deviation of the observance level of patients' rights as perceived by patients to be 6.28±1.02, or low (26). dehghan et al. showed that the mean and standard deviation of the observance level of patients' rights is 2.91±0.74, in the range of 0 to 4 from the patients' viewpoint (11). likewise, a study conducted in oman showed that healthcare providers’ adherence to patients' rights in practice is low, while their awareness of the importance of respecting patients' rights was high. that study also suggested that devising measures to improve healthcare providers’ observance of patients’ rights is critically necessary (27). another study conducted in pakistan reported that only 41% of the patients who participated in the research were satisfied with the observance of their rights, and most of them were dissatisfied (28). according to a study conducted in iran, although nurses' knowledge about patients' rights was inadequate, their performance in observing patients' rights was moderate (6). a comparison between the present study’s findings and those of previous researches shows that observance of patients' rights varies in different conditions, but most research results indicate a moderate observance level. the present study shows that the observance of patients' rights in the critical social conditions of the covid-19 pandemic is moderate to high. furthermore, the results of the present study show that observance of most dimensions of the patients' rights charter is moderate or observance of patients’ rights by physicians and nurses from … 10 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 33 december 2020 high. courteous communication (the highest), justice, quality of service from a scientific point of view, and access to information were found to be the highly observed dimensions. the dimensions of privacy, patients’ welfare and comfort, patients’ interests, and respect for patients’ choices were moderately observed. the least observed dimension from the patients’ perspective was responsibility. overall, the observance level of the patients' rights charter was moderate to high. parsapoor et al. reported a low observance level in access to information dimension, and they highlighted the necessity of closer attention to the management of information communication between healthcare providers and patients (29). the present study’s results about the highly observed dimension of patients' rights charter are consistent with those of sookhak et al. where the highest score for the observance of patients' rights was related to "the right to be treated with respect" (43.4%), indicating nurses' good performance in this area (6). sookhak et al. also reported that nurses' performance was unsatisfactory in respecting patients’ rights to have access to information, to choose, to receive appropriate care and treatment, and to complain. as with the present study, they reported the observance level of patients’ right to privacy to be moderate (6). on the contrary, sabzevari et al. found the highest observance level of patients' rights to be in domains of respecting patients' privacy and maintaining patients’ confidentiality (9). a comparison between the present study and similar studies shows that respect and courteous communication with patients are still the most highly-observed aspects of the patients' rights charter. even in the current critical conditions, physicians and nurses believe that patients should be treated with respect. one of the obvious differences between the findings of the present study and those of other studies concerns the dimension of access to information. the results of the present study regarding access to information are not consistent with those of parsapoor et al., sookhak et al., and sabzevari et al. this discrepancy can be attributed to the social conditions caused by the covid-19 pandemic where the covid19 patients are regarded as patients with special conditions compared to other patients. furthermore, due to the pandemic, hospitalization of non-covid-19 patients has greatly reduced due to fear of infection. accordingly, physicians and nurses have enough time to provide information to covid-19 patients. as with the present study, the study of farzianpour et al. showed that patients' viewpoint on observance level of "access to medical records and information" as part of the patient's rights charter was found to be moderate to high (8). farzianpour et al. also reported that the observance level of "the right to replace physicians and refuse treatment" was found to be average. this aspect of the patients’ rights is comparable with the dimension of "respect for patients’ choices" in the present study which was kamali m., et al. 11 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 33 december 2020 evaluated to be moderately observed (8). according to dehghan et al., the essential aspect of the patient's rights was receiving optimal healthcare services from both nurses' and patients' viewpoints (11). they also concluded that the most observed aspect of the patients’ rights was patients’ privacy and confidentiality and the least observed aspects were compensation for medical errors, handling patient's complaints, and respecting patients’ rights to complain (11). similarly, the present study’s participants reported the dimension of responsibility to be poorly observed. the dimension of responsibility in the present study assessed the handling of patients’ complaints by physicians and nurses. the present study’s results showed a statistically significant correlation between the total score of the observance level of patients' rights charter and the following variables: marital status, education level, and health insurance support. the married patients, compared to the divorced and widowed patients, reported a higher observance level of patients’ rights. moreover, single patients, compared to divorced patients, reported a higher observance level of patients’ rights. in addition, patients with a college degree, compared to the patients with other education levels, evaluated the patients' rights observance level to be lower, which was statistically significant. the results also showed that the patients with health insurance, compared to the patients without health insurance, reported a higher observance level of patients’ rights. regarding the history of hospitalization, mack reported that patients with a history of hospitalization were more satisfied with the received healthcare services, while the present study’s results did not show a significant relationship between these two variables (30). according to farzianpour et al., younger patients, compared to middleaged and older patients, were less satisfied with their healthcare services (8). in this study, most covid-19 patients admitted to the hospitals were in a certain age range, and the age did not appear to affect the mean of the reported observance level of these patients' rights. as with the present study, sabzevari et al. did not find a significant relationship between patients’ demographic characteristics, including age, gender, education level, and career, and their perception of observance of patients’ rights (9). vakili et al., mokhtari and khorami markani, and rafiei et al., in their studies, did not found a statistically significant correlation between patients’ marital status and their perception of observance of patients’ rights (31,32,33). as with the present study, the results of babamahmoudi et al. showed that the observance level of patients' rights from viewpoint of patients with an academic degree was statistically lower (34). although more research is required on why subjects with higher education levels evaluate observance of patients’ rights less favorably than others, observance of patients’ rights by physicians and nurses from … 12 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 33 december 2020 greater knowledge and awareness of such individuals could be a reason. the present study’s results can be extended to other provinces of iran because not many cultural differences in the aspects considered in this study can be observed among other provinces. however, further research in other provinces is suggested for more accurate results. major cultural differences among iran and the other countries prevent the generalization of this study’s results to other countries. furthermore, patients' psychological conditions, and satisfaction with hospital equipment could affect their assessment of observance of patients' rights, factors disregarded in the present study. therefore, for a more accurate evaluation, all the factors affecting patients' perception of the observance of their rights, including the interactions of medical and non-medical staff with patients and their families as well as patients’ satisfaction with medical equipment and hospital facilities should be addressed. future studies are recommended to cover more provinces with larger sample sizes, all dimensions affecting observance of patients’ rights, and dimensions of patients' rights charter with reported low observance level from the patients’ perspective. the outcomes of such studies should be considered by the healthcare system’s managers and policy-makers for planning improvement as well as future research and development. conclusion based on the present study’s findings, the observance level of patients' rights from the covid-19 patients’ viewpoint was found to be moderate. compared to similar previous studies, more dimensions of the patients’ rights charter were found to be well observed during the pandemic. courteous communication was the most highlyobserved patient right from the participants' viewpoint, indicating that the covid-19 patients were treated with respect during their hospitalization by physicians and nurses. these findings refute the hypothesis that physicians and nurses, major human resources in healthcare systems, are disregarding patients' rights during the pandemic crisis due to their fear and anxiety as well as panic of getting infected and the possibility of transmitting coronavirus to their family. this study’s findings show that, from the covid-19 patients’ viewpoint, the observance level of patients’ rights as prescribed by the patients’ rights charter has not diminished as a result of the uneasy atmosphere in the society following the outbreak of covid-19. ethical considerations permission to conduct the present study was obtained from the research department and ethics committee of zanjan university of medical sciences (ir.zums.rec.1399.164). all the study participants were informed about the objectives of the study, the confidentiality of the information, and the voluntary nature of their participation. kamali m., et al. 13 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 33 december 2020 acknowledgements the researchers would like to thank the patients who participated in this study and the hospital personnel for their cooperation despite the restrictions caused by the covid-19 pandemic. conflict of interests the authors declare no conflict of interests observance of patients’ rights by physicians and nurses from … 14 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 33 december 2020 references 1. heidari a, ahmadpour z, ghareh boughlou a. patients and nurse’s awareness of patient’s rights: a comparative study. health, spiritual med ethics. 2014; 1(1): 2-8. 2. younis aah, hassan aha, dmyatti emeh, et al. awareness and practice of patients' rights 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[in persian] ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ original article copyright © 2021 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e clarifying the concept of conscience in nurses’ ethical performance in iran: a concept analysis study *corresponding author akram sadat sadat hoseini address: school of nursing and midwifery, nosrat st, tohid sq., tehran, iran. postal code: 141973317 tel: (+98) 21 61 05 44 23 email: ashoseini@tums.ac.ir received: 13 feb 2021 accepted: 15 aug 2021 published: 3 nov 2021 citation to this article: jodaki k, esmaeili m, cheraghi ma, pashaeypoor s, sadat hoseini as. clarifying the concept of conscience in nurses’ ethical performance in iran: a concept analysis study. j med ethics hist med. 2021; 14: 14. kurosh jodaki1, maryam esmaeili2, mohammad ali cheraghi3, shahzad pashaeypoor4, akram sadat sadat hoseini5* 1.phd candidate of nursing, school of nursing and midwifery, tehran university of medical sciences, tehran, iran. 2.assistant professor, nursing and midwifery care research center, school of nursing and midwifery, tehran university of medical sciences, tehran, iran. 3.professor, department of critical care and nursing management, school of nursing and midwifery, tehran university of medical sciences, tehran, iran; health sciences phenomenology association, ministry of health and medical education, tehran, iran. 4.assistant professor, department of community health and geriatric nursing, school of nursing and midwifery, tehran university of medical sciences, tehran, iran. 5.associated professors, school of nursing and midwifery, tehran university of medical sciences, tehran, iran. abstract although conscience, as an ethical concept, has emerged widely in the field of nursing, its functional meaning and its effects on nurses' performance are not clear. therefore, the present study aimed to analyze the concept of conscience in the context of iranian nurses’ ethical performance. this study used a hybrid model including theoretical, fieldwork, and final analytic stages. in the theoretical phase, english and persian articles published up to 2020 and indexed by scientific databases were analyzed. in the fieldwork phase, semi-structured in-depth interviews were conducted on nurse participants. the last two stages were jointly considered to draw the study’s conclusions. in the theoretical phase, conscience was considered as a context-dependent concept, an inner voice, and a criterion for distinguishing right from wrong. the fieldwork phase’ results were categorized into three themes: “perception of conscience”, “commands of conscience”, and “obedience to conscience. the final definition was reached by merging the theoretical and field stages. this article aimed at investigating the relevance of conscience to ethical practice in the nursing field. findings show that conscience is an inner feeling or voice that plays a vital role in providing ethical care by nurses. keywords: conscience; concept analysis; ethics; nursing. clarifying the concept of conscience in nurses’ ethical performance in iran … 2 j med ethics hist med. 2021(november); 14:14. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e introduction ethics is entangled in various aspects of the nursing profession, and nurses frequently face different ethical challenges in providing care to patients (1). during their professional lives, nurses face situations demanding decision-making and judgment based on ethical considerations. in ethically challenging situations, nurses rely on their conscience to resolve them and provide quality care (2). different definitions for conscience in nursing literature were presented: (i) an inner sense or feeling that helps an individual make the right choice; (ii) an innate force that is the cornerstone of ethics. (3, 4). under complicated circumstances, conscience can positively affect nurses’ performance and guide nursing care toward ethical quality care (3). many studies on the concept of conscience admitted that in ethical decision making based on professional, ethical codes and guidelines, conscience guides nurses to protect both patients and their moral integrity (4-6). for instance, participants in the study by hasani et al. stated that conscience directed them to provide ethical and comprehensive care to patients. they also felt guilty if they neglected their conscience in providing care to patients (7). in many studies, including lamb et al., conscience was introduced as a commanding authority issuing a warning signal depending on the subject’s culture and context (3). other studies described conscience as the cornerstone of ethics (4, 8). when nurses follow their conscience to provide quality care, their interpretation of conscience is positive; otherwise, conscientious conflict causes a troubled conscience that can be associated with the feeling of guilt (9, 10). since conscience judges thoughts and deeds, it can help nurses preserve their ethical integrity and provide proper care to patients. if nurses do not follow the path of conscience, they may face various consequences such as guilt, troubled conscience, and stress of conscience (11, 12). conscience is a valuable asset that guides nurses towards ethical practice and has a significant impact on nursing care (2, 8, 9). studies on conscience consider it as a function of structure and culture (3, 8). in iran, studies on conscience in the nursing field have not focused on the concept of conscience in nurses’ ethical performance. additionally, conscience does not have a clear definition when considering the role of ethics in the ethical performance of nurses. hence, the present paper aimed at analyzing the concept of conscience in the context of nurses’ ethical performance in iran and clarifying this concept from iranian nurses’ perspective based on iran’s culture. clarification of the dimensions and characteristics of this concept can help in future research, educational plans, practice, benchmarking, and evaluation. moreover, a precise definition of conscience is a step towards the development of context-centered professional knowledge. jodaki k., et al. 3 j med ethics hist med. 2021(november); 14: 14. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e methods in this study, to analyze the concept of conscience, a hybrid method was used, and comprised of theoretical, fieldwork, and analytical phases (13). this method of concept analysis is one of the methods for processing and developing concepts and theories. in nursing, it is used to remove concepts’ ambiguities and help reduce concepts’ abstract load (13). the major usage of this model is to analyze a topic in nursing as well as in a specific field and context (14). theoretical phase a systematic method was used, and a protocol was utilized involving the following: selecting review questions, inclusion criteria, search strategy, study selection, data extraction, and quality assessment. literature was reviewed using articles from creditable databases including pubmed, isi, scopus, sciencedirect, and persian databases sid and magiran. the keyword "conscience" was searched in paper titles, and "nurs*" was searched in the title and abstract of the papers indexed in english and persian electronic databases. no limitation was applied to publication date as well as to selecting original and review articles, including qualitative and quantitative. the inclusion criteria involved considering articles relevant to the concept under study, english and persian languages, fulltext availability, and non-duplication. the search yielded 212 papers, including 40 reports from persian databases and 172 articles from english databases. given the overlaps of articles and that only original articles on conscience were included, 22 articles (16 english articles and 6 persian articles. diagram 1 shows the article selection process details. a domain-based evaluation, a component approach, was used to evaluate the quality of quantitative studies. each study was assigned a specific code considering randomization, sample size, blinding, and random sampling. the critical appraisal skills programme (casp) evaluation tool was used in the qualitative studies; a 10-item evaluation tool designed by the uk evidence-based medical center (15). in addition, two faculty members of tehran university of medical sciences (tums) confirmed the quality of the studies. conventional qualitative content analysis was used to analyze the texts, and data analysis was performed using graneheim and lundman's method, 2004 version (16). the text was read several times to achieve a general overview. then, the meaning units were extracted, and the extracted concepts were compressed. concepts and definitions extracted from the theoretical phase were transferred into the fieldwork phase. fieldwork phase the fieldwork phase’s objectives were to improve and refine the concept resulted from the theoretical phase. in terms of time, the fieldwork phase overlapped with the theoretical phase and focused on the experimental component. this stage was investigated in tums’ affiliated hospitals, and nurses in those hospitals were invited to clarifying the concept of conscience in nurses’ ethical performance in iran … 4 j med ethics hist med. 2021(november); 14:14. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e participate in the study. inclusion criteria were having a bachelor’s degree or higher in nursing as well as the willingness to share the experiences regarding the concept of conscience. based on the theoretical phase’s results, a semi-structured questionnaire was designed; purposeful sampling was used; and, face-toface interviews were conducted to collect data. at this phase, the interviews’ guiding questions included the following: “how does your conscience help you in clinical practice?”; “what does a conscientious nurse do while caring for a patient?” then, questions starting with "why" and "how" were asked, and, each interview lasted 30 to 60 minutes, on average. the written informed consent of participants was initially obtained, and the time and place of interviews were scheduled according to their convenience. after receiving participants’ permission, the interviews were audiorecorded. after eight interviews, data saturation was reached and sampling was completed. data collection and analysis were performed simultaneously, conventional qualitative content analysis was used to analyze the interviews, and data analysis was performed using graneheim and lundman's method, 2004 version (16). the interviews were transcribed and read several times to form a general overview of the interviews and concepts; then, meaning units were extracted, and the extracted concepts were compressed. the extracted concepts were categorized considering similarities and differences, and a suitable title was chosen for each category. analysis and management of data were performed using maxqda software, version 10. to enhance data quality in this phase of the study, the researchers used lincoln and guba 1985 to increase the trustworthiness of the data and findings. trustworthiness includes various dimensions such as credibility, transferability, confirmability, dependability, and authenticity (15). in this study, the researcher tried to increase the credibility of the data by long-term involvement in the field and establishing appropriate communication with the participants to access their actual experiences. peer checks were used to confirm the findings; the meaning units with the extracted codes were provided to observers, and their comments were applied. final analytic phase the data from the literature review and the codes obtained from the field study were compared to develop the concept of conscience in the nursing field in iran, and then the meaning and specifications of this concept were discovered and reported. ethics considerations this article resulted from a research project approved by the nursing and midwifery research center of tums and has a code of ethics from tums (ir.tums.fnm.rec.1399.142). written informed consents were obtained from the participants after full disclosure of the study’s goals. maintaining anonymity and confidentiality were observed and participation was voluntary. jodaki k., et al. 5 j med ethics hist med. 2021(november); 14: 14. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e result theoretical phase according to studies, conscience is an inner sense of right and wrong and acts as a guide to human behavior (8,12). the word conscience was derived from the latin word "conscientia", rooting in the greek word "synderesis". the word’s meaning is twofold: to share knowledge and awareness as well as to apprehension. conscience is also used to convey a sense of mind or thought (17). conscience is the bedrock of ethics, an inner voice functioning as a moral compass as well as an integrated set of personal values guiding human beings in living and behaving (2, 4, 18,19). jensen and lidell quoted from alden that conscience in theology is a manifestation of faith or a perspective of life, and if so, it has to do with ethics and ethical feelings. conscience in religious texts was defined as god’s voice (20). however, from a philosophical perspective, conscience is a theoretical construct that depends on personal emotions and thoughts (3). from a psychological viewpoint, according to juthberg et al., quoted from freud, conscience acts subconsciously and is rooted in the integrity of human beings' values (21). in the context of evaluating nursing performance, conscience is a base of ethical actions and decisions as well as ethical nursing care (22, 23). in the nursing field, conscience provides a warning signal, higher sensitivity in actions, and an ethical guide in fulfilling patients’ needs (18, 24, 25). disregarding conscience can lead to troubled conscience and stress of conscience in nurses’ professional life (8,26,27). the results of studies in iran showed that conscience is an intrinsic capability in delivering nursing care for iranian nurses. such capability provides aspects of selfawareness for an individual (28, 29). few studies on conscience in the nursing field in iran concluded that the concept of conscience was a function of culture and religion. in this regard, hasani et al. defined conscience as an inner and innate asset that can advance under the influence of the environment (7). they believed that conscience monitors human beings’ actions, and if they act contrary to the call of conscience, as a judge of actions, it begins to blame (7, 30). another study in iran in the field of nursing considered conscience as a guide that influenced by environmental, occupational, and personal factors. this study found workload, personality type, history of hospitalization (individuals or their relatives) as the factors affecting conscience (31-33) (table 1). the working definition of conscience from the theoretical phase’s findings, the researchers concluded that conscience, existing since birth, may develop and change under the influence of environmental factors (e.g., family, society, culture, and religion) and during the process of personal growth. clarifying the concept of conscience in nurses’ ethical performance in iran … 6 j med ethics hist med. 2021(november); 14:14. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e figure 1flow diagram of search process number of articles retrieved from the databases pubmed: 64 scopus: 57 web of science: 51 magiran: 5 sid: 35 n= 212 number of remaining articles after removing duplicate articles n= 108 number of related articles after reading the abstracts n= 53 number of removed articles n= 104 number of removed articles n= 51 number of studies included in the theoretical analysis phase n= 22 original article (n = 18), review article (n = 4) number of additional records n= 1 number of articles after evaluating articles through reading full text n= 21 number of removed articles n= 32 jodaki k., et al. 7 j med ethics hist med. 2021(november); 14: 14. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e table 1studies including the concept of conscience in nursing field author and year type of paper/method sample setting country ahlin et al (2012) questionnaire validation 503 hcp hospital sweden saarnio et al (2012) quantitative study 350 nurses nursing homes finland glasberg et al (2006) questionnaire validation 444 hcp hospital sweden lamb et al (2017) concept analysis n/a n/a canada jensen and lidell 2009 qualitative study 15 nurses hospital western sweden cleary and lees(2019) review article n/a n/a australia mazaheri et al (2018) qualitative study 10 nurses residential care settings sweden mazaheri et al (2015) qualitative study 10 nurses residential care settings sweden genuis and lipp(2013) review article n/a n/a canada glasberg et al 2006 quantitative study 423 hcp hospital sweden dahlqvist et al (2007) development of questionnaire 444 nurses and physicians hospital sweden ahlin et al (2015) quantitative study 488 nurses nursing homes sweden juthberg et al (2010) quantitative study 146 nurses hospital sweden tuvesson et al (2012) quantitative study 93 nurses hospital sweden zhang et al (2013) quantitative study 100 nurses hospital china ko et al (2020) quantitative study 167 nurses hospital south korea morton and kirkwood (2009) review article n/a n/a canada vanaki and memarian (2009) qualitative syudy 36 nurses hospital iran hasani et al (2013) qualitative study 9 nurses hospital iran foolad et al (2019) quantitative study 569 nurses hospital iran lak et al (2018) quantitative study 193 nurses hospital iran jasemi et al (2018) qualitative study 14 nurses hospital iran nasirzadeh (2015) review article n/a n/a iran conscience, as an inner voice or feeling, testifies to the rightness or wrongness of an action. conscience is a personal moral compass that governs a person’s thoughts and feelings, judges actions and behaviors, and provides a reference for future needs. in complex moral situations, conscience enables individuals to distinguish right from wrong as well as acts as a motivator and leader in performing morally right nursing care. fieldwork phase’s findings in this study, eight nurses with an average age of 34.99±7.35 years were interviewed. table 2 shows the participants’ characteristics. table 2characteristics of the participants variable n (%) gender male female 3(37.5) 5(62.5) education level b.sc. m.sc. 6(75) 2(25) marital status single married separated 3(37.5) 4(50) 1(12.5) work experience 1-6 years 7-12 years more than 12 years 3(37.5) 3(37.5) 2(25) using conventional qualitative content analysis with graneheim and lundman's method, 612 initial codes were extracted. clarifying the concept of conscience in nurses’ ethical performance in iran … 8 j med ethics hist med. 2021(november); 14:14. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e after compressing the codes and classifying them, the fieldwork phase’s results were categorized into three categories: “perception of conscience”, “commands of conscience”, and “obedience to conscience” (table 3). table 3categories, subcategories and codes of conscience in the field work phase categories subcategories codes perception of conscience inner voice superior feeling guide and observer conscience is the voice of god conscience is the inner inspiring factor conscience is a transcendental sense conscience is the supreme inner power conscience is an inner guide conscience is a human observer commands of conscience conflict of conscience strong commanding center conscience is the agent distinguishing right from wrong conscience is a factor of choosing right from wrong conscience is a restraining agent conscience is an inner stimulus obedience to conscience troubled conscience clear conscience conscience is a blame factor conscience is a cause of guilt conscience is a satisfying factor conscience is a soothing factor perception of conscience this category is related to nurses’ understanding of the concept of conscience, divided into the following subcategories: inner voice, superior sense, guide, and observer. under the “perception of conscience” theme, most participants defined conscience as an inner voice or feeling that leads nurses to perform the right actions. moreover, conscience is a superior feeling, guide, and observer that helps nurses perform their professional duties. in this regard, participant no. 2 stated as follows: "when i get stuck in a dilemma, a voice from within tells me what to do, as if god is talking to me. for example, i have always tried not to fail in my job because my conscience tells me that i have accepted its responsibility. " commands of conscience (commanding conscience) this category referred to the commanding nature of conscience, divided into two subcategories: “conflict of conscience” and “strong, commanding center”. “conflict of conscience” recommends or prohibits an action as a “strong, commanding center”. based on nurses’ experiences, conscience motivates nurses to fulfill responsibilities to patients in the best possible way and encourages them to provide quality care beyond their job description. in summary, conscience helps nurses distinguish right from wrong, encourages them to do the right actions, and prevents them from doing the wrong actions. in this regard, participant no. 4 stated as follows: "i informed anesthesiologists when the patient developed respiratory distress and hypoxia and was in urgent need of jodaki k., et al. 9 j med ethics hist med. 2021(november); 14: 14. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e intubation. unfortunately, they arrived too late. it was not my task to intubate the patient, but i did so because my conscience did not allow me to let the patient remain in that state of respiratory distress." obedience to conscience this category is related to submission to conscience, divided into two subcategories: “troubled conscience” and “clear conscience”. therefore, if individuals follow their conscience, they will enjoy contentment as well as mental and spiritual peace; otherwise, they will feel guilty. conscience provides a persistent inner warning and once neglected, it starts blaming, and hence conscience acts as an internal stressor. hence, nurses enjoyed a clear conscience when they appropriately performed their professional duties. when they failed to meet patients’ needs, they suffered from a troubled conscience accompanied by feelings of guilt, incapacity, fatigue, and discomfort. not to suffer from a troubled conscience and not to experience such painful feelings, nurses should listen to their conscience call in patient care. in this regard, participant no. 7 said: "i have always tried to do my work such that my conscience stays at ease. then, i do not feel guilty and upset because patients’ affairs have been abandoned or i have allocated inadequate time to do their related tasks. last week, when a patient with covid-19 developed respiratory apnea, we immediately began resuscitating the patient. she was a 39-year-old woman, and although we worked hard to save the patient, she died. i think the patient has taken too much sedative drug and developed apnea. i still have a guilty conscience for not paying enough attention." final analytic phase after merging the results of the theoretical and fieldwork phases, conscience in the context of ethical performance of nurses in iran was defined to be an internal voice and feeling, guide, and observer of the individual since birth. conscience develops and evolves under the influence of environmental factors (e.g., family, society, culture, and religion). moreover, during the personal growth process, various aspects of consciousness are developed: “perception of conscience”, “command of conscience”, and “obedience to conscience”. due to the nature of commanding and obedience aspects, conscience affects nurses’ ethical performance. conscience assists nurses to distinguish right from wrong, motivates them to do the right actions, and helps them make the right choices and decisions. if nurses listen to the voice of their conscience and follow it, they can enjoy a clear conscience with inner peace and joy. if nurses fail to follow their conscience, they suffer from troubled conscience and may experience guilt and tension along with despair, powerlessness, and helplessness. to refuse such consequences, they should listen to their conscience call to provide the best ethical patient care. based on the results of the analytical stage, conscience is defined as follows: if nurses do their best professionally and ethically to clarifying the concept of conscience in nurses’ ethical performance in iran … 10 j med ethics hist med. 2021(november); 14:14. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e provide ideal patient care, the internal stimulus that motivates nurses to make such quality effort is conscience. conscience is an inner voice or feeling that accompanies human beings since birth and forms the foundation of ethics. conscience can develop depending on the environmental factors (e.g., family, society, and religion) and involves several aspects: “perception of conscience”, “commands of conscience”, and “obedience to conscience.” discussion this study aimed at clarifying the concept of conscience in the context of nurses’ ethical performance. conscience is a dynamic and innate concept that can affect human beings’ lives depending on their cultural and social conditions. moreover, conscience helps nurses provide the best possible professional and ethical care to patients. according to the participants, conscience is the bedrock of ethics and a fair judge that helps them in ethical dilemmas. in complex moral situations where ethics may not be observed, conscience warns nurses about the consequences of ignoring conscience call. several papers in the field of nursing have defined conscience as a basis for ethical undertakings and ethical care for nurses and assisting nurses in clinical situations requiring ethical considerations (3, 4, 8,34). in this research, conscience is an inner feeling and voice that guides nurses to perform the right actions. in the studies by lamb et al. and glasberg et al., conscience is defined as the inner voice, which is the cornerstone of ethics (2, 3). the present study showed that conscience is activated since birth in humans and has a dynamic nature. conscience is developed and changed throughout human life in three aspects: “perception of conscience”, “commands of conscience”, and “obedience to conscience”. thus, alirezaie et al. showed that conscience can be developed and enhanced through education, which can result in performance improvement of staff and organizations (35). mazaheri et al. also pointed to the dynamic and changing nature of conscience throughout human life. environmental factors such as family and religion, particularly, affect the growth or development of conscience (8). lamb et al. also consider conscience as a culturally related concept (3). dahlqvist et al. defined conscience as an asset, a sensitivity, a responsibility, and a culture-dependent concept (4). therefore, “perception of conscience”, “commands of conscience”, and “obedience to conscience” can have different meanings in different cultures, and hence their effects vary. in the present study, an aspect of conscience is the “perception of conscience”, implying that conscience is a superior sense and inner guide forming the base of nurses’ ethics. imani et al. argued that individuals with a robust professional conscience are more sensitive to negligence in observing ethical codes by their colleagues and tend to react to such behaviors, a sign of their commitment to ethics. individuals with a strong conscience call and perception of conscience tend to commit more to ethics (36). according to the present study’s results, conscience is a restraining factor. ignoring conscience commands leads to conflict in jodaki k., et al. 11 j med ethics hist med. 2021(november); 14: 14. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e nurses’ actions and behaviors, as ford and austin emphasized the importance of paying attention to conscience commands (10). moreover, studies in nursing fields have shown that if the conflict of conscience is repeated in different care situations, nurses will suffer from a troubled conscience, accompanied by guilt, sadness, and helplessness (12, 37) as the consequences of ignoring obedience to conscience. moreover, studies showed that if nurses follow their conscience call, a sense of clear conscience is attained, obedience to conscience is exercised, and the conscience’s role is perceived positively (8). thus, ignoring the aspects of “command of conscience” and “obedience to conscience” leads to the conflict of conscience and troubled conscience, negatively affecting nurses. studies showed that these consequences can lead to burnout and reduced quality of nursing care (23, 38). gustafsson et al. found that negligence of conscience eventually leads to tension and job depression (39). therefore, paying attention to conscience and its role in the nurses’ professional life is crucial. conclusion this study's findings indicated that conscience is an innate voice, inner feeling, observer, and guide; the concept of conscience involves three aspects or dimensions: “perception of conscience”, “command of conscience”, and “obedience to conscience”. identifying such dimensions can improve the status, importance, and application of this concept in the nursing field. however, concept analysis is an ongoing process, and with increasing knowledge and experience, the concept should be developed and extended further. since iran is a country with iranian islamic culture and various subcultures, more studies are needed to deeply identify the concept of conscience and its consequences in the iranian nursing community. acknowledgements the authors wish to thank all the participants and those who made this study possible. conflicts of interests none declared. clarifying the concept of conscience in nurses’ ethical performance in iran … 12 j med ethics hist med. 2021(november); 14:14. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e references 1. gorbanzadeh b, rahmani a, mogadassian s, behshid m, azadi a, taghavy s. levels of conscience and related factors among iranian oncology nurses. asian pac j cancer prev. 2015; 16(18): 8211-4. 2. glasberg al, eriksson s, dahlqvist v, et al. development and initial validation of the stress of conscience 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of medicine research center, tehran university of medical sciences, tehran, iran; 3professor, department of health management and economics, school of public health and institute of public health research, and center for academic and health policy, tehran university of medical sciences, tehran, iran.     corresponding author: fariba asghari address: medical ethics and history of medicine research center, #21, shanzdah azar st.tehran, iran email: fasghari@tums.ac.ir tel: 98 21 66 41 96 61 fax: 98 21 66 41 96 61 received: 23 jan 2013 accepted: 22 jun 2013 published: 05 aug 2013 j med ethics hist med, 2013, 6:7 http://journals.tums.ac.ir/abs/23708 © 2013 fariba asghari et al.; licensee tehran univ. med. sci. abstract education  needs  assessment  is  one  of  the  essential  components  of  curriculum  development.  in  this  study,  we  aimed to assess the educational needs of general physicians for medical ethics.  we conducted a three‐stage delphi study of general physicians’ views on important ethical issues in their practice.  in the  item generation stage we retrieved 45  important educational  items from a survey of general physicians,  patients, well known ethical clinicians, and a review of other universities’ curricula and international literature. the  questionnaire was designed to ask the  importance of each generated  item. we then sent the questionnaire to  general physicians. items scored as highly important by more than 80% of the respondents in the first or second  consensus development surveys were considered as educational priorities. four academic medical ethics teachers  reviewed and commented on the findings.  the  response  rate  to  the  first  consensus  development  survey  was  38%,  of  whom  77%  also  responded  to  the  second survey. we developed consensus on 24 medical ethics items for inclusion in medical ethics curriculum. all  items were also considered important by medical ethics teachers, and they added four further items to the list.  despite the attention given to ethical issues originating from technological advances, the most important educa‐ tional needs of general physicians in medical ethics are still the traditional  issues concerning the doctor‐patient  relationship and professionalism.    keywords: needs assessment, medical ethics education, delphi method, general practitioners j med ethics hist med 6:7 june, 2013 jmehm.tums.ac.ir fariba asghari et al. page 2 of 7 (page number not for citation purposes)     introduction medical ethics is a core component of medical education intended to empower practitioners in ethical decision making (1); it is in light of its importance that the contents and the teaching methodology of the course are constantly criticized and reviewed (2,3). linking education with the needs of the society is an important prerequisite for effective education. otherwise it may become impossible to achieve the goals of education, and this can lead to a waste of human and financial resources. educational needs assessment is the process of determining the gaps between the required competencies of trainees and the reality (4) and it is an essential part of curriculum development (5). educational needs assessment is even more important in designing curricula for subjects such as medical ethics in which the cultural and religious underpinnings of the society should be reflected. in recent years, different methods of needs assessment have been used to identify the needs of medical students and residents in terms of medical ethics and professional behaviour. in some approaches, students are asked to rank the importance of a number of professional ethics issues (6,7). in others, students are assessed in their ability to make ethical judgments when confronted with common issues in practice (8,9). results of such studies have pointed to different needs that vary by medical specialty and by society. medical ethics syllabus in iran had initially been developed based on expert opinion. in tehran university of medical sciences, content revision of the medical ethics course was made in 2006 using a review of literature and expert opinions (10), although its validity was not examined by needs of general practitioners. in this study we assessed the views of general physicians on their educational needs in medical ethics. we aimed to identify those medical ethics topics that should be included in the undergraduate medical education curriculum. method design the delphi method is a useful approach for developing consensus among a relatively large number of participants (11) and has been used extensively for the purpose of developing educational programmes (12-15). we conducted a threestage delphi study (item generation plus two consensus development surveys) and complemented the findings with expert opinions. figure 1 demonstrates the general outline of the study. participants for two reasons we selected our participants from general physicians: firstly because they have completed the medical education programme and are familiar with the medical ethics course contents, and secondly because they are more likely to offer realistic arguments concerning the importance and necessity of incorporating different medical ethics topics in the curriculum since they are practicing medicine. we approached the attendees of a national continuing medical education (cme) conference and distributed announcements about the study among them. the said conference is one of the largest in iran covering about 50 half-day cme events in all specialties. one hundred and thirty six general physicians volunteered to participate. item generation we used five different approaches for the generation of items for inclusion in our consensus development exercise: 1. we sent a letter to the 136 general physicians volunteering for participation in the study. it contained one open-ended question: “considering your practice experience, please state the most common medical ethics issues that you have encountered during your professional career.” we also enclosed the purpose and methods of the study and sent a reminder after one month. 2. four clinical academics known as role models for their consideration of ethical issues in practice were interviewed. they were asked to express their opinions of a general physician’s needs in terms of medical ethics. 3. patients attending two general physician clinics in tehran (one in the north, one in the south, 5 patients each) were interviewed about their expectations from their physicians. eight items related to medical ethics were extracted from their responses. 4. we reviewed the syllabi of the medical ethics courses of shiraz and isfahan universities of medical sciences. 5. based on the literature, we assessed a review of medical ethics training in north american universities (16), a study of the agreement between the lecturers of medical ethics and law in the uk (17), and a study of designing the core course of medical ethics in australian universities (18). we extracted 29 individual items from responses to the letter. thirteen items were extracted from interviews with clinical academics, eight items from interviews with patients, nine items from review of other universities’ curricula, and ten items from literature review. several items overlapped and ultimately a list of 45 issues in medical ethics was included in our questionnaire (table 1). j med ethics hist med 6:7 june, 2013 jmehm.tums.ac.ir fariba asghari et al. page 3 of 7 (page number not for citation purposes)     consensus development in our first consensus development survey, we sent the questionnaire to 136 general physicians and asked them to score the importance of each item on a 1-9 scale (1 indicating low importance, 9 indicating high importance) for inclusion in the medical ethics curriculum. we sent a reminder with a copy of the questionnaire after two months. the second survey questionnaire included 31 items for which no agreement was reached in the first survey. we also reported to the participants which items had already reached the consensus level. this questionnaire was sent exclusively to the respondents of the first survey (52 people) (figure 1). for each respondent we presented the score they had given to the 31 items, and the relative frequency of other respondents’ views on the importance of the items. we then asked them to re-score the importance of each item after taking others’ views into consideration. we also asked for their comments on the scores they assigned to each item. we sent two reminders each after one month. analysis and measuring consensus to analyze the scores given to each item, we classified the responses into three categories: low importance (scores 1-3), medium importance (scores 4-6), and high importance (scores 7-9). we also calculated the median score for each item. ‘reaching consensus’ was defined as having 80% agreement on any level of importance and was calculated for each item separately. all analysis criteria were set a priori (19). expert opinion while reviewing the responses and comments given to the second survey, we noticed that some physicians had commented on their agreement with certain behaviours relevant to the item, and not on their agreement on whether the item should be covered as part of the medical ethics curriculum. for example, instead of commenting on the importance of teaching the item “truthfulness towards the patient and their families”, they had expressed their opinion on whether truthfulness should be observed in poor prognosis conditions or not. table 1. items developed in the item generation stage and included in the questionnaire  no. item no. item 1.   ethics in teaching medical students 24. fairness among patients 2.   ethics in research 25. referral to qualified physicians when necessary 3.   new advances in assisted reproductive technology (ivf, embryo donation, egg donation) 26. conflict of interest (advertising or prescribing particular medications) 4.   confronting end of life issues and do not resuscitate orders 27. conflict of interest (accepting gifts from patients or industry) 5.   ethical dealing with lab animals 28. conflict of interest (high fees, fee splitting) 6.   constructive interaction with media 29. adherence to religious beliefs and moral values 7.   doctor-patient responsibilities 30. avoiding waste of public resources 8.   role of family in completing the diagnosis and treatment process 31. telling the truth to patients and their families 9.   respect for patient’s privacy 32. admitting to own medical error 10. respecting patients’ religious and cultural beliefs 33. disclosing peers’ errors 11. dealing with requests for inappropriate treatment 34. relationship with other members of health care team (nurses, etc.) 12. making efforts to relieve patients’ pain 35. relationship with peers 13. obtaining informed consent 36. visiting peers free of charge 14. abortion 37. confidentiality of patient data 15. maintaining respect for the profession by physicians 38. use of unnecessary or expensive diagnostic tests 16. practitioners’ personal appearance and grooming 39. confronting difficult patients 17. dealing with unethical requests 40. respect for patient autonomy, and involving them in decision making 18. knowledge of theoretical foundations of ethics and philosophy 41. responsibility for treatments administered to the patient 19. thorough completion of patient records 42. complete history taking and clinical examinations 20. knowledge of different insurance policies 43. allocating enough time to each patient 21. knowledge of and respect for the law 44. appropriate relationship with patients 22. accountability when on call 45. issuing false certificates 23. commitment to updating scientific knowledge ivf=in vitro fertilization j med ethics hist med 6:7 june, 2013 jmehm.tums.ac.ir fariba asghari et al. page 4 of 7 (page number not for citation purposes)     to overcome this limitation, we assessed the views and opinions of medical ethics teachers about the delphi results. for this purpose, we sent the first survey questionnaire to four academic medical ethics teachers, and asked them to score each item. after collecting their responses, we sent them the collated views of the general physicians and asked them to state their reasons for scoring items differently where applicable. results forty three (32%) physicians participated in item generation. the questionnaire for the first survey was sent out to all 136 volunteers, and 52 (38%) responded. we sent the second survey questionnaire to the 52 respondents, of whom 39 (75%) responded. 59% of the participants were male, their mean age was 38 ± 6 years, and their practice experience was 9 ± 4 years. table 1 reports the results of the item generation stage. in the first consensus development survey, we observed consensus on the importance of 14 items. the participants achieved consensus for a further ten items in the second round (table 2). items with the least importance were ethical dealing with lab animals and constructive interaction with media with a median score of 5 each. compared with general physicians, the medical ethics teachers had significantly different opinions on the importance of four items. adding the items to those already reported in table 2 provided us with 28 items for inclusion in medical ethics teaching curriculum (table 3). table 2. items with consensus on high level of importance no. item percentage of respondents who scored items in these categories median score (1-9) high (7-9) intermediate (4-6) low (1-3) items with consensus after the 1st consensus development survey (14 items) 1 appropriate relationship with patients 90 4 6 9 2 allocating enough time to each patient 86 8 6 9 3 complete history taking and clinical examinations 84 10 6 9 4 relationship with peers 80 18 2 7 5 confidentiality 90 8 2 9 6 adherence to religious beliefs and moral values 82 16 2 8 7 referral to qualified physicians when necessary 82 18 0 8 8 commitment to updating the scientific knowledge 82 16 2 9 9 responsibility for treatments administered to the patient 86 14 0 9 10 accountability when on call 80 18 2 9 11 knowledge of and respect for the law 90 10 0 9 12 maintaining respect for the profession by physicians 86 12 2 9 13 doctor-patient responsibilities 82 14 4 9 14 ethics in teaching medical students 85 13 2 9 items with consensus after the 2nd consensus development survey (10 items) 15 respecting patients’ religious and cultural beliefs 82 15 3 8 16 relationship with other members of the health care team (nurses, pharmacists, etc.) 87 13 3 8 17 telling the truth to patients and their families 82 18 0 8 18 thorough completion of patient records 85 10 5 8 19 making efforts to relieve patients’ pain 85 15 0 9 20 dealing with requests for inappropriate treatment 90 10 0 8 21 respect for patient’s privacy 85 15 0 8 22 knowledge of different insurance policies 82 18 0 8 23 obtaining informed consent 80 20 0 8 24 fairness among patients 80 17 3 8 discussion the results of our study present us with a list of 28 important items that need to be taught to medical students. the participants reached consensus on the educational importance of 24 items. according to our results, ethics priorities for general physicians are not brought about by modern technology or advances in medicine (e.g. reproductive health issues); basically they are the same items that have long been among ethical commitments or challenges of physicians. these items require physicians to take on the role of a healer and maintain an ethical approach that gives priority to patient needs rather than their ability to perform complicated ethical analysis on current ethical dilemmas. j med ethics hist med 6:7 june, 2013 jmehm.tums.ac.ir fariba asghari et al. page 5 of 7 (page number not for citation purposes)     contrary to our expectations, there was a conflict of opinion on the importance of “respect for autonomy and involving patients in decision making”. this is while participating patients in the item generation phase of the study had clearly indicated that they expected such respect from physicians. the study by asghari et al. also showed that patients preferred to receive information and be involved in decision making (20). reviewing practitioners’ comments on this item suggested the predominance of a paternalistic approach towards doctor-patient relationship among them. one physician stated, “the patient must thoroughly and completely follow the orders of his/her doctor. the patient’s knowledge of the chosen treatment modality is too limited to give them the option of autonomy”. the medical ethics teachers, however, disagreed with this view and found the item important. table 3. academic medical ethics teachers’ and general physicians’ opinions on selected items item % of physicians scoring the item highly important median score given by physicians median score given by senior lecturers medical ethics teachers’ opinion respect for patient autonomy, and involving them in decision making 62 6 8 it seems general practitioners do not believe in this right for patients, but it is very essential. conflict of interest (high fees, fee splitting) 66 7 8 unfortunately, they happen so often, that they seem very natural to do. issues on doctorpatient conflict of interest are common and are damaging the reputation of physicians. use of unnecessary or expensive diagnostic tests 69 7 8 due to a lack of adequate insurance coverage in our country, this issue is rather important confronting difficult patients 32 6 8 although it is not as important as previously mentioned items, in current medical practice there are many difficult patients two years ago, major amendments were made to the entirety of the medical ethics curriculum in iran (10). comparing the results of our study with the pre-amendment content of the course showed that 7 sessions (out of a total of 15 sessions) were not in accordance with the essential needs of general physicians. nonetheless, our results indicate that the course contents may need to be readdressed. after the amendments, this was reduced to 4 out of 17 issues, such as abortion, end of life issues, ethics in research and resource allocation. some items belonged more in the legal realm than in ethics (knowledge of different insurance policies, knowledge of and respect for the law), which in our curriculum are not included. we plan to negotiate with the forensic medicine department about covering these two items in forensic medicine and medical law course. although the results of our study did not indicate the need for resource allocation for general practitioners, their giving high scores to the item of “fairness among patients” might mean that they need resource allocation to be discussed at the micro level. in 1998, teachers of medical ethics and law in medical schools throughout the uk offered their consensus statement about the medical ethics curriculum (17), and in 2010 they updated their statement (21). compared to their recommendations, we found 5 of the 12 topics were relatively unimportant in the clinical practice of general physicians in iran; these include research, fertility, genetics, death and termination of life, resource allocation, mental disorders and disabilities (21). in comparison with the consensus statement of teachers of ethics and law in australian and new zealand medical schools regarding the educational content, again six topics were detected unimportant in our survey: research ethics, reproductive ethics, issues in genetics and biotechnology, ethical issues in commercialization of medicine, resource allocation and end of life decisions (18). in a survey of ethics education at u.s. and canadian medical schools, end of life issues and allocation of scarce resources were taught in 92 and 75 percent of medical schools respectively. surprisingly about half of them did not cover genetic tests, reproductive technologies, abortion, research ethics and medical error (16). our study has some limitations. physicians’ scorings for educational purposes can be biased by their belief in a given ethical issue as demonstrated earlier by discussing patient autonomy. we used the comments raised by medical ethics teachers to j med ethics hist med 6:7 june, 2013 jmehm.tums.ac.ir fariba asghari et al. page 6 of 7 (page number not for citation purposes)     minimize this potential source of bias. another limitation is the extent to which we can generalize our findings. random sampling is not required in the delphi method if the participating individuals have enough expertise (or experience) to provide a balanced judgment. nonetheless, considering the variety of general physicians’ services and the recipient populations, it may seem more appropriate to have a representation of the total population of general physicians. random selection from all general practitioners was not feasible, and we believed ethical issues encountered in tehran would not be significantly different from those in other provinces, yet a more extended study would give a more accurate understanding of physicians’ educational needs throughout the nation. we also received a relatively low response rate. it has been shown that the topic of a survey affects response rate (22) and hence we expected to receive more responses as the participants were volunteers. still our response rates were similar to many surveys of physicians around the world (23,24). our results can be informative for designing courses in other developing and islamic countries. our search did not reveal any published study from islamic countries using similar methods for assessing medical ethics educational needs. revising course contents based on learner needs is only the first step for enhancing the learning process and educational outcomes (i.e. improving physician behaviour). change in course content will enhance the outcomes only if effective educational methods are used (25). medical ethics courses should be continuously assessed in terms of their contents, educational methods and change in behaviour, and revised in light of the results of such studies. figure 1. flowchart demonstrating the study process item generation stage  1 st  round of consensus  development  response rate=38%  (n=52)  sample selection medical ethics teachers’  opinions  results  volunteer general physicians  attending the cme event   open ended question about  the most common ethical  issues encountered  patients’ opinions  clinical academics’ opinions  review of course curriculum  in other universities  scoring the importance of 45  items on 1‐9 scales   2 nd round of consensus  development  response rate=75%  (n=39)   scoring the importance of 31  items on 1‐9 scales    j med ethics hist med 6:7 june, 2013 jmehm.tums.ac.ir fariba asghari et al. page 7 of 7 (page number not for citation purposes)     conflict of interests: none funding: according to contract number 132/7941, this study was funded by tehran university of medical sciences. acknowledgements we thank all physicians who participated in our study. the authors wish to thank dr ali jafarian, dr azim mirzazadeh and dr seyed hasan emami razavi for their collaboration in evaluating the delphi results as medical ethics teachers. references 1. miles sh, lane lw, bickel j, walker rm, cassel ck. medical ethics education: coming of age. acad med 1989; 64: 705-14. 2. mattick k, bligh j. teaching and assessing medical ethics: where are we now? j med ethics 2006; 32(3): 181-5. 3. gross ml. medical ethics education: to what ends? j eval clin pract 2001; 7(4): 387-97. 4. kern de, thomas pa, harward dm, bass ed. curriculum development for medical education: a six step approach. baltimore: john hopkins press; 1998. 5. vajargah k. educational need assessment: models and methods. tehran: aeesh; 2005. [in persian] 6. asghari f. prevalence of ethical issues in clinical practice. proceedings of the 7th national medical education congress; 2005; tabriz, iran; tabriz university of medical sciences; 2005. 7. asghari f. intern's view on quality of medical ethics education. proceedings of the 7th national medical education congress; 2005; tabriz, iran; tabriz university of medical sciences; 2005. 8. mayeda m, takase k. need for enforcement of ethicolegal education an analysis of the survey of postgraduate clinical trainees. bmc med ethics 2005; 6: 8. 9. wayne db, muir jc, darosa da. developing an ethics curriculum for an internal medicine residency program: use of a needs assessment. teach learn med 2004; 16: 197-201. 10. asghari f, mirzazadeh a, samadi a, et al. reform in medical ethics curriculum: a step by step approach based on available resources. j med ethics hist med 2011; 4: 8. 11. jones j, hunter d. consensus methods for medical and health services research. bmj 1995; 311: 376-80. 12. broomfield d, humphris gm. using the delphi technique to identify the cancer education requirements of general practitioners. med educ 2001; 35: 928-37. 13. yousefi-nooraie r, rashidian a, keating j, schonstein e. teaching evidence-based practice: the teachers consider the content. j eval clin pract 2007; 13: 569-75. 14. maiburg bh, rethans jj, van ree jw. gps' needs for practice-oriented nutrition education; a delphi study among dutch gps. fam pract 2004; 21: 425-8. 15. smith ta, lyon he, hardison d, bogia b. using a delphi technique in a needs assessment for an innovative approach to advanced general dentistry education. j dent educ 1995; 59: 442-7. 16. lehmann ls, kasoff ws, koch p, federman dd. a survey of medical ethics education at u.s. and canadian medical schools. acad med 2004; 79: 682-9. 17. anonymous. teaching medical ethics and law within medical education: a model for the uk core curriculum. j med ethics 1998; 24: 188-92. 18. braunack-mayer aj, gillam lh, vance ef, et al. an ethics core curriculum for australasian medical schools. med j aust 2001; 175: 205-10. 19. murphy mk, black na, lamping dl, mckee cm, sanderson cfb, askham j, marteau t. consensus development methods, and their use in clinical guideline development. health technol assess 1998; 2(3): 1-88. 20. asghari f, mirzazadeh a, fotouhi a. patients' preferences for receiving clinical information and participating in decision-making in iran. j med ethics 2008; 34: 348-52. 21. stirrat gm, johnston c, gillon r, et al. medical ethics and law for doctors of tomorrow: the 1998 consensus statement updated. j med ethics 2010; 36: 55-60. 22. rashidian a, van der meulen j, russell i. differences in the contents of two randomized surveys of gps' prescribing intentions affected response rates. j clin epidemiol 2008; 61: 718-21. 23. barclay s, todd c, finlay i, grande g, wyatt p. not another questionnaire! maximizing the response rate, predicting non-response and assessing non-response bias in postal questionnaire studies of gps. family pract 2002; 19: 105-11. 24. cull wl, o'connor kg, sharp s, tang ss. response rates and response bias for 50 surveys of pediatricians. health serv res 2005; 40: 213-26. 25. thomson o'brien ma, freemantle n, oxman ad, wolf f, davis da, herrin j. continuing education meetings and workshops: effects on professional practice and health care outcomes. cochrane database syst rev 2001; (1). hhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh copyright © 2023 tehran university of medical sciences. this work is licensed under a creative commons attribution-non commercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. keywords: ethics; gestational diabetes. introduction: gestational diabetes mellitus (gdm) is a health problem that affects about 7-10% of pregnant women worldwide (1-3). in iran, the prevalence of gdm is 3.4% on average, and the highest prevalence rates have been reported in karaj (18.6%) and the lowest in ardebil (1.3%) (4). the rate is increasing due to the growth in the prevalence of obesity and the age of mothers (5). the growing number of gdm cases is likely to raise ethical and social issues that may have a serious impact on the country's health-care system and impose related burden. despite the high prevalence of gdm, there are many differences of opinion regarding diagnosis and treatment of this condition, which has caused ethical challenges (6). through this commentary, we hope to initiate a discussion on some ethical *corresponding author bagher larijani address: endocrinology and metabolism research institute, north kargar ave., tehran university of medical sciences, tehran, iran. postal code: 1411713135 tel: (+98) 21 88 22 00 38 email: emrc@tums.ac.ir received: 6 feb 2023 accepted: 1 aug 2023 published: 19 aug 2023 citation to this article: asadi m, zahedi f, ebrahimpur m, larijani b. ethical challenges in gestational diabetes. j med ethics hist med. 2023; 16: 6. questions that may arise in this field which many clinicians may not be fully aware of them. ethical challenges in gestational diabetes 1. associate professor, diabetes research center, endocrinology and metabolism clinical sciences institute, tehran university of medical sciences, tehran, iran. 2. researcher, endocrinology and metabolism research center, endocrinology and metabolism clinical sciences institute, tehran university of medical sciences, tehran, iran. 3. associate professor, elderly health research center, endocrinology and metabolism population sciences institute, tehran university of medical sciences, tehran, iran. 4professor, endocrinology and metabolism research center, endocrinology and metabolism clinical sciences institute, tehran university of medical sciences, tehran, iran; medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. mojgan asadi1, farzaneh zahedi2, mahbube ebrahimpur 3, bagher larijani4* ethical challenges in gestational diabetes j. med. ethics. hist. med. 2023 (aug); 16: 6. 2 ethical framework health-care professionals should constantly update their competence in analyzing and resolving ethical problems. in the case of gestational diabetes mellitus (gdm), different ethical frameworks can be used for ethical decision-making. while the ethical issues in this field can be discussed from the perspectives of utilitarian, deontological and virtue ethics, principlism seems to have certain advantages in this regard. the four principles of "respect for autonomy", "beneficence", "non-maleficence" and "justice" are accepted as the fundamentals of the principlism theory (7). with regard to the principle of "autonomy", titus states, "it is therefore imperative that a woman who presents with gdm is counselled extensively during pregnancy in order that she can make an informed choice in the management of her pregnancy" (8). while helping people and doing no harm are concepts that trace back to ancient times, they are also emphasized in the utilitarian theory of ethics. early medical oaths such as those credited to hippocrates and maimondies have emphasized these principles as well. however, implications of these two principles in clinical cases such as pregnant mothers with gdm must be thoroughly examined. beauchamp and childress propose to acknowledge"non-maleficence" (not to inflict evil or harm) and "beneficence" (in three forms: to prevent evil or harm, to remove evil or harm, and to do or promote good) (7). the principle of "justice", which refers to "fair, equitable, and appropriate distribution in society" (7), is a complex idea consisting of medical and social paradigms (9). the medical paradigm of justice, which mainly addresses distribution of scarce resources among patients, does not pay enough attention to the social determinants of health. in the case of gdm, although fair access to appropriate services is important, providing the necessary infrastructure for addressing social factors (such as absence of health insurance, poor education, stigmatization, etc.) is crucial. the social paradigm calls attention to social and environmental factors determining the risk for disease, suffering and death in a population. it means that before we ask, "how should scarce health-care resources be allocated to sick individuals?" we must ask, for example, "how does lack of health insurance predict risk of suffering?" (9). there may be some conflicts among the ethical principles as well, for instance, none of them asadi m., et al. 3 j. med. ethics. hist. med. 2023 (aug); 16: 6. provides a sufficient tool and complete guide to good decision-making in all situations. however, the ethical knowledge of practitioners, their moral sensitivity, and expertise in ethical problemsolving will pave the way for ethical management of the cases. social, cultural and religious determinants may also influence decision-making in some cases, but contemporary bioethics tend to emphasize "common morality" in this regard (10-12). in order to contemplate more on gdm cases, we will discuss specific ethical queries under three subtitles: 1) the benefit/risk ratio and gdm screening, 2) the dilemma of cut-off points, and 3) limited options for treatment and research during pregnancy the benefit/risk ratio and gdm screening gestational diabetes exposes mother and fetus to short-term and long-term complications (13). some potential adverse outcomes in children include: stillbirth, neonatal death, congenital malformations, macrosomia, birth trauma, and shoulder dystocia (14). as for mothers, potential adverse outcomes in the short term include: preeclampsia, gestational hypertension, cesarean delivery, traumatic labor/perineal tears, and postpartum hemorrhage (15), and in the long term, recurrence of gdm, type 2 diabetes mellitus, hypertension, and ischemic heart disease (16). according to the above-mentioned evidence, the majority of medical associations recommend universal screening of gestational diabetes during pregnancy (17-19). however, it has been shown that pregnant women who have no risk factor (table 1) do not benefit from screening tests (20). table 1. risk factors of gestational diabetes in pregnant women ♦ previous gdm ♦ an ethnicity with a high prevalence of diabetes ♦ maternal age > 35 years ♦ family history of diabetes ♦ first-degree relative with diabetes ♦ obesity (bmi > 30 kg/m2) ♦ previous macrosomia (birth weight > 4500 g) ♦ polycystic ovary syndrome ♦ iatrogenic: glucocorticoids and antipsychotic medication taking into account the above-mentioned points, clinicians may face an important moral query about justification of routine screening for all pregnant women. some believe that increased medicalization of normal pregnancies through universal screening programs may result in more ethical challenges in gestational diabetes j. med. ethics. hist. med. 2023 (aug); 16: 6. 4 interventions during labor (inductions and cesarean sections) and even a higher rate of small for gestational age (sga) babies because of nutritional and treatment approaches (21). in low-risk cases, the cost of the test and the suffering caused by drinking the glucose solution and the blood-sampling should be discussed with the patient. a very important consideration is that gdm sreening tests may sometimes create psychological stress for pregnant mothers and their families. a competent pregnant woman is capable of making a decision about whether or not to undergo the screening test. on the other hand, a risk-stratified approach may be suggested to improve the overall cost-effectiveness of gdm screening, especially in low-income countries. in the era of precision medicine, it is expected to use more precise measures for analyzing benefits and risks by accounting for individual-level patient characteristics (22). it is noteworthy, however, that balancing the benefits and harms may be a problem for clinicians when the benefit (e.g., mortality reduction) is not commensurate with the risk of harm (e.g., diverting health resources) (23). there is no doubt that in high-risk cases, the potential complications of undiagnosed gestational diabetes should be clearly discussed with the patient (and her family, if needed). when an informed pregnant woman does not consent to the test, her decision must be respected, but her refusal to consent should be documented in the medical records. the dilemma of cut-off points in addition to diagnostic tests, there is some debate about the cut-off points for these tests, as lower or higher glycemic criteria can be used for diagnosis. the lower glycemic criterion is a fasting plasma glucose level of at least 92 mg per deciliter (≥ 5.1 mmol per liter), a 1-hour level of at least 180 mg per deciliter (≥ 10.0 mmol per liter), or a 2-hour level of at least 153 mg per deciliter (≥ 8.5 mmol per liter). the higher glycemic criterion is a fasting plasma glucose level of at least 99 mg per deciliter (≥ 5.5 mmol per liter) or a 2-hour level of at least 162 mg per deciliter (≥ 9.0 mmol per liter) (24). evidence shows that if lower glycemic criteria are used for diagnosis, more pregnant women fall into the category of gdm, while the risk of having a baby with a birth weight above the 90th percentile is the same in both groups (24). similar to many other diseases, an increase in the number of gdm diagnoses may considerably increase the burden on the national health system. also, choosing the best treatment should be based on accurate diagnosis. in cases of conflict, a large number of pregnant women will be treated who not only do not benefit asadi m., et al. 5 j. med. ethics. hist. med. 2023 (aug); 16: 6. from the treatment, but may even be exposed to side effects, and this clearly contradicts the ethical principle of beneficence and non-maleficence. it is worth mentioning that in many screening programs, health professionals (and even policymakers) may overlook the fact that "doing more" does not actually mean "doing better" (23). limited options for treatment and research during pregnancy the main challenge in gestational diabetes is that there are limited therapeutic options. despite the existence of a large number of oral agents, treatment is limited to insulin, metformin and glyburide due to the limited clinical research in this area. in fact, insulin is the only medication in the list that has been approved by the fda. seeing as pregnant women are a vulnerable group, it seems that such research should be carried out using ethically justifiable criteria and clinical feasibility, and therefore potential fetal-maternal risks limit research in this field. it should be added that a lot of research on gdm cannot be done on animals, which is another reason why research in this area is not adequate. in order to carry out research on gestational diabetes, as chervenak and mccullough suggested, there is a need to establish "maternalfetal intervention clinical centers". these centers would have the mission to conduct both innovation (experiments that are performed for the benefit of an individual patient) and research (experiments that are conducted to create generalized knowledge) within ethical frameworks that ensure the safety of the pregnant mother and the fetus. the goal of these centers would be to develop new treatments for gestational diabetes (25). currently, the relative advantages and disadvantages of insulin, metformin and glyburide in the treatment of gestational diabetes are unclear. the long-term consequences of these drugs in children subject to prenatal exposure are unclear, and current guidelines provide contradictory recommendations (26). the american diabetes association (ada) and the american college of obstetricians and gynecologists (acog) specify insulin as the first line of treatment (19, 27), while the society for maternal fetal medicine (smfm) recommends metformin as a reasonable alternative for women who are unable or unwilling to use insulin (28). in iran, insulin is currently the first line of treatment in gestational diabetes because metformin and glyburide pass through the placenta. pregnant women should be informed about this, even though the short-term consequences of these drugs have not been observed in children subject to ethical challenges in gestational diabetes j. med. ethics. hist. med. 2023 (aug); 16: 6. 6 prenatal exposure (29). the ethical principle of respect for autonomy requires the health-care provider to empower the patient to make the right decision about her treatment by giving comprehensive and accurate information. in the field of treatment, sometimes only one drug can be prescribed, and the health-care provider should explain the clinical benefits and risks of that drug to the patient. however, when there are several medications available for a particular condition, it is the responsibility of the health-care provider to tell the patient about the advantages and risks and recommend the best medication. if none of the medications have a definite advantage over the others, then the choice will be based on the patient's preference. sometimes patients are reluctant to accept their health-care provider’s recommendations. in such cases, it is important to respect the patient's decision, but to also inform her in more details about the risks of not following the recommendations. the health-care provider should also ask the patient to reconsider her decision for the sake of her own health and that of the fetus. if the patient still refuses the treatment, the healthcare provider should document her refusal in the medical records. this will help to protect the health-care provider from any legal liability if adverse outcomes occur (30). conclusion pregnant women are considered a vulnerable group and therefore specific ethical considerations should be observed in patients with gestational diabetes. the recommendations to these patients should be in accordance with updated scientific evidence and available guidelines for diagnosis and treatment, and their individual autonomy must be respected at all times. to observe the principle of "beneficence", the best interests of the unborn child should also be considered. other factors that need to be taken into account in health-care system plans include social justice and medical justice. considering the differences in the opinions of scientific societies about diagnosis and treatment of gestational diabetes, it seems necessary to establish mother and fetus research centers to provide a scientific response to these cases, while considering ethical challenges. acknowledgements the study was not funded. conflict of interests there are no competing interests to declare. asadi m., et al. 7 j. med. ethics. hist. med. 2023 (aug); 16: 6. references: 1. xiong x, saunders l, wang f, demianczuk n. gestational diabetes mellitus: prevalence, risk factors, maternal and infant outcomes. international journal of gynecology & obstetrics. 2001;75(3):221-8. 2. nguyen cl, pham nm, binns cw, duong dv, lee ah. prevalence of gestational diabetes mellitus in eastern and southeastern asia: a systematic review and meta-analysis. journal of diabetes research. 2018; 2018. 3. adams s, rheeder p. screening for gestational diabetes mellitus in a south african population: prevalence, comparison of diagnostic criteria and the role of risk factors. south african medical journal. 2017;107(6):523-7. 4. jafari shobeiri m, ghojazadeh m, azami aghdash s, et al. prevalence and risk factors of gestational diabetes in iran: a systematic review and meta-analysis. iranian journal of public health. 2015; 44(8): 1036. 5. ferrara a. increasing prevalence of gestational diabetes mellitus: a public health perspective. diabetes care. 2007; 30(supplement 2): s141-s6. 6. zera ca, seely ew. controversies in gestational diabetes. touch reviwe in endocrinology. 2021; 17(2): 102. 7. childress jf, beauchamp tl. common morality principles in biomedical ethics: responses to critics. cambridge quarterly of healthcare ethics. 2022; 31(2): 164-76. 8. titus m. diabetes in pregnancy: ethical considerations: ethics focus. south african journal of diabetes and vascular disease. 2011; 8(2): 74-5. 9. jecker ns. a broader view of justice. the american journal of bioethics. 2008; 8(10): 2-10. 10. larijani b, anaraki fz. islamic principles and decision making in bioethics. nature genetics. 2008; 40(2): 123. 11. zahedi f, larijani b. common principles and multiculturalism. journal of medical ethics and history of medicine. 2009; 2. 12. larijani b, zahedi f. the impact of ethics philosophy on moral decision-makings in medicine. iranian journal of diabetes and metabolism. 2005; 4: 25-38. ethical challenges in gestational diabetes j. med. ethics. hist. med. 2023 (aug); 16: 6. 8 13. burlina s, dalfrà m, lapolla a. short-and long-term consequences for offspring exposed to maternal diabetes: a review. the journal of maternal-fetal & neonatal medicine. 2019; 32(4): 687-94. 14. szmuilowicz e. diabetes mellitus gestational. endocrinol metab clin north am. 2019; 48(3): 47993. 15. shand a, bell j, mcelduff a, morris j, roberts c. outcomes of pregnancies in women with pre‐ gestational diabetes mellitus and gestational diabetes mellitus; a population‐based study in new south wales, australia, 1998–2002. diabetic medicine. 2008; 25(6): 708-15. 16. shou c, wei y-m, wang c, yang h-x. updates in long-term maternal and fetal adverse effects of gestational diabetes mellitus. maternal-fetal medicine. 2019; 1(02): 91-4. 17. pediatrics aao. american college of obstetricians and gynecologists; committee on obstetric practice. the apgar score. adv neonatal care. 2006; 6: 220-3. 18. blumer i, hadar e, hadden dr, jovanovič l, mestman jh, murad mh, et al. diabetes and pregnancy: an endocrine society clinical practice guideline. the journal of clinical endocrinology & metabolism. 2013; 98(11): 4227-49. 19. care d. care in diabetes 2022. diabetes care. 2022; 45: s17. 20. miailhe g, kayem g, girard g, legardeur h, mandelbrot l. selective rather than universal screening for gestational diabetes mellitus? european journal of obstetrics & gynecology and reproductive biology. 2015; 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[cited on 2023]; available from: https://apps.who.int/iris/bitstream/handle/10665/330829/9789289054782eng.pdf 24. crowther ca, samuel d, mccowan lm, edlin r, tran t, mckinlay cj. lower versus higher glycemic criteria for diagnosis of gestational diabetes. new england journal of medicine. 2022; 387(7): 587-98. asadi m., et al. 9 j. med. ethics. hist. med. 2023 (aug); 16: 6. 25. chervenak fa, mccullough lb. ethically justified, practical guidance for the professionally responsible investigation of maternal-fetal intervention for fetal or neonatal benefit. maternal-fetal medicine. 2021; 3(03): 208-12. 26. sweeting a, wong j, murphy hr, ross gp. a clinical update on gestational diabetes mellitus. endocrine reviews. 2022. 27. caughey ab, turrentine m. acog practice bulletin: gestational diabetes mellitus. obstetrics and gynecology. 2018; 131(2): e49-e64. 28. barbour la, scifres c, valent am, friedman je, buchanan ta, coustan d, et al. a cautionary response to smfm statement: pharmacological treatment of gestational diabetes. american journal of obstetrics and gynecology. 2018; 219(4): 367. e1-7. 29. langer o. pharmacological treatment of gestational diabetes mellitus: point/counterpoint. american journal of obstetrics and gynecology. 2018;218(5):490-9. 30. gelber se, mccullough lb, chervenak fa. ethical dimensions of counseling about the clinical management of gestational diabetes. american journal of perinatology. 2016; 33(13): 1262-5. ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ 1 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e letter to editor volume 13 (suppl.) number 30 december 2020 copyright © 2020 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. ethical communication to patient & society: a critical responsibility in covid-19 pandemic *corresponding author saptarshi chatterjee barasat barrackpore road, 24 pgs. north, jagannathpore, kolkata-700126, west bengal, india. tel: (+91) 70 16 63 66 78 email: saptarshi.chatterjee@adamasuniversity.ac.in received: 14 jun 2020 accepted: 1 dec 2020 published: 27 dec 2020 citation to this article: chatterjee s. ethical communication to patient & society: a critical responsibility in covid-19 pandemic. j med ethics hist med. 2020; 13(suppl.): 30. saptarshi chatterjee * assistant professor, department of microbiology, school of life science & biotechnology, adamas university, west bengal, india. dear editor, since december 2019, the emergence of the covid-19 and the consequent pandemic by the world health organization (who) has been a threat to public health, raising a challenge to the entire society (1,2). the challenge faced by scientists, researchers, and clinicians is to find an appropriate solution for the menace of the covid-19. the scientific and medicinal community has failed to provide any medicine or vaccine up to now. yet, encouraging results have been reported. in the present situation, responsible and ethical interactions with the patients are expected from the scientific community as well as from society. ethics in updating the status of effective medicine since there is no definite antiviral medicine against covid19, clinicians are mostly dependent on supportive therapy to reduce the severity of symptoms. several medicines such as hydroxychloroquine and remdesivir have been applied empirically. although, none of them have received approval from the usfda. remdesivir has received emergency use authorization (eua) from the usfda for emergency use in the treatment of suspected or laboratory-confirmed covid19 adults as well as adolescents hospitalized with severe symptoms (3). therefore, it is the ethical responsibility of the clinicians to update the patient with this information and receive their consent before usage. ethical communication to patient & society: a critical responsibility in covid-19 pandemic 2 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 30 december 2020 awareness of fraudulent medication the absence of medications for treating covid-19 has led to the emergence of drugs and formulations for covid-19. many of them have been manufactured and sold under the anti-covid-19 label. the usfda has already published a list of such fraudulent medicines along with their manufacturers (4). essential oils, herbal products, liposomal vitamin c, cannabidiol, homeopathic drugs, and colloidal silver nanoparticles are examples of such products. many of these are the result of in vitro labstudies in the absence of clinical trials, leading to ambitious and misleading statements. it is now leaning on the ethical responsibility of clinicians and scientists to prevent the application of such medications and preventing them from resulting in a sense of false security. alternative medicine along with modern medicine, several forms of alternative medicine like ayurveda, yoga, unani, siddha, and homeopathy are applied in combating the pandemic (5). however, there are ‘no confirmed remedies’ to cure covid-19. most of these treatments, which are known to strengthen immunity, require more research in terms of specific disease management. ethics in social media social media has been playing as a crucial source for retrieving information during the lockdown period which has caused ‘social distancing’. this is while many rumors and unscientific information are shared in the name of scientists, scientific organizations, and the ministry of health and family welfare. the indian government (6), who (7), and other agencies are committed to refute such information and encourage awareness among the citizens. it is the responsibility of the scientific and medical community to counter the wrong advice with accurate information. several videoadvertisements by clinicians are also found to be fraudulent/flawed in terms of scientific information (8). clinicians should refrain from disclosure and emphasis inadequately proven facts, especially on social media. ethics in product endorsement the issue of medicinal product endorsement by clinicians has been a long-time ethical debate. however, several products including sanitizers and masks are essentials for preventing the covid-19 spread and occurrence. clinicians are frontline warriors who require personal protective equipment (ppe) and the n-95 masks to deal with infected as well as suspected patients. an ethical guideline on the usage of such essential products and their rational use can help with the inadequate demand and supply situation. awareness of non-effective products (9) and proper advice on essential commodities (10) are coveted from scientific and medical fraternity. generalization statements the society has received comments from unprofessional individuals regarding issues such as the artificial creation of the covidchatterjee s. 3 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 30 december 2020 19 strain in china, the eradication of the disease in hot summer months, and lowincome countries to be immune to the disease. these are based on partial facts that comply with the proper understanding of the disease situation. the counter facts that are proven by scientists, seldom reach the society. as a result, misconceptions like artificial origin of covid-19 strain (11) or low-income countries being immune to covid-19 (12) spreads. ethically, it is important to refrain from such comments which can create a havoc impression on society, especially if it is stated by an influential or educated community. research & publication since the occurrence of the covid-19, there has been a considerable increase in the number of research articles published regarding the virus, related disease, and pandemic. most of them are redundant, insignificant and report initial studies that could not be relied upon. it is the ethical responsibility of the scientific community to publish scientific evidence to prevent the creation of misleading information (13). conclusion the covid-19 challenge has offered significant introspection in an ethical context especially in terms of providing information to patients and society, at large, to cope with the situation. an urgent response from the scientific and medicinal community can help to overcome the current situation. ethical communication to patient & society: a critical responsibility in covid-19 pandemic 4 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 30 december 2020 references 1. anonymous. who: there is a current outbreak of coronavirus (covid-19) disease. [cited 2020 december]; available from: https://www.who.int/health-topics/coronavirus#tab=tab_1 2. anonymous. world health organization. statement on the second meeting of the international health regulations (2005) emergency committee regarding the outbreak of novel coronavirus (2019-ncov). [cited 2020 december]; available from: https://www.who.int/emergencies/diseases/novel-coronavirus2019?gclid=cjwkcajwy42fbhb2eiwajy0yqsfpjmgwctfg1gifkegf0xrzqi5anyz736xib6rj15 ctbjif33md9bocsikqavd_bwe 3. anonymous. fact sheet for healthcare provider emergency use authorization |(eua) of veklury® (remdesivir) for hospitalized paediatric patients weighing 3.5 kg to less than 40 kg or hospitalized paediatric patients less than 12 years of age weighing at least 3.5 kg. [cited 2020 december]; available from: https://www.fda.gov/media/137566/download 4. anonymous. fraudulent coronavirus disease 2019 (covid-19) products. [cited 2020 december]; available from: https://www.fda.gov/consumers/health-fraud-scams/fraudulentcoronavirus-disease-2019-covid-19-products 5. chaturvedi s, kumar n, tillu g, deshpande s, patwardhan b. ayush, modern medicine and the covid-19 pandemic. indian j med ethics. 2020; 13;-(-):1-4. 6. anonymous: covid-19 book of five. [cited 2020 december]; available from: https://www.mohfw.gov.in/pdf/3pocketbookof5_covid19_27march.pdf 7. anonymous. world health organization: how to report misinformation online. [cited 2020 december]; available from: https://www.who.int/campaigns/connecting-the-world-to-combat-coronavirus/how-to-reportmisinformation-online?gclid=cj0kcqiaifzbrdjarisaeelygkervid5s1sygzgrrmidptsr8rnzutluanwtrstsjxkv6mmtp9ndumaaqgiea lw_wcb 8. ratna nh. exercise caution when sharing medical advice about coronavirus on social media. popul health manag. 2020; 23(5): 400. 9. bae s, kim mc, kim jy, et al. effectiveness of surgical and cotton masks in blocking sars-cov2: a controlled comparison in 4 patients. ann intern med. 2020; 173(1): w22-w23. 10. anonymous. who: advice on the use of masks in the community, during home care and in healthcare settings in the context of the novel coronavirus (2019-ncov) outbreak: interim guidance. [cited 2020 december]; available from: https://apps.who.int/iris/handle/10665/330987 11. andersen kg, rambaut a, lipkin wi, holmes ec, garry rf. the proximal origin of sars-cov2. nat med. 2020; 26(4): 450‐2. 12. roy s. low-income countries are more immune to covid-19: a misconception. indian j med sci. 2020; 71(1): 5-7. 13. munafo m. covid-19: scientific journals are now pumping out research faster than ever. [cited 2020 december]; available from: https://scroll.in/article/961299/covid-19-scientific-journals-arenow-pumping-out-research-faster-than-ever letter 181 omid asemani 17-8-94.docx journal of medical ethics and history of medicine commentary a complementary response to the article “breaching confidentiality: medical mandatory reporting laws in iran” omid asemani *1 1assistant professor, department of medical ethics and philosophy of health, faculty of medicine, shiraz university of medical sciences, shiraz, iran. corresponding author: omid asemani address: department of medical ethics and philosophy of health, school of medicine, zand st. imam hossein sq. shiraz, ir iran. p.o. box: +987134853185 email: asemanio@sums.ac.ir tel/fax: +987132348980 received: 1 oct 2014 accepted: 1 july 2015 published: 10 nov 2015 j med ethics hist med, 2015, 8:10 © 2015 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract physicians’ knowledge of therapy and counseling stands among the most important issues in the viewpoints of clients who refer to psychiatric centers. transsexual patients are very important in this regard. the goal of this research is to study their attitude toward doctors’ empathy. a group of transsexual patients who referred to the tehran institute of psychiatry, iran, answered the jefferson scale of empathy. the relationship of the patients’ age, gender, education level, and lifestyle with their attitude was measured. this study was conducted on 40 patients, including 16 women (40%) and 24 men (60%). in terms of education, 8 patients had a degree below high school diploma (20%), 9 had high school diploma (22.5%), and 23 patients were university students or of higher education level (57.5%). among these patients, 6 were unemployed (15%), 10 were students (25%), and the rest were employed. moreover, 8 participants lived alone (20%), 5 lived with their friends (12.5%), and 27 lived with their family (67.5%). gender had no influence on the average score of the questionnaires, yet level of education had some influence. lifestyle also had a significant influence on the patients’ attitude. on the other hand, patients whose problems began before the age of 12 had lower score than others. experienced psychologists in referential centers can express greater levels of empathy to specific diseases and this trend is very effective on the patients’ cooperation level. in order to create an effective relationship between physicians and patients, the efficiency of the health system and increasing satisfaction of specific patients should be considered. keywords: patients’ attitude, sexual identity disorder, transsexual, empathy mailto:asemanio@sums.ac.ir j med ethics hist med 8:10 november, 2015 jmehm.tums.ac.ir omid asemani page 2 of 3 (page number not for citation purposes) enthusiastically, i read the article published in the issue 2014 (1) well addressed an abiding conflict between “professional confidentiality” and “mandatory reporting laws”. in the following have been tried to provide a brief explanation in purpose of introducing the nature of the conflict in a more comprehensive view. in this way, i have discussed why medical confidentiality needs to be protected completely unless formal laws make members of the health care team to divulge minimum professional information to specific legal authorities. in this way, i have described that every society, as a multiindividual organism, needs to defend its integrity against individual's harmful (not legitimate) desires and actions through enforcing laws and regulations. at the beginning, it is important to clarify, or better say, remind that one of the main consequences or i see, purposes of respecting confidentiality in medical practice is bolstering people confidence in health care providers. knowingly, trust is a critical prerequisite of medical practice; therefore, the critical role of confidentiality in building a safe medical environment and thus providing a good medical care is incontrovertible. in this way, bolstering trust in the physician-patient relationship via emphasizing on a complete medical confidentiality could overall improve public health for at least two main reasons: patients could willingly seek medical attention and then give doctors authentic information they need to provide a good care. surely, lack of professional commitment on confidentiality would not guarantee a secure atmosphere for patients to be treated free from any concern to get stuck in undesired and unpredicted circumstances (2-4). in spite of this importance, oppositely, there are circumstances in which protecting absolute confidentiality of an individual does not bring about constructive consequences for (all) others. for example, practically, complete confidentiality in cases of murder, child abuse and so on clearly contradicts public health, social security and social responsibility. in fact, in these conflicting situations, confidentiality might practically run counter to those positive outcomes (trust related outcomes) expected to be achieved when preserving it in an absolute way. overall, medical confidentiality might result in two kinds of individual and public consequences, those that not only might not be necessarily in line with each other but also opposing. accordingly, a complete protection of confidentiality for an individual might be harmful for another individual or the public in short and especially long terms. certainly, the conflict could not be logically dealt with in the medical field, because logically, the profession itself cannot be synchronously the source of two conflicting things: to recommend absolutism on one side and to determine breaking instances on the other side. generally, we need to solve conflicts as soon and precise as possible for they fritter away our limited time, energy and money. but, other than the logic of the issue, medical professionalism should not determine breaking criteria or instances by itself for at least two trust-related reasons; firstly, for the fundamental importance of building a trusty relationship between patients and health care team and its critical role in preserving and improving public health especially in long terms; and secondly, for destructive effects of losing the trust in endangering public health and security (2) and also its –trustreally hard and lengthy reconstruction to the level that could works constructively in social reactions. for these reasons, we ought to approach the conflict from outside of medicine for minimizing disadvantages. in this respect, law, i think, has been the best case for having three main characteristics all suitable for mediating negative outcomes of breaching medical confidentiality: its concern for justice, extensive public acceptance and having executive power; applying these positive potentials, we could hope that destructive effects of breaking confidentiality, especially on the trust, to be dealt with to a minimum. otherwise, absolutism in medical confidentiality could jeopardize "public autonomy" in both short and long terms. here, "public autonomy" can be considered as a shared autonomy by which members of a society agree to respect it as "a common interest"; so that their personal autonomies would be confined within the boundaries of the public as long as they live or attend that society. usually, regulations, laws and legal authorities have charge of protecting and supporting the "public autonomy". as a general rule of social living, no personal action or desire should neglect “public interest”; otherwise, legal authorities defend the “public autonomy” and counteract it using laws and legal forces. this is true about all social structures and establishments including medicine. therefore, personal irresponsibility and intemperate and self-centered behavior of individuals that might harm others could not be socially disregarded even under the coverage of professional confidentiality. as aforementioned, in these instances, law, because of its specific characteristics, has been the best case for making conditional exceptions of medical confidentiality with the least negative effects. in sum, i believe we, members of the health care team, are strongly in need of maintaining a total confidentiality for the critical matter of trust and its profound effects on the public health and security. on the other hand, we are also required to obey "mandatory reporting laws" as a necessary requirement of social living and as an efficient mean in controlling harmful and anti-social behavior of individuals. nevertheless, in line with the professional confidentiality, our first-line duty is basically to spend enough time and energy for solving conflicting cases within the boundaries of the profession (to observe a complete confidentiality) unless someone wants to pursue his/her socially harmful decision or behavior obstinately which then should be managed using related laws. j med ethics hist med 8:10 november, 2015 jmehm.tums.ac.ir omid asemani page 3 of 3 (page number not for citation purposes) references 1. milanifar a, larijani b, paykarzadeh p, ashtari g, akhond mm. breaching confidentiality: medical mandatory reporting laws in iran. j med ethics hist med 2014; 7: 13. 2. asemanio o, ebrahimi s. medical confidentiality. iran j med ethics hist med 2014; 6(6): 64-76. [in persian] 3. mavroforou a, giannoukas ad, mavrophoros d, michalodimitrakis e. confidentiality governing surgical research practice. world j surg 2005; 29(2): 122-3. 4. singer pa. bioethics at the bedside: a clinicians guide, 1st ed. canada: canadian medical association; 1999, p. 55-62. dilator editted 4-94e-fainal journal of medical ethics and history of medicine balloon dilators for labor induction: a historical review james andrew smith1 1 assistant professor, department of electrical & computer engineering, ryerson university, toronto, canada corresponding author: jaes andrew smith address: department of electrical and computer engineering, ryerson university 350 victoria st. toronto, on, m5b 2k3 canada email: jasmith@ee.ryerson.ca tel: 416-979-5000 fax: 416-979-5280 received: 05 apr 2013 accepted: 26 oct 2013 published: 3 nov 2013 j med ethics hist med, 2013, 6:10 © 2013 james andrew smith.; license tehran univ. med. sci. abstract a number of recent articles attribute the origin of the use of cervical balloon dilation in the induction of labor to either barnes in the 1860s or embrey and mollison in the 1960s. this review examines the historical record and reveals that, based on current practice attribution should rather be made to two contemporaries of barnes: the storer and mattei. more importantly, storer’s warning about the rubber used in dilators was ignored, leading to decades of possibly unnecessary deaths following childbirth. to conduct this study key search terms for pubmed, google scholar and the website of the university of ryerson were utilized as “barnes”, “woodman”, “balloon dilation”, “balloon catheter”, “foley”, “colpeurynter”, “cervix uteri” and “induction.” subsequent analysis was done on downloaded articles using bibdesk. keywords: balloon dilation, cervical dilation, foley catheter, hydrostatic dilator, induction of labor mailto:jasmith@ee.ryerson.ca j med ethics hist med 6:10 sep, 2013 jmehm.tums.ac.ir james andrew smith page 2 of 4 (page number not for citation purposes) introduction the use of balloons for dilation is widespread in contemporary medical practice, including in obstetrics and gynecology, dilatation and curettage, induction of labor, control of hemorrhaging, sonohysterography and hysterosalpingography, and fertility treatment. the scope of this analysis will be limited to the use of balloon dilators in induction of labor. the goal of this review is to point out inaccurate attribution of prior art, specifically the tendency of contemporary authors to attribute the origin of cervical balloon dilation in the induction of labor to either barnes in the 1860s (1) or embrey and mollison in the 1960s (2). had barnes and others paid closer attention to storer’s earlier balloon dilator work (3), which raised the issue of rubber’s biocompatibility risks, the infection and mortality rate during labor from the 1860s onward may have been reduced. survey of the literature in 1591 alpinus described how air could be used to inflate distensible material in the urethra (4). later, bromfeild used liquid-based distention of animal intestine to remove stones in a girl’s bladder (5). animal-sourced balloon dilators were replaced with vulcanized rubber by the 1850s. the new material could be more easily cleaned prior to usage, although it carried similar risks of bursting and leaking. in 1854 gariel described balloon dilator designs for the cervix (6), but no medical interventions using these devices were published. it was reported in 1855 that braun had used water-distended rubber balloons to dilate the cervix (7). braun applied his colpeurynter during a labor that had already commenced but was complicated by the presenting of the baby’s shoulder. mattei detailed use of a rehydrated sheep’s bladder design to dilate the cervix during labor in patients in 1855 as an alternative to digital dilation. mattei suggested that the ideal placement of the balloon was within the uterus and that traction should be applied to dilate the cervix. like braun, this method was applied to labor which had already commenced and the procedure lasted only a few minutes (8). in 1859 a controversy began when murray claimed to have used a rubber-based air-distended dilator to induce labor (6). it was immediately recognized that murray’s work was too closely tied to his supervisor, keiller, to consider it murray’s own unique accomplishment (9). storer, in response to murray, made a claim (3) for the use of a balloon dilator for the induction of labor. storer observed that vulcanized rubber was bulky and apt to break down after contact with bodily fluids (10), opting for the more hygienic gold-beater’s skin, a material commonly used for condoms. unlike keiller and murray, storer used water to distend the balloon. barnes (11) and tarnier (12) improved on these earlier designs which were subsequently well received (1, 13), even though they broke down (14) or burst (15). tarnier’s device spawned both the boissard and voorhees designs (15, 16). by the early 20th century warnings were raised about the voorhees design (17) and alternatives (18), and it was concluded that they were not optimal for induction of labor (18). the decline of the invasive and infection-prone balloon corresponds to the ascension of pharmacological alternatives from ergot to oxytocin and prostaglandins. embrey and mollison’s use of the foley catheter reintroduced the medical community to induction balloons (2). the foley is the most commonly used balloon dilator (19) but there are alternatives (20). analysis while barnes first published results seven years after mattei, his name quickly became synonymous with the balloon dilator. woodman criticized tarnier for not citing barnes’ earlier work but did not cite any of barnes’ predecessors either (1). likewise, corner made no mention of barnes’ predecessors (13). the deferral to barnes is possibly due to his standing within the medical community (13, 21). more recently, embrey and mollison, as well as calder glossed over historical prior art (2, 22). further issues regarding addressing of prior art are expanded upon below. oversights in the historical record many historical examinations of balloons for labor induction go no further than embrey and mollison, either limiting the scope to the foley instantiation (23) or mistakenly limiting any balloon-based cervical ripening to them (24). baniirshaid et. al wrongly attribute use of the foley catheter to krause in 1833 – one hundred years before its actual invention (25, 26). while embrey and mollison were the first to use one particular instantiation of a balloon catheter, the foley, they were not the first to use balloons. the following are very clear-cut cases in which attribution is incorrect. lurie and rabinerson misstated barnes’ role in 1997 (27). similarly mozurkewich (28) and guinn et al. attribute the balloon’s origin to barnes (29, 30). pettker et al. also wrongly refer to barnes as the first implementer (31). williamson mistakenly advanced the introduction of barnes’ fiddle-shaped dilator to 1852 (32), eight years earlier than barnes admits to in any of his own publications. other works overlook important contributions by some of the main players in the 1859 controverj med ethics hist med 6:10 sep, 2013 jmehm.tums.ac.ir james andrew smith page 3 of 4 (page number not for citation purposes) sy related to murray’s original publication. hibbard makes mention of both barnes and murray but neither keiller nor storer (33). duchatel ignores the 1859 controversy but cites relevant and important work by mattei (16). credit should be attributed to the design which bears the critical design and application features which are used today: a relatively hygienic material, distention with water, dilation of the cervix using pressure from above, and application to the induction of labor. mattei used dehydrated sheep’s bladders because of convenience, not hygiene. storer made it clear that vulcanized rubber was a poor choice for dilation due to its propensity for breaking down after contact with bodily fluids. in the long term, it appears that while the balloons were mechanically effective, they carried a hygienic risk, which led most practitioners to abandon them prior to embrey and mollison’s reintroduction. storer was correct in his concerns about vulcanized rubber but it is difficult to know if, had others used goldbeater’s skin, the outcome would have been different prior to the introduction of latex. the issue of water distention is an important one. bromfeild described water-based urethral dilation in 1773 (5). air-based techniques were later proposed by gariel (34) and implemented by keiller and murray (9). barnes, a strong fluid distention advocate, wrongly attributed murray (and, by extension, keiller) as the first to have used fluid to distend a cervical dilator balloon (35) as murray specifically states that he used air to distend his air pessary in 1859. it was storer rather who correctly applied fluid (i.e. liquid) rather that the more dangerous air alternative (10), just as today it is standard practice to use saline solution to distend the foley during induction. embrey and mollison were not the first to place their balloon dilator in or against the interior os of the cervix, as is common practice today (36). both mattei and storer advocated for the “from above downwards” (10) approach to dilating the cervix, as opposed to applying force from the vagina upwards or radially within the cervix itself. judging by today’s standards, the waterdistended balloon dilators of both mattei and storer appear to be the forebears of the contemporary foley dilator. storer’s approach, however, was perhaps more hygienic than mattei’s sheep’s bladder or the vulcanized rubber used by barnes and others. conclusion this review examined the historical record related to the development of balloon dilators, specifically those used in dilation of the cervix to induce labor. while some attribute invention of the contemporary hydrostatic dilators such as the foley catheter to either embrey or mollison in the 1960s or to barnes one century prior, credit should be partially given to keiller and murray for their approach which was nearly completely correct, except for their use of air. however, both mattei and storer applied liquid-based distention in a downwards manner prior to barnes’ first published results. storer’s results stand out for his hygienic concerns. had barnes and others paid closer attention to storer’s earlier work, subsequent infection and mortality rates may have been reduced. acknowledgment the author would like to thank donald smith for proofreading the document. the author states that he has no financial conflict of interest or other interests that influence this manuscript. references 1. woodman wb. induction of labour at the eighth month, and delivery of a living child in less than four hours by dr. barnes’s method. lancet 1863; 81(2053):10–11. 2. embrey mp, mollison bg. the unfavorable cervix and induction of labour using a cervical balloon. int j obstet gynaec 1967; 74(1): 44–48. 3. storer hr. on an uterine dilator. med times gazette 1859; 19: 388. 4. alpin p. la médecine des egyptiens, vol. 1. la collection des voyageurs occidentaux en egypte. paris: institut français d’archéologie orientale; 1980. [in french] 5. bromfeild w. chirurgical observations and cases. england: t. cadell; 1773. 6. murray jj. placenta praevia – air-pessary used to plug and dilate the os uteri. med times gazette 1859; 18: 596 – 7. 7. chiari j, braun c, spaeth j. klinik der geburtshilfe und gynaekologie. ealangen: verlag von ferdinand enke; 1855. [in german] 8. mattei a. essai sur l’accouchement physiologique. paris: victor masson; 1855. [in french] 9. keiller a. air-dilators and plugs in obstetrics practice. med times gazette 1859; 18: 639. 10. storer hr. the uterine dilator. am j med sci 1859; 38(75):107–113. 11. barnes r, barnes f. a system of obstetric medicine and surgery: theoretical and clinical. london: smith, elder & co; 1885, vol 2. j med ethics hist med 6:10 sep, 2013 jmehm.tums.ac.ir james andrew smith page 4 of 4 (page number not for citation purposes) 12. galante h. de l’emploi du caoutchouc vulcanisé dans la thérapeutique médico-chirurgicale. paris: bailliere; 1869. 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(obituary). bjog 1907; 11(6): 519-522. 22. calder aa. cervical ripening; physiology and therapy. j obstet gynaecol 1988; 8(s1): s2–s6. 23. sherman dj, frenkel e, tovbin j, arieli s, caspi e, bukovsky i. ripening of the unfavorable cervix with extraamniotic catheter balloon: clinical experience and review. obstet gynecol surv 1996; 51(10): 621–7. 24. lewis s, collins m. induction of vaginal birth after cesarean using intracervical foley bulb. j midwifery womens health 2008; 53(6): 565–6. 25. foley feb. a hemostatic bag catheter a one piece latex rubber structure for control of bleeding and constant drainage following prostatic resection. j urol 1937; 38(1):134–139. 26. bani-irshaid i, athamneh tz, bani-khaled d, al-momani m, dahamsheh h. termination of second and early third trimester pregnancy: comparison of 3 methods. east mediterr health j 2006; 12(5): 605–9. 27. lurie s, rabinerson d. balloon ripening of the cervix. lancet 1997; 349(9050): 509. 28. mozurkewich e. commentary on foley catheter insertion for preinduction cervical ripening was faster and more efficacious than prostaglandin e2 gel. evidence-based obstet gynaecol 2000; 2(2): 41. 29. guinn da, goepfert ar, christine m, owen j, hauth jc. extra-amniotic saline, laminaria, or prostaglandin e(2) gel for labor induction with unfavorable cervix: a randomized controlled trial. obstet gynecol 2000; 96(1): 106–12. 30. guinn da, davies jk, jones ro, sullivan l, wolf d. labor induction in women with an unfavorable bishop score: randomized controlled trial of intrauterine foley catheter with concurrent oxytocin infusion versus foley catheter with extra-amniotic saline infusion with concurrent oxytocin infusion. am j obstet gynecol 2004; 191(1): 225–9. 31. pettker cm, pocock sb, smok dp, lee sm, devine pc. transcervical foley catheter with and without oxytocin for cervical ripening: a randomized controlled trial. obstet gynecol 2008; 111(6): 1320–6. 32. williamson h. the induction of premature labour. j obstet gynaecol 1905; 8(4): 252–71. 33. hibbard bm. the obstetrician’s armamentarium: historical obstetric instruments and their inventors. california: norman publishing; 2000. 34. gariel mm. medico-chirugical uses of vulcanised india-rubber. translated by murray jj. medical times and gazette1859; 40(1033 (new series no 472): 64–66. 35. barnes r. on the indications and operations for the induction of premature labour and for the acceleration of labour. in obstetrical society of london, transactions of the obstetrical society of london. london: longmans, green and co; 1861; 3:107-141. 36. tenore jl. methods for cervical ripening and induction of labor. am fam physician 2003; 67(10): 2123–8. ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ 1 commentary volume 13 number 10 september 2020 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e copyright © 2020 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. human resources and patient rights during covid-19 pandemic in iran seyedhassan adeli1, morteza heidari2, akram heidari3* 1.associate professor, spiritual health research center, qom university of medical sciences, qom, iran. 2.researcher, spiritual health research center, qom university of medical sciences, qom, iran. 3.professor, spiritual health research center, qom university of medical sciences, qom, iran. on february 19, 2020, first cases of covid-19 positive were reported in iran. when covid-19 declared pandemic by the world health organization (who) in march 2020, iran was among the most affected countries (1). iran was ranked 11th among pandemic-affected countries with more than 328,844 laboratory-confirmed cases as of august 11, 2020 (2). the rapid spread of the pandemic disease and not knowing about covid19-affected areas necessitated making immediate decisions and adopting appropriate control measures. the burden of the pandemic, added to that of the common diseases, imposed additional pressures on hospitals and healthcare centers, with various consequences such as patient’s rights disregard. covid19 patients as well as other inpatients during the pandemic deserved their legitimate rights of being treated with the highest possible care and attention. in patient's rights charter (3), various aspects of patient's rights include providing appropriate healthcare service, necessary information, freedom of choice in therapeutic services, and ethical considerations (e.g., privacy and confidentiality). fulfilling these rights was challenged by shortcomings in hospital capacity, equipment, financial resources, and even necessary knowledge regarding effective treatment. inadequacy and lack of human resources (4) was a major challenge because healthcare staff count could not be increased to comply with the continuously increasing patient count (4). *corresponding author akram heidari no. 83, shahid lotfi niassar alley, jahad daneshgahi street, safashahr, qom, iran. tel: (+98) 25 32 94 47 11 email: heidari@muq.ac.ir received: 27 may 2020 accepted: 12 aug 2020 published: 16 sep 2020 citation to this article: adeli sh, heidari m, heidari a. human resources and patient rights during covid-19 pandemic in iran. j med ethics hist med. 2020; 13: 10. human resources and patient rights during covid-19 pandemic in iran 2 volume 13 number 10 september 2020 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e moreover, loss of staff due to covid-19 was a serious challenge; in iran, according to statistics, more than 10,000 medical and healthcare staff were infected and more than 100 deceased as of may 20, 2020 (5). furthermore, absence from the workplace by medical and healthcare staffs due to the infection risk reduced the capacity of human resources in hospitals and health care centers (6).the healthcare providers and hospital administrators as well as staff, called iranian health advocates during covid-19, were aware of their responsibilities regarding patient’s rights and were committed to doing their best, even if external expectations could not be fully met due to the pandemic. covid-19 patients occupied almost the entire capacity of public and private hospitals. the necessity for isolating patients and the large number of patients in need of care and treatment have exacerbated the exhaustion of the nursing staff. to meet the critical need for additional human resources and to improve the situation of human resources, three approaches were adopted: (i) temporary transfer of medical specialists and nursing staff from other divisions of the healthcare system, including educational and research medical centers; (ii) call for retired or non-working nurses and other healthcare specialists to join the healthcare system; and , (iii) recruiting non-specialist volunteers. to provide non-specialized human resources, use of volunteer force has often been a valuable solution in crisis management (7). in qom, a city in center of iran, due to the rapid covid-19 spread, almost all hospitals were engaged in treating patients. qom university of medical sciences and health services, as the main healthcare responsible party for the under-supervision population, as well as the emergency operations center (eoc) issued calls for volunteers through social media. hundreds of people filled up application forms and enrolled to assist the healthcare staff. the volunteers, most of whom were educated and engaged in non-medical occupations, helped the healthcare system during the difficult days of the epidemic, despite the panic caused by the unknown and insidious virus. after initial screenings, to avoid unpredictable and unintended consequences of utilizing volunteers, empowerment procedures were required for those who volunteered with a sense of benevolence. to ensure fulfilling patient's rights, the volunteers needed training before entering hospitals and healthcare center so that they could perform their expected duties. therefore, intensive training courses were presented online to the volunteers, and after completing the courses and subsequent exams, id cards were issued as their permits to enter hospitals and healthcare centers. this training process was necessary for the volunteers in order to acquire basic skills, to activate those skills in establishing effective communication with healthcare staff, and to familiarize them with the workplace climate. various subjects of the training courses ranged from medical terms to self-care and effective communication to counseling skills. apart from volunteers who provided logistic support and were not in contact with the patients, 325 volunteers, including 104 females (32%) and 221 males (68%), passed the exams and received id cards to enter the hospitals as caregivers. managing of the volunteer caregivers was implemented adeli sh., et al. 3 volume 13 number 10 september 2020 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e through a coordinating body consisting of the eoc's public participation committee and the agents in charge of coordination, control, and supervision of the volunteers' activities in the hospitals. a significant number of the volunteers were muslim clergies and islamic seminarian. the volunteers helped fulfill all the basic needs of the patients, especially health care and treatments; however, the volunteer clergies provided the patients with spiritual support. like chaplain supportive services addressing counselling and psycho-spiritual needs of the medical staff and patients (8), muslim clergies or islamic seminarian were more than just volunteers during the pandemic. by incorporating spiritual support into physical care and being in line with patients' religious beliefs, they impact their recovery and wellbeing both in body and soul. these volunteers responsibly participated in end-of-life care for the end-stage patients, and the subsequent rituals, including burial and spiritual support for families of the deceased, as well as participated in providing support for families of other patients and hospital-isolated medical and healthcare staff. a source of relief for patients, medical and healthcare staff, and their families, these volunteers took on responsibilities that those in charge avoided because of the potential risks of covid-19. fulfilling different needs of patients, including their spiritual needs and psychological well-being of their families, was a serious requirement of ensuring the observance of patient’s rights. in short, adhering to the patient's rights according to iranian charter of patient’s right is necessary in all circumstances including covid-19. during the pandemic, human resource inadequacy was compensated through temporary transferring of medical and healthcare staff from other divisions of healthcare system, recruiting retired or nonworking nurses and healthcare specialists, and using volunteer caregivers. during the covid-19 pandemic, these compensation approaches were effective in fulfilling patient’s rights and avoiding the probable harms of insufficient human resources. human resources and patient rights during covid-19 pandemic in iran 4 volume 13 number 10 september 2020 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e references 1. raoofi a, takian a, sari aa, olyaeemanesh a, haghighi h, aarabi m. covid-19 pandemic and comparative health policy learning in iran. arch iran med. 2020; 23(4): 22034. 2. anonymous. who: coronavirus disease (covid-2019) situation reports -204. [cited on september 2020]; available from: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200811-covid19-sitrep-204.pdf?sfvrsn=1f4383dd_2 3. parsapoor a, bagheri a, larijani b. patient's rights charter in iran. acta med iran. 2014; 52(1):24-28. 4. joolaee s, tschudin v, nikbakht‐nasrabadi a, parsa‐yekta z. factors affecting patients' rights practice: the lived experiences of iranian nurses and physicians. int nurs rev. 2008; 55(1): 55-61. 5. karimi n, elhennawy n. iran: more than 10k health care workers infected with virus. [cited on september 2020]; available from: https://medicalxpress.com/news/2020-05-iran-10khealth-workers-infected.html 6. groenewold mr, burrer sl, ahmed f, uzicanin a, free h, luckhaupt se. increases in health-related workplace absenteeism among aorkers in essential critical infrastructure occupations during the covid-19 pandemic-united states, march-april 2020. [cited on september 2020]; available from: https://www.cdc.gov/mmwr/volumes/69/wr/mm6927a1.htm 7. aminizade m, nekouei moghaddam m, birami jam m, shamsi m, majidi n, amanat n, et al. the role of volunteer citizens in response to accidents and disasters. health in emergencies & disasters quarterly. 2017; 2(3): 107-24. 8. koenig hg. ways of protecting religious older adults from the consequences of covid19. am j geriatr psychiatry. 2020; 28(7): 776–79. ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ 1 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e commentary volume 13 (suppl.) number 26 december 2020 copyright © 2020 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. medical students' value-rich exposures in clinical setting during the covid-19 pandemic *corresponding author shahram yazdani no. 65, national center for strategic research in medical education, saeedi st., ayatollah hashemi rafsanjani intersection, valiasr st., tehran, iran. postal code: 1967846911 tel: (+98) 21 75 48 44 44 email: shahram.yazdani@sbmu.ac.ir received: 19 oct 2020 accepted: 1 dec 2020 published: 19 dec 2020 citation to this article: sabeghi h, afshar l, foroutan sa, yazdani s. medical students' value-rich exposures in clinical setting during the covid-19 pandemic. j med ethics hist med. 2020; 13(suppl.): 26. hakimeh sabeghi1, leila afshar2, seyed abbas foroutan3, shahram yazdani4 * 1.phd candidate, virtual school of medical education and management, student research committee, shahid beheshti university of medical sciences, tehran, iran. 2.associate professor, department of medical ethics, shahid beheshti university of medical sciences, tehran, iran. 3.associate professor, permanent member, academy of medical sciences of iran, tehran, iran. 4.professor, virtual school of medical education and management, shahid beheshti university of medical sciences, tehran, iran. abstract exposing medical students to real-world situations and clinical practice experiences during their education years can help them build their professional value frameworks. the covid-19 pandemic is one of the most challenging conditions that medical students have experienced; however, this pandemic have provided value-rich opportunities assisting in development and enhancement of their professional identity. this commentary aimed to emphasize the importance of medical students’ exposure to clinical practice during the pandemic and the potential that such encounters provide for internalizing values. keywords: values; exposure; clinical education; pandemics. medical students’ value-rich exposures in clinical setting … 2 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 26 december 2020 introduction the world health organization (who) declared the covid-19 a pandemic in march 2020, which shocked the medical community (1). the significant impact of the pandemic on medical education, especially clinical education, is unprecedented, and clinical education has widely changed since the advent of pandemic. medical schools around the world have suspended their clinical rotations in response to lack of personal protective equipment, concerns for students’ health, and risks of the virus spreading to communities. however, cancellation of clinical education has a negative effect on students as medical community members and leads to loss of opportunities to gain experience (2). one of the important aspects of medical education, along with teaching knowledge and skills, is value education. values in the healthcare system are defined as normative guidelines that help resolve conflicts and challenges, choose the right course of actions, and function effectively in clinical decision-making and judgment process (3). students’ lived experiences during their education years help them acquire values that build their value framework. yazdani et al., stated that a value-rich exposure is an appropriate method for internalizing values (4). exposure to real-world situations through clinical experiences during education years is an opportunity to transfer values to medical students, and hence eliminating such exposure deprives them of acquiring necessary competencies needed for their future professional life. value-rich exposures during the pandemic despite the pandemic’s challenges, the authors believe that it has provided opportunities for medical students to develop their professional identity. the first concern is whether the pandemic makes medical students feel valued and efficient in the healthcare system or makes them feel ignored. how can medical students realize their value as members of the medical and healthcare team whose clinical rotations have been disrupted during the pandemic, and as a result their learning interests and interventions have been undermined? during the pandemic, health risks to students in clinical settings are serious challenges that need to be addressed. according to the association of american medical colleges (aamc) guideline in august 2020, medical schools should carefully evaluate their local condition to decide about students’ participation in bedside clinical teaching. to maintain students’ safety, program directors should arrange for appropriate safeguards to protect them from contracting covid-19 and their participation in clinical courses only when crucial according to educational program objectives (5). five value-rich exposures for students during this pandemic are as follows: 1. patients’ triage process since the onset of the pandemic, hospital sabeghi h., et al. 3 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 26 december 2020 visits have increased so significantly that hospital triage standards have changed, and even severely-ill patients may not be admitted due to lack of hospital beds. given the importance of fulfilling the rights of justice and equality for all patients, such situations create rich exposures of values. in these situations, medical students can become familiar with the difficulties of the medical team in the pandemic crisis, where they must decide which patient should be prioritized for hospital admission based on hospital equipment and patient safety concerns. 2. duty to care versus right to protection during the pandemic, simultaneous protection of patients and staff can be challenging (6), and providing necessary care to patients endangers the health of medical and health care staff, who are called “health advocates” (7). turale et al., stated that, “the language of today is reminiscent of war time: working on the frontline, facing battles, making sacrifices, being sacrificed, being resilient, doing our bit and joining forces” (8). not only do medical and healthcare team have professional duties to provide care for patients, but they also have responsibilities for the health of themselves and that of family and loved ones, and striking a balance between these two is required for the best outcome. this pandemic is a unique opportunity for students to observe the trade-offs between death and survival in patients' health and staff’s health, choices that are value-based options and considering medical ethics principles. 3. patient-provider interaction in the pandemic patients’ comfort is a significant aspect involving in their treatment, which is threatened by the pandemic conditions. the covid-19 patients are often alone in isolated wards with minimal communication, whereas effective communication is a fundamental requirement in patient-provider interaction. during the pandemic, healthcare providers try to convey warm smiles and good moods to comfort patients despite limitation caused by wearing full personal protective equipment (6). real-world experiences in such valuerich conditions can enhance students’ skills to manage such situations, help patients, and provide care and comfort for patients. 4. difficult clinical decision-making in pandemic conditions, one of the challenging and agonizing decisions for the medical and healthcare team is about not resuscitating patients due to lack of ventilator devices as well as prioritizing and rationing available devices among patients. not allowing the families to accompany and visit their hospitalized patients is another difficulty in the pandemic condition. in this pandemic, value-based decision-makings are extensively required, and being exposed to such conditions prepares medical students for similar situations in their future professional practice. medical students’ value-rich exposures in clinical setting … 4 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 26 december 2020 5. patient dignity in end-of-life care human dignity is a major concern in bioethics and value education. in the pandemic, numerous patients died in isolated wards alone with no farewell opportunity and no support or strength of heart in the last minutes of their lives. a professional duty of physicians and nurses is to help the patient to be in peace in dying process. during the pandemic, due to the risk of infection, postmortem and burial ceremonies or traditions have not been permitted, which can lead to emotional distress in the patient's family, relatives, and friends, as well as create a sense of disrespect for the deceased patient’s dignity. despite all obstacles during the pandemic, decision-makings about maintaining patient dignity include valuerich exposure experiences for students affecting their future professional skills. conclusion presence of medical students in clinical settings during the pandemic is a valuable opportunity for value education, a critical principle in medical education. during the pandemic, medical education and teaching authorities should not deprive medical students of the uniquely different experiences that can teach value-based concepts. given the unique and important situations created in this pandemic, medical universities, by emphasizing the importance of value education in medicine, should provide safe conditions for students to take advantage of these opportunities. this commentary discussed such value-rich experience opportunities that can help internalize value concepts such as love, equality, justice, security and peace in medical students. acknowledgment the researchers heartily appreciate all the medical students, teachers and other healthcare staff who work selflessly in this crisis. conflict of interest the authors declare no conflicts of interest. sabeghi h., et al. 5 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 26 december 2020 references 1. anonymous. who organization. who director-general’s opening remarks at the media briefing on covid-19. [cited 2020 december]; available from: https://www.who.int/directorgeneral/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid19---11-march-2020 2. anderson ml, turbow s, willgerodt ma, ruhnke gw. education in a crisis: the opportunity of our lives. j hosp med. 2020;15(5): 287-9. 3. marzorati c, pravettoni g. value as the key concept in the health care system: how it has influenced medical practice and clinical decision-making processes. j multidiscip healthc. 2017; 10: 101-6. 4. yazdani s, akbarilakeh m, ahmady s, afshar l, foroutan sa. value-based curriculum model from the viewpoints of experts in education of ethics and values in shahid beheshti university of medical sciences. iranian journal of medical education. 2015; 15: 304-18. 5. anonymous. association of american medical colleges. guidance on medical students’ participation in direct in-person patient contact activities. [cited 2020 december]; available from: https://www.aamc.org/media/43311/download 6. gopichandran v. clinical ethics during the covid-19 pandemic: missing the trees for the forest. indian j med ethics. 2020; -(-): 1-5. doi: 10.20529/ijme.2020.053. online ahead of print. 7. mcdougall rj, gillam l, ko d, holmes i, delany c. balancing health worker well-being and duty to care: an ethical approach to staff safety in covid-19 and beyond. journal of medical ethics. 2020; doi: 10.1136/medethics-2020-106557 8. turale s, meechamnan c, kunaviktikul w. challenging times: ethics, nursing and the covid‐19 pandemic. int nurs rev. 2020; 67(2): 164-7. ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ commentary copyright © 2021 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e ethical considerations for clinicians faced with patients lacking the capacity to form reasoned judgments regarding covid-19 tests and isolation jeffrey yuk-chiu yip lecturer, school of health sciences, caritas institute of higher education, hong kong, china. introduction dealing with patients suffering severe mental health problems during the coronavirus disease 2019 (covid-19) pandemic have raised several, complex, clinical and ethical questions (1). such patients may need to be treated within secure facilities where many patients and staff live in close proximity, increasing the risk of disease transmission. in february 2020, in the daenam hospital in south korea, an infection cluster was found in the psychiatric ward, with 101/103 patients testing positive (2). in this pandemic’s unprecedented circumstances, psychological pressure on medical staff has been severe (3). clinical staff have been significantly at risk when dealing with psychiatric inpatients, especially in areas where high infection levels have led to shortfalls in personal protective equipment supply. several strategies are required to reduce infection risks for psychiatric inpatients and their caregivers. such strategies may include a comprehensive test program, mask-wearing, and social distancing. however, psychiatric patients would frequently not possess the capacity to make reasoned judgments regarding the refusal of testing or noncompliance with anti-infection protocols. because of psychiatric illness, such patients may refrain from being tested or following protocols such as maskwearing or isolation. thus, clinicians have faced with serious ethical problems when dealing with psychiatric inpatients during this pandemic, in that they must balance the requirements of respecting patient autonomy and allowing them as much freedom of self-determination as is appropriate, against the need to protect the patient from infection and prevent them from infecting others. this commentary aimed at assisting clinicians facing with such ethical dilemmas. *corresponding author jeffrey yuk-chiu yip address: 8/f, school of health sciences, caritas institute of higher education, 2 chui ling lane, tseung kwan o, new territories, hong kong, china. postal code: 999077 tel: (+852) 3702 4264 email: jeffreyycyip@gmail.com received: 13 feb 2021 accepted: 1 aug 2021 published: 3 nov 2021 citation to this article: yip jyc. ethical considerations for clinicians faced with patients lacking the capacity to form reasoned judgments regarding covid-19 tests and isolation. j med ethics hist med. 2021; 14: 13. ethical considerations for clinicians faced with patients lacking the capacity to … 2 j med ethics hist med. 2021 (november); 14: 13. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e pragmatic and ethical approaches for clinicians to manage the aforementioned problem, engaging patients in the decision-making process must be a priority as this process relates to their care and treatment. such engagement may require a combination of education, therapy, medication, and assistance of the patient’s family and other individuals of significance. in this process, compassion is essential when managing patients with serious mental health issues and assisting them to have input into their care regime. non-mandatory interventions are more likely to succeed than imposed interventions when the patient objects. nevertheless, clinicians may have to impose interventions in case of a failure in the shared decision-making process. imposing such interventions may be done through judicial reviews, that is, with the clinicians petitioning a judge who can order that a patient be treated despite objection. however, several problems may arise with such interventions. medical procedures such as testing for severe acute respiratory syndrome coronavirus 2 (sars‑ cov‑2) may not be regarded as falling within the aegis of “treatment over objection”; they may be more likely to be considered under the “emergency treatment” protocols (4). whether such regulations apply to testing for sars-cov-2 is not yet clear. furthermore, arranging court hearings can take considerable time while the patient may remain at the risk of contracting the infection or infecting others. such delays can cause problems in seeking an award for “treatment over objection”; and, addressing the patients’ mental health symptoms can ultimately mean that they would be more likely to comply with infection control protocols. a significant concern is whether it is ever ethically permissible to use coercion or compulsion to impose testing or treatment when other strategies have failed. szmukler and appelbaums detailed a hierarchy of treatment methods, beginning with persuasion and ending with compulsion (5). the authors stated that the threshold allowing the treatment to be ethically justified becomes higher as moving through this hierarchy. compulsion must have extremely robust justification and should only be used when all other measures have failed. compulsion measures that can be used, on the condition that safeguards are installed to ensure the patient comes to low harm, may include the use of physical restraints, either with or without sedation, for obtaining vital signs, taking swabs and other specimens for laboratory testing. additionally, if patients cannot comply with isolation protocols, they may need to be mechanically restrained, sedated, or secluded either by being locked in a specific room or otherwise blocked from leaving their rooms by the staff. existing regulations related to restraint and seclusion demand that a patient must have demonstrated the propensity towards violence or self-harm that places themselves or those around them in imminent physical danger. a discussion might be yip jyc. 3 j med ethics hist med. 2021 (november); 14: 13. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e necessary regarding whether the risk of contracting or transmitting covid-19 represents an imminent physical danger, however regulators may not regard it as such (6). forceful interventions, as a last resort, are not well defined within the regulations. should forceful intervention be considered, appealing to the standard principles regarding respecting autonomy may not help much, becoming more confusing by introducing a debate on how far self-determination for patients lacking full mental capacity may be permitted amidst a global pandemic. a solution should be sought based on justice and goodwill that uses public-health solidarity and caring coercion principles. if all possible reasonable measures have been taken to persuade the incapacitated patient and failed, coercion can be morally justified, provided it is recognized as a last resort. in case of an urgent need to protect the patient, other individuals and the wider community, the patient's right to refuse medical intervention may be overridden. any decision about coercion must be taken transparently and should be according to all ethical and legal standards (7). physicians and other staff should be proactive and collaborative in engaging with the patient, those who care for them, and those who support them, offering educative and therapeutic measures to persuade reluctant patients to accept necessary treatment to prevent them from contracting and spreading the virus. to assess the urgency of testing accurately, a hospital should undertake daily assessments of contagion risks in its facility utilizing all data available including the followings: (i) exposure history; (ii) possible indications and symptoms of covid-19; (iii) the chances of the patient physically contacting vulnerable patients and staff; and, (iv) opinions of experts in preventing and controlling infections. if a patient refuses to accept testing, isolation, or treatment for covid19, psychiatrists must carefully assess and document the capacity of a patient in rejecting treatments. if delayed testing is comparatively safe, psychotherapy or medication may be appropriate to enhance patient’s capacity. if coercive restriction is considered the only option, it should be applied such that the safety of both patients and staff is maintained to the maximum extent possible, and any restrictions should be regularly reevaluated to gain patients’ compliance and their cooperation being continued. a hospital’s ethics committee should be central to the development and implementation of the abovementioned protocol. finally, inpatient psychiatric facilities should be modified (and in new facilities, designed with such changes in mind) to stop infectious diseases from spreading as much as possible and allow patients to be more autonomous and move around the facility safely and as freely as possible. hospitals should develop a set of ethics-based guidelines that allow the patients to retain their autonomy without compromising health of others, in the current pandemic and the aftermath (8). such ethical considerations for clinicians faced with patients lacking the capacity to … 4 j med ethics hist med. 2021 (november); 14: 13. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e interventions must be adequately funded. conclusion this paper presented a path for clinicians to manage pragmatically ethical concerns regarding care for patients with severe mental health problems who refuse to take the covid-19 tests or to comply with protocols designed to prevent infection. at the outset, the patients should be given the support required to decide themselves; however, in certain instances, decisions might be made by the clinicians based on the individuals’ expressed beliefs, values, and wishes while incorporating their family’s opinion on what the patients would choose if they had the capacity to decide for themselves. clinicians can employ various treatment methods, beginning with persuasion and ending with coercion. legal authorization might be necessary should patient right to liberty be impinged. depending on the jurisdiction of different countries, if patients are deemed to present an immediate risk to others, including other patients and employees in the facility, clinicians might be legally empowered to detain and restrain patients for a finite period. the opinions of a hospital’s ethics committee might be sought, particularly when frontline clinicians are confronted with complex ethical questions in caring for these patients. with the involvement of medical ethicist, the committee may provide professional advice by contextualizing the problems which otherwise may not be adequately addressed by the established ethical frameworks of the national health authorities. acknowledgments none conflict of interests none declared. yip jyc. 5 j med ethics hist med. 2021 (november); 14: 13. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e references 1. bojdani e, rajagopalan a, chen a, et al. covid-19 pandemic: impact on psychiatric care in the united states. psychiatry research. 2020; 289: 113069 . 2. shao y, shao y, fei jm. psychiatry hospital management facing covid-19: from medical staff to patients. brain behav immun. 2020; 88: 947 . 3. montemurro n. the emotional impact of covid-19: from medical staff to common people. brain behav immun. 2020; 87: 23-24 . 4. anonymous. codes, rules, and regulations of the state of new york, title 14, part 527. [cited on oct 2021]; https://govt.westlaw.com/nycrr/browse/home/newyork/newyorkcodesrulesandregulations?gui d=ic69a0390b7ec11dd9120824eac0ffcce&originationcontext=documenttoc&transitiontype=defa ult&contextdata=(sc.default) 5. szmukler g, appelbaums ps. treatment pressures, leverage, coercion, and compulsion in mental health care. journal of mental health. 2008;17(3): 233-44. 6. anonymous. controlling the spread of infectious diseases. [cited on oct 2021]; https://www.who.int/healthsystems/topics/health-law/chapter10.pdf 7. szmukler g. compulsion and “coercion” in mental health care. world psychiatry. 2015; 14(3): 25961. 8. jeffrey di. relational ethical approaches to the covid-19 pandemic. journal of medical ethics. 2020; 46(8): 495-8. ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ 1 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e letter to editor volume 13 (suppl.) number 24 december 2020 copyright © 2020 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. covid-19 pandemic and the ethical challenges in patient care ali sahebi1, siamak moayedi2, mohamad golitaleb3* 1.phd candidate in health in emergencies and disasters, department of health in emergencies and disasters, school of public health and safety, shahid beheshti university of medical sciences, tehran, iran. 2.assistant professor, department of emergency medicine, university of maryland school of medicine, baltimore, usa. 3.instructor, department of nursing, school of nursing, arak university of medical sciences, arak, iran. the covid-19 disease is a recent human infectious disease caused by the severe acute respiratory syndrome corona virus 2 (sars-cov-2). this virus has affected almost all world's countries, and hence challenged the global healthcare system (1). healthcare providers should comprehend ethical aspects of providing care services during the covid-19 pandemic, and the following factors highlight the need for providing ethical care services: (i) ongoing advances in diagnosis and treatment of covid-19, (ii) discovery of new pharmaceuticals, and (iii) disparities in accessing to healthcare among the pandemicaffected (2). the centers for disease control and prevention (cdc) and the world health organization (who) have proposed healthcare guidelines for standard precautions while caring for the covid-19 patients and observing quarantine principles (3). social distancing and quarantining can lead to neglect of vulnerable patients, discrimination against them, as well as limiting their access to health services, educational and social programs. the consequences of social distancing and quarantining can become risk factors in violating patient rights. physicians and nurses have a moral duty to fulfill patients’ rights (2, 4), and failure to adhere to professional ethics leads to the challenges reducing care quality (2). *corresponding author mohamad golitaleb basij sq., sardasht region, arak, iran. postal code : 6941738481 tel : (+98) 86 34 17 35 24 email: m.golitaleb@arakmu.ac.ir received: 8 oct 2020 accepted: 1 dec 2020 published: 19 dec 2020 citation to this article: sahebi a, moayedi s, golitaleb m. covid-19 pandemic and the ethical challenges in patient care. j med ethics hist med. 2020; 13(suppl.): 24. mailto:m.golitaleb@arakmu.ac.ir covid-19 pandemic and the ethical challenges in patient care 2 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 24 december 2020 patient rights established by who include the followings: (i) receiving high-quality care and treatment, (ii) equitable access to healthcare services and information, (iii) confidentiality of information, (iv) informed consent, (v) selfdetermination and independence, (vi) access to health education, and (vii) the right to complain and demand compensation (2). social stigma and discrimination due to fear and misinformation can promote significant violations of these basic rights (2, 5) . violating rights, such as receiving information, education, and care, compromises individuals’ basic rights (e.g., medical care and social services) during pandemics such as covid19, thereby making individuals more vulnerable. to reduce vulnerabilities, individuals and communities should be empowered not only to make effective choices but also to manage what threatens their health. moreover, consequences of not adhering to ethics reduce both patients’ satisfaction and healthcare providers' service quality. considering the importance of ethics in providing healthcare services during the pandemic, this article aimed at addressing eight ethical challenges in providing such services to the covid-19 patients (2, 6). challenge of allocating limited resources a key ethical issue in the covid-19 pandemic is fair allocation of the limited available resources among patients. during this pandemic, involved 218 world countries, due to the virus’s highly-contagious nature, maximum capacity of most hospitals has been consummated, and their need for medical and life-saving equipment (e.g., mechanical ventilation, extra-corporeal membrane oxygenation (ecmo) device) has been high and increasing. hence, resource triage is a difficult challenge for healthcare staff, and these limited resources should be appropriately allocated. almost always, high priority is given to young patients who may have higher survival chance. the covid-19 disease often presents itself with acute respiratory distress syndrome (ards), and allocating a ventilator, currently being rationed among patients, has been one of the most difficult decisions to make. during this pandemic, repetition triage or reallocation has been necessary. for example, with a shortage in ventilators, nurses and other healthcare staff need to constantly monitor the effects of invasive ventilation on specific patients and reallocate the ventilator to a patient with higher recovery chance (4). medical and healthcare staff are not unlimited resources, and the virus has seriously affected them during this pandemic as well as inflicted them with severe burnout. therefore, in caring for the covid-19 patients, in addition to limitations in medical equipment and personal protective equipment (ppe), a shortage in human resources is another important challenge that should be managed by hiring new staff or employing trained volunteers. ethical challenges in researches ethical challenges in researches are among the most important issues during the covid-19 pandemic. as of november 8, more than 10 months after the advent of covid-19 and the time of writing this article, no definitive treatment or vaccine is publicly available. due sahebi a., et al. 3 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 24 december 2020 to high prevalence and mortality of covid-19, pharmaceutical and vaccine companies around the world are rigorously competing, and several companies have claimed to produce medication or vaccine so far. in addition, to acquire more profits and to introduce their products earlier, these companies may disregard research ethics in respective interventional studies and clinical trials (7). hence, observing protocols according to the guidelines of research ethics committees and the principles of the helsinki declaration is critical to respect human dignity in all circumstances. safety of medical and healthcare staff in the fight against covid-19, the safety of nurses as well as other medical and healthcare staff at the forefront is a significant ethical issue, given that their high-risk work situation threatens their health. although covid-19 is not as mortal as human immunodeficiency virus/acquired immune deficiency syndrome (hiv/aids) or swineorigin influenza (h1n1), medical and healthcare staff confront high risk and unknown conditions due to limited knowledge regarding the virus (e.g., pathophysiology, transmission routes, vulnerability, and contagious rate) and lack of adequate ppe supplies. inadequate protection of medical staff in hospitals and healthcare centers raises an ethical concern about the extent to which they have a professional patient-care duty since the pandemic disrupted their routine tasks and increased their workload. in addition, the conflict between civil duty and self-interest makes nurses more vulnerable and confused in their fight against covid-19. therefore, they make best effort to balance their personal interests and duties to be able to care for patients, as well as to compensate for shortcomings in healthcare systems. therefore, they try to make such efforts in a way that is compatible with their duties and rights to protect themselves and their families. politicians and authorities should realize the risks associated with the nursing profession as well as related emotional burden and consequences. healthcare staff’s concern about ppe are not only because of their own protection, but also due to their fear of transmitting the infection to their family members, especially those with underlying diseases and higher vulnerability. additionally, a nurse can be the only and primary caregiver at home for their children or older family members (e.g. parents). both healthcare organizations and healthcare and medical staff have a responsibility to utilize all their resources for providing care (4, 8). regardless of the presence or absence of ppes, organizational leaders should appropriately guide and support nurses and other medical and healthcare staff. moreover, they should endeavor to provide ppes, encourage proper use of them, and manage shortage or lack of them. respecting patient’s independence as a key component in providing ethical care, all medical and healthcare providers need to guarantee and respect patient's independence. patient’s independence is referred to patient’s ability to make informed or rational decisions, covid-19 pandemic and the ethical challenges in patient care 4 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 24 december 2020 requiring adequate information from medical and healthcare team (2, 5, 9). in addition to promoting trust, respecting patients’ independence enhances their mental and physical comfort, as well as increases adherence to treatment. however, in caring for the covid-19 patients, adhering to this principle may present challenges, as the patients ' refusal to accept treatment or quarantine endangers not only their personal health but also community’s general health. given these dangers, relying on paternalism, along with the traditional patient care approaches while noticing medical and healthcare team's decisions, is a predominant and practical care approach during this pandemic. educating patients about the risk of death and disease transmission can improve the situation, and with patients’ participation, right decisions can be made to continue treatment (6, 8). healthcare providers may have high medical experience and knowledge; however, patients prefer participatory decision-making. such decision-making requires patients to have adequate information and appropriate education that must be offered by medical and healthcare team as well as healthcare organizations and providers. ethics in quarantine quarantine, as a mandatory isolation, restricts physical contact of a person exposed to an infectious disease to prevent its spread. since quarantine restricts freedom, patient's rights and independence may be endangered. although maintaining public health takes precedence over the individual’s independence and interests, public health interventions should be conducted with appropriate ethical justification and efforts should be made to minimize violations of patient independence. quarantine can also impose economic and social consequences, thereby raising many other ethical concerns. in implementing quarantine policies, a balance should be struck between public health benefits and human rights violations. adherence to ethics enhances trust of the quarantined individuals, boosts their cooperation, and ensures the success of the treatment and management processes (2, 6). several parameters increase the trust and cooperation of the quarantined individuals (6, 8): (i) participation of the quarantined in decision-making, (ii) ability to perform necessary tasks if the required facilities are provided, (iii) convincing individuals about the benefits of processes, approaches, or restrictions, (iv) fair distribution of health resources among individuals, (v) officials’ timely response, (vi) determination in implementing guidelines, (vii) authorities’ adherence to transparency principle such that they fully explain the background reasons for implementing restrictions, (viii) psychological support, and (ix) financial and insurance supports as the quarantined may be day laborers or lose their jobs during the pandemic. duty of care during this pandemic, traditional caregivers (e.g., friends and family members) were asked to maintain social and physical distance from their patients as well as were not allowed to visit their hospitalized patients. these traditional caregivers often, acting as their patient advocate, raise concerns with medical sahebi a., et al. 5 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 24 december 2020 providers and make requests from them (10). during this pandemic, however, medical professionals should be ethically required to act as advocates for the coivd-19 patients. because the community as well as friends and family may leave the covid-19 patient alone, medical and healthcare staff should provide care to the covid-19 patients despite the risks imposed on their health. the high morbidity and mortality of covid-19 has increased the fear and panic in medical and health staff because in case of close and frequent contact with such patients, the risk of contracting this disease increases (8, 9). however, due to their professional ethics and commitment as the patients’ sole advocate, medical and healthcare staff need to perform their duty while observing safety measures and standard precautions. reciprocity principle the duty of care can endanger medical and healthcare staff’s health; for example, 50% of those who died during severe acute respiratory syndrome (sars) were medical and healthcare staff (2). likewise, a considerable mortality rate has been reported among healthcare staff during the covid-19 pandemic. in italy, 10% of healthcare staff contracted the disease, and 3% of them died of the disease (8). according to the reciprocity principle, hospitals have reciprocal responsibilities regarding their staff. healthcare organizations should implement appropriate measures and create infrastructures to support their staff (2), including the followings: (i) effective communication, (ii) appropriate interventions to control disease spread, (iii) motivating staff to perform their duties, (iv) providing adequate resources including ppes, (v) providing training required to create a safe environment, (vi) providing psychological and medical care to the afflicted staff, and (vii) giving priority for vaccination to the staff. responsibility and accountability of governments in caring for covid-19 patients governments should provide opportunities for individuals to achieve their maximum possible rights. control and management of pandemics are among the most difficult duties of healthcare systems, and fulfilling such duties requires the country’s executive organizations and institutions to become involved in decisionmaking and implementation processes as well as requires financial resources, trained staff, facilities, and stable infrastructure (2). undertakings to ensure the health and wellbeing of individuals in this pandemic should be fulfilled under ethically-approved conditions. to this end, undertakings need to be clearly defined as well as their effectiveness need to be evaluated. interventions should be performed justly and free of discrimination (including ethnic, race, gender and economic status), as well as based on scientific evidences. transparency in decision-makings is crucial in convincing the public about the benefits of difficult policies. consistency and flexibility in the implementation of the decisions, along with the assessment of their outcomes, promote the success of adopted policies. the covid-19 patients are only guided toward understanding and fulfilling their rights, including the right to covid-19 pandemic and the ethical challenges in patient care 6 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 24 december 2020 receive healthcare, when necessary requirements are provided for them (2, 6, 8). to do so, the policies and programs should be designed to develop social support and services to families and communities. conclusion this study’s findings highlight the necessity of considering ethical principles in caring for the covid-19 patients. hence, healthcare providers need to be educated regarding professional ethics and ethical decisionmaking. moreover, practical solutions should be provided to prevent ethical challenges, support patients’ rights, and present quality healthcare to patients during the pandemic. for this purpose, governments and health policymakers should resolve these challenges and support healthcare providers in various aspects including the followings: (i) safety and personal protection, (ii) mental and psychological health, (iii) financial issues, (iv) providing medical equipment, and (v) hiring new staff. informed and ethical decisionmakings are necessary for optimal management and increasing healthcare staff’s satisfaction, leading to enhancing patients’ contentment and health. conflict of interests authors declare no conflict of interests. sahebi a., et al. 7 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 24 december 2020 references 1. vardanjani ae, ronco c, rafiei h, golitaleb m, pishvaei mh, mohammadi m. early hemoperfusion for cytokine removal may contribute to prevention of intubation in patients infected with covid-19. blood purif. 2021; 50(2): 257-60. 2. dehghan nayeri n, taghavi t, shali m. ethical challenges in the care of emerging diseases: a systematic literature review. journal of bioethics. 2018; 7(26): 85-96. 3. khademi f, moayedi s, golitaleb m, karbalaie n. the covid‐19 pandemic and death anxiety in the elderly. international journal of mental health nursing. 2020: https://doi.org/10.1111/inm.12824. 4. morley g, grady c, mccarthy j, ulrich cm. covid‐19: ethical challenges for nurses. hastings cent rep. 2020; 50(3): 35-9. 5. rubenstein l, decamp m. revisiting restrictions of rights after covid-19. [cited december 2020]; available from: https://www.hhrjournal.org/2020/06/revisiting-restrictions-of-rights-after-covid-19/ 6. khaji a. quarantine and its related ethical issues. journal of medical ethics. 2020 ;14(45): 3. [in persian] 7. ma x, wang y, gao t, et al. challenges and strategies to research ethics in conducting covid‐ 19 research. journal of evidence‐based medicine. 2020; 13(2): 173-7. 8. mokhtari r, moayedi s, golitaleb m. covid‐19 pandemic and health anxiety among nurses of intensive care units. international journal of mental health nursing. 2020; 29(6): 1275-7. 9. bakewell f, pauls ma, migneault d. ethical considerations of the duty to care and physician safety in the covid-19 pandemic. cjem. 2020; apr 24: 1–4. 10. singh r, subedi m. covid-19 and stigma: social discrimination towards frontline healthcare providers and covid-19 recovered patients in nepal. asian j psychiatr. 2020; 53: 102222. ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ commentary copyright © 2021 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e approaches to critical care resource allocation and triage during the covid-19 pandemic: an examination from a developing world perspective saurav basu senior resident, department of community medicine, maulana azad medical college, new delhi, india. introduction the distribution of scarce critical care resources during public health emergencies in an ethically justified manner has been widely acknowledged as a major bioethics concern (1, 2). the center for disease control (cdc) recommends that critical care allocation during a pandemic emergency should uphold basic biomedical principles through maintenance of procedural justice which requires decision-making that is consistent, impartial, neutral, and nondiscriminatory (3). during the current covid-19 pandemic, health systems, even in developed countries with robust existing health infrastructure, have experienced sustained demands that have compelled the rationing of critical medical infrastructure, especially ventilators and intensive care beds (4, 5). conventionally, triage prioritizes medical utility by sorting and allocating the limited available care to patients based on their disease severity and favoring those whom the critical care intervention would give the highest survival chances (6, 7). during a public health emergency such as a pandemic, the overarching utilitarian goal of achieving the greatest good for the greatest number usually attains paramountcy. this dominant mainstream ethical view unequivocally advocates maximizing medical outcomes in terms of either lives saved or life-years gained when allocating scarce medical resources during pandemics (8, 9). equity considerations and unresolved concerns pertaining to social justice are usually deemed secondary and may be disregarded, especially when in conflict with the utility view. however, reid has strongly emphasized the need to firmly integrate justice-related concerns in resource allocation by elevating the ideals related to egalitarianism, non-discrimination and social justice (10). *corresponding author saurav basu address: department of community medicine, maulana azad medical college, new delhi, 110002, india. tel: (+91) 84 47 52 74 52 email: saurav.basu1983@gmail.com received: 4 jan 2021 accepted: 13 feb 2021 published: 28 feb 2021 citation to this article: basu s. approaches to critical care resource allocation and triage during the covid-19 pandemic: an examination from a developing world perspective. j med ethics hist med. 2021; 14: 5. approaches to critical care resource allocation and triage during the covid-19 2 j med ethics hist med. 2021 (mar); 14: 5. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e a survey of literature also reveals that in this confrontation between utilitarian and egalitarian strategies, triage management protocols during pandemics usually shun references to controversial concepts related to social utility (11), except for the limited application of instrumental value (1). nevertheless, existing ethical approaches in resolving the ethical conflicts pertaining to critical care resource allocation scenarios during the covid-19 pandemic are predominantly derived from experiences in developed countries with their state of the art health systems, high doctor-to-population ratio, improved social determinants of health, and reduced income equalities (12, 13). in contrast, several developing countries frequently experience a shortage of ventilators and rudimentary critical care resources with further worsening of the situation due to the heightened demand resulting from a surge in cases during public health emergencies (14). consequently, we argue that resolving the ethical conflicts related to pandemic triage by applying existing ethical paradigms in the resourceconstrained settings of the developing world is ineffectual in facilitating ethically sound decision-making. furthermore, the incorporation of alternative pragmatic approaches in achieving ethical propriety may be preferable to advancing universal paradigms lacking consensus and feasibility. the disadvantages of prioritizing the utilitarian approach over pandemic triage ethicists mostly reject the first-come, firstserved basis of allocating intensive care resources during a pandemic since it would compromise the tenets of both utilitarianism and equity (10, 15). for instance, patients with better awareness, social influence, and preexisting health insurance in countries where it is not universal or mandatory have better opportunities of obtaining early access to critical care if needed. the greater the social and economic disparities are in a society, the more acute the health inequity and the resultant discrimination in pursuing such an approach towards resource allocation will be. the fundamental principles guiding allocation decisions through a utilitarian approach involve maximizing benefits by either: (i) saving the most lives by advancing care to the worst-off or (ii) saving the most life-years by allocation of critical care to relatively younger patients or those having better prognosis with higher chances of survival (1, 4). moreover, some countries have constituted triage committees to promote unbiased and collective decisionmaking in the process of critical care allocation to patients (16). the primary threat in implementing a utilitarian approach during pandemic triage is when treatment prioritization based on measurement of objective medical criteria such as the sequential organ failure assessment (sofa) score or the clinical frailty scale (cfs) yield a tied prognostic score. moreover, when multiple patient scores are clustered in a narrow range, they may not vary sufficiently to permit differentiation among the patients requiring critical care but having a similar chance of recovery. furthermore, in developing basu s. 3 j med ethics hist med. 2021 (mar); 14: 5. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e countries with limited health infrastructure and poorer health indicators, there exists a higher probability of such emergent situations when insufficient medical evidence would preclude the implementation of triage by overriding the individual’s right to autonomy and equal treatment (6, 10). several months into the covid-19 pandemic, there is a lack of universal consensus among experts regarding the preferred approach when two patients are likely to benefit equally from scarce medical interventions. higher age as a tie-breaker criterion for triage during the covid-19 pandemic has been advanced previously by applying the ‘fair innings’ argument based on life-cycle considerations which elevates the goal of enabling individuals with an equal opportunity to traverse the various stages of life, irrespective of their social utility (1, 17). moreover, early in the pandemic, when health systems were overwhelmed in some european countries, especially italy, younger patients were favored over the elderly in receiving lifesaving treatment, considering their higher likelihood of survival (18). however, use of any arbitrary age-limit to withhold emergency treatment is often discriminatory both in principle and practice (19). advanced age can also reduce the discriminant ability of emergency triage systems, causing the misclassification of patients into triage categories (20). furthermore, there is growing recognition that comorbidities (and not age alone) are an independent predictor of adverse outcomes and mortality in covid-19 cases. consequently, despite advancing consideration for younger patients, most of the global guidelines for pandemic triage caution against age-discrimination and favor assessing long-term prognosis for determining triage categories (21). in several developing countries, the applicability of age as a triage criterion has been further flawed due to the inverse population pyramid wherein the elderly constitute a smaller proportion of the population compared to that in the developed world (22). consequently, a large proportion of those affected by covid-19 in developing countries comprise a relatively younger population (23), and age would be a less significant consideration in resolving the allocation dilemmas. although chronic illnesses like diabetes and hypertension generally signify poor prognosis in covid19 cases, nearly 80% of the global burden of these diseases is concentrated in lower middle-income countries (24), increasing the likelihood of having multiple patients with a similar morbidity profile. under such circumstances, when triage based on the medical utility approach is not feasible, the lottery (ballot) method is usually considered a reasonably egalitarian and fair selection process (25) whose execution is efficient in terms of time and other resources. moreover, beauchamp and childress also assert that the lottery method is likely to be more acceptable than other methods based on social worthiness, even for those not selected for treatment (26). however, this theory lacks empirical validation and assumes that approaches to critical care resource allocation and triage during the covid-19 4 j med ethics hist med. 2021 (mar); 14: 5. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e patients and their relatives searching for lifesaving care will rationally accept triage based on chance nonchalantly without having any misgivings about the process (27, 28). however, the operational feasibility of implementing the randomized lottery method of triage during a pandemic situation, particularly in those societies experiencing protracted social conflicts based on race, ethnic, religious or political ideologies that fuel distrust amongst citizens, is yet to be ascertained. furthermore, in corruptionridden societies lacking transparency, the bypassed patients and their families may be unwilling to repose their faith in an ostensible ‘fair’ lottery system during a life or death situation. governments and administrations should strive to promote transparency and demonstrate responsiveness to enable building trust within communities to facilitate triage through the lottery method whenever required. however, realizing these goals in a critical time-bound manner during an ongoing pandemic is a difficult proposition as it requires a long-term focus. the disadvantages of prioritizing equitable approaches over pandemic triage an equitable approach to pandemic triage seeks to provide a fair and just but not necessarily equal opportunity for access to lifesaving care (9, 29). an individual's socioeconomic status (ses) is linked to the extent of their risk of contracting the infection during a pandemic. socioeconomically affluent individuals can insulate themselves from the risks of getting infected with covid-19 by staying at home and living on their savings, working from home, traveling in their personal vehicles, using medicalgrade protective masks, and maintaining social distancing in spacious homes. therefore, socioeconomically disadvantaged individuals would have a higher risk of contracting covid-19 due to the preexisting suboptimal social determinants related to their living environments, workplace employment, transport and poor nutrition. in the context of developing countries with large impoverished populations, a majority may experience adverse social determinants that increase their vulnerability to covid-19 (30). to resolve the moral dilemmas stemming from the underlying social inequalities and promoting an equitable pandemic response, reid (2020) has proposed balancing solutions for inculcating considerations of social justice and affirmative action in the scoring criteria for pandemic critical care triage protocols (10). nevertheless, objective and valid data to truly differentiate patients as per their socioeconomic class or health inequities may be lacking. even if such data can be obtained, their application for pandemic triage management could stoke ethnic conflicts and intensify social fault lines in heterogeneous societies lacking social trust. moreover, in a pandemic situation, instances of unavoidable infections that can be attributed to an individual’s underlying social determinants are mostly un-differentiable from avoidable infections resulting from their non-adherence to preventive measures. certain social determinants, especially limited accessibility to intensive care among populations living in rural, remote, and basu s. 5 j med ethics hist med. 2021 (mar); 14: 5. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e underserved areas (like urban slums), represent a potentially insurmountable challenge in the absence of creating new health facilities. in countries with a dual public and private health system, access to the latter usually requires individuals to incur either steep out-of-pocket expenses or private insurance. a forcible takeover of private facilities by the government and distributing these resources in accordance with social justice norms may be unjustified since it involves trusting the government to achieve the goal of universal health coverage within days, which is what it has failed to do in years, probably since its inception. moreover, such decisions may prevent people from availing themselves of their private health insurance for health access during a public health emergency, a violation of fair contract. finally, ensuring sustainable operations of private healthcare facilities may not be viable below an economic threshold (31). a place for social utility? prospects and threats according to the utilitarian theory, social utility is a measure of an individual’s usefulness determined based on an interval scale with the potential for interpersonal comparisons (11). the concept of social utility encompasses both social value and social worth. social value refers to the instrumental quality of performing essential tasks and maintaining services that benefit the society by saving and sustaining lives and thus preserving social harmony. prioritizing health allocation for the individuals involved in fulfilling these key societal activities especially in case of healthcare workers (hcws) fulfills reciprocity-based obligations, but may also conflict with their duty to treat patients (32). however, the ethical dilemma in protecting hcws confronted between balancing the duty towards self and serving their patients can be countered by considering their social instrumental value in protecting several other lives in a multiplier effect (1, 11). so far, recognizing instrumental social value as a factor in triage assessment during a pandemic has been usually restricted to healthcare workers. moreover, using social value as the criterion for making allocation decisions has been criticized since it would prioritize the economically dominant over the economically marginalized as the former are likely to be linked with greater social productivity (33). nevertheless, we find that such reasoning is unwarranted especially in developing countries since social value can be recognized in a substantial category of essential workers belonging to low socioeconomic backgrounds. these include agriculturalists, dairy workers, retail shop employees, and those involved in home delivery of essential goods and services, etc., who also happen to experience occupational hazards during the pandemic. some of them, especially urban sanitation workers, often experience societal discrimination, and frequently operate without appropriate safety equipment (34), further aggravating their risk of contracting the infection. therefore, in a pandemic, resource-allocation conundrums are complicated by competing claims from approaches to critical care resource allocation and triage during the covid-19 6 j med ethics hist med. 2021 (mar); 14: 5. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e individuals with higher occupational social value in modern societies where interdependence is the norm. furthermore, quantifying the social value of an individual through their employment (and associated risks) that enables others to meet their life sustaining needs lacks a validated metric with wide acceptability. social worth refers to an individual's subjective or intrinsic worth inclusive of past service to their communities and also the objective or extrinsic worth informed by their existing social value which critically envisage their potential contribution towards rebuilding the post-pandemic society (11). conventionally, the concept of social worth is considered controversial in deciding health allocation and triage issues since it conflicts with the principle of egalitarianism, which deems all individuals to have equal moral worth and an equal right to access lifesaving treatment. accordingly, most ethicists shun the idea of social worth considerations influencing rationing and triage decisions even during a severe pandemic due to the apprehension of undermining an individual’s dignity (3, 11). moreover, factors influencing social worth, including social status, economic affluence and social influence, can determine access to scarce health resources in many developing countries (35), including the preferential or out of turn allotment of lifesaving treatment and intensive care hospital beds. conversely, in these settings, those with lower social worth are likely to be unfairly deprived of lifesaving care, such as prisoners compelled to live in crowded prison environments, the majority of whom are undertrials awaiting trial verdicts without having been convicted for their alleged crimes (36, 37). we argue that in a resource scarce scenario during a pandemic among individuals with tied or nearly tied prognostic scores needing lifesaving treatment, allocation methods based on a social utility consideration may be more equitable and consistent with justice concerns compared to random allocations. such an ethical framework would measure the social utility of an individual by recognizing both their social value and their extrinsic social worth, while being oblivious to their intrinsic social or moral worth. considerations for assessment of higher extrinsic social worth could possibly include the beneficiary's potential role in rebuilding the society in a post-pandemic environment (11), accounting for the impact of the breadwinner's death on the family, or recognizing the long-term psychosocial impact of the death of an only child on a middle-aged couple (38). previous surveys in developed western countries have also highlighted the willingness of people to prioritize healthcare allocations among patients who are caregivers of dependents in exclusion of other considerations related to their socioeconomic status (39 41). furthermore, the possibility that the triage decision that accounts for social utility is more acceptable than the one based on a lottery can only be definitively answered through empirical probing of all stakeholders on this delicate question of ethical propriety. this is because random allocation based on chance, which distributes events equally, basu s. 7 j med ethics hist med. 2021 (mar); 14: 5. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e presupposes the absence of greater long-term societal good achievable through an alternative allocation paradigm based on social utility. there is also emerging evidence of the feasibility of ordinary groups of citizens making informed decisions on complex problems related to healthcare allocation (42). furthermore, in eastern and asian societies the family's relational involvement in medical decision-making is more likely to be prioritized over individual decision-making compared to western countries (43). consequently, when resolving ethical dilemmas related to pandemic triage, western paradigms based on the atomist view favoring radical individualistic notions of the self may lack applicability in developing countries with vastly different family structures, morals, and cultural beliefs (44, 45). conclusion the reconciliation of utilitarian and equitable approaches to pandemic triage through a universal ethical proposition for allocation of critical care health resources is ineffective in most of the developing world primarily due to their large population size/density, and limited pre-existing healthcare availability. in these settings, existing parameters for triage assessment based on considerations of age, equity, restricted instrumental value, and social justice may be inadequate for achieving the goals of maximizing both medical and equitable outcomes. implementing random intensive care allocation among multiple patients with an equal need and an equal chance of recovery is further complicated within a complex social milieu in heterogeneous societies with prevalent ethnic tensions and social distrust. consequently, greater expansion of social utility considerations in critical care resource allocation during public health emergencies as a policy warrants further inquiry and consultation among diverse and credible stakeholders, especially in multiethnic societies. public engagement to solicit the opinions of health professionals, public intellectuals, civil society activists, and representatives from the lay public would be necessary for making such life and death decisions further efficient, consistent, and just. acknowledgments none conflict of interests the author declares no conflict of interest. approaches to critical care resource allocation and triage during the covid-19 8 j med ethics hist med. 2021 (mar); 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j, nosek ba, haidt j, iyer r, koleva s, ditto ph. mapping the moral domain. j pers soc psychol. 2011; 101(2): 366-85. microsoft word professionalism tannaz ahadi 23-12-93 journal of medical ethics and history of medicine original article professionalism in residents of physical medicine and rehabilitation in iran tannaz ahadi1, elaheh mianehsaz2*, gholamreza raissi3, seyed alireza moraveji4, vahid sharifi5 1 assistant professor, department of physical medicine and rehabilitation, firouzgar hospital, iran university of medical sciences, tehran, iran; 2clinical research unit, shahid beheshti hospital, kashan university of medical sciences, kashan, iran; 3associate professor, department of physical medicine and rehabilitation, firouzgar hospital, iran university of medical sciences, tehran, iran; 4associate professor, department of community medicine, kashan university of medical sciences, kashan, iran; 5medical student, iran university of medical sciences, tehran, iran; 5medical student, iran university of medical sciences, tehran, iran. corresponding author: elaheh mianehsaz address: clinical research unit, shahid behesti hospital, ghotbe-ravandi ave, kashan, iran. email: elaheh.mianehsaz@gmail.com tel: 98 3155510026 received: 23 apr 2014 accepted: 10 mar 2015 published: 15 mar 2015 j med ethics hist med, 2015, 8:3 © 2015 tannaz ahadi et al.; licensee tehran univ. med. sci. abstract professionalism is the foundation of trust on which the doctor-patient relationship is built. this study was performed to measure professionalism in iranian physical medicine and rehabilitation residents as a baseline assessment tool for future studies. this was a descriptive study. the persian version of the american board of internal medicine (abim) questionnaire was distributed among all the second and third-year residents of the medical state universities of iran (n=43). data were summarized as mean (sd), and independent samples t-test was used for comparison of means between genders, and also between the second and third-year residents. forty questionnaires were analyzed. the mean (± sd) age of respondents was 29.95 (± 2.37) years. the mean score (sd) for the overall score was 115.15 (± 17.36) out of 150, and the mean score (± sd) for all items was 7.67 (± 1.15) out of 10. the respondents averaged 5.88 (± 1.69) for items forming the ‘excellence’ factor, 7.98 (± 1.48) for items in ‘altruism/respect’ and 8.92 (± 1.26) for items in the ‘honor/integrity’ subscale. these data may serve as a baseline for future research in this field. the lowest score pertained to excellence, which needs more focus in future studies. keywords: professionalism, physical medicine and rehabilitation, abim questionnaire j med ethics hist med 8:3 mar, 2015 jmehm.tums.ac.ir tannaz ahadi et al. page 2 of 6 (page number not for citation purposes) introduction over the past decades, more global attention has been given to medical professionalism. in iran, teaching professionalism is an essential part of medical residency training in all programs including physical medicine and rehabilitation (pm&r). professionalism can be defined as behaviors, goals, or qualities that characterize a profession or a professional person (1) and in medicine it requires physicians to serve patients’ needs and interests above their own (2). in other words, professionalism is the foundation of trust on which the doctor-patient relationship is built. according to the american board of internal medicine (abim), professionalism seeks altruism, accountability, excellence, duty, service, honor, integrity, and respect for others (2, 3). traditional medicine in iran has an inseparable relation with teachings of avesta (4) comprising codes of medical conduct and characteristics of a good physician. the latter include conscience, compassion, modesty, avoiding abortion and prescription of abortive and lethal drugs and considering the financial situation of patients, and failure to comply with these rules would lead to punishment (5). later, during the islamic era, wellknown iranian physicians like tabari, avicenna, and razi dedicated a part of their books to medical conduct (4). in recent years, more research has been conducted on medical ethics and professionalism in medical schools of iran and other parts of the world. additionally, several papers have been published focusing on the moral and professional issues in iranian traditional medicine and historical perspectives (4, 5). although professionalism is an element of all physician training and practice, each specialty defines specific professionalism criteria and uses particular questionnaires. abim has created a charter for physician professionalism, which defines professionalism for internists (6). furthermore, the specialty-specific professionalism questionnaire has been reported for several specialties including pm&r (7), emergency medicine (8), and orthopedics (9-11). a widely recognized tool to measure professionalism in medical training environments has been developed by arnold et al. and is a questionnaire comprising 12 items, each component representing a specific component of professionalism as operationally defined by abim (3, 12). following this study, delisa et al. carried out a study applying a revised version of the abovementioned questionnaire. theirs was a 12-item questionnaire, which aimed to assess professionalism in pm&r residents of six pm&r residency training programs in the united states (7). aramesh et al. assessed the persian version of the abim questionnaire (13). the questionnaire was distributed among residents of 19 fields of specialty (except pm&r) in two major universities of medical sciences in iran. results showed that the 15-item persian version of the modified abim questionnaire is a reliable and valid instrument for measuring professionalism (13). since aramesh et al. did not assess professionalism in iranian residents of pm&r, we used this instrument to measure professionalism in iranian pm&r residents. method we performed this descriptive study in all 5 medical state universities of the country (iran, shahid beheshti, shiraz, tabriz, and isfahan). in iran, pm&r is a three-year specialty after internship and there are 7 residency programs educating about 25 residents annually. in the annual pm&r conference a lecture has been presented by raissi concerning the importance of professionalism in the field of pm&r. rosters of all medical residents were obtained from the education office of each university. considering the inadequate presence of first year residents in pm&r departments (since 3 months ago), the questionnaires were distributed among all second and third-year residents (n=43). chief pm&r residents and attending physicians were instructed to explain our goals of the project to all the second and the third-year residents, distribute the questionnaires among them, and once the forms were filled, collect them. thereafter, the completed questionnaires were sent to the research team by mail. the whole process of distributing, filling out and delivering the questionnaires lasted three months (from december 2012 to february 2013). in this study, the persian version of the modified abim questionnaire was used. content validity and internal reliability of this questionnaire was evaluated by aramesh et al. (13). in the final questionnaire they omitted one question from the original abim questionnaire, which was: ‘during this rotation (residency training), i have met individuals whom i consider role models’. the justification was that the concept overlapped with that of another item: ‘during my most recent clinical rotation (residency training), i have encountered individuals who display and promote professional behavior’. moreover, aramesh et al. added four new items (12 to 15 as seen in table 1) to the final recommended questionnaire. thus, their final questionnaire included 15 items in 3 subscales, ‘excellence’, ‘honor/integrity’, and ‘altruism/respect’ (table 1). aramesh et al. reported the internal reliability of the scale to be 0.88 based on cronbach’s alpha, which meets nunnally’s minimal requirement, and we used this short, reliable and j med ethics hist med 8:3 mar, 2015 jmehm.tums.ac.ir tannaz ahadi et al. page 3 of 6 (page number not for citation purposes) valid questionnaire to measure professionalism in the present study. a comparison of the questions of the original abim (2), delisa et al. (7) and aramash et al. (13) are presented in table 2. our subjects were also asked whether they had participated in any conferences or workshops on professionalism during their residency-training program. other questions were about self-training in the subject and their gender, age and the year of study (second or third-year residency). table 1factors and items used for measuring professionalism factor 1: excellence 1. during my most recent clinical rotation (residency training), i have encountered individuals who display and promote professional behavior. 2. my residents (resident colleagues) have assisted me in attaining educational material (e.g., journal articles, textbooks) pertaining to my patients. 3. i have observed that my residents (resident colleagues) place the needs of their patients ahead of their own selfinterest. 4. i observed that the residents (resident colleagues) i have worked with educate their patients about their illnesses. factor 2: honor/integrity 5. i have been instructed to withhold data from a patient’s chart without being given an explanation by my senior resident or attending physician. 6. i have observed my residents (resident colleagues) lie to a patient. 7. the residents (resident colleagues) i have worked with asked me to write orders or fill out forms and sign their names. 8. i have been urged by my residents (resident colleagues) to copy their history and physical examination rather than gather my own information from the patient. factor 3: altruism/respect 9. i have observed residents (resident colleagues) referring to patients as ‘hits, gomers, real citizens, walkie-talkies, players, frequent flyers’ or other offensive terms. 10. i have observed residents (resident colleagues) making derogatory statements about other medical/surgical specialty groups or other health care workers. 11. i have observed residents (resident colleagues) scheduling tests or performing procedures at times that are more convenient for themselves than for the patient. 12. i have observed residents (resident colleagues) referring patients to other emergency units or hospitals without a justifiable reason. 13. i have observed residents (resident colleagues) using the materials and equipment of the hospital squanderingly. 14. i have observed residents (resident colleagues) consider their low income and welfare as a reasonable excuse to deliver insufficient services to their patients. 15. i have observed residents (resident colleagues) disclose the private issues of their patients to other residents. table 2 a comparison of three questionnaires used to measure professionalism items of questionnaire arnold et al. (abim) delisa et al. aramesh et al. and current study during my most recent clinical rotation (residency training), i have encountered individuals who display and promote professional behavior. + + + my residents (resident colleagues) have assisted me in attaining educational material (e.g., journal articles, textbooks) pertaining to my patients. + + + i have observed that my residents (resident colleagues) place the needs of their patients ahead of their own self-interest. + + + i have observed that the residents (resident colleagues) i have worked with educate their patients about their illnesses. + + + during this rotation (residency training), i have met individuals whom i consider role models. + _ _ i have observed that the residents i work with actively contribute to the community they serve by participating in community activities outside of their responsibilities at the hospital. _ + _ i have been instructed to withhold data from a patient’s chart without being given an explanation by my senior resident or attending physician. + + + j med ethics hist med 8:3 mar, 2015 jmehm.tums.ac.ir tannaz ahadi et al. page 4 of 6 (page number not for citation purposes) i have observed my residents (resident colleagues) lie to a patient. + + + the residents (resident colleagues) i have worked with asked me to write orders or fill out forms and sign their names. + + + i have been urged by my residents (resident colleagues) to copy their history and physical examination rather than gather my own information from the patient. + + + i have observed residents (resident colleagues) referring to patients as ‘hits, gomers, real citizens, walkie-talkies, players, frequent flyers’ or other offensive terms. + _ + i have observed residents (resident colleagues) making derogatory statements about other medical/surgical specialty groups or other health care workers. + + + i have observed residents (resident colleagues) scheduling tests or performing procedures at times that are more convenient for themselves than for the patient. + + + i have observed resident colleagues referring patients to other emergency units or hospitals without a justifiable reason. _ _ + i have observed resident colleagues using the materials and equipment of the hospital squanderingly. _ _ + i have observed resident colleagues consider their low income and welfare as a reasonable excuse to deliver insufficient services to their patients. _ _ + i have observed resident colleagues disclose the private issues of their patients to other residents. _ _ + +: present -: absent statistical analysis mean and standard deviation (sd) were measured. independent samples t-test was used for comparison of means between genders, and also between the second and third-year residents. all statistical analyses were calculated by spss software version 21, and p values smaller than 0.05 were considered statistically significant. results of the 43 distributed questionnaires, 42 were returned (a response rate of 97.6%). however, two sheets were incomplete and were therefore excluded from the study, and a total of 40 sheets were used in the final analysis. the mean (± sd) age of respondents was 29.95 (± 2.37). the mean score (sd) for the overall score was 115.15 (± 17.36) out of a maximum 150. the subjects’ responses to the items forming each factor were also examined. on a scale of 0 to 10 where 10 represents the highest level of professionalism, the mean score (± sd) for all items was 7.67 (± 1.15) out of 10. the respondents averaged 5.88 (± 1.69) for items forming the ‘excellence’ factor, 7.98 (± 1.48) for items in ‘altruism/respect’, and 8.92 (± 1.26) for items in ‘honor/integrity’ factor. there was no significant difference between the second and third-year, or male and female residents (table 3). all the residents had participated in medical ethics, which is a 36-hour course in the undergraduate period. only four residents had taken part in not only medical conduct classes but also a professionalism workshop or conference, although their responses showed no significant statistical difference compared with others (table 3). moreover, five residents had self-training in the field of professionalism, but their responses were not significantly different from the others (table 3). table 3 mean (and sd) of subscale scores stratified by gender, year of study, participation in professionalism workshops, self-training and professionalism of respondents. subscale scores characteristics excellence score honor score altruism score total score p value gender male (n = 20) 23.30 ± 6.79 36.55 ± 3.62 55.85 ± 10.96 115.70 ± 17.46 > 0.05 female (n = 20) 23.85 ± 6.83 34.85 ± 6.12 55.90 ± 10.07 114.60 ± 17.69 year of study year 2 (n = 23) 21.87 ± 6.66 36.04 ± 4.19 57.43 ± 8.82 115.35 ± 14.21 > 0.05 year 3 (n = 17) 25.88 ± 6.29 35.00 ± 6.23 53.76 ± 12.16 114.88 ± 21.37 professionalism yes (n = 4) 25.25 ± 7.97 36.25 ± 2.06 57.50 ± 4.20 119.00 ± 13.44 > 0.05 j med ethics hist med 8:3 mar, 2015 jmehm.tums.ac.ir tannaz ahadi et al. page 5 of 6 (page number not for citation purposes) workshop no (n = 36) 23.39 ± 6.68 35.64 ± 5.28 55.69 ± 10.88 114.72 ± 17.84 self-training in professionalism yes (n = 5) 26.6 ± 6.18 37.40 ± 2.40 62.60 ± 3.97 126.60 ± 12.17 > 0.05 no (n = 35) 23.14 ± 6.77 35.46 ± 5.28 54.91 ± 10.69 113.51 ± 17.50 discussion professionalism has had a long history in iran, and many studies have recently been conducted in this field (13-16). pm&r education is also among topics of interest in the country (17), and pm&r specialists quite often encounter challenging ethical problems in their practice (18). nevertheless, there has been a shortage of studies on the status of professionalism in iran during recent years. the present study was conducted on the pm&r residents throughout the country. the response rate in this study was 97.6%, which is higher than that of similar studies, for instance 75% in arnold et al. (3), and 59% in delisa et al. (7). this was due to the cooperation of chief residents and the request of other residents to fill out the questionnaire rather than send them by mail. in the present study, the mean score (± sd) for all items was 7.67 (±1.15) out of 10, and this shows a high level of professionalism among the pm&r residents. the same score was 7.7 and 6.12 for delisa et al. (7) and aramesh et al. (13) respectively. according to our findings the highest score (8.92 ± 1.25) pertained to the ‘honor/integrity’ subscale and the lowest (5.88 ± 1.69) to the ‘excellence’ subscale. the same order of subscales was also reported by delisa et al. (7) and aramesh et al. (13). the ‘honor/integrity’ factor shows the point to which the respondents consider their colleagues to be honest and refrain from behaving unprofessionally. examples of unprofessional conduct are telling lies to patients and encouraging their junior residents to keep data from patients’ charts or to make copies of their history and physical tests (13). in the present study, the highest score pertained to the ‘honor/integrity’ factor, suggesting that the study subjects believed their colleagues were quite honest. the ‘altruism/respect’ element signifies the respondents’ view of their colleagues’ respect for their patients, their colleagues, and the rules of the hospital, which prevent them from using resources and tools inefficiently. this subscale also reflects the responders’ views regarding their colleagues’ consideration for patients’ needs and convenience in scheduling tests and procedures (13). the ‘excellence’ factor evaluates the responders’ opinions of their colleagues as health service providers who demonstrate and promote professional conduct, help their coworkers, place their patients’ needs above their own, and educate their patients (13). in the present study, the lowest score was reported in the ‘excellence’ subscale signifying that the respondents believed their role models required improvement. the responses of residents who had participated in professionalism workshops or conferences (n=4) or had self-training in this area (n=5) were not significantly different from those who had not. nevertheless, this may be due to the small sample size, and further studies are required to investigate the effect of participation in classes, workshops and seminars on the level of professionalism in residents. conclusion this article is a preliminary study on professionalism in pm&r residents in iran, and future research is needed to recognize factors affecting health service providers’ level of professionalism. educational courses can be assessed from this standpoint so that professional training programs and workshops may be added to the pm&r residency curriculum. conflict of interest none of the authors had any personal or financial conflict of interest. acknowledgments the authors express their gratitude to residents of iran, shahid beheshti, shiraz, tabriz, and isfahan universities of medical sciences, dr. bina eftekharsadat and dr. kiarash aramesh for their helpful assistance. j med ethics hist med 8:3 mar, 2015 jmehm.tums.ac.ir tannaz ahadi et al. page 6 of 6 (page number not for citation purposes) references 1. swick hm. toward a normative definition of medical professionalism. acad med 2000; 75(6): 612-16. 2. anonymous. american board of internal medicine. project professionalism. philadelphia, pa: abim; 1995. 3. arnold el, blank ll, race keh, cipparrone n. can professionalism be measured? the development of a scale for use in the medical environment. acad med 1998; 73: 1119–21. 4. ghaffari f. a perspective of medical ethics and patients’ rights according to iranian and islamic traditional medicine texts. med hist 2010; 2(4): 11-45 [in persian] 5. farsam h. the pathology of pharmacy ethics. iran j med ethics hist med 2008; 1: 61-66. [in persian] 6. 2005 rsna professionalism committee. medical professionalism in the new millennium: a physicians' charter. radiology 2006; 238(2): 383-6. 7. delisa ja, foye pm, jain ss, kirshblum s, christodoulou c. measuring professionalism in a physiatryresidency training program. am j phys med rehabil 2001; 80: 225–9. 8. larkin gl. evaluating professionalism in emergency medicine: clinical ethical competence. acad emerg med 1999; 6(4): 302-11. 9. baldwin dc jr, bunch wh. moral reasoning, professionalism, and the teaching of ethics to orthopedic surgeons. clin orthop relat res 2000; 378: 97-103. 10. rowley bd, baldwin dc jr, bay rc, karpman rr. professionalism and professional values in orthopedics. clin orthop relat res 2000; 378: 90-6. 11. rowley bd, baldwin dc jr, bay rc, cannula m. can professional values be taught? a look at residency training. clin orthop relat res 2000; 378: 110-4. 12. anonymous. accreditation council for graduate medical education. advancing education in medical professionalism. http://medprof.bjmu.edu.cn/xsqy/8_acgme%20advancing%20education%20in%20mp%20profm_packet6.pdf (accessed in 2015) 13. aramesh k, mohebbi m, jessri m, sanagou m. measuring professionalism in residency training programs in iran. med teach 2009; 31(8): 356-61. 14. asghari f, samadi a, rashidian a. medical ethics course for undergraduate medical students: a needs assessment study. j med ethics hist med 2013; 6:7. 15. borhani f, jalali t, abbaszadeh a, haghdoost aa, amiresmaili m. nurses' perception of ethical climate and job satisfaction. j med ethics hist med 2012; 5: 6. 16. javadi m, asghari f, salari p. assessment of professionalism in iranian pharmacists. j med ethics hist med 2011; 4: 6. 17. raissi gr, ahadi t, forogh b, adelmanesh f. forty years history of physical medicine and rehabilitation in iran. j rehabil med 2011; 43(4): 369. 18. raissi gr. earthquakes and rehabilitation needs: experiences from bam, iran. j spinal cord med 2007; 30(4): 369-72. ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e review article copyright © 2021 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. incivility toward nurses: a systematic review and meta-analysis *corresponding author soolmaz moosavi address: vali-asr avenue, cross of vali-asr avenue and hashemi rafsanjani (neiaiesh) highway, opposite to rajaee heart hospital, tehran, iran. postal code: 1996835119 tel: (+98) 21 88 20 25 21 email: moosavi.soolmaz@sbmu.ac.ir received: 16 jan 2021 accepted: 1 sep 2021 published: 3 nov 2021 citation to this article: atashzadeh shoorideh f, moosavi s, balouchi a. incivility toward nurses: a systematic review and meta-analysis. j med ethics hist med. 2021; 14: 15. foroozan atashzadeh shoorideh 1, soolmaz moosavi 2*, abbas balouchi 3 1.professor, department of psychiatric nursing and management, school of nursing and midwifery, shahid labbafinezhad hospital, shahid beheshti university of medical sciences, tehran, iran. 2.assistant professor, department of medical surgical nursing, school of nursing and midwifery, shahid labbafinezhad hospital, shahid beheshti university of medical sciences, tehran, iran. 3.student research committee, phd student of nursing, school of nursing and midwifery, iran university of medical sciences, tehran, iran. abstract one important part of a nurse’s job is to create and help maintain a safe work environment. evidence shows that negative behaviors such as incivility are not uncommon in the nursing profession. this systematic review and meta-analysis aimed to examine the prevalence of incivility toward nurses. for this purpose, all observational studies that primarily investigated the rate of incivility toward nurses were selected. the electronic databases pubmed, embase, web of sciences, magiran, irandoc, and scopus were searched for studies published during the period of january 1, 1996 to december 31, 2019. the quality of studies was assessed using hoy’s critical assessment checklist. the study was undertaken using the random effects model, and data were analyzed using stata14. data on 60 articles, including data on 30801 individuals, published between 1997 and 2019, entered the study. the findings showed the prevalence of incivility to be 55.10% (95%, ci: 48.05, 62.06). due to the high prevalence of uncivil behavior, especially of the verbal type, nursing managers should identify risk factors in the workplace. planners should develop programs to increase workplace safety, especially in centers that are most exposed to these behaviors. it is also recommended that future studies focus on implementation of effective evidence-based interventions based on organizational culture. keywords: incivility; uncivil behavior; nurses; workplace violence. incivility toward nurses: a systematic review and meta-analysis 2 j med ethics hist med. 2021(november); 14: 15. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e introduction civility is defined as being polite and kind in disposition and speech. civil behavior refers to polite behavior toward others and ensuring that their dignity is maintained. on the contrary, incivility is defined as the negative behavior of insulting others or violating the common norms of behavior in the workplace (1). incivility is a new concept in the psychology of occupational health (1) with most of the related literature being published at the beginning of the current century. in recent years, the increasing number of publications on this topic indicates that incivility occurs more frequently than other extreme behaviors in the work environment. a study by bjorkqvist et al., showed that 32% of university employees had experienced incivility (2). a study conducted by duncan reported the rate of incivility toward nurses to be higher than 46% and stated that onethird of nurses had been exposed to physical violence. this study reported that 100% of er nurses had been exposed to verbal violence and more than 80% to physical violence (3). incivility was first defined by anderson and pearson as “negative behaviors with lowintensity and unclear intention that damage the targeted person” (4). some of the terms used to describe incivility are lateral violence, disruptive behavior, abuse, conflict, bullying and aggression. these behaviors occur frequently in healthcare environments, lead to numerous negative consequences and can lead to more severe violence (4, 5). uncivil behaviors include verbal abuse, nonverbal abuse, sexual harassment, and passive aggressive behavior. verbal abuse involves shouting, raising one’s voice in a hostile manner, threatening a person verbally and overtly scolding or criticizing them, as well as using insulting and disgracing words, disrespectful tones, impoliteness, sarcastic behavior and humiliation (6). nonverbal abuse includes raising the eyebrows, screwing up the eyes, scowling, creating physical distance, excluding someone from conversations, and/or invading someone’s privacy (7). sexual harassment may be manifested in the form of inappropriate behaviors that could be construed to have sexual intention, offensive sexual jokes, words that are sexual in nature, unwanted sexual advances, requests for sex and accidental sexual contact (7). passive aggressive behaviors in the workplace are among uncivil behaviors that can be particularly destructive. they include lack of support for colleagues, plotting against work rivals, refusing to communicate with an individual, impatience with other people’s questions and manifesting a negative attitude, all of which affect colleagues’ confidence (8). studies on incivility in the work environment suggest that it is often produced by emotionally annoying interactions due to inappropriate demonstrations of anger and anguish, tension, heavy workload, lack of communication, occupational insecurity, organizational change, poor task management, differences in social power atashzadeh shoorideh f., et al. 3 j med ethics hist med. 2021(november); 14: 15. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e and reciprocal relation of duties (1). these variables, as stressors, may lead to depression and undesirable physical symptoms. experience of incivility in the work environment is negatively correlated with psychosomatic health (2) and is recognized as the prerequisite for aggressive behaviors and violence in the workplace (5). individuals enter the workplace with experiences related to their family life, personal values, communication styles, cultural or ethnic prejudices and other events that can affect their attitudes and practices and lead to destructive behaviors in the workplace (9,10). in addition, organizational factors such as power position and a number of irregularities and even some performance improvement schemes such as feedback and incentive systems may lead to non-civil behavior by increasing competition (11). on the other hand, an individual experience of incivility can lead to the continuation of this chain and its expansion by creating a motivation for retaliation (12,13). generally, creation and maintenance of a safe work environment is included in the nursing role. disruptive behaviors negatively affect patient outcomes and nursing performance. therefore, nurses should support patients and help them deal with disruptive behavior to create and maintain a safe environment for giving quality care. a review of previous studies showed that few studies have focused on incivility. azami et al.’s study investigated incivility toward nurses in iran; they found that in 26 studies, the rate of prevalence of examined variables including violence and verbal, physical, sexual and racial threat in the work environment were 80.8%, 24.8%, 6.14%, and 44%, respectively (14). a systematic review was carried out by dalvand et al., to assess violence in iranian nurses’ work environment. the results showed that 74% of the nurses had been exposed to verbal, and 28% to physical violence. previous research had also showed a high prevalence of workplace violence toward nurses (15). the systematic review by d’ambra and andrews was aimed at assessing the effect of incivility on recently-graduated nurses. in this study, sixteen papers were extracted that demonstrated incivility in the workplace to be an important predictor of low job satisfaction among beginner nurses (16). the systematic review by edward et al. was conducted on the correlation between workplace violence and nurses’ anxiety. the results demonstrated that nurses in emergency wards were more frequently exposed to verbal violence than other wards. the most frequent time of exposure to violence was reported to be the point of direct care of patients, and violence was committed either by the patients or their attendants. as a rule, nurses did not report the violence due to various organizational reasons (17). the review study of sources by hawkins et al. assessed beginner nurses’ experiences of negative behaviors. the findings suggested that between 3% and 57% of the nurses had incivility toward nurses: a systematic review and meta-analysis 4 j med ethics hist med. 2021(november); 14: 15. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e experienced negative behaviors leading to depression, anxiety and work leave (18). the systematic review by zhu et al. aimed to explore the experience of incivility in nursing students. the results showed that nursing students experienced incivility during their clinical training and confirmed the importance of the managers’ role in reducing these behaviors (19). finally, a systematic review was conducted by hodgins et al. to assess effective interventions for decreasing violence and incivility in the workplace. the results revealed that weak interpersonal communication was one of the most important causes of incivility, and that training and awareness of incivility and violence can be effective in reducing the incidence of these behaviors (20). in summary, a review of previous studies shows that systematic reviews on incivility toward nurses are few. several studies have examined the prevalence of incivility toward specific groups of nurses or in certain countries, regions and limited wards. however, to the best of our knowledge, there have been no studies on the global prevalence of incivility toward nurses. also, non-civil behavior in the workplace leads to negative outcomes such as low productivity, conflict, reduced job satisfaction and less organizational commitment; therefore, awareness of this ethical problem can help with the assessment of the current situation as well as effective and realistic planning to prevent and also follow up on the consequences. subsequently, our systematic review and meta-analysis aimed to determine the prevalence of incivility toward nurses. methods design of the study this systematic review and meta-analysis was conducted on observational studies concerning the prevalence of incivility in nurses’ workplace. in this systematic review and meta-analysis, observational studies were selected based on condition, context, population (cocopop) (21). the review question was: what is the prevalence of incivility toward nurses working in health centers? to achieve the goals, the guideline “meta-analysis of observational studies in epidemiology (moose)” was used (22). inclusion criteria all observational studies (descriptive and analytical) focusing on investigation of the rate of prevalence of incivility toward nurses were selected, regardless of the sampling method they had used. exclusion criteria letters to the editor, protocols, review studies, case series, case reports and studies with sample volumes less than 25 were excluded from the study. in addition, studies were excluded if they used researcher-made instruments to examine incivility, were repetitious, or involved non-reporting of incivility. there were no limitations in the language of the studies as we used free translators like imtranslator, bing, google translate, and applied languages to translate papers into other languages. search strategy in this study, the databases including atashzadeh shoorideh f., et al. 5 j med ethics hist med. 2021(november); 14: 15. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e medline (via pubmed), embase, scopus, web of science, irandoc, and magiran were searched for works published from january 1, 1996 to december 31, 2019. moreover, related studies, dissertations and conference papers were searched. the search strategy is given in the following medline script: ((incivility[title/abstract] or uncivil behavior*[title/abstract] or workplace incivility [title/abstract] or rudeness [title/abstract] or bullying[title/abstract] or abuse [title/abstract] or lateral violence [title/abstract] or horizontal violence [title/abstract] or relational aggression [title/abstract] or workplace violence [title/abstract] or negative act* [title/abstract] or negative behavior* [title/abstract] or disruptive behavior* [title/abstract] or horizontal hostility [title/abstract])) or incivility [mesh terms])) and (nurs* [title/abstract] or personnel nurs* [title/abstract] or registered nurs* [title/abstract] or caregiver* [title/abstract])) and (prevalence [title/abstract] or incidence [title/abstract] or frequency [title/abstract] or occurrence [title/abstract] or burden [title/abstract] or epidemiology [title/abstract])) data extraction two independent researchers (sm, ab) completed the initial screening of the studies based on titles and abstracts. in the next stage, two researchers (sm, fa) studied the full texts of papers presumed to have reported consequences in more detail. then, the relevant papers were outlined in a checklist. only studies that examined the prevalence of non-civil behavior were included. data such as study features including author(s), publication date and type of journal, setting of the study, goal(s), design and type of study, sample volume, sampling method, and characteristics of the participants such as age, gender, ward and work experience were extracted. in all of these stages, any disagreement or conflict between the two researchers was settled by consensus via bilateral debate or by a third party. qualitative assessment the selected studies were assessed qualitatively using hoy’s critical assessment checklist in 10 items. items 1 4 assess external validity (target population, sampling framework, sampling method, and bias of lack of responding), items 5 9 assess internal validity (data collection method, case definition, and instruments), and item 10 evaluates analytical bias. each question is given a score of "0" (yes) or "1" (no), which indicate low risk and high risk, respectively. an overall score between 0 and 3 indicates low risk, a score between 4 and 6 indicates moderate risk, and a score between 7 and 9 indicates high risk (23). result description of the studies at first, 6876 studies were identified across electronic databases. after removing duplicate studies and those not meeting the inclusion criteria, a total of 60 studies remained, which were covered in this incivility toward nurses: a systematic review and meta-analysis 6 j med ethics hist med. 2021(november); 14: 15. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e review. the numbers of the extracted studies categorized by database were as follows: pubmed: 1391; web of science: 225; scopus: 3190; and embase: 2070. after omitting 3451 repetitious studies, 3425 studies entered the screening phase and 3235 irrelevant studies were excluded. next, 190 studies entered the full text reading stage, of which 130 studies were excluded due to differences in participants (70 cases) and study design (60 cases), so that finally, 60 studies entered the study (figure 1). fig. 1the search flowchart for articles in databases based on the prisma 2009 checklist these studies had been conducted between 1997 and 2019 on 30801 participants. the characteristics of the selected works are presented in table 1. the largest and smallest numbers of participants were 3835 and 80, respectively. most studies pertained to asian countries (n = 31) (24 54), followed by the united states (n = 15) (5569), africa (n = 8) (71 78), europe (n = 2) (79 80), and eurasia (n = 4) (81 84). among the asian countries, iran (n = 6) (25,26,33,36,41,54) and taiwan (n = 5) (24, 27,29,35,50) had the greatest number of studies. it should be added that 30 studies had atashzadeh shoorideh f., et al. 7 j med ethics hist med. 2021(november); 14: 15. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e been conducted in developed, and 30 in developing countries. 21 studies used random sampling (26,27,30-33,36,37,41,42,47,5456,58,59,60,63,70,71,73,74,79), eight used census sampling (35,53,65,66,72,76), and 23 used convenient sampling (24,28,29,34,39,4447,49,51,52,61,62,64,67,69,75,77,78,81-83). eight studies did not announce which sampling method they had used (25,38,40,43,50,57,68,80). forty studies used cross-sectional design (25-27,29,3140,42-47,49-51,53,57,61,62,66,68,70,7073,77,78,80-83), and twenty studies were descriptive (24,28,30,41,52,54-56,58-60,6365,67,69,74-76,79). the minimal rate of response was 3% and the maximal rate was 100%. three studies did not report the response rate. six studies were performed in the psychiatric ward, 6 in emergency care, and 2 in icu. most studies (n = 46) involved general hospitals and all wards. the most frequently used instruments were “workplace violence in the health sector” developed through the collaboration of the international labor organization (ilo), the who, the icn, and the psi in 2003 (27 cases), and “negative acts questionnaire” (10 cases). table 1studies dated 1997 2019 included in the systematic review (n = 60) id author year country s.size objective results quality. a** 1 sauer& mccoy 2016 u.s.a 2250 the impact of nurses’ resilience on the healthrelated consequences of bullying 40% had been bullied, and had lower physical and mental health. low risk 2 heydari et al. 2015 iran 200 the frequency of incivility between nurses and head nurses 28.8% had observed non-civil behaviors at least once. low risk 3 budin et al. 2013 u.s.a 2007 the relationship between verbal abuse and demographic characteristics the level of verbal abuse from nurse colleagues was higher. low risk 4 lu et al. 2019 china 2124 the prevalence of verbal and physical violence against nurses in psychiatric ward verbal violence was 84.2% and physical violence was 57.9%. low risk 5 tsukamoto et al. 2019 brazil 242 the prevalence of and factors associated with occupational violence among members of the nursing team prevalence of physical violence 20.2%; verbal abuse 59.1%; sexual harassment 12.8%. low risk 6 jaradat et al. 2018 palestine 372 workplace aggression and its association with psychological distress and reduced job satisfaction 27.1% reported exposure to workplace aggression of some sort. low risk 7 cheung & yip 2017 hong kong 16082 the socio-economic and psychological correlates of workplace violence 44.6% had experienced workplace violence low risk 8 boafo et al. 2015 ghana 1021 the incidence, sources and effects of workplace verbal abuse and sexual harassment 12% had experienced sexual harassment, 52.2% verbal abuse at least once. low risk 9 alkorashy & al moalad 2016/saudi 500 the prevalence rate of workplace violence against nursing professionals half of the participants had experienced violence. low risk incivility toward nurses: a systematic review and meta-analysis 8 j med ethics hist med. 2021(november); 14: 15. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e id author year country s.size objective results quality. a** arabia 10 fute et al. 2014 ethiopia 660 and associated factors of workplace violence among nurses workplace violence 29.9%, physical 18.22%, verbal 89.58%, sexual 13.02%. low risk 11 baran aksakal et al. 2011 turkey 650 the frequency of and risk factors for physical violence, verbal violence and mobbing. physical violence, verbal violence and mobbing were 13.9%, 41.8%, and 17.1%, respectively. low risk 12 abou-elwafa 2015 egypt 286 the prevalence and associated risk factors for different types of violence against nurses 28.1% of emergency, and 46.9% of non-emergency ward nurses reported violence. low risk 13 bambi et al. 2014 italy 1504 the extent of lateral hostility and its effects on the quality of life 79.1% had experienced some form of lateral hostility. low risk 14 galián-muñoz et al. 2013 spain 200 how exposure to this kind of violence affects the onset of burnout extrinsic job satisfaction influences the relationship between nonphysical violence and emotional exhaustion. low risk 15 lemelin et al. 2003 canada 300 the prevalence, origins and forms of workplace violence 86.5% of the nurses had been victims of violent behavior. low risk 16 manderino & berkey 1997 u.s.a 300 the prevalence and consequences of verbal abuse 90% of the nurses in the sample reported abuse. low risk 17 chen et al. 2012 taiwan 1004 the prevalence, types and sources of violence 81.5% reported having suffered from workplace violence. low risk 18 suhaila & rampal 2012/ malaysia 455 the prevalence of sexual harassment the prevalence of sexual harassment among these nurses was 51.2%. low risk 19 khademloo et al. /2013/ iran 440 the prevalence of verbal and physical abuse 29.1% had experienced physical, 95.9% verbal abuse. low risk 20 fallahi khoshknab et al. 2011/ iran 200 the prevalence of violence in psychiatric wards the prevalence of violence was 71%. low risk 21 berry et al. 2011 u.s.a 5000 the prevalence and effects of workplace bullying 72.6% of novice nurses had reported a workplace bullying low risk 22 ahmed as 2012 jordan 500 the prevalence and sources of verbal and physical workplace abuse verbal and physical abuse 37.1%, 18.3%, were respectively. low risk 23 pai & lee 2011 taiwan 700 the risk factors and mental health consequences of physical and psychological violence the prevalence rates of physical violence, verbal, mobbing and sexual were 19.6%, 51.4%, 29.8% and 12.9%, respectively. low risk 24 abualrub & alasmar 2008 jordan 496 the incidence of psychological violence, explore the reactions of nurses to this type of violence, and identify the factors 70% of the participants had been exposed to verbal abuse. low risk 25 hsieh et al. 2016 taiwan 550 the relationship between workplace bullying, mental health and an intention to bullying was negatively correlated with self-efficacy and mental health. low risk atashzadeh shoorideh f., et al. 9 j med ethics hist med. 2021(november); 14: 15. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e id author year country s.size objective results quality. a** leave 26 hampton et al. 2018 u.s.a 175 the exposure of nurse leaders in manager, director, or executive level roles to bullying 60% had experienced bullying, 26% severe workplace bullying. low risk 27 zhao et al. 2015/ china 1013 the prevalence of workplace violence 67.2% had been exposed workplace violence. low risk 28 noorana zahra & feng 2018/ indonesia 245 the experiences of violent incidents 10% of the emergency nurses had experienced physical, 54.6% non-physical violence low risk 29 zhang et al. 2014/ china 4123 the prevalence of workplace violence 25.77% reported experiencing physical violence, 63.65% nonphysical, 2.76% sexual low risk 30 karatza et al. 2013/ greece 1000 the relationship between workplace bullying and general health status 30.2 % reported that they had been psychologically harassed. low risk 31 jafree 2013-4/ pakistan 804 the prevalence and patterns of workplace violence 73.1% reported experiencing some sort of violence. low risk 32 ridenour et al. 2015/ u.s.a 284 the risk factors associated with patient aggression toward the nursing staff 60% reported verbal, and 19% physical aggression. low risk 33 estes 2013/ u.s.a 1524 the influence of abusive supervision on nursing performance the incidence of abusive supervision was 46.6%. low risk 34 esmaeilpour et al.2011/ iran 196 the frequency and nature of physical and verbal workplace violence 19.7% of the nurses had faced physical violence. low risk 35 fujishiro et al. 2011 philippines 1000 workplace aggression was associated with self-rated health and work-related injury and illness verbal abuse was associated with poor general health. physical assault and verbal abuse with work-related injury. low risk 36 abbas/ 2010 egypt 1600 the prevalence and nature of workplace violence 27.7% reported abuse of some sort, 69.5% verbal abuse, and 9.3% physical low risk 37 shiao et al. 2010/ taiwan 1228 the incidence of assaults and their effects 28.1% had experienced physical and/or verbal low risk 38 yildirim 2009/ turkey the workplace and the bullying of nurses 21% of the nurses had been exposed to bullying. low risk 39 joubert et al. 2005/ south africa 120 whether private sector physicians verbally abuse nurses 79% of the nurses admitted that sort of verbal abuse low risk 40 honarvar et al./2017 – 2018/ iran 420 the various aspects of violence against nurses 89.6% of the nurses had been exposed to at least one kind of violence. low risk 41 yun et al. 2012/ korea 170 the relationship between perceived work environment and workplace bullying 94.0% of the icu nurses had experienced at least one negative act low risk 42 johnson & rea/2009/ u.s.a 249 nurses’ experiences of and the characteristics related to workplace bullying 27.3% had experienced workplace bullying. low risk 43 jiao et al. 2013/ china 700 the prevalence of workplace violence 7.8% experienced physical, 71.9% nonphysical low risk 44 park et al. 1027 the prevalence and verbal abuse was 63.8%, low risk incivility toward nurses: a systematic review and meta-analysis 10 j med ethics hist med. 2021(november); 14: 15. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e id author year country s.size objective results quality. a** 2014 korea perpetrators of workplace violence threats of violence 41.6%, physical 22.3%, and sexual 19.7%. 45 niu et al. 2019 taiwan 480 the prevalence of workplace violence physical and psychological violence were 55.7% and 82.1%, low risk 46 obeidat et al. 2018 amman 340 the prevalence of workplace bullying and its relationship with perceived competence 43% of the participants to be victims of severe workplace bullying. low risk 47 pandey et al. 2018/ nepal 200 the prevalence of workplace violence and its associated factors 64.5% of the nurses had experienced some sort of violence. low risk 48 al-shamlan 2015/ saudi arabia 450 the prevalence of verbal abuse 30.7% of the nurses experienced verbal abuse. low risk 49 sisawo et al. 2014 gambia 223 the prevalence and perpetrators of workplace violence and the factors associated with it verbal abuse, physical violence and sexual harassment were 59.8%, 17.2% and 10%, low risk 50 chang & chong 2012 2013 korea 391 the prevalence of workplace violence verbal abuse was 59.6%, threats of violence 36.9%, physical 27.6%, bullying 25.6%, sexual 22.4%. low risk 51 an & kang 2014 korea 380 the relationship between organizational culture and experience of workplace bullying the prevalence of workplace bullying was 15.8%. low risk 52 tiruneh et al. 2015 ethiopia 428 the prevalence of workplace violence and its associated factors among the study population. the prevalence of workplace violence was 26.7 %. low risk 53 fafliora et al. 2014 greece 120 the workplace violence encountered by nurses 76% of the nurses experienced workplace violence. low risk 54 li et al. 2003 -2004 hong kong 1650 the prevalence and nature of workplace violence 76% had experienced abuse: verbal abuse 73%; bullying 45%; physical abuse 18%; and sexual harassment 12%. low risk 55 rowe & sherlock 2005 u.s.a 307 the types and frequency of verbal abuse against nurses verbal abuse against nurses is quite costly to individual nurses, hospitals and patients. low risk 56 campbell et al. 2011 u.s.a 4165 the prevalence of workplace violence and demographic, work-related, adult and childhood abuse histories as risk factors 30% had workplace violence (19.4% physical, 19.9% psychological). low risk 57 hanrahan et al. 2010 u.s.a 688 the occurrence of adverse events the rate of verbal abuse toward registered nurses was 79%. low risk 58 may & grubbs 2002 u.s.a 125 nurse perceptions of the incidence and nature of verbal and physical assault or abuse 100% reported verbal, and 82.1% physical assault. low risk 59 dehghanchaloshtari & ghodousi/2014 iran 100 all forms of violence against nurses all nurses had experienced at least one type of violence low risk 60 cook et al. 200 the incidence and impact of 91% had experienced some sort low risk atashzadeh shoorideh f., et al. 11 j med ethics hist med. 2021(november); 14: 15. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e id author year country s.size objective results quality. a** 2001 u.s.a physicians’ verbal abuse on perioperative nurses of verbal abuse * by ilo/icn/who/psi/2003 ** quality assessment: an overall score between 0 and 3 indicates low risk risk of bias and publication bias the qualitative assessment of the studies by hoy et al.’s instrument showed a low rate of statistical bias in the studies (table 1). as shown in figures 2, and based on the egger test, there was no publication bias in the studies. figure 2 funnel plot of publication bias of studies of the prevalence of incivility incivility toward nurses: a systematic review and meta-analysis 12 j med ethics hist med. 2021(november); 14: 15. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e table 2subgroup analysis of incivility prevalence according to characteristics of included studies type of incivility subgroup number of studies prevalence (95% ci) heterogeneity % (pvalue) verbal country classification developed 14 15.70% 29.57, 58.81 98.99% (< 0.001) developing 21 15.59% 49.26, 68.69 99.17% (< 0.001) instrument who 25 75.57% 49.22, 65.87 98.93% (< 0.001) naq 1 76.45% 70.71, 81.35 0% (< 0.001) verbal scale 1 24.96% 92.77, 98.08 0% (< 0.001) other 8 17.74% 55.98, 88.86 99.24% (< 0.001) setting general 25 62.69% 53.48, 71.45 99.15% (< 0.001) emergency/acute care 4 74.29% 47.20, 93.97 98.18% (< 0.001) psychiatric 6 60.25% 41.67, 77.43 99.12% (< 0.001) sampling method random 18 66.22% 55.28, 76.35 99.28% (< 0.001) convenience 10 60.99% 49.36, 72.02 98.09% (< 0.001) not reported 7 60.29% 38.19, 80.39 99.23% (< 0.001) physical country classification developed 14 25.54% 14, 39.13 99.29% (< 0.001) developing 20 21.23% 15, 32.38 99.17% (< 0.001) instrument who 24 20.15% 13.71, 27.46 99.06% (< 0.001) naq 1 72.31% 66.36, 77.57 0% (< 0.001) verbal scale other 9 30.58% 16.28, 47.11 99.21% (< 0.001) setting general 24 20.18% 14.36, 26.69 98.89% (< 0.001) emergency/acute care 5 19% 8.78, 31.91 94.91% (< 0.001) psychiatric 5 51.42% 24.91, 77.51 99.54% (< 0.001) sampling method random 20 24.54% 15.52, 34.85 99.44% (< 0.001) convenience 9 24.12% 11.01, 40.32 99.03% (< 0.001) not reported 5 22.75% 7.73,42.68 98.83% (< 0.001) sexual country classification developed 9 20.67% 9.26, 35.12 98.91% (< 0.001) developing 13 9.57% 5.41, 14.74 97.42% (< 0.001) instrument who 17 10.25% 6.11, 15.28 97.97% (< 0.001) naq verbal scale other 5 28.04% 13.28, 45.73 97.99% (0.00) setting general 16 13.18% 7.53,20.10 98.71% (0.00) emergency/acute care 4 14.09% 2.71, 31.93 96.85% (0.00) psychiatric 2 22.61% 19.37, 26.02 0% (0.00) sampling method random 14 13.48% 8.23, 19.77 98.02% (0.00) convenience 6 11.63% 0.89, 31.42 98.02% (0.00) not reported 1 24.63% 21.43, 27.97 0% (0.00) mobbing no subgroup 10 35.69% 21.23, 51.60 98.77% (0.00) psychological no subgroup 7 54.27% 30.65,76.92 99.58% (0.00) table 3subgroup analysis of incivility prevalence according to type of incivility atashzadeh shoorideh f., et al. 13 j med ethics hist med. 2021(november); 14: 15. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e type of incivility subgroup number of studies prevalence (95% ci) heterogeneity % (p value) verbal country classification developed 14 15.70% 29.57, 58.81 98.99% (< 0.001) developing 21 15.59% 49.26, 68.69 99.17% (< 0.001) instrument who 25 75.57% 49.22, 65.87 98.93% (< 0.001) naq 1 76.45% 70.71, 81.35 0% (< 0.001) verbal scale 1 24.96% 92.77, 98.08 0% (< 0.001) other 8 17.74% 55.98, 88.86 99.24% (< 0.001) setting general 25 62.69% 53.48, 71.45 99.15% (< 0.001) emergency/acute care 4 74.29% 47.20, 93.97 98.18% (< 0.001) psychiatric 6 60.25% 41.67, 77.43 99.12% (< 0.001) sampling method random 18 66.22% 55.28, 76.35 99.28% (< 0.001) convenience 10 60.99% 49.36, 72.02 98.09% (< 0.001) not reported 7 60.29% 38.19, 80.39 99.23% (< 0.001) physical country classification developed 14 25.54% 14, 39.13 99.29% (< 0.001) developing 20 21.23% 15, 32.38 99.17% (< 0.001) instrument who 24 20.15% 13.71, 27.46 99.06% (< 0.001) naq 1 72.31% 66.36, 77.57 0% (< 0.001) verbal scale other 9 30.58% 16.28, 47.11 99.21% (< 0.001) setting general 24 20.18% 14.36, 26.69 98.89% (< 0.001) emergency/acute care 5 19% 8.78, 31.91 94.91% (< 0.001) psychiatric 5 51.42% 24.91, 77.51 99.54% (< 0.001) sampling method random 20 24.54% 15.52, 34.85 99.44% (< 0.001) convenience 9 24.12% 11.01, 40.32 99.03% (< 0.001) not reported 5 22.75% 7.73,42.68 98.83% (< 0.001) sexual country classification developed 9 20.67% 9.26, 35.12 98.91% (< 0.001) developing 13 9.57% 5.41, 14.74 97.42% (< 0.001) instrument who 17 10.25% 6.11, 15.28 97.97% (< 0.001) naq verbal scale other 5 28.04% 13.28, 45.73 97.99% (0.00) setting general 16 13.18% 7.53,20.10 98.71% (0.00) emergency/acute care 4 14.09% 2.71, 31.93 96.85% (0.00) psychiatric 2 22.61% 19.37, 26.02 0% (0.00) sampling method incivility toward nurses: a systematic review and meta-analysis 14 j med ethics hist med. 2021(november); 14: 15. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e type of incivility subgroup number of studies prevalence (95% ci) heterogeneity % (p value) random 14 13.48% 8.23, 19.77 98.02% (0.00) convenience 6 11.63% 0.89, 31.42 98.02% (0.00) not reported 1 24.63% 21.43, 27.97 0% (0.00) mobbing no subgroup 10 35.69% 21.23, 51.60 98.77% (0.00) psychological no subgroup 7 54.27% 30.65,76.92 99.58% (0.00) ci: confidence interval results based on the results displayed in table 3, there was high heterogeneity in the studies, and therefore the random effects model with reverse variance was used. thus, the total prevalence of incivility was 55.10% (95% ci: 48.5, 62.06), and the prevalence rates of verbal, physical and sexual incivility and mobbing behavior were 61.63% (95% ci: 56, 95, 70), 15.24% (95% ci: 33.17, 70.31), 67.13% (95% ci: 52.8, 77.19), and 69.35% (95% ci: 23.21, 60.51), respectively (figures 3). fig. 3forest plot based on the population studied for the prevalence of incivility in the range of 95% confidence interval the results of heterogeneity of the studies are presented in tables 3 and 4. since there atashzadeh shoorideh f., et al. 15 j med ethics hist med. 2021(november); 14: 15. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e was an expressive heterogeneity in the studies, the subgroups were analyzed according to country classification, instrument, setting and sampling methods. the results demonstrated that the greatest and smallest prevalence rates of incivility pertained to verbal and sexual aspects, respectively. the prevalence of incivility was higher in studies that used random sampling, in psychiatric wards, and in developing countries. the meta-regression test indicated a correlation between publication date and the prevalence of incivility, in that the latter decreased over the recent decades (figure 4). fig. 4forest plot based on the population studied for the prevalence of physical incivility in the range of 95% confidence interval discussion this systematic review and meta-analysis assessed the prevalence of incivility and violence toward nurses by examining 60 studies. the findings of the study showed a higher-than-average rate of incivility toward nurses. the highest rate pertained to violence and verbal abuse, experienced by almost all nurses, and the lowest rate pertained to sexual violence. moreover, the prevalence of incivility in the form of mental abuse was greater than physical violence and threat. the study by li et al. suggested that although the rate of violence against physicians and nurses is high, the rate of incivility toward nurses is higher than physicians (84). taylor and rew asserted that more than 80% of nurses consider their incivility toward nurses: a systematic review and meta-analysis 16 j med ethics hist med. 2021(november); 14: 15. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e workplace unsafe and believe the prevalence of verbal and physical threat to be high (85). the study by pompeii et al. revealed that the greatest rate of incivility pertained to violence and verbal threat (86). it appears that poor communication skills, devoting insufficient time to one’s duties, and delay in sharing information may foster the incidence of verbal incivility. the search process showed that there were more studies targeting nurses compared to other health professionals. even the number of studies on nursing students was greater than the studies on other groups of students. the studies showed a higher prevalence of incivility toward nurses than other healthcare staff. it seems that the more time the staff spend with patients and other individuals, the greater will the rate of incivility be (87). the behavioral patterns of managers and supervisors can also affect both employees and those who monitor their actions and help to spread the prevalence of uncivil behavior. other possible reasons may be job insecurity or high workload along with low autonomy, which exposes a person to non-civil behavior (88). meta-regression based on publication date indicated that the rate of incivility and violence has decreased over time. one of the reasons that the prevalence of violence has diminished in recent years may be nurses’ increased awareness of the rules and regulations in the profession, and legal mitigation and pursuit. awareness of rules and laws enables nurses to defend their own rights and therefore reduce incivility. nonetheless, the rate of prevalence of verbal violence has not decreased tangibly. one reason for conducting research on the subject is raising the awareness of nurses and managers in this regard. managers’ and policymakers’ awareness about their importance as role models in reinforcing polite behavior can also be effective in reducing the prevalence of non-civil behavior. jenkins et al. found that training in the subject of incivility and its importance and consequences, as well as teaching stress management and coping strategies can help reduce the prevalence of incivility (89). our findings showed that most primary studies had been carried out in general hospitals on nurses in various wards, but the prevalence of incivility and violence was greater in psychiatric wards. furthermore, the incidence of physical incivility was greater in these wards compared to other types of non-civil behavior. verbal incivility occurred more frequently than other behaviors in the er and icu because er patients experience critical situations, and it is highly important to settle their anxiety as quickly and efficiently as possible. the nature and sensitivity of the er is such that any shortcoming in organizational and manpower factors can lead to disastrous consequences. chaotic situations, unpredictable conditions, stressful atmospheres, and limitations in therapeutic processes for evaluating the effect of interventions and care may expose the er staff to verbal incivility. some studies report that nurses in the er, mental health inpatient units, and pediatric, neurology and neurosurgery departments are subject to violence more frequently. this may well deter young nurses from working in such environments (90). it seems that the critical condition of patients admitted to these atashzadeh shoorideh f., et al. 17 j med ethics hist med. 2021(november); 14: 15. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e wards, as well as the stress and anxiety of their companions, causes verbal abuse and increases the incidence of incivility in these wards. while our findings suggested a great prevalence of incivility in developing countries, the prevalence of verbal, physical and sexual incivility was higher in developed countries. decreased reports of sexual violence in some countries may be attributed to cultural reasons. the variety and great number of studies in different countries show that incivility and violence toward healthcare providers and caregivers are quite common in most clinical environments. our findings demonstrated that asian countries, especially iran and taiwan, had the greatest number of studies in this field. this can be due to the high prevalence of non-civil behavior in these countries, which may be attributed to personal factors as well as heavy workload, shortage of manpower, poor team-work skills, or lack of programs to manage healthcare violence (85). in studies on sexual harassment, publication bias can occur as a result of socio-cultural factors. physical and psychological problems, decreased motivation and commitment to the workplace, and work leave are among the consequences of sexual harassment. organizational factors such as social support and workplace reporting systems, as well as people’s vulnerability in terms of race, marital status, age, etc. can affect the reporting of this event. studies have shown the importance of an organization’s atmosphere, its sensitivity to the issue, and its support in reducing sexual harassment and encouraging the reporting of its incidence (91). incivility not only creates a hostile workplace for nurses, but also forms a dangerous environment for patients, leading to diminished patient satisfaction (7). clark and springer concluded that inappropriate behaviors might result in medical and nursing errors and poor patient outcomes (9). on the other hand, legal mitigation by victims in hostile environments may impose some costs on hospitals. additionally, work leave, nurse transfer and hostile environments can affect employment in the organization, and the nurse victims may seek legal consultation, possibly affecting the financial affairs, reputation and credibility of the center (7). consequently, incivility is associated with overwhelming healthcare costs, compensatory payments related to tension among the staff, increased numbers of legal lawsuits, and poor-quality care (91). the results of studies demonstrate that incivility is the most important factor that negatively affects occupational satisfaction among nurses (90), resulting in lack of commitment and more frequent work leaves, finally influencing quality of care, costs and organizational reputation both directly and indirectly. members of the staff that experience incivility in the workplace deliberately reduce the quality of their work, which will lead to diminished efficacy (92,93). however, parameters such as social and organizational support, transparent rules, enhanced communication skills, increased incivility toward nurses: a systematic review and meta-analysis 18 j med ethics hist med. 2021(november); 14: 15. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e level of abilities and empowerment of nurses can attenuate the rate of incivility (85). in many cases, nurses cannot pursue issues related to incivility due to absence of centers and committees for recording and managing violence, or due to individuals’ request for nonpursuit of the problem. finally, studies report that many nurses stated there was no particular place within the organization to report incivility and they were puzzled who to turn to in such conditions. therefore, many incivility cases remain unreported. also, junior nurses experience higher rates of incivility but cannot take appropriate action due to poorer communication skills and lack of support from their coworkers and the organization. hence, the incidence of such behaviors is seldom substantiated in the organizational culture. limitations of the study one limitation was inaccessibility of the full texts of some of the papers, which was resolved through communication with the author(s). in addition, the diverse terms used to assess the extent of non-civil behavior have made the studies heterogeneous in this area. lastly, the nurses' perceptions of the concept of non-civil behavior were very different. conclusion the findings of the systematic review and meta-analysis showed that the prevalence of incivility toward nurses was higher than the average rate. given the wide range of studies in terms of time, setting and environment, it appears that planners and policy-makers need to develop programs to decrease violence and increase workplace safety. healthcare managers and supervisors should be aware that disruptive and threatening behaviors are a serious problem in the healthcare system. for instance, verbal abuse, refusal to help the staff perform their specified duties and physical threats induce failure of teamwork and harm the interaction and cooperation required for care provision. nurses play a highly significant role in caregiving, and therefore deserve to have a safe work environment. consequently, nursing managers ought to identify the risk factors in the workplace and pay due attention to nurses’ concerns in this regard. in view of the high prevalence of non-verbal incivility in recent years, nursing managers should identify the risk factors in the workplace, especially in critical wards. in addition, creating a responsive and supportive organizational environment can help prevent or reduce incivility and even encourage staff to report such behaviors. managers and policy makers should also support nurses and plan for their empowerment and education to deal with non-civil behavior and report violence. finally, future studies should focus on identification and implementation of effective evidence-based interventions in keeping with the respective organizational culture. conflict of interests there is no conflict of interests to declare. all authors worked in close collaboration and were responsible for critical revision of the manuscript. competing interests atashzadeh shoorideh f., et al. 19 j med ethics hist med. 2021(november); 14: 15. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e the authors have no competing interests to declare. ethics approval consent to participate was not applicable in this study. the research was approved by the organizational ethics committee of shahid beheshti university of medical sciences (no. ir.sbmu.rec.1398.143). funding statement this research received no grant from any funding agency in the public, commercial or not-for-profit sectors. acknowledgments the authors would like to acknowledge the efforts of dr. mahmoud yousefifard and georgina riley for their diligent and thoughtful editing of the manuscript. incivility toward nurses: a systematic review and meta-analysis 20 j med ethics hist med. 2021(november); 14: 15. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e references 1. gopalkrishnan p. workplace incivility and employee strain in reactions: the moderating effects of perceived organisational support and job insecurity. 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________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ 1 letter to editor volume 13 number 11 september 2020 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e copyright © 2020 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. thoughts about “other” patients’ rights during covid-19 pandemic dimosthenis chrysikos1*,constantinos g. zografos2, george c. zografos3 1.consultant surgeon, first department of propaedeutic surgery, hippocration hospital, school of medicine, university of athens, athens, greece. 2.surgeon, first department of propaedeutic surgery, hippocration hospital, school of medicine, university of athens, athens, greece. 3.professor of surgeon, first department of propaedeutic surgery, hippocration hospital, school of medicine, university of athens, athens, greece. to the editor pandemic, (originates from greek word παν, pan, that means 'all' and δήμος, demos, which refers to people') is a global outbreak in most cases, of an infectious disease, that has spread over multiple countries or continents (1). according to world health organisation (who), “ischemic heart disease, stroke, chronic obstructive lung disease and lower respiratory infections have been estimated as the leading causes of death worldwide during the past decade “(2). for a disease or condition to be a pandemic, merely besides being widespread or lethal, it should also be infectious or contagious. on that basis, cancer, trauma and other chronic diseases that cause increasing numbers of deaths worldwide, are not considered a pandemic because these diseases are neither infectious nor contagious. past pandemics and lessons to learn in history, there have been a number of severe pandemics. one of the most catastrophic pandemics recorded in human history was the bubonic plague (the black death) caused by a bacterium known as yersinia pestis. this pandemic has been reported to have killed around 75–200 million people in the 14th century, through asia, africa and europe. another devastating pandemic that wiped out millions of people was the spanish flu that took place in 1918 and more recently the h1n1 flu pandemic that occurred in 2009 (3). *corresponding author dimosthenis chrysikos 9 gortynias, athens, greece. postal code: athens,16561 tel: (+30) 6973063590 email: dichrysik@med.uoa.gr received: 21 may 2020 accepted: 10 aug 2020 published: 16 sep 2020 citation to this article: chrysikos d, zografos cg, zografos gc. thoughts about “other” patients’ rights during covid-19 pandemic. j med ethics hist med. 2020; 13: 11. thoughts about “other” patients’ rights during covid-19 pandemic 2 volume 13 number 11 september 2020 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e nowadays, pandemics include hiv/acquired immune deficiency syndrome and the 2019 coronavirus disease, which was declared by the who a pandemic on 11 march 2020. past pandemics in human history have as a consequence to gain experiences from ancient cultures by the way the reacted to contagious diseases. even in middle ages, ancient doctors of that period have observed that there might be a correlation between time exposure and the outbreak of symptoms of lethal and contagious diseases like the black death. it has also been noted that, after a period of observation, patients who had not developed symptoms of the illness would potentially not be affected and remarkably, would not have the capability to spread the disease upon entering the ancient city (4). to that point, mandatory isolation was the first measure taken historically. nowadays, this form of social distancing is called “quarantine”. the scientific and medical community during outbreaks of infectious diseases has to adopt measures regarding prevention, immunization and antimicrobial treatments, in order to preserve the good of public health. through this process there are many lessons to learn and practices to avoid in the future. historically, it has been proved that from the spanish influenza pandemic of 1918, virtually all deaths were due not to influenza itself, but to complicating secondary infections. the lack of vaccination and pharmaceutical modalities targeting the influenza virus, has led the medical community and the authorities to adopt measurements that would potentially restrict the worldwide scale spread of the viral disease. such measurements were control efforts to isolate the people, social distancing by abandoning public gatherings, quarantines and optimal personal hygiene by every means (5,6). despite the catastrophic effects of the spanish influenza on the global civilization, the defence was to fade it from the public and scientific attention. one of the possible explanations towards this attitude, might be the fact that the pandemic was overshadowed by more fundamental historical events, such as world war i (6). the ongoing covid-19 pandemic certainly, the new pandemic of covid-19, is an emerging, rapidly evolving situation. governments worldwide without exception, have focused to fight the pandemic and support measures recommended by the who. in order to defeat the pandemic, all current financial resources are redistributed to provide prevention, detection, treatment and recovery of covid-19 disease. for instance, intensive care units are to be tremendously expanded and medication or new vaccines need to be developed. this is the most serious global challenge. nowadays, medical and political systems and particularly the politicians face a global criticism, if their response to pandemic fails to effectively restrain it. we should all admit that during the pandemic, the medical profile, in the most of the countries, has not changed at all. mortality and morbidity rates due to the chrysikos d., et al. 3 volume 13 number 11 september 2020 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e covid-19 will occupy an unknown ratio that most probably will not make us reconsider the top ten causes of death worldwide (2). this raises the question: what about “other” patient’s rights-that have not been infected by the corona virus disease? human rights and patients’ rights the universal declaration of human rights is considered a milestone effort to record in a document the human rights. it was created in 1948 in paris (7) and continues to inspire the concept of the person, the fundamental dignity and the equality of all human beings. patients' rights vary all over the world, due to various ethics, cultural and social forms. it is a fact that the fundamental patient-physician relationship reflects the relationship of citizens with the state and the authorities (8). it has been shown that during the pandemic, screening examinations such as mammography and colonoscopy are postponed. undoubtedly, this is attributed not only due to personal responsibility, but due to the fear that has been evolved by mass media along with state health measurements like quarantines and social distancing. to postpone medical visits, or screening examinations might mean that existed or forthcoming diseases might change their course or stage and could even deteriorate in the future. in addition, many potentially vulnerable general practitioners or older medical doctors with multiple comorbidities who belong to high risk groups, avoid examining their own patients with symptoms suspecting the pandemic disease, in fear of dissemination of the viral disease. as a result, they prefer to refer them to the dedicated public hospitals. the problem that emerges is that chronic or forthcoming diseases are underestimated or overlooked. this situation endangers patients’ rights to health care providers. access to outpatient’s departments is also restricted, according to the measurements that have been taken. the number of patients with cardiovascular disease is significantly decreased, this is mainly due to the fact that patients postpone their visit to the hospitals. however, mortality and morbidity rates of cardiovascular diseases have remained stable (2). the oncological patients patients with malignant neoplasms should continue to fight and undergo specialized treatment without feeling that they are 'depriving' the lives of other people who are suffering and succumbing to a pandemic currently affecting the global community. on the contrary, they are doubly anxious at this stage of dealing with such difficult diseases while at the same time being aware that they have an increased risk of mortality from covid-19 infection. for instance, patients with hematologic malignancies and solid tumors are at high risk for serious complications of the disease due to the immunosuppression they cause, both the neoplastic disease itself and the treatments given to treat it. it is therefore necessary to systematically apply to this vulnerable group of the population, measures to prevent the transmission and spread of the corona virus. thoughts about “other” patients’ rights during covid-19 pandemic 4 volume 13 number 11 september 2020 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e in the field of therapeutic interventions (chemo, radiotherapy) there are recommendations from asco (american society of clinical oncologists) and other related organizations (9). regarding patients who have completed treatment and are on follow-up, it is recommended to postpone their reassessment visits in order to avoid unnecessary burden on health structures of preventive measures and transmission of the virus. patients also undergoing maintenance treatment with intravenous therapy, may be postponed or given longer intervals, depending on their disease and the phase of treatment. on the contrary for those patients who have active disease, either at an early stage, locally advanced, or metastatic, and need special treatment, it should not be missed or postponed. other patients with abdominal symptoms or other non-lethal symptoms should not be disregarded. in other cases, all other symptoms are attributed to the pandemic. this may lead to erroneous differential diagnosis. corresponding phenomena could be observed by the delay in chemotherapy or radiotherapy and transplantation. it is therefore important to evaluate each case individually, so that these patients are not deprived of necessary interventions at the right time, but also that the health system's resources are not wasted unnecessarily. it is equally important for all of us to take and comply with all necessary measures to reduce the pandemic, so that health and social structures can meet the needs of all other patients suffering from other diseases, and especially those most vulnerable to infections (9). a vicious cycle of panic during the covid-19 pandemic another, equal important parameter is patients’ phobias to come to hospital. it is surprising to see how many people do not attend in the premises of the hospital, in the fear of contacting with covid-19. in case patients seek medical help during the pandemic, they have to wait for many hours to be examined and after having been tested negative for covid-19, leading to delayed presentations for several sometimes even fatal cases. medical doctors from their side, should provide informed and written consent about the risk to operate or perform an invasive examination procedure to non-symptomatic patients during the pandemic. for example, delaying oncological surgeries could lead to disease progression and to tumors that are no longer surgically excluded, limiting patients' chance of healing. moreover, patients have the right to life-saving interventions and this responsibility lies in medical systems and governments that fight pandemics. another thought provoking aspect that should be addressed during the covid-19 outbreak, is medical doctors’ professional independency. physicians, who follow up other patients during the covid-19 pandemic in the majority of developed countries, are not in the position to decide on the allocation of medical resources. as a consequence, the most appropriate treatment must be provided to their patient at all times. it prevails the medical approach of “one size fits at all” that means personalized medicine is disregarded. indeed, resource allocation is the responsibility of policymakers and health chrysikos d., et al. 5 volume 13 number 11 september 2020 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e care providers while defining the right policies might be very helpful in respecting the other patients’ rights during the covid19 pandemic. everyone has the right to health without discrimination. patients belong to a certain group of population. patients with disabilities, older patients and those living in extreme poverty, as well as patients in detention, the homeless, refugees and other minority communities need special government support. prevention and increased care by physicians and nurses and in general from those who provide medical support it is crucial to this difficult time for mankind. at this phase patient need apart from increased medical care, understanding, vigilance, and psychological support. it sounds simple but it is not. the mass of population has to be convinced that the wide acceptance of the restrictive measures during pandemics is critical. these interventions might be criticized that they violate human rights and are against the principles of democracy. to get the balance right, back to normal life and everyday activities to the best extent possible, it is mandatory, when the pandemic fades away (10). conclusions in conclusion, the ongoing covid-19 pandemic has led governments and healthcare professionals worldwide, to adopt mandatory restrictive measurements. the scientific and medical community have focused by every means to fight the covid19 pandemic. as a result, the oncological patients and other patients with chronic diseases who have not been infected are at risk, because their medical visits are postponed or because of fear of infection, they are not followed up from their medical doctors. this situation endangers those patient's rights who belong to subgroup of vulnerable population. societies and governments have to respond effectively to the global threat of covid-19 pandemic, however, we must not let it overshadow everything and overlook the needs, the personalized therapy and follow up of the non-infected patients who have the right to continue to have access to the services of the public health system. finally, it is of paramount importance to learn from our history. we cannot afford to repeat past mistakes from previous devastating pandemics, by neglecting other patients, when battling the inevitable pandemic of covid-19 or other pandemics in the future. conflict of interest authors declare no conflict of interest thoughts about “other” patients’ rights during covid-19 pandemic 6 volume 13 number 11 september 2020 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e references 1. porta m. dictionary of epidemiology. uk: oxford university press; 2008; p.179 2. anonymous. health statistics and information systems. [cited on september 2020]; available from: www.who.int/healthinfo/global_burden_disease/en 3. dumar am. swine flu: what you need to know. usa: wildside press llc; 2009; p. 7. 4. sehdev ps. the origin of quarantine. clin infect dis. 2002; 35(9): 1071–2. 5. garcia-sastre a, whitley rj. lessons learned from reconstructing the 1918 influenza pandemic. j infect dis. 2006 ;194 (suppl. 2): s127-32. 6. parmet we, rothstein ma. the 1918 influenza pandemic: lessons learned and notintroduction to the special section. am j public health. 2018; 108(11): 1435-36. 7. anonymous. united nations: universal declaration of human rights. [cited on september 2020]; available from: https://www.un.org/en/universal-declaration-human-rights/ 8. anonymous. who: patients’ rights. [cited on september 2020]; available from: www.who.int/genomics/public/patientrights/en/ 9. gosain r, abdou y, singh a, rana n, puzanov i, ernstoff ms. covid-19 and cancer: a comprehensive review. curr oncol rep. 2020; 22(5): 53. 10. mehta a, quinn tc. addressing future epidemics: historical human rights lessons from the aids pandemic. pathog immun. 2016; 1(1): 1-11. jmehm-8-5 journal of medical ethics and history of medicine original article developing an ethical guideline for clinical teaching in tehran university of medical sciences akram hashemi1, habibeh yeketaz2, fariba asghari3* 1phd candidate, department of medical education, iran university of medical sciences, tehran, iran; 2md, school of medicine, tehran university of medical sciences, tehran, iran; 3associate professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. corresponding author: fariba asghari address: medical ethics and history of medicine research center, #23, shanzdah azar st.tehran, iran email: fasghari@tums.ac.ir tel: 98 21 66 41 96 61 fax: 98 21 66 41 96 61 received: 20 sep 2014 accepted: 04 apr 2015 published: 15 apr 2015 j med ethics hist med, 2015, 8:5 © 2015 akram hashemi et al.; licensee tehran univ. med. sci. abstract clinical education is an essential part of medical trainees’ education process, and curriculum planners agree that it should be based on ethical standards and principles in the medical field. nevertheless, no explained and codified criteria have been developed for ethics in clinical teaching. this study was aimed to develop an ethical guideline for medical students and teachers as the first and most important step in respecting patients' rights in educational centers. the initial draft included the codes of ethics in clinical education and was developed based on library studies. subsequently, it was improved through a qualitative study using semi-structured interviews and focus group sessions with medical students, patients, and medical teachers in educational hospitals affiliated to tehran university of medical sciences. the improved draft was reviewed and validated by a medical expert panel to prepare the final draft. the codes derived from this study included patients’ choices and rights in purely educational procedures, and special considerations for a) obtaining informed consent for educational procedures; b) performing procedures on deceased persons, patients under anesthesia and those lacking decision making capacity; c) educational visual recordings of the patients; and d) safety monitoring in clinical education. the guideline developed in this study incorporates codes of ethics into clinical training. therefore, in addition to providing efficient education, the interests of patients and their rights are respected, and the ethical sensitivity of learners in primacy of patients’ best interests will be preserved and enhanced. keywords: clinical teaching, ethical guideline, medical education mailto:fasghari@tums.ac.ir j med ethics hist med 8:5 apr, 2015 jmehm.tums.ac.ir akram hashemi et al. page 2 of 6 (page number not for citation purposes) introduction medical students encounter numerous educational opportunities and situations in the course of their training where ethical decision-making is important, and they have to respect the patients’ rights while considering their training needs (1). studies have shown that 60 to 90 percent of patients agree to participate in the training of students and make their information available to them (2 4). patients, however, believe that they are not provided with enough information on the trainees’ role in their medical care (5), and in many cases faculty members and students do not clarify their position to patients (6). all related ethical guidelines insist on obtaining informed consent for students performing clinical examinations on unconscious patients, and the majority of them consider a written consent as the preferred form. research related to clinical examinations and interventions by students on anesthetized patients have shown that in about 25% of the cases no valid informed consent was obtained from the patients to perform such actions (7-10). numerous studies indicate that it is common to perform clinical interventions on deceased or dying individuals in educational-treatment centers of teaching hospitals (11) often without requesting permission from their families (12). in the area of ethics in medical education, issues related to the mutual rights of educators and learners have been discussed in ancient iranian literature, while very little attention has been paid to patients' rights as educational subjects (13). similarly, most topics in contemporary medical ethics pertain to health care and medical research, and ethics of medical education has rarely been discussed. since most instances of modeling respect for patients’ rights occur at bedside, neglecting patients’ rights in the training process can seriously damage learners’ ethical sensitivity. it is essential to review the balance between providing outstanding health services and creating an appropriate educational environment for the students. in absence of appropriate clinical teaching, future physicians will not have the sufficient skills to provide the required medical services and may cause harm to the patients (7, 14-16). on the other hand, it is necessary to develop certain criteria for clinical education and the training process so as to respect the rights and interests of patients and maintain and enhance students’ ethical sensitivity. as a result, students will be guided to respect the rights of patients and prioritize their health and well-being while receiving efficient training (8, 16, 17). the present study aimed to develop an ethical guideline to safeguard patients’ rights in clinical teaching and guarantee ethical and humane bedside training. method this study was performed in three phases consisting of library study, qualitative research, and preparing the draft of the guideline. initially, a comprehensive literature review was conducted by searching pubmed, google, google scholar and university web pages using the following keywords: ethics, ethical guideline, clinical teaching, education, and patients’ rights. the above-mentioned web sources were also searched for papers and guidelines about patients’ rights in educational health centers and hospitals. through this review and considering the cultural, social and religious conditions of the community, the initial draft of the ethical guideline on patient bedside training in clinical educational centers was developed in 17 clauses. the initial draft was reviewed by the academic advisors (four research members of the medical ethics and history of medicine research center) and after considering their comments was approved as the preliminary guideline. then, in the qualitative phase of the study, the draft was discussed in groups of stakeholders, including patients, clinical faculty members, students in different clinical grades, and medical ethics experts. purposive sampling of stakeholders was performed in tehran university of medical sciences until data saturation. the information of the participants was collected using interviews and focus group discussions. in total, the comments of 21 patients (equal numbers of patients in the emergency rooms and clinics and hospitalized patients) were collected through interviews. the comments of 21 students (6 trainees and 7 interns) were received through focus group discussions, and the comments of 6 specialized residents and 2 subspecialty residents were recorded through interviews. similarly, the comments of 7 clinical professors who were in charge of educational affairs or had executive training positions, and 4 medical ethics experts in the medical ethics and history of medicine research center were collected through interviews. informed consent was obtained from participants for audio-recording of all individual and group interviews. in all the notes, a numerical code specific to each person was used rather than the names of participants. the collected comments were summarized and categorized separately for each article of the guideline. in the third stage, a consulting workshop attended simultaneously by 2 to 3 people from each stakeholder group was held. in this session, the initial draft of the ethical guideline on patient bedside training and the comments gathered in the second stage were reviewed. the final changes were applied based on the collected feedback and the issues discussed in the consulting workshop, and the final version was prepared. ultimately, the guideline was reviewed and edited. j med ethics hist med 8:5 apr, 2015 jmehm.tums.ac.ir akram hashemi et al. page 3 of 6 (page number not for citation purposes) results after a comprehensive review of the literature related to patients’ rights in educational health centers and hospitals and considering the cultural, social, and religious conditions of the community, the initial draft of the ethical guideline on patient bedside training in clinical educational centers was developed. in the development of all sections of this guideline, compliance with common medical professional commitments was taken into account. instances of these commitments included: improvement of professional competency and quality of care, honesty with patients, confidentiality, professional responsibilities, appropriate relations with patients, and justice. this guideline contained special considerations on individuals lacking decision-making capacity, that is, patients with reduced consciousness, those suffering from intellectual disabilities or mental disorders, and children. in order to include such patients in educationaltreatment programs, at least their verbal assent must be first obtained and then their parents’ or guardians’ consent should be sought (18-22). as for children, they should be provided with relevant information and consequently their parents’ or legal guardians’ consent should be obtained (18-22). some issues were also raised regarding learning procedures and examinations on patients under anesthesia. the general consensus was that in such cases, patients should be informed before anesthesia and their consent must also be obtained in writing (710). performing educational clinical interventions on deceased individuals was one of the cases discussed in developing this guideline. such measures are aimed at training the students and improving their skills before they practice the procedures on live patients, and although they do not harm the deceased, it is essential to respect patients’ dignity in order to win and maintain their trust. it should be added that almost all reviewed literature considered it necessary to obtain written consent to perform such interventions on deceased patients. the society for academic emergency medicine states that consent should be obtained from family members before practicing any procedures on freshly deceased bodies. the american medical association (ama) ethical guideline advises that the educational procedures should not be performed on deseased patients in situations where it is not possible to obtain consent. the american heart association’s emergency cardiac care committee suggests that informed consent should be obtained before using the newly dead for research or training purposes unless institutional guidelines specifically address circumstances under which consent is unnecessary (23-25). in terms of obtaining consent to perform procedures on deceased patients, there was consensus among the participants in the present study; however, the disputed issue was the time to obtain the consent. requesting such consent appears to be inhumane and perhaps unpractical in the distressing conditions experienced by the relatives of the deceased. it is preferable to seek patients’ consent under more normal circumstances as is the case for organ transplantation consent. this area of medical education ethics is rather challenging and requires further investigation and more extensive studies. nevertheless, one can conclude that performing clinical interventions on deceased people is acceptable after obtaining consent from the deceased patients’ relatives provided that patients’ dignity is respected. regarding patients participating in training programs, the reviewed sources emphasized that the medical team should respect the patients’ rights to choose, and subjects have to be assured that they can withdraw from the training programs any time without compromising the health care they receive (2, 30, 31). as for making and using visual and audio recordings of patients, the reviewed literature considered patients’ consent necessary, although most sources agreed that verbal consent is sufficient in such cases (26, 27). most members of the consultative workshop believed that written consent should be obtained for identifiable records due to the legal liabilities associated with such practices. in addition, the guideline developed in the present study stated that the photos or videos should be viewed by patients, and their potential request for discarding or not publishing them should be respected. some of the issues discussed in this guideline pertained to supervising students. the complex issues in this area can be summarized as follows: 1. the students should be trained on moulages, standardized patients or their classmates prior to entering clinical courses. although the true learning of skills is achieved when practiced on real patients, the latter could be harmed or injured in the process. 2. to eliminate or reduce the risks for patients, the learners' participation in clinical interventions can be conditional on direct and appropriate supervision of a trained senior. the senior in charge of the medical team would naturally be responsible for monitoring the students and possible damage and harm to the patients. 3. issues to be considered in training for clinical skills using patients include reviewing the risks associated with students practicing the interventions on patients, informing patients about participation in clinical interventions and obtaining their consent, and fair distribution of the medical training load among different patients. through the stages described above, the final draft of the guideline was finalized. this draft j med ethics hist med 8:5 apr, 2015 jmehm.tums.ac.ir akram hashemi et al. page 4 of 6 (page number not for citation purposes) included an introduction, ethical principles based on which the guideline was developed, codes (including 15 items presented in table 1) and the glossary. table 1. a brief review of an ethical guideline for clinical teaching 1 patients should be well informed about the role of medical trainees in their care process. 2 all members of the medical team have to introduce themselves and explain their roles and responsibilities to patients. 3 all members of the medical team should wear id cards. 4 all members of the medical team should respect patients’ autonomy in receiving "purely educational" procedures. 5 prior to performing educational procedures on incompetent patients, all members of the medical team should ask for their guardians’ permission and respect the patients’ refusal to cooperate. 6 prior to performing anesthesia, the medical team have to obtain patients’ written consent for examinations with "purely educational" purposes. 7 for clinical interventions with "purely educational" purposes on deceased patients, the medical team have to respect the dead patients’ dignity and obtain their (families’) consent. 8 the senior in charge of the medical team has to appropriately make sure that students have acquired the basic clinical skills, and then allow them to perform the procedures on patients under the senior’s supervision. 9 based on the intervention risks and the skills and experience level of the students, the senior in charge of the medical team has to appropriately supervise the quality of clinical interventions offered by the students. 10 the medical team should use the patients’ information in unnamed forms in morning report sessions and educational conferences, and should otherwise ask for the patients’ consent. 11 the medical team have to respect patient privacy in "purely educational” programs in terms of patients’ participation in the class, morning reports or students’ exams, and make sure not to pressure them in any way. 12 the medical team have to ask for the patients’ consent for any visual recordings of them, and if such recordings are identifiable, written consent will have to be obtained. 13 the medical team have to inform the patients of their right for presence of a chaperone in any sensitive examinations, or examinations by persons of the opposite gender. 14 the medical team should respect the child patients’ rights for presence of their parents. 15 the senior in charge of the medical team has to make sure that appropriate communication is conducted between patients and the trainees involved in their care. discussion the purpose of developing this guideline was to create a balance between training the next generation of physicians and respecting the rights of patients who participate altruistically in the process of medical education. in a number of medical universities in other countries, such as queen's university of canada, and the university of sydney, guidelines for ethics in clinical teaching have been developed, and professors and students in different grades are required to follow them (28, 29). the ethical guideline developed in this study has very much in common with most other guidelines, although it is different in some respects. the reason is apparently the divergence in cultures and the different regulations governing the health systems as well as universities. among these issues, monitoring patients’ safety in clinical teaching can be mentioned. in some universities, due to strict observation of patient safety criteria and serious legal responsibilities of the physician in charge in case of damage to patients’ health, there is close monitoring of the students’ performance. as a result, there has been no need to explain the subject extensively in their ethical guidelines for training at patients’ bedside. for example in the ethical guideline of capital & coast district health board (ccdhb) in new zealand and queen’s university of canada, seniors’ responsibility for supervision on patient safety has been mentioned briefly (28, 30). in iran, however, there are shortcomings in patient safety monitoring in hospitals, and we have therefore discussed senior supervision and assessment of the students’ skills in our ethical guideline in detail. another prominent point in our guideline is making visual recordings of patients for use in training. this issue has not been discussed in guidelines of universities of the us, uk and malaysia where specific national guidelines are in place for audio visual recordings for service, research and education (26, 27, 31). in the case of our ethical guideline, the topic of images and videos from patients was not related to clinical teaching. nevertheless, it was necessary to examine the subject in detail due to the importance of using photos and videos of the patients in medical j med ethics hist med 8:5 apr, 2015 jmehm.tums.ac.ir akram hashemi et al. page 5 of 6 (page number not for citation purposes) education and lack of ethical and legal standards within the health care system in this regard. another issue that was extensively discussed in our guideline was the necessity of informing patients about the specific rules of educational hospitals and the role of trainees in providing services in these settings. there are serious deficiencies in providing the patients with information on the general regulations of health care centers and institutions, the specific rules of teaching hospitals, the hierarchy in providing services, and the role and duties of medical students at different levels. thus, the above issues were particularly emphasized in our ethical guideline. our ethical guideline for bedside teaching is helpful for medical trainees of all levels and can play an important role in institutionalization of medical ethics in clinical education. additionally, observance of the issues discussed in this guideline can be considered a sort of practical and applied training in medical ethics during clinical courses. on the other hand, it leads to winning the patients’ trust through respecting and observing their rights. as a result, patients will be more cooperative during bedside training, and the students’ educational level and respect for patients’ rights will be improved. developing this guideline and its implementation can unify the learners’ professional behavior in dealing with patients and reduce the likelihood of various forms of abuse resulting from patients' lack of knowledge. after compiling and communicating the ethical instructions on clinical teaching to the affiliated educational hospitals, they are expected to design and execute a comprehensive plan for informing the patients about their rights and brief the students and professors on the guideline. although the ethical guidelines on clinical teaching are not considered a legal set of instructions, they can be used to prevent possible abusive behaviors or violation of patients’ rights in educational hospitals. in addition to medicine, a number of other fields of medical sciences such as dentistry, clinical pharmacy, nursing and rehabilitation medicine offer some clinical teaching during their educational courses. the current guideline can serve as a model for developing an ethical framework for clinical practice in such fields. on one hand, the guideline is beneficial for the students in these fields and on the other hand, it will be a safeguard to protect the patients’ rights in educational centers. regarding clinical interventions on deceased persons, it seems necessary to do more extensive studies to investigate the views of community members and the possible drawbacks of obtaining informed consent. although developing this guideline required considerable effort, it is not beyond criticism and before its implementation in universities, the comments of all the professors and students must be taken into consideration. acknowledgement this manuscript is based on the dissertation by dr. habibeh yeketaz. we would like to express our gratitude to the following for their valuable comments on the draft of this guideline: mohammad jalili, malihe kadivar, azim mirzazade, hamid emadi, mohammad afzalimoghadam, zahra ahmadinejad, sadeghian, zhamak khorgami, saeed reza mehrpour, nasser karimi, marzieh ghalamkari, mahdi farrokhnia, hussein googol, mona deljoo, azadeh nasiri and mohammad amin ahangari. references 1. larijani b, ghafourifard s , zahedi f. ethical consideration in clinical education. iran j diabetes lipid disord 2005; 4: 105-9. [in persian] 2. lowe m, kerridge i, mcphee j, hart c. do patients have an obligation to participate in student teaching? med educ 2008; 42(3): 237-41. 3. abdulghani hm, al-rukban mo, ahmad ss. patient attitudes towards medical students in riyadh, saudi arabia. educ health 2008; 21(2): 69. 4. choudhury tr, moosa aa, cushing a, bestwick j. patients’ attitudes towards the presence of medical students during consultations. med teach 2006; 28(7): e198-203. 5. king d, benbow sj, elizabeth j, lye m. attitudes of elderly patients to medical students. med edu 1992; 26(5): 360-3. 6. beatty me , lewis j:when students introduce themselves as doctors to patients. acad med. 1995;70(3):175-6. 7. kalantari sp. ethics in medical education. indian j anaesth. 2003;47(6):435-6. 8. coldicott y, pope c, roberts c. the ethics of intimate examinations-teaching tomorrow’s doctors. bmj 2003; 326(7380): 97-101. 9. bibby j, boyd n, redman cwe, luesley dm. consent for vaginal examination by students on anaesthetized patients. lancet 1988; 2(8620): 1150. 10. liu ke, shapiro j, robertson d, chamberlain s. pelvic examination by medical students. j obstet gynaecol can 2010; 32(9): 872–4. 11. kaldjian lc, wu bj, jekel jf, kaldjian ep, duffy tp. insertion of femoral-vein catheters for practice by medical house officers during cardiopulmonary resuscitation. n engl j med 1999; 341(27): 2088-91. 12. fourre mw. the performance of procedures on the recently deceased. acad emerg med 2002; 9(6): 595-8. 13. hojati smb. [adabe talim va taallom dar islam], translated by hojati smb. tehran: islamic culture publication bureau; 2008.[in persian] j med ethics hist med 8:5 apr, 2015 jmehm.tums.ac.ir akram hashemi et al. page 6 of 6 (page number not for citation purposes) 14. doyal l. closing the gap between professional teaching and practice. bmj 2001; 322(7288): 685-6. 15. gates ea. new surgical procedures: can our patients benefit while we learn?. am j obstet gynecol 1997; 176(6): 12939. 16. shooner c. the ethics of learning from patients. can med assoc j 1997; 156(4): 535-8. 17. salter rh. learning from patients: unfashionable but effective. postgrad med j 1996; 72(849): 385. 18. hope t, frith p, craze j, mussai f, chadha a, noble d. developing guidelines for medical students about the examination of patients under 18 years old. bmj2005; 331(7529): 1384-6. 19. lane jl, ziv a, boulet jr. a pediatric clinical skills assessment using children as standardized patients. arch pediatr adolesc med 1999; 153(6): 637-44. 20. tsai tc. using children as standardised patients for assessing clinical competence in paediatrics. arch dis child 2004; 89(12): 1117-20. 21. blake k, mann kv, kaufman dm, kappelman m. learning adolescent psychosocial interviewing using simulated patients. acad med 2000; 75(10): s56-8. 22. joorabchi b. objective structured clinical examination in a pediatric residency program. am j dis child 1991; 145(7): 757-62. 23. anonymous. the council on ethical and judicial affairs of the american medical association, authors. performing procedures on the newly deceased. acad med 2002; 77(12 pt 1): 1212–16. 24. anonymous. recommendations of the 1992 national conference. ethical considerations in resuscitation. jama. 18; 268: 2282–88. 25. schmidt ta, , abbott jt, geiderman jm, et al. ethics seminars: the ethical debate on practicing procedures on the newly dead. acad emerg med 2004; 11(9): 962–6. 26. anonymous. making and using visual and audio recordings of patients. http://www.gmcuk.org/static/documents/content/making_and_using_visual_and_audio_recordings_of_patients.pdf (accessed in 2013). 27. anonymous. opinion 5.046 filming patients for education of health professional. http://www.amaassn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion5046.page? (accessed in 2014). 28. anonymous. code for the ethical conduct of clinical teaching encounters. http://meds.queensu.ca/undergraduate/policies/code_for_ethical_conduct (accessed in 2014). 29. anonymous. involving patients in medical education: ethical guidelines for medical students and clinical teachers. sydney.edu.au/medicine/northern/tutors/pdfs/ethical_guidelines.pdf (accessed in 2014). 30. anonymous. ethical guidelines: involving patients in clinical teaching. www.ccdhb.org.nz/patient/rights_egct.htm (accessed in 2014). 31. anonymous. audio and visual recordings guideline of the malaysian medical council. http://mmc.gov.my/v1/docs/20100112%20audio%20and%20visual%20recordings_15.03.2011.pdf (accessed in 2014). http://www.gmc http://www.ama http://meds.queensu.ca/undergraduate/policies/code_for_ethical_conduct http://www.ccdhb.org.nz/patient/rights_egct.htm http://mmc.gov.my/v1/docs/20100112%20audio%20and%20visual%20recordings_15.03.2011.pdf jmehm-6-8 journal of medical ethics and history of medicine continuing review of ethics in clinical trials: a surveillance study in iran fariba asghari1, seyedeh mojgan ghalandarpoorattar2 1 medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran; 2 department of obstetrics & gynecology, tehran university of medical sciences, tehran, iran. corresponding author: fariba asghari address: medical ethics and history of medicine research center, #23, shanzdah azar st.tehran, iran email: fasghari@tums.ac.ir tel: 98 21 66 41 96 61 fax: 98 21 66 41 96 61 received: 12 march 2013 accepted: 04 sep 2013 published: 08 sep 2013 j med ethics hist med, 2013, 6:8 © 2013 fariba asghari et al.; licensee tehran univ. med. sci. abstract this study was conducted to examine adherence to ethical principles during research and the necessity to conduct systematic and continuing review of ongoing research in iran. all clinical trials approved by the research ethics committee of tehran university of medical sciences (tums) ongoing in 2007 (n = 21) were reviewed through receiving principal investigators’ (pis) reports, as well as reviewing patient consent forms. two questionnaires were sent to pis, one to collect information about the study and the other to evaluate pis’ perception and awareness about ethical codes of clinical trials. a representative of the tums research ethics committee was sent to the research site to fill a checklist by reviewing the obtained informed consent and fill the other checklist by interviewing a sample of participants regarding their perception of their volunteer participation in the clinical trial and receiving adequate information. only in 66.7% of the surveyed trials the objectives of the trial had been explained in the informed consent, and in 38.6% of the trials it was mentioned in informed consent that participation is voluntary. among participants, 34.7% (n = 26) were not aware they were enrolled in a research project, 29.3% (n = 22) had not understood the information they had received, 74.7% (n = 56) did not know they could refuse to participate and still receive care from their physician, and 58.7% did not realize they were free to drop out of the study at any time. the results point to the need for continuing review of clinical research, especially clinical trials, and the necessity for thorough assessment of patient consent forms during the process of approval in terms of their contents and their understandability. keywords: continuing review; clinical trial; research ethics; informed consent mailto:fasghari@tums.ac.ir j med ethics hist med 6:8 sep, 2013 jmehm.tums.ac.ir fariba asghari et al. page 2 of 6 (page number not for citation purposes) introduction research ethics committees (recs) were established in iran more than 15 years ago. the national guideline of research ethics was released in 2000, and six specific guidelines were added in 2005 to place more focus on ethical considerations in research areas of clinical trials, genetics, vulnerable groups, organ and tissue transplantation, animals, and research on human embryo (1). the increasing number of medical researches and papers in iran point to the important role of recs in preserving the rights of participants. recs in iran are active in reviewing research proposals; however, it is not clear whether the review of proposals is enough to ensure protection of participants’ rights. one of the essential duties of recs, as explicitly stated in the declaration of helsinki and the iranian ethics guidelines, is ethical review of ongoing projects (2). this obligation, although necessary to ensure participants’ rights and safety, is not fulfilled by any recs due to the financial burden it causes for them. for this same reason, continuing review of ongoing research projects in other countries started with much delay compared to ethical review of proposals (3). according to the study by thompson et al. in scotland in 1980, only 6 of the 34 recs (18%) had a formal process for continuing review of projects (4). in 1989, less than 50% of the recs in australia conducted continuing reviews; most of them were passive and relied on researchers’ reports (5). in 1993, the national council on ethics in human research in canada reported that 53% of committees requested annual reports from researchers and only 18% conducted continuing reviews (6). in a similar survey in 2007, the latter rate had reached 87.4%, although most continuing reviews were passive and mainly concerned clinical trials (7). tehran university of medical sciences first started continuing review of a number of projects approved by its rec during this study. since clinical trials have more serious ethical considerations, all approved clinical trials conducted during 2007 were reviewed actively. results can be a response for the needs assessment for conducting systematic continuing reviews of research projects by recs in iran. method research tools questionnaire a. this questionnaire was completed by the pis of clinical trials to collect information about the study. these included the start date, number of participants, occurrence of complications, changes in the study protocol, the intervention received by the control group, and the vulnerability of the participants. questionnaire b. in this questionnaire, investigators were asked 11 questions regarding their perception and awareness about ethical codes of clinical trials based on the national guideline of ethics in clinical trials. responses to each question were “yes”, “no”, or “don’t know”. questionnaire c. this questionnaire was a checklist of informed consent requirements which was completed by the committee representative after viewing the informed consents obtained from study participants. questionnaire d. this questionnaire was completed by the rec representative through interviews with clinical trial participants. it contained 14 items concerning participants’ information about the clinical trial in which they were participating, and their understanding of the information. we did not evaluate the reliability of our data gathering method. in terms of validity, all questionnaires were reviewed by two research ethics experts. design all ongoing clinical trials during october 2007 to march 2008 approved by the tums rec were enrolled in the study. the principal investigators (pis) were informed about the study through a letter by the secretary of the tums rec, and a representative was introduced to them for continuing review of their projects. questionnaires “a” (study information and features) and “b” (investigators’ awareness of codes of ethics for clinical trials) were sent enclosed with the letter, and investigators were asked to complete and return them. follow-up reminder calls were made to investigators who did not respond. in the next stage, the rec representative visited the investigators and requested to see informed consent forms; questionnaire “c” was then completed based on the contents of informed consent forms. investigators were required to provide the rec representative with the phone numbers and addresses of study participants. the representative randomly selected 10% of the study participants and received their contact information. the committee representative subsequently completed questionnaire “d” through phone interviews with participants by referring to their information about the study they were involved with. results there was no response to the rec secretary letter in two cases of twenty-five ongoing clinical trials (response rate: 92%), and in two cases, the study was cancelled because no funding was received. eventually, analysis was done with data j med ethics hist med 6:8 sep, 2013 jmehm.tums.ac.ir fariba asghari et al. page 3 of 6 (page number not for citation purposes) from 21 clinical trials summarized in table 1. these 21 projects were being executed by 14 pis. table 1. attributes of the reviewed clinical trials variables percent number control group intervention standard treatment 35.0 7 standard + placebo 50.0 10 placebo 5.0 1 no treatment 5.0 1 non-standard intervention 5.0 1 participants vulnerable groups 57.1 12 children 9.5 2 pregnant ladies 4.8 1 unconscious people 4.8 1 mentally disabled 23.8 5 side effects leading to sample exclusion yes 19.0 4 no 81.0 17 protocol modification during execution yes 14.3 3 no 85.7 18 informed consent form lacking 15.8 3 exists 84.2 16 informed consents of 18 studies were reviewed. in 3 trials, release of liability was obtained and information about the given study was not mentioned. table 2 shows the inclusion of necessary items in the reviewed informed consents. on average, 57.3 people were enrolled in each study. ten percent of the participants (a total of 75 people from 15 trials whose phone numbers were provided for the rec representative) were interviewed. twenty-five people (34.7%) had not signed their informed consents; in all these cases, studies were conducted on people with mental disabilities and children, and interviews were done with the person who had signed the consent form. table 3 shows the patients’ awareness of the clinical trial in which they were enrolled. table 2. adherence to the ethical guideline in informed consent forms of clinical trials items yes no (%) no no (%) 1 consent form is in simple language and free of jargons 12 (66.7) 6 (33.3) 2 consent form explicitly states the project is a research 13 (72.2) 5 (27.8) 3 research objectives are explained 12 (66.7) 6 (33.3) 4 random assignment of participants to the treatment or control group is stated 2 (11.1) 15 (83.3) 5 potential risks are explained 7 (38.9) 11 (61.1) 6 potential benefits are explained 3 (16.7) 15 (83.3) 7 other available treatment options, and their risks and benefits are stated 1 (5.6) 15 (83.3) 8 the compensation process, in case of harm, is explained 3 (16.7) 15 (83.3) 9 there is emphasis that participation is voluntary 7 (38.9) 11 (61.1) 10 the option to withdraw after giving consent, without punishment, is explicitly mentioned 10 (55.6) 8 (44.4) 11 confidentiality and its process are explained in the form 9 (50.0) 9 (50.0) 12 the person(s) whom participants can contact for receiving more information is introduced 8 (44.4) 10 (55.6) 13 circumstances that terminate participation are explained 2 (11.1) 16 (88.9) 14 approximate participation time is mentioned 5 (27.8) 13 (72.2) j med ethics hist med 6:8 sep, 2013 jmehm.tums.ac.ir fariba asghari et al. page 4 of 6 (page number not for citation purposes) table 3. patients’ awareness about the clinical trial in which they were participating question yes no (%) no no (%) i don’t know no (%) 1 did you know you were part of a clinical trial? 46 (63.3) 26 (34.7) 3 (4.0) 2 were you given written information about the research project or a copy of the informed consent form? 52 (71.2) 21 (28.8) 0 (0) 3 did you receive verbal information about the research project? 59 (78.7) 16 (21.3) 0 (0) 4 did you understand the information well? 52 (69.3) 22 (29.3) 1 (1.3) 5 did you have the chance to ask your questions about the project? 54 (72.0) 19 (25/.3) 2 (2.7) 6 were you given enough time to consider and decide about participating? 51 (68.0) 21 (28.0) 3 (4.0) 7 were you told you could withdraw without any disruption in your care? 31 (41.3) 44 (58.7) 0 (0) 8 were you informed what to do in case of side effects or concern? 27 (36.0) 47 (62.7) 1 (1.3) 9 was it your perception that you were free not to take part in this project if you did not want to and your physician would give you the due treatment? 18 (24.0) 56 (74.7) 1 (1.3) all pis (14 people) completed the questionnaire concerning their information about ethical considerations of clinical trials; their median score was 4 out of 8 (table 4). seven (50%) were not aware of the specific ethical guideline on clinical trials. all investigators believed continuing review of ongoing clinical trials was necessary to maintain research standards. table 4. principal investigators’ perception and awareness of reviewed clinical trials questions yes no (%) no no (%) i don’t know no (%) 1 is the investigator obliged to report any serious side effect to the ethics committee? 13 (92.9) 0 (0) 1 (7.1) 2 should all clinical trials be reviewed for ethical issues every 6 months? 5 (35.7) 2 (14.3) 7 (05) 3 does the ethics committee have the right to examine scientific qualifications of investigators? 5 (41.7) 4 (33.3) 3 (25) 4 is it ethically permissible to do clinical trials in emergency situations when obtaining informed consent from the patient or guardian is not possible? 0 (0) 11 (78.6) 3 (21.4) 5 it is ethically permissible to obtain release of liability from participants of a clinical trial? 3 (25) 3 (25) 6 (50) 6 does the research ethics committee have the right to access recorded research data directly? 7 (53.8) 2 (15.4) 4 (30.8) 7 is the physician ethically allowed to adjoin clinical trials with medical treatments? 8 (66.7) 2 (16.7) 2 (16.7) 8 did you know the research ethics committee should monitor research projects, especially clinical trials? 8 (57.1) 6 (42.9) 0 (0) discussion results of our study indicate that there are many shortcomings in observing ethics in research. although research proposals were reviewed in terms of ethical considerations, 14% of the trials had not obtained written informed consents for participating in the project. an almost equal number of them had obtained signatures on release of liability forms rather than informed consent forms. in addition, protocol modification and serious side effects were not reported to the rec, and thus, it appears that a simple ethical review of proposals does not ascertain adherence to codes of ethics in research and it is necessary to have continuing review during execution to monitor such adherence in practice. our results revealed how little the investigators were aware of ethics codes in research; half of them did not know there was a special guideline on ethical considerations in clinical trials. short or virtual refresher courses are needed for investigators to teach them the codes of ethics and better familiarize them with ethical principles especially in designing clinical trials. in our study, one-third of the participants were not even aware they were taking part in a clinical trial. more than two-thirds were not aware they could refuse to participate and more than half did not know they were free to withdraw from the trial at any time. part of this lack of awareness was due to failure to provide sufficient information in the informed consent forms and we found serious shortcomings in the reviewed informed consent forms. the lack of awareness can also be attributed to the readability of the forms to some extent. many studies have demonstrated how unreadable and incomprehensible informed consent forms can be compared to public material (8-10). we did not examine readability of the consent forms, but the mismatch between the amount of given information and the level of understanding them (tables 2 and 3) suggests the difficulty of the contents of the informed consents as one-third of the patients j med ethics hist med 6:8 sep, 2013 jmehm.tums.ac.ir fariba asghari et al. page 6 of 6 (page number not for citation purposes) stated they had not understood the information contained in the consent forms. another noteworthy finding was the failure to provide information regarding possible risks. in two-thirds of the trials, potential complications of participating in the study were not mentioned in the informed consent forms, and half of them had not designated someone who could be contacted in case of concerns or problems. our interviews with patients showed that two-thirds did not know what to do in case of side effects. this observation, in addition to their failure to report serious side effects to the ethics committee, questions the safety of approved studies to a great extent. in terms of trials’ adherence to ethical codes, our findings were more comparable to older studies. in the study by olver et al. in 1995, 60% of the patients had understood the contents of the informed consent form (11). in a study reported from sweden in 1991, about 40% of the patients were not aware of their right to withdraw from the study and 16% did not know they were part of a research project (12). however, more recent studies have shown a better situation compared to our study. in a 1997 study, smith et al. found that at least one consent form was incomplete in one fourth of studies (13). according to mc cuskers et al., only about 4% of consent forms differed from the original informed consent forms (14). one of the most recent studies, which was conducted in 2002 in the uk, reported that 99% of the patients understood all or most of the information and 95% had the opportunity to ask the investigators their questions (15). in our study, these figures were 79% and 72%, respectively. the rate of observing ethics in research may be lower in iran compared to the uk and the us, but comparing our results with those of a study conducted 15 years ago at tehran university of medical sciences shows a remarkable increase in this regard. according to larijani and rashidian, participants were aware of being in a trial in only 11.8% of studies, and informed consents were not obtained from 92.2% of participants; it should be mentioned, however, that one fourth of the studies were conducted on children. in 80% of the studies, the patient was charged for the treatment expenses, and if a placebo was used, participants were not aware that they were assigned randomly to one group or another (16). our study had limitations that should be noted. one limitation was that we did not match the reviewed informed consents with those presented in the proposal at the time of approval. also, our study was restricted to clinical trials, which usually have more serious ethical considerations; we did not include all research projects with human samples and thus, results cannot be generalized to all research conducted at the university. our study is the first ethical review of ongoing clinical trials in iran where all principal investigators believe continuing review of ongoing trials is necessary to maintain ethical standards in research. teaching ethical codes along with performing continuing review of research projects can increase investigators’ adherence to such codes and minimize changes that can reduce the safety of projects. nonetheless, it must be noted that continuing review programs require considerable budget and staff, and their sustainability calls for a costeffectiveness assessment of the review. based on the result of this study the tums rec pioneered to plan for continuing ethical review in iran. this study demonstrated the essential role of continuing review of research projects, especially clinical trials, and the necessity to pay more attention to the contents of informed consent forms and assessment of their comprehensibility. acknowledgements the authors wish to acknowledge the many valuable comments dr. masoud younesian and mrs. mojgan hoseini provided on the proposal of this study. the authors also thank ms. alamdar for assisting us with the correspondence and dr. aniseh samadi for collecting data. this study was financially supported by tehran university of medical sciences under the agreement number 132/99 on may 25, 2008. competing interests all authors declare having no conflict of interest. references 1. larijani b, zahedi f. contemporary medical ethics: an overview from iran. dev world bioeth 2008; 8(3): 192-6. 2. anonymous. world medical association. declaration of helsinki (may 2011) http://www.wma.net/en/30publications/10policies/b3/index.html (accessed in 2013) 3. weijer c, shapiro s, fuks a, glass kc, skrutkowska m. monitoring clinical research: an obligation unfulfilled. cmaj 1995; 152(12): 1973-80. 4. thompson ie, french k, melia km, boyd km, templeton aa, potter b. research ethical committees in scotland. br med j (clin res ed.)1981; 282(6265): 718-20. 5. mcneill pm, berglund ca, webster iw. reviewing the reviewers: a survey of institutional ethics committees in australia. med j aust 1990; 152(6): 289-96. 6. weijer c. continuing review of research approved by canadian research ethics boards. cmaj 2001; 164(9): 1305-6. 7. anonymous. national council on bioethics in human research (canada). working group on evaluation. protecting http://www.wma.net/en/30publications/10policies/b3/index.html j med ethics hist med 6:8 sep, 2013 jmehm.tums.ac.ir fariba asghari et al. page 8 of 6 (page number not for citation purposes) and promoting the human research subject: a review of the function of research ethics boards in canadian faculties of medicine. ncbhr commun 1995; 6(1): 3-32. 8. grossman sa, piantadosi s, covahey c. are informed consent forms that describe clinical oncology research protocols readable by most patients and their families? j clin oncol 1994; 12(10): 2211-5. 9. murphy j, gamble g, sharpe n. readability of subject information leaflets for medical research. n z med j 1994; 107(991): 509-10. 10. priestley ka, campbell c, valentine cb, denison dm, buller np. are patient consent forms for research protocols easy to read? bmj 1992; 305(6864): 1263-4. 11. olver in, buchanan l, laidlaw c, poulton g. the adequacy of consent forms for informing patients entering oncological clinical trials. ann oncol 1995; 6(9): 867-70. 12. lynoe n, sandlund m, dahlqvist g, jacobsson l. informed consent: study of quality of information given to participants in a clinical trial. bmj 1991; 303(6803): 610-3. 13. smith t, moore ej, tunstall-pedoe h. review by a local medical research ethics committee of the conduct of approved research projects, by examination of patients' case notes, consent forms, and research records and by interview. bmj 1997; 314(7094): 1588-90. 14. mccusker j, kruszewski z, lacey b, schiff b. monitoring clinical research: report of one hospital's experience. cmaj 2001; 164(9): 1321-5. 15. ferguson pr. patients' perceptions of information provided in clinical trials. j med ethics 2002; 28(1): 45-8. 16. larijani b, rashidian a. ethics in clinical trials: review of clinical trial thesis in tehran university of medical sciences affiliated hospitals. j med counc islam repub iran 1999; 17(1): 65-73. 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________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ 1 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e original article volume 13 (suppl.) number 28 december 2020 copyright © 2020 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. health lag: medical philosophy reflects on covid-19 pandemic alireza monajemi1, hamidreza namazi2* 1.assistant professor, department of philosophy of science and technology, institute for humanities and cultural studies, tehran, iran. 2.assistant professor, department of medical ethics, school of medicine, tehran university of medical sciences, tehran, iran. abstract in this paper, we reflect on the covid-19 pandemic based on medical philosophy. a critical examination of the corona crisis uncovers that in order to understand and explain the unpreparedness of the health systems, we need a new conceptual framework. this helps us to look at this phenomenon in a new way, address new problems, and come up with creative solutions. our proposal is that “health lag” is a concept that could help frame and explain this unpreparedness and unreadiness. the term “health lag” refers to the failure of health systems to keep up with clinical medicine. in other words, health issues in most situations fall behind clinical medicine, leading to social, cultural, and economic problems. in the first step to define health lag, we have to explain the distinction between clinical medicine and health and address the role of individual health, public health, and epidemic in this dichotomy. thereafter, the reasons behind health lag will be analyzed in three levels: theoretical, practical, and institutional. in the third step, we will point out the most important consequences of health lag: the medicalization of health, the inconsistency of biopolitics, inadequate ethical frameworks, and public sphere vulnerabilities. finally, we try to come up with a set of recommendations based on this philosophical-conceptual analysis. keywords: medical philosophy; medical humanities; medicalization; public health; covid-19; pandemics. *corresponding author hamidreza namazi no. 21, medical ethics and history of medicine research center, 16 azar st., tehran, iran. tel: (+98) 21 66 41 96 61 email: hrnamazi@tums.ac.ir recieved: 1 nov 2020 accepted: 30 nov 2020 published: 23 dec 2020 citation to this article: monajemi a, namazi h. health lag: medical philosophy reflects on covid-19 pandemic. j med ethics hist med. 2020; 13(suppl.): 28. health lag: medical philosophy reflects on covid-19 pandemic 2 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 28 december 2020 introduction bill gates, in a ted talk in 2015, compared the cold war situation with the present time. he told a story about when he was a kid, the american people were worried about nuclear war. all families had filled their cellars with cans of food and water. all people were taught what was needed to be done in a crisis: go downstairs, hunker down, and eat out of the barrel. however, nowadays, rather than a nuclear war, the greatest risk is pandemic. but it seems that we are not actually well prepared for such an epidemic (1). furthermore, the comparison between the covid-19 pandemic and the spanish flu that happened a hundred years ago reveals that the preventive technology (e.g., mask) has not changed significantly, and we use roughly the same measures against covid-19. in this period of time, however, the diagnostic and therapeutic technologies have evolved so drastically that previous technologies look as old as the hills. why is that? why prevention has remained unchanged in the past hundred years, while the diagnosis and treatment have improved drastically? why we are never ready for epidemics? in addition to the existing healthcare crises, the latest coronavirus pandemic has exposed several challenges in the healthcare systems around the world, such as system inability to rapidly detect and monitor the dissemination of the novel coronavirus, late adoption of physical-distancing protocols, contradictory and delayed national guidelines on handling the pandemic, inadequate leadership and excessive partisanship, governmental health management, distrust of the government, lack of national public health information system, poor communication between governments, health professionals, biomedical scientists, the media and the public sphere, and poor health media literacy. it is no exaggeration to say that because of the under-developed and under-resourced public health system, the response of the public health system to the covid-19 pandemic is not effective (2,3). it is currently recommended that for controlling the corona crisis the whole-government and whole-society should be involved; however, this shows the inadequacy and inefficiency of the health system (4). in this paper, the authors reflect on the covid-19 pandemic based on medical philosophy. a critical examination of the corona crisis reveals that in order to understand and explain the unpreparedness of the health system, a new conceptual framework is needed. this helps us to look at the phenomena in a new way, address new problems, and come up with creative solutions. our proposal is that “health lag” is the concept that could explain the current unpreparedness and unreadiness. so, first, we define health lag, for which purpose we have to distinct clinical medicine from health and address the role of health, public health, and epidemic in this dichotomy. thereafter, the reasons behind health lag will be analyzed in three levels: theoretical, practical, and institutional. we then will point out the most important consequences of health lag: the namazi h., et al. 3 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 28 december 2020 medicalization of the health, the inconsistency of biopolitics, inadequate ethical frameworks, and public sphere vulnerabilities. finally, we try to come up with a set of recommendations based on this philosophical-conceptual analysis. the health versus the clinical medicine what is “health lag”? the term “health lag” refers to the failure of the health system to keep up with clinical medicine advancements. in other words, health issues in most situations fall behind clinical medicine that leads to or causes social, cultural, and economic problems. health lag occurs due to unequal and undivided attention to health issues rather than medical issues. it demonstrates itself at theoretical, practical, and institutional levels, creating a gap between the material and non-material culture (5). to formulate the problem, firstly the health and the clinic are compared. prevention is linked with health, while diagnosis-treatment is linked with clinical medicine. health is more related to the community, whereas clinical medicine is correlated to the hospital. the health practice is focused on maintenance and preservation, while clinical medicine aims to bring back the healthy situation. in other words, the health is related to preservation and the clinic is related to restoration. the health is more concerned with the community, i.e., and non-medical aspects such as culture and economics, while the clinic is more about the individuals. the distinction between individual health and public health lies in clinical medicine. clinical medicine focuses on individual health, and what is left out of the medical field is related to public health. on the contrary, in the health context, individual health and public health are intertwined; in other words, individual health affects public health and vice versa. health practices (e.g. health preservation) consider both individual and public health. clinical medicine has the necessary components such as theoretical knowledge, practice, and related institution, while it seems that these components in healthcare have received little attention. an epidemic, an event that highlights the gap between individual and public health, cannot be managed only by reducing it to the clinical situation. an epidemic indicates that a specific disease has occurred at a specific time and place beyond expectations. contrary to health in which individual and public matters, public diseases do not make sense. however, the epidemic confronts us with situations in which the disease is spread in the population and therefore we need to understand the social, cultural, and political dimensions of health. this has always been neglected. the inability to control the epidemic is due to health lag rather than their insufficient clinical knowledge or inadequate clinical system. the unpreparedness of the health (theory, practice, and institution) the health lag is basically due to the health lag: medical philosophy reflects on covid-19 pandemic 4 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 28 december 2020 enigmatic nature of health. “health is often unnoticed and sustains its proper balance and proportion" (6). gadamer suggests that humans cannot understand health if everything is right. the basic meaning of health emerges and develops, only when a disease has occurred (7). consequently, the disease is the object of positive sciences and is considered a statistical abnormality. as a result, health has converted or transformed into "normality" that is directly defined in statistics. however, the statistical interpretation of normality is not value-free and is used as a mechanism of power and control when transformed into normativity (8). another aspect of the value-lateness of the health is that people are influenced by health conceptions of the society where they live, and how others try to cope with illnesses (9). this ontological situation indicates healthrelated theory, practice, and institution. theoretically, practically, and institutionally, public health sciences lag behind the medical sciences. goraya and scambler (10) have shown that public health has undergone successive transformations over the years: sanitary (1840-1870), preventative (1870-1940), and therapeutic phase (1940 -1970). in response to the industrial revolution and the associated poverty as well as the living condition of the metropolitan workers (e.g. overcrowded and insanitary), the sanitary phase started. the preventive phase began around 1870 when the appropriate public health interventions were redefined based on the germ theory of disease. as a result, public health physicians relinquished authority to deal with all aspects of environmental sanitation (e.g. housing and poverty). the emphasis switched from the public to the individual. personal preventive services (e.g. family planning and immunization) and individual health education were raised subsequently. despite the remarkable success of vaccines, infectious diseases were still not effectively treated until the 1940s. the discovery of antibiotics put forward the concept of the ‘magic bullet’. paradoxically, public health physicians, who were expected to investigate the social and cultural determinants of health and to plan services accordingly, became administrators of medical interventions. the transformations in the public health conception could explain why health sciences have dissociated from public health problems, theories, and practices. epidemiology proclaims itself the foundation of public health; however, rather than focusing on the research applications, it has been preoccupied with the design and methodology of research. furthermore, the gap between public health sciences and practices is widening as the design and implementation of interventions in social and political contexts inevitably create tensions. ill-structured health institutions are the main reasons behind this gap (11). the consequences of health lag health lag has several consequences, the namazi h., et al. 5 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 28 december 2020 most prominent ones are: medicalization of heath, inconsistency of the biopolitics concepts, and inadequate health ethics frameworks. this highlights the huge impact of health lag on the fields outside medicine. medicalization of heath medicalization refers to the expansion of medicine outside its borders. the causes of medicalization are different. for example, escaping from problems and the inability to face the ups and downs of life are among the reasons behind the success of medicalization in society. health is a governmental affair in most countries around the world, and therefore, unlike medicine, it is less commercially successful. it also seems that more attention is paid to health research when it is designed and conducted in a medical context. after all, health is political, and medicalization can depoliticize it, making it scientific and socially acceptable. therefore, health always needs an integrated strategy. this strategy is the same as what is used for medicine. the medicalization of the health, on the one hand, negatively affects the preventive nature of health and that leads to neglecting the care (12). compared to other health concepts, health care is a misleading concept. this is because healthcare defines issues based on individual diagnosis and treatment strategies. a network consists of medical professionals, industries, technologies, and pharmaceuticals, medicalize health problems. medicalization has neglected the necessary social, community, or political actions, shifting public health issues towards looking for medical and technical solutions (13). public health, on the contrary to individual health, is based on the concept of population and epidemiology and is more objective. replacing the concept of health with normality is due to the fact that in the age of technoscience, mobilizing public opinion, changing policies and attitudes, and allocating research funding requires scientificization and technicalization (14). inconsistency of biopolitics health lag indicates that health is not simply limited to clinical medicine and has cultural, social, and political aspects. although “medicalization of health” depoliticizes it, it makes managing events such as epidemics difficult and complicated. experts in epidemiology and other health sciences as well as clinical specialists try to provide solutions to the pandemic macro-control policy. however, since they considered the medical institution-society relationship as the doctor-patient relationship and sought community compliance rather than the social, cultural and political, aspects of health, the controlling measures have remained ineffective. in other words, they see the socio-cultural aspects of health as obstacles to overcome to control the epidemic. politicians, on the other hand, understand health as clinical medicine but listen to expert advice as long as it does not interfere with socio-political concerns. health lag: medical philosophy reflects on covid-19 pandemic 6 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 28 december 2020 biopolitics links health with clinical issues (15). this does not mean biopolitics that aims at eugenesis, nor does it seek social control, but it is a concept close to care-politics. since health is described as a governmental duty and a right for the citizens, care policy does not mean governmental stewardship but requires everyone to take care of their own health as well as that of others. inadequate health ethics frameworks commonly, medical ethics applies to the doctor-patient relationship, while the interactions between an agency or institution and a community or population are the focus of public health ethics. medical ethics is based on four principles (i.e., autonomy, nonmaleficence, beneficence, and justice), while justice, interdependence, community trust, and fundamentality are the central issues of public health ethics. as public health is intertwined with social, cultural, and political issues, medical ethics is incapable of dealing with public health plans and interventions (16). the three mistakes in moral reasoning in the covid-19 pandemic highlight the other aspects of health ethics inadequacy: “illusion that we can avoid trade-offs,” “leave it to the experts”, and “precautionary paradox” (17). public sphere vulnerabilities as health is not based on an independent theory and knowledge, popularization of health leads to medical language usage. using medical vocabulary and literature to encourage people to preserve health will lead to health anxiety. this is because we have to look for possible diseases in ourselves to make sure that we are healthy. this requires a visit to the doctor and one to the laboratory and medical imaging. examples of effective health internships can be seen in established health institutions. the meaning of ‘health’ is of central importance to the orientation of public health activities. if ‘health’ is equated with the absence of disease, as it is in epidemiology, more emphasis will be shifted towards disease prevention. if it is interpreted in a broader sense, more stress will be on involving the equitable distribution of the health foundations and health promotion. if public health theory and practice are quite distinct from the individualistic approach to health, the conception of public health will be based on a strong commitment to collective endeavor (18). conclusion the most recent use of the term ‘new public health’ has emerged from the recognition of the fact that major health problems cannot be solved by current medical care (18). for epidemiology to become reintegrated with public health practices, changes will be required in both the education and training of epidemiologists as well as in the practice of public health. it will not be easy for epidemiology to regain its population purposes and have a closer connection with healthy public policies. in this regard, a social policy approach to healthy lifestyles’ rather than the current ‘lifestyle approach to social namazi h., et al. 7 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 28 december 2020 policy’ is required (18). in order to overcome health lag, medical humanities should play a crucial role both in reflecting on the health lag and criticizing the contemporary approach to health. in this regard, a paradigm shift towards critical medical humanities should take place (15). interdisciplinary disciplines such as health policy, bioethics, and medical education that originally belong to the field of medical humanities1 have forgotten their roots and become highly technicalized and bureaucratized. will discovering the corona vaccine solve all the problems? 1 . medical humanities is a field of research, education, and practice that examines health and medical issues from the perspective of medical philosophy, medical ethics, medical hermeneutics, medical sociology, medical history, literature and medicine, and so on. medical humanities, while trying to neutralize and overcome the reductive and dehumanizing approach of biomedicine, has attempted to improve and enrich clinical practice, patient care, and medical education (5). do we no longer need to deal with health lag? would science reclaim its superiority with the discovery of the vaccine? is it true to say that the main reason behind the priority of clinical medicine over health is greater efficiency and less complexity? would these questions still be relevant in the presence of the vaccine? should the vaccine be given to everyone? if not, who is in priority? obviously, these are not the main clinical concerns. so, it could be concluded that there is no escape from prioritization, which is a philosophical, political, social, and cultural issue and belongs to the health realm. health lag: medical philosophy reflects on covid-19 pandemic 8 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 28 december 2020 references 1. gates b. the next outbreak? we ‘re not ready. [cited 2020 december]; available from: https://www.ted.com/talks/bill_gates_the_next_outbreak_we_re_not_ready/transcript ?language=en 2. blumenthal d, fowler ej, abrams m, collins sr. covid-19 implications for the health care system. n engl j med. 2020; 383(15): 1483-8. 3. wang h, cleary pd, little j, auffray c. communicating in a public health crisis. the lancet digital health. 2020; 2(10): e503. doi: https://doi.org/10.1016/s25897500(20)30197-7 4. raoofi a, takian a, akbari sari a, olyaeemanesh a, haghighi h, aarabi m. covid19 pandemic and comparative health policy learning in iran. arch iran med. 2020; 23(4): 220–34. 5. monajemi a, namazi h. medical humanities meets corona virus pandemic: a report of the webinar on the dialogue between medicine and humanities. international journal of body, mind and culture. 2020; 7(1): 44-7. 6. gadamer hg. the enigma of health: the art of healing in a scientific age, 1st ed. usa: stanford university press; 1996, p.103-17. 7. svenaeus f. the hermeneutics of medicine and the phenomenology of health: steps towards a philosophy of medical practice, 1st ed. usa: springer; 2000, p. 78-94. 8. foucault m. the birth of the clinic. uk: routledge; 2012, p 39-41. 9. chadwick r. normality as convention and as scientific fact. in: schramme s, edwards e, eds. handbook of the philosophy of medicine, 1st ed. netherlands: springer; 2017, p. 1728. 10. goraya a, scambler g. ‘from old to new public health: role tensions and contradictions’. critical public health. 1998; 8(2): 141–51. 11. bhopal r. concepts of epidemiology: integrating the ideas, theories, principles, and methods of epidemiology, 3rd ed. uk: oxford university press; 2016, p. 389-425. 12. contino g. the medicalization of health and shared responsibility. new bioeth. 2016; 22(1): 45-55. 13. clark j. medicalization of global health 1: has the global health agenda become too medicalized? glob health action. 2014; 7: 10.3402/gha.v7.23998. 14. monajemi a. clinical practice in the techno-science age: living in crisis. international journal of body, mind & culture. 2018; 5(2): 84-8. 15. atkinson s, evans b, woods a, kearns r. ‘the medical’ and ‘health’ in a critical medical humanity. j med humanit. 2015; 36(1): 7181. 16. swain gr, burns, ka, etkind p. preparedness: medical ethics versus public health ethics. journal of public health management and practice. 2008; 14(4): 354-57. 17. stefánsson ho. three mistakes in the moral reasoning about the covid-19 pandemic. [ cited 2020 december]; available from: https://www.iffs.se/en/publications/working-papers/three-mistakes-in-the-moralreasoning-about-the-covid-19-pandemic/ 18. beaglehole r. public health at the crossroads (achievements and prospects), 2nd ed. uk: cambridge university press; 2004, p. 250-84.. microsoft word 4 journal of medical ethics and history of medicine       attitude  and  practice  of  dental  surgeons  towards  pharmaceutical  companies’ marketing gifts   shaila tahir1, adeela rafique1, farkhanda ghafoor2, akif saleem1 and amanullah khan1   1fatima memorial college of medicine & dentistry, lahore, pakistan; 2pmrc centre nhrc, shaikh zayed medical complex lahore, pakistan.   corresponding author: farkhanda ghafoor senior research officer, pmrc centre nhrc, shaikh zayed medical complex, lahore, pakistan. email : fghafoor99@hotmail.com received: 06 sep 2012 accepted: 23 jan 2013 published: 05 apr 2013 j med ethics hist med, 2013, 6:4 http://journals.tums.ac.ir/abs/23423 © 2013 shaila tahir et al.; licensee tehran univ. med. sci. abstract interaction of pharmaceutical companies (pc) with healthcare services has been a reason for concern. in medicine,  awareness of the ethical implications of these interactions have been emphasized upon, while this issue has not  been highlighted in dentistry. this study undertook a cross‐sectional rapid assessment procedure to gather views  of  dentists  in  various  institutions  towards  unethical  practices  in  health  care  and  pharmaceutical  industry.  the  purpose  of  this  study  was  to  assess  the  need  for  the  formulation  and  implementation  of  guidelines  for  the  interaction of dentists with the pharmaceutical and device industry in the best interest of patients.  a  group  of  209  dentists  of  lahore  including  faculty  members,  demonstrators,  private  practitioners  and  fresh  graduates responded to a questionnaire to assess their attitudes and practices towards pharmaceutical companies’  marketing gifts.  the study was conducted during 2011 and provided interesting data that showed the pharmaceutical industry is  approaching  private  practitioners  more  frequently  than  academicians  and  fresh  graduates.  private  practioners  accepted the gifts but mostly recognized them as unethical (over 65%). both groups considered sponsoring of on‐ campus lectures as acceptable (over 70%).  respondents are not fully aware of the ethical demands which are imperative for all health care industries, and  there is a dire need of strict guidelines and code of ethics for the dentist’s interaction with the pharmaceutical and  device industry so that patient interest is protected.    keywords: attitude, practice, pharmaceutical companies, dentists, marketing gifts introduction the global pharmaceutical industry has grown at a tremendous pace reaching up to $956 billion and is expected to rise to nearly $1.2 trillion in 2016, representing a compound annual growth rate of 3-6 percent the world over (1). with this aggressive growth and ever increasing competition the marketing strategies of pharmaceutical and some dental/medical equipment companies are becoming ethically questionable (2-4). although the pharmaceutical industry is sponsoring a lot of research j med ethics hist med 6:4 april, 2013 jmehm.tums.ac.ir shaila tahir et al. page 2 of 5 (page number not for citation purposes)     worldwide, the major portion of their budget is allocated to promotional activities (4, 5). the usual promotional activities are obliging doctors by minor gifts, like stationery items, donating equipments, kits and even invitations for dinners, or sponsoring participation in seminars and training programs. this brings about a conflict between the physician’s financial interest and the welfare of the patient (4-13). in medicine, awareness of the ethical implications of such gifts has been raised for the past few decades and a code of ethics has been formulated for interaction between medical practitioners and pharmaceutical companies. in dentistry, the need to realize the ethical implications of such interactions is greater than medicine because of the more active involvement of device industry and material manufacturers. the interactions of dentists include those with pharmaceutical, biotech, medical device and research equipment industry. interactions with these industries can be positive if kept above reproach (14). however, with the growing competition amongst the pharmaceutical industry, device industry and material manufacturers, the unethical marketing practices are also growing. the present study was undertaken to assess the attitudes and practices of fresh dental graduates, faculty members and private practitioners in dentistry towards pharmaceutical gifts, and consequently the need for implementation of guidelines and a code of ethics in the dental fraternity in pakistan. another purpose of this study was to assess the difference in perception of fresh graduates, residents, faculty members and private practitioners. method the study sample included dentists of various categories: fresh graduates, residents/demonstrators, faculty members and private practitioners. the assessment tool was a questionnaire that was designed based on previously published studies in india (15) and norway (16). it was handed out at various teaching and training dental institutions, clinics and dental conferences, and was filled in anonymously. the data was collected from october 2011 to december 2011. the teaching & training institutions included in this study were de’ montmorency college of dentistry, sharif medical and dental college, lahore medical and dental college and fatima memorial dental college and hospital. the sample size for each category selected was based on the expected representative size. all the data was compiled and analyzed using microsoft excel (windows 7) and spss (version 17). for testing significance, since the data was predominantly qualitative in nature, chi square test was applied at a p value of 0.05 or less. results a total of 220 participants were requested to fill a study instrument, 209 (95 %) completed it and were included for data analysis. the participants included fresh graduates (fg), demonstrators (d), faculty members (fm) and private practitioners (pp) working in dentistry. the demographic data of the study participants are summarized in table 1 and figure 1. table 1: demographic data of study participants category (dentist) respondents data completed fresh graduates 70 67 demonstrators 90 87 faculty members 30 26 private practitioners 30 29 total 220 209 (95%) gender (n=209) male 98 46.9% female 111 53.1% age (years) < 30 74 35.4% >30 135 64.6% the response of the four different groups to the pharmaceutical representative (pr) is shown in tables 2 and 3. it appeared that private practitioners (pp) were more frequently contacted by the prs. during the previous 3 months, 89.6% of pps had been visited as compared to 62.8% of faculty. a similar trend was observed in the offering of gifts, with the highest percentage of gifts being offered to private practitioners (over 75%) as against 61.1% to fresh graduates, demonstrators and faculty members. when gifts were offered, the pps accepted in higher proportion (69.0%) than faculty (43.1%). from the ethical point of view of accepting gifts, a very high percentage (92%) of faculty members declared that accepting gifts from j med pharmace of fresh fig. 1 table 1 2 3 4 5 6 7 8 *thes table 1 2 3 4 5 6 7 8 *thes f re q u e n cy d ethics hist m eutical industr graduates, 7 : work experi e 2: response views/r interaction cal represen 3 months gifts offere gifts accep considerin unethical gifts affect allowing p campus lec receiving h lecture acc considerin interaction se values were e 3: response views/r interaction representati gifts offere gifts accept considering gifts affect allowing p lectures receiving acceptable considering tion as usefu se values were f re q u e n cy   6 med 6:4 april, 2 ry was unethic 70.1% of dem ience of study outcome of p responses n with pharmac ntatives in the ed pted ng accepting g t prescription prs to arrange ctures honorarium fo eptable ng pharmaceut as useful e statistically s outcome of p responses with p ives in the last ed ted g accepting gi prescription prs to arrang honorarium g pharmaceut ful e statistically s 8 67 2013 cal while 58.2 monstrators a y participants articipants of fr n= ceutie last 43 43 31 gifts 39 31 e on 57 or a 44 tical 58 significant articipants of pharmaceutica t 3 months ifts unethical ge on campu for a lecture tical interac significant work experi 25 7 jmehm.tums 2% and 65 ac the academic resh graduates =67 3 (64.1%) 3 (64.1%) 1 (46.2%) 9 (58.2%) 1 (46.2%) 7 (85.0%) 4 (65.6%) 8 (86.5%) the academic academ group (n=180)* al 113 (62 110 (61 78 (43. 124 (69 72 (40. s 135 (75 e 106 (59 144 (80 ence  1 s.ac.ir 5% of priv cceptance of g group s dem n=87 54 (6 54 (6 41 (4 61 (7 39 (4 61 (7 51 ( 67 (7 and private g mic p tion (n=2 2.8%) 2 1.1%) 2 .3%) 2 9.0%) 1 .0%) 1 5.0%) 2 9.0%) 1 0.0%) 2 13 (page num vate practitio gifts as unethic monstrators 7 62.0%) 62.0%) 47.0%) 70.1%) 44.8%) 70.1%) 58.6%) 78.1%) groups private practi ners 29) 25 (89.6%) 22 (75.8%) 20 (69.0%) 19 (65.5%) 12 (41.3%) 21 (72.4%) 15 (55.1%) 22 (75.8%) shaila t mber not for citati oners consid cal. faculty n=26 16 (61. 13(50.0 6 (23.0 24 (92. 2 (7.6% 17(65.3 11 (42. 19 (73. ip valu <0.05 <0.05 <0.05 >0.05 >0.05 >0.05 >0.05 >0.05 tahir et al. page 3 of 5 on purposes)     dered the y .5%) 0%) 0%)* .3%) %)* 3%) .3%)* .0%) e j med ethics hist med 6:4 april, 2013 jmehm.tums.ac.ir shaila tahir et al. page 4 of 5 (page number not for citation purposes)     the academic group included fresh graduates, demonstrators and teaching faculty. an interesting observation was that almost 69% of private practitioners accepted gifts from the prs but 65% of them considered it unethical at the same time. this shows a clear contrast in their actions and opinions. an average of 44% of the fresh graduates, demonstrators and private practitioners revealed that their prescriptions were affected by their interaction with the prs while only 7.6% of the faculty members considered their interaction with prs to affect their prescribing habit. it was interesting to note that both fresh graduates and demonstrators were offered gifts and accepted them in the ratio of 1.4: 1, while the academic staff accepted gifts to a lesser degree, the ratio between gifts offered and accepted being 2.2: 1.0. in the additional question on commenting about the gift as ethical or unethical, the academic group by far declared them as unethical and the ratio of labeling it as unethical was faculty: demonstrators: fresh graduates: 1.6: 1.2: 1. in terms of accepting and declaring it as unethical, the academic staff provided a ratio of 4 declaring unethical: 1 accepting. this ratio was much narrower in the other groups. in the entire study group 75% of the subjects who were offered gifts accepted them, and acceptance of gifts affected 40% of the prescribing practice. discussion this study gave an insight on the impact of pharmaceutical industry’s interaction with dental surgeons at various levels from fresh graduates to faculty members and private practitioners. historically, pharmaceutical industry has been trying to influence doctors’ prescribing habits and has often not adhered to ethical principles (17). in dentistry, interaction with device industry and material manufacturers is also a necessary evil along with the pharmaceutical industry. this renders a dentist more susceptible to their marketing strategies than a physician (13). pharmaceutical industry exploits the fact that long term habits are developed early in a doctor’s career, so they make special efforts to stay in constant touch with the fresh graduates and students along with the senior members of the dental fraternity (18). these efforts of the pharmaceutical industry create a conflict of interest in ethical practices (8-12). the pharmaceutical industry seems to focus significantly more on private practitioners than on fresh graduates, demonstrators or the faculty members of different teaching institutions. private practitioners showed the highest percentage of accepting gifts offered to them and they also appeared to disregard the ethical considerations, and their approach was mainly more focused on the business and commercial aspects of their relationship with the pharmaceutical industry. in comparison, faculty members were offered 10% less gifts than private practitioners, while their gift acceptance rate was almost 63% less than private practitioners. this contrast in percentage of accepting gifts can be attributed to the difference in the level of education of private practitioners and faculty members, since most of the private practitioners are general dentists while faculty members invariably have some postgraduate qualification. according to a study, physician response to the pharmaceutical industry may vary by practice settings. a more ethically aware environment in a university setting leads to better ethical practices, while professional isolation of private practice may lead to being influenced by the information provided by the pharmaceutical representatives (19). this trend was also reported in a very recent study conducted in libya (20). the results showed some confusing responses especially in fresh graduates and demonstrators who accepted gifts regardless of considering them as unethical. this finding is similar to one of the recent studies in which it was concluded that although physicians understood the concept of conflict of interest, their interaction with the pharmaceutical industry led to psychological dynamics that influenced their reasoning (2). in some of the earlier studies, however, no statistically significant differences were found in the responses of the faculty members and residents (5). such trends probably indicate inadequacies in the training and curricula in terms of professional ethics. one limitation of the present study was an absence of control over the validity of the responses since it could not be ascertained whether the respondents were trying to project certain concepts or simply report their actual practices. true evaluation for built-in validity assessment could be a blend of knowledge, attitudes and practices. the majority of fresh graduates, demonstrators and private practitioners seemed to have their prescribing habits affected by gifts; however, only a very small percentage of faculty members appeared to be influenced by gifts. this difference can again be attributed to the latter’s academic qualifications and their awareness of ethical implications. on the other hand, all the four groups considered their interaction with the pharmaceutical industry as useful. this finding is also similar to results from previous studies (21). the present study highlights the need for regulations to be imposed by the government, but laws alone cannot reinforce ethical practice, and physicians themselves need to abstain from the negative commercial influences of marketing (22). j med ethics hist med 6:4 april, 2013 jmehm.tums.ac.ir shaila tahir et al. page 5 of 5 (page number not for citation purposes)     conclusion the present study indicates lack of awareness on ethical implications of interaction with the pharmaceutical industry in the undergraduate and postgraduate training. pakistan medical and dental council has laid clear guidelines on interaction with the pharmaceutical industry, but unfortunately most of the medical and dental graduates are unaware of even the existence of such a document. these guidelines should be updated with the changing trends and implemented at all levels in the noble profession of health care. continuing dental education should also have an ethical component and pakistan medical and dental council should implement a mandatory component on ethics for renewal of practicing license in order to reinforce ethical considerations periodically. acknowledgement: authors are grateful to mr. muneeb rehmat of fatima memorial college of medicine & dentistry for his help when required. references 1. anonymous. ims institute for healthcare informatics. the global use of medicines: outlook through 2016. report by the ims institute for healthcare informatics 2011. 2. chimonas s, brennan ta, rothman dj. physicians and drug representatives: exploring the dynamics of the relationship. j gen intern med 2007; 22(2): 184-90. 3. rodwin ma. medicine, money, and morals: physicians conflict of interest. oxford: oxford university press; 1993. 4. gagnon ma, lexchin j. the cost of pushing pills: a new estimate of pharmaceutical promotion expenditures in the united states. plos med 2008; 5(1): e1. 5. wazana a. physicians and the pharmaceutical industry: is a gift ever, just a gift? jama 2000; 283: 373–80. 6. chimonas s, rothman dj. new federal guidelines for physician pharmaceutical industry relations: the politics of policy formation. health aff 2005; 24(4): 949–60. 7. studdert dm, mello mm, brennan ta. financial conflicts of interest inphysician relationships with the pharmaceutical industry: self-regulation in the shadow of federal prosecution. n engl j med 2004; 351: 1891–900. 8. brett as, burr w, moloo j. are gifts from pharmaceutical companies ethically problematic? a survey of physicians. arch intern med 2003; 163: 2213-8. 9. morgan ma, dana j, loewenstein g, zinberg s, schulkin j. interactions of doctors with the pharmaceutical industry. med ethics 2006; 32: 559–63. 10. brodkey ac. the role of the pharmaceutical industry in teaching psychopharmacology: a growing problem. acad psychiatry 2005; 29: 222-9. 11. gülöksüz s, oral et, ulaş h. attitudes and behaviors of psychiatry residents and psychiatrists working in training institutes towards the relationship between the pharmaceutical industry and physicians. turk psikiyatri derg 2009; 20(3): 236-42. 12. margolis lh. the ethics of accepting gifts from pharmaceutical companies. pediatrics1991; 88: 1233-7. 13. chiodo gt, tolle sw, donhoe mt. ethical issues in the acceptance of gifts: part 2. gen dent 1999; 47(4): 357-60. 14. anonymous. policy and guidelines for interactions between schulich school of medicine and dentistry and pharmaceutical, biotech, medical device and research equipment supplies industry (“industry”) approved at the joint schulich council / ecsc meeting on june 4, 2010. 15. sharma v, aggarwal s, singh h, garg s, sharma a, sharma r. attitudes and practices of medical graduates in delhi towards gifts from the pharmaceutical industry. indian j med ethics 2010; 7(4): 223-5. 16. lea d, spigset o, slørdal l. norwegian medical students' attitudes towards the 17. pharmaceutical industry. eur j clin pharmacol 2010; 66(7): 727-33. 18. komesaroff pa, kerridge ih. ethical issues concerning the relationships between medical practitioners and the pharmaceutical industry. med j aust 2002; 176: 118-21. 19. austad ke, avorn j, kesselheim as. medical students' exposure to and attitudes about the pharmaceutical industry: a systematic review. plos med 2011; 8(5): e1001037. 20. anderson bl, silverman gk, loewenstein gf, zinberg s, schulkin j. factors associated with physicians' reliance on pharmaceutical sales representatives. acad med 2009; 84(8): 994-1002. 21. alssageer ma, kowalski sr. a survey of pharmaceutical company representative interactions with doctors in libya. libyan j med 2012; 7. 22. fischer ma, keough me, baril jl, et al. prescribers and pharmaceutical representatives: why are we still meeting? j gen intern med 2009; 24(7): 795–801. 23. grande d. limiting the influence of pharmaceutical industry gifts on physicians: self-regulation or government intervention? j gen intern med 2010; 25(1): 79–83. microsoft word 3 journal of medical ethics and history of medicine       occupational therapists and patients’ rights: their level of clinical  knowledge   leila dehghan1, hamid dalvand1*, hojjat allah haghgoo2, seyed ali hosseini3 and masoud karimlou4   1phd student of occupational therapy, department of occupational therapy, university of social welfare & rehabilitation sciences, tehran, iran; 2assistant professor, department of occupational therapy, university of social welfare & rehabilitation sciences, tehran, iran; 3associate professor, department of occupational therapy, university of social welfare & rehabilitation sciences, tehran, iran; 4associate professor, department of biostatistics and computer science, university of welfare & rehabilitation, tehran, iran.  corresponding author: hamid dalvand address: koodakyar ave, daneshjoo blvd, evin. department of occupational therapy, university of social welfare & rehabilitation sciences, tehran, iran. postal code: 1985713834 tel: +989122063968 fax: +982122180018 e-mail: hamiddalvand@gmail.com , h.dalvand@uswr.ac.ir received: 20 aug 2012 accepted: 14 jan 2013 published: 22 jan 2013 j med ethics hist med, 2013, 6:3 http://journals.tums.ac.ir/abs/22986 © 2013 leila dehghan et al.; licensee tehran univ. med. sci. abstract addressing patients’ rights issues brings occupational therapists ethical and political responsibilities that  involve  patients’ privileges and new facilitating factors which influence their needs. the goal of this study was to deter‐ mine the level of occupational therapists’ knowledge about patients’ rights.  the present research was a cross‐sectional study which involved 125 occupational therapists chosen by a conven‐ ience sampling strategy in tehran during the year of 2012. a four‐part questionnaire was used for data collection,  and the degree of the subjects’ self‐assessment of their knowledge was measured based on the obtained numbers  of correct answers in the third part. the validity and reliability of this questionnaire were assessed prior to its being  distributed among participants.   the results demonstrated no significant association between the level of occupational therapists’ knowledge about  patients’ rights and their existing experiences within their areas of occupational therapy (p>0.05). based on the  result,  53.6%  of  the  respondents  had  high  level  of  knowledge  about  patients’  rights.  facilitating  factors  which  influence the attainment of patients’ rights were classified into three groups: organizations, therapists and clients.   the  results  of  the  present  research  demonstrated  that  the  level  of  occupational  therapists’  knowledge  about  patients’ rights were high. furthermore, this study showed that for optimal result, there is a need to provide milieu  for observing the patients’ rights in clinical occupational therapy services.    keywords: occupational therapy, patients’ rights, medical ethics leila dehghan et al. j med ethics hist med 6:1 jmehm.tums.ac.ir january, 2013  page 2 of 6 (page number not for citation purposes)     introduction the patients’ rights movement have promoted patient involvement in health care for 50 years (1). patients’ rights encompass legal and ethical issues in the provider-patient relationship, including a person’s right to privacy, the right to quality medical care without prejudice, the right to make informed decisions about care and treatment options, and the right to refuse treatment. the patients’ rights charter of iran was approved by health policy council with a new and comprehensive viewpoint which aimed to clarify the rights of the health service recipients and ensure observance of moral standards in the treatment and medical fields on november 26, 2009, and on december 1st of the same year, it was corresponded to all relevant centers (2, 3). one of the health services which patients may get involved in is occupational therapy (ot). according to the world federation of occupational therapy (wfot), ot is a client-centered health profession which concerns promoting the health and well-being of patients through their occupation. professional ethics and standards for regulating ethical conduct will reinforce level of confidence between patients and health professionals in ot, which in turn will result in protection of community (4). galheigo reported in 2011 that occupational therapists and scientists need to be attentive of human rights issues (5) and they must provide a supportive environment which facilitates patients’ efforts in getting involved in their own health care services (6). nowadays, people’s public health information and awareness of patients’ rights has increased. furthermore, observing patients’ rights may help to achieve more satisfaction among patients and the medical team, while not observing these rights would lead to distrust, damages and losses in the patients and the medical team. hence, ot professionals must be aware of patients’ rights and try to observe them. up to the present time, no descriptive study has been reported in iran in regard to the relationship between occupational therapists’ work experience, their educational level and level of their knowledge about patients’ rights in all areas of their clinical practice. therefore, this study was conducted to examine the level of occupational therapists’ knowledge about patients’ rights in this effective health care professional service. method the present research was a descriptive, analytic, and cross-sectional study. the study samples consisted of 125 occupational therapists that were chosen by convenience sampling strategy from rehabilitation clinics under the supervision of the university of social welfare rehabilitation sciences (uswr) and departments of ot in the school of rehabilitation of uswr, tehran university of medical sciences and shahid baheshti university of medical sciences. the sample size determined for the current study was five participants per variable (7). occupational therapists with more than six months’ work experience were included. the study was approved by the ethical committee of uswr, and all participants were informed about study objectives and their written and signed informed consents were obtained. questionnaires were anonymized and the information got collected privately by the researchers. the data collection instrument was a questionnaire designed by the researchers and consisted of four-parts: the first part included demographic information (age, gender, work experience, educational level); the second part consisted of five questions about participants’ self-assessment of their knowledge about deputy police of the medical council medical council of islamic republic of iran, legal rules and regulations, ethics committee of medical council, ot code of ethics and patients’ rights charter of iran; the third part consisted of 20 questions based on ten sections of the patients’ rights charter of iran (8) and the last part included an open question about facilitating factors involved in patients’ rights. the participants’ answers to the questions of the third part were quantified based on a four-score scale: “high” (4 scores), “moderate” (3 scores), “low” (2 scores) and “none” (1 score). the validity was assessed using content validity. the questionnaire was given to 10 faculty members of uswr and their comments were applied accordingly. the reliability was examined using a test-retest method in which the questionnaire was given to 10 eligible participants twice with a 10-day interval, and the respective interclass correlation coefficient (icc) of the first and second answers obtained was 0.82 (95% ci, 0.146 0.951). these eligible participants were excluded from the main study population. the questionnaires were completed within three months in target clinics and universities. obtained quantitative data were expressed as mean±sd. one-way analysis was used for comparing scores of occupational therapists’ knowledge of patients’ rights according to educational level, areas of practice in occupational therapy and work experience. all statistical analyses were done using spss 16.0 statistical software (spss inc, chicago, il). results demographic data of the participating occupational therapist, including their gender, educational levels, different areas of clinical practice and periods of their work experiences are shown in leila dehghan et al. j med ethics hist med 6:1 jmehm.tums.ac.ir january, 2013  page 3 of 6 (page number not for citation purposes)     table 1. as it is illustrated, the majority of these participants were females (59.2%). the participants’ self-assessment of their knowledge about deputy police of the medical council of islamic republic of iran, legal rules and regulations, ethics committee of medical council and ot code of ethics (second part of the questionnaire) are shown in table 2. furthermore, the sum of the scores based on answers to the questions in the third part of the questionnaire showed 67 (53.6%) of respondents had scores above the median, hence, 67 (53.6%) of occupational therapists had high level of knowledge about sections of patients’ rights charter of iran. it should be noted that the calculated median score was 62. there was no significant difference between male and female participants’ knowledge of patients’ rights charter of iran (p>0.05). likewise, we could not find a relationship between occupational therapists’ knowledge of patients’ rights charter of iran and their educational level, areas of practice in ot and periods of their work experience (table 3). table1. demographic data of the occupational therapists variables n (%) sex male 51 (40.8%) female 74 (59.2%) educational level bachelor 32 (25.6%) master student 48 (38.4%) master 30 (24%) phd student 15 (12%) areas of practice child 69 (55.2%) adult 34 (27.2%) psychosocial 22 (17.6%) work experience < 5 years 65 (52%) 5-10 years 20 (16%) >10 years 40 (32%) table 2. level of occupational therapists’ knowledge about general information of ethics variables high moderate low none n (%) n (%) n (%) n (%) how much do you know about the deputy police of the medical council of islamic republic of iran? 7 (5.6) 18 (14.4) 19 (15.2) 81 (64.8) how much do you know about the rules and regulations of the ministry of health and medical education? 9 (7.2) 26 (20.8) 44 (35.2) 46 (36.8) how much do you know about the ethics committee of the medical council? 9 (7.2) 20 (16) 30 (24) 66 (52.8) how much do you know about the code of ethics in ot? 9 (7.2) 24 (19.2) 20 (16) 72 (57.6) how much do you know about the patients’ rights charter of iran? 33 (26.4) 33 (26.4) 33 (26.4) 26 (20.8) table 3: the level of occupational therapists’ knowledge about patients’ rights occupational therapists’ knowledge about patients’ rights mean  sd f p value educational level bachelor 61.81  8.97 2.268 0.084* master student 61.58  9.02 master 59.33  8.34 phd student 66.73  10.05 areas of practice in ot child 61.89  8.38 2.348 0.102* adult 63.58  8.62 psychosocial 58.27  11.31 work experience < 5 years 61.78  9.19 1.999 0.140* 5-10 years 58.35  7.66 >10 years 63.30  9.41 *p> 0.05 was considered as non significant. leila dehghan et al. j med ethics hist med 6:1 jmehm.tums.ac.ir january, 2013  page 4 of 6 (page number not for citation purposes)     in the next step, regression analysis was performed to determine the relationship between total scores of occupational therapists’ knowledge about patients’ rights and sex, educational level, areas of practice in ot and work experience. the obtained results showed that the sex, educational level, areas of practice in occupational therapy and work experience did not have any significant correlation with occupational therapists’ knowledge of patients’ rights (p>0.05). finally, participants’ answers to open-ended questions about facilitating factors of patients’ rights were categorized. these factors were classified in three groups of factors related to the organization, therapists and clients (table 4). table 4: facilitating factors promotion of patients’ rights groups factors n factors related to the organization approval of health insurance 95 patients’ rights charter installed in occupational therapy clinics 50 ethical committee 38 dealing with the welfare state of the therapist 23 careful monitoring of therapeutic interventions 18 enough staff 21 consultancy and social work units 9 factors related to the therapists ethics curricula for undergraduates 85 workshops for therapists 54 in-service training 32 using an evidence-based rehabilitation 16 factors related to the clients increasing patients’ knowledge of their rights 89 discussion one of the most important components of patients’ rights is to provide an ethical and humanistic care. european regional office of the world health organization (who) states that promoting patients’ rights is a multi categorized topic, and goals should be followed through multilateral efforts. in addition, who has presented solutions to this issue, most of which involve active participation by both the service recipients and service providers in formulating health policy and developing training programs, specifically for service providers and the entire community (9). based on the findings of the present study, more than half of the participants had a high level of knowledge in regard to patients’ rights, especially concerning issues of preserving patients’ privacy, the right to receive respectful and prompt care despite cultural and racial differences and also the right to permit the presence of those who are not directly involved in the treatment process. the present results were more consistent with previous studies, which have shown that health care professionals have a high level of knowledge about their patients’ rights (8, 10, 11). on the other hand, the level of knowledge about patients’ rights do not correlate directly to their observance (10, 12). liedó showed that 84% of professionals know the patients’ rights, but a mere 64.4% observe them (10). arnetz also showed that physicians, registered nurses, and practical nurses did not differ significantly in their views of patient involvement, but did differ significantly in behavior (12). another study demonstrated, however, that there is a relationship between awareness of the rights of the patient and observing them (13). this may be due to the research methods and the questionnaire in the mentioned study to determine the tendency of nurses to implement their roles to advocate patients’ rights. despite the high knowledge of occupational therapists, there seems to be a gap between awareness of patients’ rights and their observation in practice. hooshmand et al. suggested in 2006 that there are many other requirements that should be recognized and identified in order for patients’ rights to be observed in practice (8). jolaee et al. showed in 2008 through a qualitative study the facilitating factors which affect patients’ rights in clinical practice. issues categorized as barriers to patients’ rights practice and facilitators of patients’ rights practice were further classified into three subgroups: awareness, resources and accountability (14). patients’ rights can be fully implemented only if health services identify the barriers and strategies in employment of such charters of rights (15, 16). in this regard, another finding of the present study was related to facilitating factors of patients’ rights, which were classified in three groups (factors related to the organization, factors related to therapists, factors related to clients). the most important organizational factor was a need for approval of health insurances by the responsible organizations. in economic models, the primary function of health insurance is to alleviate the leila dehghan et al. j med ethics hist med 6:1 jmehm.tums.ac.ir january, 2013  page 5 of 6 (page number not for citation purposes)     financial risk associated with unanticipated adverse health events. in general, people dislike risk and are willing to trade a small amount of money to buy insurance premium for their protection against a potentially large loss of their income (17). health insurance improves the quality of care and introduces user entitlements known as patients’ rights (18). the next important factor was to test patients’ knowledge level and identify responsive organizations’ roles in accomplishing their needs and rights as clients. findings of other studies have shown only few patients knew the rules composed within their charter of rights (19). this indicates the need for extensive education of patients and healthcare professionals in related subjects. other important facilitating factors in the promotion of patients’ rights are ethics courses designed for undergraduate students, workshops for therapists, patients’ rights charter installations in occupational therapy clinics and the generation of ethical committees within related organizations. a report by the association of american medical colleges (aamc) argued that medical schools “must ensure that before graduation, a student will have demonstrated knowledge of the theories and principles that govern ethical decision making and of the major ethical dilemmas in medicine…” (20). the aamc’s statement reflects a growing consensus among medical educators that ethics education should be a core component of medical schools’ curricula. at the present time, there is no ethics curriculum for occupational therapists in iran and this study hopes to initiate introduction of such courses in iranian academic centers. our findings revealed that occupational therapists had a high knowledge of patients’ rights, but they would need to train for their implementation. students of occupational therapy should graduate with a baseline level of knowledge in ethics, as they do in the basic sciences. the current state of education, however, does not ensure a common standard for ethics education in occupational therapy. furthermore, as the client-centered approach is very important in ot, ethics are dependent on the cultural and social characteristics of societies (21), and therefore the view of the iranian patients towards the issue urges the ministry of health and medical education of the islamic republic of iran to accelerate the implementation of the patients’ rights charter of iran (22). it is suggested that a qualitative research be done to determine the views of occupational therapists and clients about observing the patients’ rights in iran. one of the limitations of our study was the greater number of bachelor-level participants compared to other educational levels, due to the convenience sampling method. this may affect the results based on analyses of the relationship between the level of knowledge about patients’ rights and educational level conclusion although, the level of occupational therapists’ knowledge about the patients’ rights charter are high, it is necessary to provide context for observing patients’ rights by involving related facilitating factors such as different organizations, therapists, and clients within the field of clinical occupational therapy professionalism. acknowledgement the authors are grateful to all the occupational therapists that devoted time and participated in this study. references 1. gibson ch. a concept analysis of empowerment. j adv nurs 1991; 16(3): 354-61. 2. rad m, mohammd a, esna ashari p. patients and physicians awareness of patients' rights and its implementation at beheshti hospital in isfahan. iran j med edu 2004; 4(1): 45-54. [in persian] 3. parsapoor a, bagheri a, larijani b. patient’s right charter in iran. iranian j med ethics hist med 2009; (suppl): 39-47. 4. anonymous. american occupational therapy association. enforcement procedures for the occupational therapy code of ethics. am j occup ther 2004; 58: 655-62. 5. galheigo sm. what needs to be done? occupational therapy responsibilities and challenges regarding human rights. aust occup ther j 2011; 58 (2): 60-6. 6. kyler-hutchison p. ethical reasoning and informed consent in occupational therapy. am j occup ther 1988; 42(5): 283-7. 7. munro bh. statistical methods for health care research. philadelphia: lippincott, williams & wilkins; 2005. 8. hooshmand a, joolaee s, mehrdad n, bahrani n. nurses’ information and their view points about patient’s rights and practical facilitators in clinics. hayat 2006; 12(4): 57-66. [ in persian] 9. anonymous. world health organization. patients' rights and citizens' empowerment: through visions to reality: joint consultation between the who regional office for europe, the nordic council of ministers and the nordic school of public health. copenhagen: world health organization, regional office for europe; 1999. 10. lledo r, salas l, gonzalez m, et al. the rights of the hospital patient: the knowledge and perception of their fulfillment on the part of the professional. the group in catalonia of the spanish society of care for the health services user. rev clin leila dehghan et al. j med ethics hist med 6:1 jmehm.tums.ac.ir january, 2013  page 6 of 6 (page number not for citation purposes)     esp 1998 ; 198(11): 730-5. 11. swisher ll. a retrospective analysis of ethics knowledge in physical therapy (1970-2000). phys ther 2002; 82(7): 692-706. 12. arnetz je, winblad u, arnetz bb, hoglund at. physicians' and nurses' perceptions of patient involvement in myocardial infarction care. eur j cardiovasc nurs 2008; 7(2): 113-20. 13. ersoy n, altun y, beser a. tendency of nurses to undertake the role of patient advocate. eubios j asian int bioeth 1997; 7: 167-70. 14. joolaee s, tschudin v, nikbakht-nasrabadi a, parsa-yekta z. factors affecting patients' rights practice: the lived experiences of iranian nurses and physicians. int nurs rev 2008; 55(1): 55-61. 15. ghodsi z, hojjatoleslami s. knowledge of students about patient rights and its relationship with some factors in iran. procedia soc behav sci 2012; 31: 345-8. 16. nejad em, roghayehehsani s. nurses awareness of patients rights in a teaching hospital. j med ethics hist med 2011; 4: 2. 17. mclaughlin cg, chernew me. health insurance: economic and risk aspects. in: smelser nj, baltes pb, eds. international encyclopedia of the social and behavioral sciences. the university of michigan: elsevier; 2001, pp. 6570-6. 18. fotaki m. users’ perceptions of health care reforms: quality of care and patient rights in four regions in the russian federation. soc sci med 2006; 63(6): 1637-47. 19. kuzu n, ergin a, zencir m. patients' awareness of their rights in a developing country. public health 2006; 120(4): 290-6. 20. anonymous. learning objectives for medical student education--guidelines for medical schools: report i of the medical school objectives project. acad med 1999; 74(1): 13-8. 21. albishi aa. the saudi patients’, physicians’, and nurses’ perceptions of and lived experience with patients’ rights in saudi arabia: qualitative phenomenological study [dissertation]. virginia. george mason university; united states; 2004. 22. dargahi h. the implementation of the sharia law in medical practice: a balance between medical ethics and patients rights. j med ethics hist med 2011; 4: 7. ____________________________________________________________________________________________________________________________________________ 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____________________________________________________________________________________________________________________________________________ 1 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e letter to editor volume 13 (suppl.) number 29 december 2020 copyright © 2020 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. the significance of shared humanity during the covid-19 pandemic *corresponding author arpi manookian school of nursing and midwifery, dr mirkhani st., tohid sq., tehran, iran. postal code: 1419733171 tel: (+98) 21 61 05 43 22 email: ar-manookian@sina.tums.ac.ir received: 19 nov 2020 accepted: 30 nov 2020 published: 23 dec 2020 citation to this article: manookian a. the significance of shared humanity during the covid-19 pandemic. j med ethics hist med. 2020; 13(suppl.): 29. arpi manookian* assistant professor, department of medical-surgical nursing, school of nursing and midwifery, tehran university of medical sciences, tehran, iran. the covid-19 pandemic is widely considered to be the most catastrophic crisis that has caused widespread suffering worldwide. a growing body of literature has shown that the covid-19 pandemic has brought multifaceted health challenges and devastating effects on people's psychological, social and spiritual health. this crisis does not only affect the general population, but is also associated with increased mental and spiritual distress among medical staff including nurses (1). we should all admit that nurses are on the front lines of the covid-19 pandemic and are therefore facing greater risks than they normally do in their routine practice. they spend more time in close contact with covid-19 patients and sit by patients’ bedsides instead of spending time with their own families or fulfilling their physical, psychological, and spiritual needs (2). many concerns have arisen about nurses’ emotional breakdown and also well-being. nurses struggle with physical and psychological burdens and the burn-out resulting from the covid-19 pandemic, and most of them continue to be on the front line fighting covid-19 and providing nursing care (1, 2). achieving this requires more than simple nursing interventions, but rather the application of "nursing presence" (3). much work has been carried out on “nursing presence” (3, 4) and “caring capacity” (5). nursing presence is a critical concept in nursing practice that has been defined as a therapeutic interaction where both the nurse and the patient share common humanity through establishing a deep connection, attentiveness, and compassionate care (3, 4). the significance of shared humanity during the covid-19 pandemic 2 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 29 december 2020 along the same lines, each individual possesses a certain quality called “caring capacity”. it is a unique moral power which elucidates that we deserve respect for our worth and dignity. in this regard, miller pointed out that “care refers to responding to others’ needs by understanding and adopting their ends as one’s own and making an effort to cultivate and restore their agency” (5). thus, nursing care is not an obligation but rather a vocation that seeks to serve people and help maintain their dignity through care. in the process of caring for patients, nurses will have the opportunity to contemplate the common needs of all humans, and even concepts such as humanity itself. however, there is still a critical issue related to the key motivational factor that inspires nurses to go beyond their capacity and professional duty and risk their own life and that of their family members to save others. they make the sacrifice to help fight the covid19 pandemic despite the various threats they face. but what inspires nurses to risk their lives and work so hard to protect others in these tough times? why are they so deeply and intrinsically driven to care for those who need help? this may partly be due to their professional obligations and sense of commitment, but nurses do not seem to be merely bound by their professional duties, particularly during the covid-19 pandemic. it appears that nurses’ strong motivation is the result of their faith in their intrinsic value as human beings and the inherent worth of their profession. in other words, nurses work so selflessly to maintain their standards in terms of humanity and actualize their perception of themselves as nurses (6). nurses work so tirelessly to help the patients in these tough times of the covid-19 pandemic not just because they have to, but because they feel a sort of connection to them. the care process forms a bond between the nurse and the patient that opens a window of humanity for both (7), and this shared humanity seems to be the key factor in overcoming the ethical challenges associated with the covid-19 crisis. in this regard, ursula von der leyen, president of the european commission, said, “none of us will be safe until everyone is safe” (8). this is a manifestation of our shared humanity, as reflected in a poem by the well-known persian poet saadi: the children of humanity are like limbs that share an origin in their creator when one limb passes its days in pain, the other limbs cannot remain”. indeed, covid-19 reminds us once again that we are one human community. finally, the covid-19 crisis could be considered a time to think deeply about what matters most in our personal and professional life. given that, the current crisis may offer a moment of enlightenment for nurses and trigger them to reflect on their values, beliefs, and the assumptions underlying their practice. manookian a. 3 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 29 december 2020 in this regard, in one of my previous studies, the results indicated that the concept of dignified care implies “enlightened practice” (9). thus, the current crisis of covid-19 has brought us to realize the significance of humanistic interactions between patients and nurses, our interconnectedness, and also the fact that dignified care may be a new path to enlightenment. in conclusion, the covid-19 crisis provides us with an opportunity for ethical reflections on the intrinsic values in our profession, our common needs and ends, and also our shared humanity. furthermore, the current crisis may help us reach personal and professional growth and development by recognizing our interconnectedness, not only during these times, but for years to come. the significance of shared humanity during the covid-19 pandemic 4 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 29 december 2020 references 1. van bavel jj, baicker k, boggio ps, et al. using social and behavioral science to support covid-19 pandemic response. nat hum behav. 2020; 4(5): 460-71. 2. gallagher a. learning from florence nightingale: a slow ethics approach to nursing during the pandemic. nurs inq. 2020; 27(3): e12369. 3. bozdoğan yeşilot s, öz f. nursing presence: a theoretical overview. journal of psychiatric nursing. 2016; 7(2): 94-9. 4. finfgeld-connett d. meta-synthesis of presence in nursing. j adv nurs. 2006; 55(6): 708-14. 5. miller sc. the ethics of need: agency, dignity and obligation, 1st ed. new york: routledge; 2013, p.79. 6. watson j. nursing's global covenant with humanity–unitary caring science as sacred activism. j adv nurs. 2020; 76(2): 699-704. 7. manookian a, cheraghi ma, nikbakht-nasrabadi a. the mirror of humanity: a hermeneutical perspective in nursing. nursing practice today. 2017; 4(3): 112-4. 8. ghebreyesus ta, von der leyen u. world health organization: a global pandemic requires a world effort to end it – none of us will be safe until everyone is safe. [cited 2020 december]; available from: https://www.who.int/news-room/commentaries/detail/a-global-pandemic-requiresa-world-effort-to-end-it-none-of-us-will-be-safe-until-everyone-is-safe 9. cheraghi ma, manookian a, nikbakht nasrabadi a. patients' lived experiences regarding maintaining dignity. j med ethics hist med. 2015; 8: 6. ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ original article copyright © 2021 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e medical students’ perception of professionalism climate in clinical settings *corresponding author maliheh kadivar address: department of neonatology, children’s medical center, no. 62, gahrib st., tehran, iran. postal code: 1419733151 tel: (+98) 21 66 91 76 48 email: kadivarm@tums.ac.ir received: 8 dec 2020 accepted: 10 jan 2021 published: 31 aug 2021 citation to this article: hoobehfekr s, asghari f, sayarifard a, kadivar m, kashefinejad s. medical students’ perception of professionalism climate in clinical settings. j med ethics hist med. 2021; 14: 10. saba hoobehfekr1, fariba asghari2, azadeh sayarifard3, maliheh kadivar4*, shayan kashefinejad 5 1.resident of psychiatry, department of psychiatry, school of medicine, tehran university of medical sciences, tehran, iran. 2.associate professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. 3.community based participatory research center, iranian institute for reduction of high-risk behaviors, tehran university of medical sciences, tehran, iran. 4.professor, department of neonatology, children’s medical center, tehran university of medical sciences, tehran, iran. 5.resident of psychiatry, department of psychiatry, iran university of medical sciences, tehran, iran. abstract medical professionalism has a crucial role in educating medical students. the role of professionalism in the clinical environment is therefore an important factor in medical education. this study attempts to evaluate the opinions of medical students in the teaching hospitals of tehran university of medical sciences (tums) about the professionalism environment in this university. a sample of 165 students filled out the persian translation of umkc-som (climate of professionalism survey) questionnaire. this instrument evaluates students’ perspectives on the degree of adherence to professionalism by faculty, residents and other students. the results of the study revealed that the total score of professionalism climate was 53.9 for faculty, 42.09 for residents, and 50.76 for students and the difference between these three groups was statistically significant (p-value < 0.01). results of further analysis through post-hoc tests for multiple comparisons among the groups revealed that the students found their fellow students and faculty more professional than residents. the study also showed that the medical ethics course had no impact on perceptions observations (p-values > 0.05). the study results also revealed that the students found their fellow students and faculty more professional than residents. this finding demonstrates the importance of teaching professionalism to residents since they serve as role models for students. further multicenter studies are needed to improve the professionalism climate in the medical teaching environment. keywords: iran; medical student; professionalism climate. medical students’ perception of professionalism climate in clinical settings … 2 j med ethics hist med. 2021(aug); 14: 10. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e introduction medical professionalism is considered as the professional commitments specified by the “social contract” between the society and health-care providers (1). the most important base for this contract is the public trust in medical service providers including physicians. this trust is established on the truthfulness and integrity of physicians and the profession they belong to (2). however, studies have reported challenges and some deterioration in professional behavior (3 8). as a reaction to these defects, medical schools designed courses, conferences, various programs and guidelines to teach professionalism and promote it among medical students (9 16). however, professional behaviors will be meaningful after the trainees are provided with a clear definition of professionalism as an essential competency (1, 17). on the other hand, unprofessional behaviors in medical schools could lead to unprofessional behaviors in future medical practices (11). the most prominent features of professionalism are considered to be accountability, trustworthiness, honesty, competence, respect and integrity in many medical institutions along with social contract with society (18 20). evaluation is an essential component of teaching medical professionalism (20). different methods have been developed to assess professionalism, for instance observing behavior, knowledge and attitude, feedback, portfolio, appraisal of critical incidents, peer review, and so on (21). some scales have been used to assess professionalism, including the “nijmegen professional scale” and the “professional mini evaluation” (22, 23). according to the recommendations from the ottawa 2010 conference, there are numerous elements associated with professionalism and it should therefore be assessed at various levels such as “individual, interpersonal, and societal/institutional” (24). however, organizational climate is an important issue in the development of professionalism (24, 25). what medical students learn in clinical settings is, however, broader and deeper than what is taught in classes or written in books. in fact, observing clinical behaviors shapes medical students’ thoughts and acts. professionalism is a behavior that might be better learnt through ‘learning by doing’ under decisive observation (25-27). assessing medical students’ behaviors is crucial in medical environments and it is an important issue in social contract with the society (28, 29). quaintance et al. reported a significant difference in the perceived professional behavior of the clinical student compared to the preclinical student (30). based on this study, clinical exposure continues to shape ethical judgment and the role of hidden curriculum should not be underestimated in behaving professionally. in other words, not only are teaching, education and evaluation important issues in professional identity formation, but also the organizational climate has a critical role in this regard (24). consequently, evaluating the “climate of professionalism” is important to examining hoobehfekr s., et al. 3 j med ethics hist med. 2021(aug); 14: 10. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e the status of professionalism in educational environments. the climate of professionalism instrument (umkc-som1 questionnaire) was first introduced by quaintance et al (30), and was designed to assess medical learners’ perspectives on professionalism. in this study, we chose umkc-som because it assessed responders’ views on the degree of adherence to professionalism by members of all three groups of faculty, residents, and students. previous studies on climate of professionalism in iran are scarce and almost all of them have used abim scale as the instrument for the evaluation of climate of professionalism (31, 32). moreover, they showed that the perceived professional climate among residents was not good (32). to cover the professionalism challenges of clinical settings in tehran university of medical sciences, it is essential to figure out the most problematic areas of professional behaviors. umkc-som is a novel instrument in iran and its findings can reveal new insights into ethical behaviors. in this study, we aimed to evaluate medical students’ observations of professionalism in other students, residents, and faculty in the educational hospitals of tehran university of medical sciences. methods this was a cross sectional study done from may to august 2017, approved by the tums research ethics committee (ir.tums.vcr.rec.1396.2052). 1 university of missouri-kansas city school of medicine a questionnaire was sent online through the google form platform for 250 medical students studying in the teaching hospitals of tums (3rd and 4th year of school), and 165 questionnaires were filled out and returned (82.5% response rate). the students’ e-mail address was given to us by their representative at the university after obtaining their permission. there was no obligation to take part in this research. we used the umkc-som climate of professionalism questionnaire introduced by quintanses (30) after asking the questionnaire developer’s permission. the questionnaire was translated into persian, and then back-translated into english by an english expert who had not seen the original version of the questionnaire, and finally, it was translated into persian again. in order to evaluate the validity of the questionnaire, several experts on professionalism assessed the questionnaire and confirmed its content validity. next, some modifications were performed to make the questionnaire compatible with local needs, and the final version was then prepared. all participants filled the approved persian translation of the umkc-som questionnaire, which consisted of 12 items regarding professional and unprofessional behaviors observed in other students, residents and faculty members. the frequency of these behaviors was categorized as rarely, sometimes, often and mostly. for scoring professional behaviors, +1, +2, +3 and +4 scores were considered for rarely, sometimes, often and mostly, respectively. unprofessional behaviors were scored reversely, and the total score was medical students’ perception of professionalism climate in clinical settings … 4 j med ethics hist med. 2021(aug); 14: 10. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e then calculated. in order to have a better understanding of the scores, we converted the scores (12 48) to (0 100) scaling. demographic variables were also recorded, and data analysis was performed using the spss version 18 software. descriptive analysis was reported as frequency, percentage, mean, and standard deviation. anova was used for comparison of groups, and post-hoc tests were used for multiple comparisons. kruskal-wallis and mann-whitney tests were used for the comparison of question grades among the three groups and pairwise comparisons, respectively. p-values under 0.05 were considered as statistically significant. result overall, out of 250 students, 165 (82.5%) participated in the study and filled the 12item questionnaire regarding their perception of the professional behavior of students, residents and faculty members in the clinical environment (66% response rate). of this number, 106 responders (64.24%) were male and 59 (35.75%) were female. the details of answers to each item of the questionnaire are shown in table 1. table 1 students’ perception of professionalism adherence in faculty, residents and students item rarely sometimes often mostly p-value* 1. show disrespect for patients, students, faculty, staff or other healthcare personnel medical students 86 (52.1%) 71 (43.0%) 8 (4.8%) 0 (0.0%) 0.000 residents 19 (11.5%) 100 (60.6%) 43 (26.1%) 3 (1.8%) faculty 65 (39.4%) 87 (52.7%) 11 (6.7%) 2 (1.2%) 2. advocate for the well-being of patients, students, colleagues, the community and/or the medical profession medical students 23 (13.9%) 53 (32.1%) 73 (44.2%) 16 (9.7%) 0.007 residents 20 (12.1%) 63 (38.2%) 71 (43.0%) 11 (6.7%) faculty 24 (14.5%) 31 (18.8%) 81 (49.1%) 29 (17.6%) 3. make oneself look good at the expense of others medical students 54 (32.7%) 80 (48.5%) 26 (15.8%) 5 (3.0%) 0.000 residents 33 (20.0%) 76 (46.1%) 46 (27.9%) 10 (6.1%) faculty 69 (41.8%) 75 (45.5%) 17 (10.3%) 4 (2.4%) 4. exceed expectations in patient care, class, conferences and/or rounds medical students 87 (52.7%) 59 (35.8%) 18 (10.9%) 1 (0.6%) 0.046 residents 96 (58.2%) 58 (35.2%) 10 (6.1%) 1 (0.6%) faculty 79 (47.9%) 57 (34.5%) 27 (16.4%) 2 (1.2%) 5. perform one’s duties and help others do theirs medical students 51 (30.9%) 69 (41.8%) 40 (24.2%) 5 (3.0%) 0.000 residents 65 (39.4%) 59 (35.8%) 35 (21.2%) 6 (3.6%) faculty 97 (58.8%) 50 (30.3%) 15 (9.1%) 3 (1.8%) 6. complain about professional obligations medical students 19 (11.5%) 61 (37.0%) 65 (39.4%) 20 (12.1%) 0.000 residents 7 (4.2%) 29 (17.6%) 79 (47.9%) 49 (29.7%) faculty 57 (34.5%) 83 (50.3%) 21 (12.7%) 4 (2.4%) 7. lie to patients, professors, colleagues/peers or in the medical record medical students 74 (44.8%) 69 (41.8%) 18 (10.9%) 4 (2.4%) < 0.001 residents 58 (35.2%) 78 (47.3%) 25 (15.2%) 4 (2.4%) faculty 114 (69.1%) 41 (24.8%) 8 (4.8%) 2 (1.2%) 8. show respect and compassion toward patients, students, faculty, staff or other healthcare personnel medical students 5 (3.0%) 56 (33.9%) 86 (52.1%) 18 (10.9%) < 0.001 residents 22 (13.3%) 83 (50.3%) 57 (34.5%) 3 (1.8%) faculty 9 (5.5%) 67 (40.6%) 80 (48.5%) 9 (5.5%) hoobehfekr s., et al. 5 j med ethics hist med. 2021(aug); 14: 10. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e item rarely sometimes often mostly p-value* 9. accurately and spontaneously report one’s own mistakes or uncertainties medical students 105 (63.6%) 45 (27.3%) 14 (8.5%) 1 (0.6%) 0.060 residents 125 (75.8%) 29 (17.6%) 9 (5.5%) 2 (1.2%) faculty 119 (72.1%) 33 (20.0%) 10 (6.1%) 3 (1.8%) 10. ignore the unprofessional behavior of others medical students 35 (21.2%) 71 (43.0%) 45 (27.3%) 14 (8.5%) 0.007 residents 28 (17.0%) 70 (42.4%) 56 (33.9%) 11 (6.7%) faculty 35 (21.2%) 94 (57.0%) 32 (19.4%) 4 (2.4%) 11. do just enough to get by in patient care, class, conferences and/or rounds medical students 12 (7.3%) 49 (29.7%) 82 (49.7%) 22 (13.3%) < 0.001 residents 9 (5.5%) 42 (25.5%) 88 (53.3%) 26 (15.8%) faculty 32 (19.4%) 55 (33.3%) 58 (35.2%) 20 (12.1%) 12. enjoy serving others medical students 16 (9.7%) 58 (35.2%) 69 (41.8%) 22 (13.3% < 0.001 residents 37 (22.4%) 77 (46.7%) 42 (25.5%) 9 (5.5%) faculty 14 (8.5%) 52 (31.5%) 82 (49.7%) 17 (10.3%) *significant p-value < 0.05 final scores were calculated as explained previously and it was revealed that the total scores for students, residents and faculty were 53.91 ± 13.37, 42.09 ± 12.64 and 50.76 ± 11.99, respectively (figure 1). anova analysis showed a significant difference among the groups (p-value = 0.000). results of further analysis through post-hoc tests for multiple comparisons among the groups are shown in table 2. table 2students’ perceptions of the differences among faculty, residents and students 1st group 2nd group mean difference standard error p-value* faculty residents 11.81 1.398 < 0.001 students 3.14 1.396 0.063 residents faculty -11.81 1.398 < 0.001 students -8.66 1.398 < 0.001 students faculty -3.14 1.396 0.063 residents 8.66 1.398 < 0.001 *significant p-value < 0.05 figure 1total scores of study groups medical students’ perception of professionalism climate in clinical settings … 6 j med ethics hist med. 2021(aug); 14: 10. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e item by item analysis of the questionnaire was performed using the kruskal-wallis test. the difference among the groups was significant in all items (p < 0.05) except item 9 (p = 0.060). results of the mannwhitney test across the groups are shown in table 3. table 3students’ perceptions of different groups’ adherence to each item item group* mean rank p-value** group mean rank p-value group mean rank p-value item 1 1 196.53 0.000 1 154.26 0.016 2 124.45 < 0.001 2 134.47 3 176.74 3 206.55 item 2 1 180.34 0.003 1 176.79 0.022 2 162.17 0.497 2 150.66 3 154.21 3 168.83 item 3 1 191.35 0.000 1 174.90 0.051 2 148.47 < 0.001 2 139.65 3 156.10 3 182.53 item 4 1 177.18 0.013 1 171.43 0.214 2 159.65 0.209 2 153.82 3 159.57 3 171.35 item 5 1 146.55 0.000 1 139.58 0.000 2 159.22 0.204 2 184.45 3 191.42 3 171.78 item 6 1 221.98 0.000 1 201.74 0.000 2 137.84 < 0.001 2 107.67 3 129.26 3 192.00 item 7 1 194.68 0.000 1 186.13 0.000 2 156.72 0.069 2 136.32 3 144.87 3 174.28 item 8 1 183.03 0.000 1 155.47 0.035 2 138.70 < 0.001 2 147.97 3 175.53 3 192.30 item 9 1 180.84 0.002 1 175.37 0.042 2 160.98 0.360 2 150.16 3 155.63 3 170.02 item 10 1 185.31 0.000 1 180.15 0.003 2 159.72 0.229 2 145.69 3 150.85 3 171.28 item 11 1 191.99 0.000 1 167.65 0.660 2 141.81 < 0.001 2 139.01 3 163.35 3 189.19 *group 1: faculty; group 2: residents; group 3: students **significant p-value < 0.05 we evaluated the effect of gender on total scores perceived by students in three groups, which is shown in table 4. table 4the effect of gender on total scores group gender mean sd p-value* faculty female 56.44 12.98 0.001 male 49.34 12.92 residents female 42.16 12.64 0.915 male 41.94 12.73 students female 50.41 12.04 0.629 male 51.36 11.97 *significant p-value < 0.05 among the responders, 117 individuals (70.90%) had participated in ethics conferences, while 48 students (29.09%) reported no history of participation in these sessions. the details of the impact of ethics education on total scores are presented in table 5. hoobehfekr s., et al. 7 j med ethics hist med. 2021(aug); 14: 10. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e table 5the effect of history of participation in ethics conferences and courses on total scores group history of participation in ethics conferences mean sd p-value faculty yes 53.08 13.64 0.220 no 55.90 12.58 residents yes 41.19 12.42 0.152 no 44.32 13.01 students yes 49.33 12.06 0.017 no 54.22 11.19 *significant p-value < 0.05 assessment of the impact of the university entrance year on total scores yielded no significant association with total scores (pvalues of 0.080, 0.913 and 0.084 for faculty, residents and students, respectively). discussion nearly all medical schools around the world offer medical ethics courses for medical students, but it seems that these programs are not very efficient. the reason might be that the courses are too short or too brief (33). hidden curriculum is considered as the not-so-obvious messages that are conveyed via behaviors seen in the learning environment mostly from physicians in higher educational ranks. this makes routine daily exposure to ethical attitudes and behaviors of other students, residents and faculty members an important route of education with a great impact on the ethical foundations of medical care in learners. the results of this study showed that students believe professional standards of behavior are not adequately respected in the clinical environment. professionalism is fundamental to shaping the behavior of those involved in medical practice, but the organization should also be sensitive to this concept (34). professionalism has been regarded as an essential part of the medical profession since 1980 (26). in modern medicine, the way to establish and develop professionalism in medical students and clinical practitioners is especially important and should be clear (25), but as hidden curricula in medical schools, it should be monitored and evaluated (27,28). spiwak et al., evaluated the professional behavior of different training levels and reported that perception of adherence to professionalism principles varies according to the educational level and depends on the extent of contact with instructors and teachers (35). these findings were confirmed by the results of the present study. perceptions of professional behavior were similar among students and faculty, but were significantly lower in the residents. an underlying cause might be the fact that members of a certain group usually consider themselves more positive because their identity in the society is recognized with their group; therefore, it is not irrational for them to report more positive features and behaviors in their own group. as can be seen in our study, students regarded themselves medical students’ perception of professionalism climate in clinical settings … 8 j med ethics hist med. 2021(aug); 14: 10. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e more professional than the residents. it is interesting that another study has reported that both students and residents consider their own group more professional than the other group simultaneously (33). al gahtani et al., who used the same instrument as we did, found that students rated their peers’ professional behavior higher than that of faculty and residents (36). the explanation may be that residents usually spend more time in the hospital than students and faculty members and are exposed to more workload and stress, and so their threshold for unprofessional behaviors lowers. however, in a study on residents’ perceptions of their own professionalism, gillespie et al., emphasized the influence of the learning environment on the development of professionalism in residents (37). it should be noted that unprofessional acts outweigh more professional acts and play a greater role in the ethical perception of behaviors. observing an unethical behavior can diminish the positive effect of other ethical behaviors on students’ perception of an individual’s professionalism (29). the three lowest scored items were “complaining about professional obligations”, “showing disrespect for patients, students, faculty, staff or other healthcare personnel” and “enjoying serving others”. therefore, we recommend modifications in the formal teaching of professionalism and behaviors of role models with focus on these items. it should be noted, however, that according to the findings of the present study, the changes must be directed at alteration of residents’ attitudes and behaviors. as demonstrated by another study, the clinical environment should reward and reinforce professional acts and behaviors among health-care professionals (7). another finding of our study was that gender had a significant impact on students’ perception of the professional climate. female students rated faculty members’ adherence to professional standards higher that male students did. the explanation for these findings should be investigated in further studies. in this regard, recommendations from the ottawa 2010 conference highlighted the importance of various issues such as culture, gender, hierarchy, background, generation, etc. in evaluation of professionalism (24). hoonpongsimanont et al., argued that the influence of generations and their values should be considered in assessment of professionalism (38). however, in modern medical curricula professionalism is integrated in clinical practices (25). also, in becoming a physician it is important to develop one’s medical professional identity (27, 39). however, professionalism is a complex competency, so its assessment should be multidimensional (21). the main limitation of our study was absence of perceptions and observations of other groups (residents and faculty) to be compared with students’ views. future studies can be more informative by including the views of these two groups. our study was performed in only one university, so further studies in multiple universities can lead to more comprehensive results. hoobehfekr s., et al. 9 j med ethics hist med. 2021(aug); 14: 10. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e conclusion this study was evaluated the medical students’ perception of professionalism climate in clinical settings of tums. according to these study students observed their peers and faculty more professional than residents. meanwhile, most of the respondents argued that medical ethics courses and conferences did not have any impact on the professional behavior of medical students. another major finding was that the improvement of residents’ professional training is crucial as they have a major role in influencing and shaping students’ professional behavior. alongside with this is the huge impact of the professional climate of clinical practices on elevating the professional behavior of everyone engaged in healthcare. however, further multicenter studies are needed to evaluate the impact of the professionalism climate on the faculty, residents, and students. conflicts of interests there are no conflicts of interests. funding this project was supported by the medical ethics and history of medicine research center of tehran university of medical sciences (# 30433). the project was part of the first author’s thesis in general medicine from tehran university of medical sciences (# 22355), and was approved by tums research ethics committee (ir.tums.vcr.rec.1396.2052) acknowledgements the authors would like to extend their sincere thanks and appreciation to all medical students, residents and faculties in the teaching hospitals of tehran university of medical sciences who participated in the study. the authors are very thankful to dr. quaintance for granting permission to use their developed instrument. medical students’ perception of professionalism climate in clinical settings … 10 j med ethics hist med. 2021(aug); 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[in spanish] 35. spiwak r, mullins m, isaak c, barakat s, chateau d, sareen js. medical students' and postgraduate residents' observations of professionalism. educ health (abingdon). 2014; 27(2): 193-9. 36. al gahtani hms, jahrami ha, silverman hj. perceptions of medical students towards the practice of professionalism at the arabian gulf university. bmc medical education. 2021; 21: 38. 37. gillespie c, paik s, ark t, zabar s, kalet a. residents’ perceptions of their own professionalism and the professionalism of their learning environment. j grad med educ. 2009; 1(2): 208-15. 38. hoonpongsimanont w, sahota pk, chen y, et al. physician professionalism: definition from a generation perspective. int j med educ. 2018; 9: 246-52. 39. forouzadeh m, kiani m, bazmi sh. professionalism and its role in the formation of medical professional identity. med j islam repub iran. 2018; 32: 130. conceptualization of idle (laghw) and its relation to medical futility journal of medical ethics and history of medicine original article conceptualization of idle (laghw) and its relation to medical futility mohsen rezaei aderyani1, mohsen javadi2*, saeid nazari tavakkoli3, mehrzad kiani3, mahmood abbasi3 1medical ethics phd candidate, department of medical ethics, school of traditional medicine, shahid beheshti university of medical sciences, tehran, iran; 2professor, university of qom, qom, iran; 3associate professor, department of medical ethics, school of traditional medicine, shahid beheshti university of medical sciences, tehran, iran. corresponding author: mohsen javadi address: old isfahan road, amin blvd, university of qom, qom, iran. postal code: 3716146611 email: j_mohsen@hotmail.com tel/fax: +982532103360 received: 3 nov 2015 accepted: 29 nov 2015 published: 1 apr 2016 j med ethics hist med, 2016, 9:1 © 2016 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract a major debate in medical ethics is the request for futile treatment. the topic of medical futility requires discrete assessment in iran for at least two reasons. first, the common principles and foundations of medical ethics have taken shape in the context of western culture and secularism. accordingly, the implementation of the same guidelines and codes of medical ethics as western societies in muslim communities does not seem rational. second, the challenges arising in health service settings are divergent across different countries. the quranic concept of idle (laghw) and its derivatives are used in 11 honorable verses of the holy quran. among these verses, the 3rd verse of the blessed al-muminūn surah was selected for its closer connection to the concept under examination. the selected verse was researched in the context of all dictionaries presented in noor jami` al-tafasir 2 (the noor collection of interpretations 2) software. "idle" is known as any insignificant speech, act, or thing that is not beneficial; an action from which no benefit is gained; any falsehood (that is not stable or realized); an entertaining act; any foul, futile talk and action unworthy of attention; loss of hope; and something that is not derived from method and thought. the word has also been used to refer to anything insignificant. the notes and derived interpretations were placed in the following categories: a) having no significant benefit (when medical care does not benefit the patient (his body and/or soul and his life in this world and/or the hereafter), it is wrong to proceed with that medical modality; b) falsehood (actions that fail to provide, maintain, and improve health are clearly futile); c) unworthy of attention (an action that neither improves health nor threatens it is wrong and impermissible). keywords: holy quran, quran-related dictionary,iidle, laghw, medical futility mailto:j_mohsen@hotmail.com j med ethics hist med 9:1 april, 2016, jmehm.tums.ac.ir mohsen rezaei aderyani et al. page 2 of 7 introduction medical ethics can be interpreted as the establishment of the do's and don’ts in medicine. medical ethics is an interdisciplinary field of knowledge that is associated with various domains of knowledge. the main scientific domain that deals with medical ethics is philosophy. hence, the foundations of the philosophical school adopted play a critical role in directing recommendations, guidelines, and codes of medical ethics. however, given the profound influence of secularism in general western culture and in the academic milieu, the foundations of medical ethics in the western world have been developed based on secular ideology worldview. for example, medical ethics is said to have been secular since the enlightenment of american and european societies (from the 18th century onwards). it is emphasized that this medical ethics does not refer to god or the revelatory tradition and is just focused on the needs and offerings of rational discourse (1). in their "principles of biomedical ethics", beauchamp and childress (2) refer to western philosophical ideas as the basis of ethical analysis. although this fourprinciple approach has sought to offer general, comprehensive principles and rules for medical ethics in the form of common morality, the religious and cultural contexts of western countries and the aforementioned philosophical foundations have inevitably had their influence on it. based on this framework, principles, rules, guidelines, and codes have been devised; and in specific cases (such as abortion, end-of-life care, euthanasia, and medical futility), results consistent with that particular cultural context have been achieved. the advances made in medical technology have provided the opportunity for life-prolonging interventions over the last 50 years. the prolonged life of critically ill patients often depends on devices during the final stages of life, and they do not have a normal connection to the world around them. the increased possibility of interventions has raised new ethical questions (3). in the 1980s, a new term was coined for inappropriate interventions: medical futility (4). medical futility is a term used to describe medical interventions that are expected to result in little or no benefit to a patient (5). a major debate in medical ethics is the topic of requesting futile medical care. this issue can threaten the physician-patient relationship (6). dissipation of medical resources, elimination of or reduction in the opportunity for other patients in need of medical services, erosion of trust in the medical team, and the emergence of legal complexities for the medical team are only a few examples. although the requests for medical futility compose only a small part of the health system in its totality, they can cause severe psychological and ethical tension for the patient, their family, and the medical team (7). in rare cases, the problem might become so gravely complicated that the matter is taken to the legal authorities by the patient or the hospital (8). if we are to analogize the health setting's confrontation with pathogenic factors to a battleground (9), we should recognize that success and failure in this field are not always limited to one front. in this combat zone, there are times when the health domain triumphs and the disease is defeated by the efforts of health service providers and conversely, there are occasions when the tables turn and the disease triumphs. the question, therefore, arises as to how far and to what extent the health setting should mobilize its forces against the disease and pathogenic factors and under which circumstances the health setting should surrender to the disease. this challenge also rears its head in another guise: the allocation of health resources. for example, the icu bed and the ventilator are aiding a patient whose imminent death is expected while concurrently, there is a patient in the hospital with a disease amenable to treatment (e.g. guillain-barré, a disease that paralyzes the muscles, including the respiratory muscles, for a while, but is reversible and curable) and there is no possibility of setting up another bed and another device. the ventilator is connected to a patient who will die within a few days while another patient is in dire need of the same device to regain his health. unrealistic expectations such as "technology is a cure-all" have led to extraordinary demands on the part of patients or substitutes (surrogate decisionmakers) to the effect that "anything possible will be done", which can create conflict and disagreements between the health care team and the patient or the substitute relatives (4). the idea of requesting medical futility is far from being a novel concept. indeed, hippocrates advises physicians: "in refusing the treatment of those who have been overcome by their diseases, realize that treatment is powerless." (10). the important point is that, for at least two reasons, medical futility requires a separate examination in iran. first, the common principles and foundations of medical ethics have been developed in the context of western culture (11) and secularism, with secularist values and principles having inescapably permeated all its aspects. there are fundamental differences between secular ontology, anthropology, and epistemology and what is found in a religionoriented ethical school (12, 13). based on these differences, planning, goal-setting, and determining ways of achieving objectives are dissimilar in these two worldviews. as the majority of the iranian population is muslim and islam is the country’s official religion (14), the implementation of some doctrines and codes of medical ethics pertaining to western societies in muslim communities does not appear to be rational. muslim scholars (in particular j med ethics hist med 9:1 april, 2016, jmehm.tums.ac.ir mohsen rezaei aderyani et al. page 3 of 7 iranian intellectuals) need to develop a set of ethical principles and values for the muslim community by careful examination of traditional resources (the revelation and the tradition of the infallibles) and intellectual resources. in accordance with these fundamental values and principles, muslim medical ethics experts should then develop guidelines and codes of medical ethics for application within a muslim community. second, challenges in a health service setting (health and care) vary across different countries. in iran, major developments have occurred in health services since the islamic revolution. the development of human resources and facilities in health services has completely transformed conditions in this sector compared to how it was years ago. though before the islamic revolution, iran was a country dependent for providing its basic health services, it has now, according to reports from the ministry of health and the world health organization (who), reached acceptable levels with regard to some major indicators of health services and has garnered the praise of the who's experts and inspectors. challenges emerge when instructions, policies, and guidelines have not been developed concurrently with the development of these health services. in other words, the vast majority of efforts have been focused on developing the quantity of services and, apparently, the quality of services has not been addressed in proportion to this quantitative development. to develop issues of medical ethics in the health system, either the same ideas and principles and codes of western societies should be translated and instructed in iran, or, if it is established that the basic foundations and values and, consequently, the codes of western medical ethics are not consistent with iranian culture, customs, and religion and are incompatible with the principles and values of the iranian society, then attempts should be made to prepare and develop codes of medical ethics based on principles and values appropriate to the iranian society. as was mentioned above, given that the majority of the iranian population is muslim and islam is the country’s official religion and it seems that islamic thought and its derived principles may be different from secular thought, this study was planned to investigate the concept of "futility" in the holy quran and quran-related dictionaries with a view to determining the similarities and dissimilarities between these two doctrines. materials and methods this paper is a part of a thesis entitled “medical futility: a comparative study from the perspective of secular and religious ethics”. given the subject of "futility" and its conceptual congruence with the quranic concept of "idle" (laghw), the online software "pars quran" (at http://www.parsquran.com/was) and noor jami` altafasir 2 software were drawn upon for this word. the root of the word "laghw" and its derivatives are used in 11 honorable verses of the blessed surahs of the holy quran, namely al-baqarah: 225; alma’idah: 89; maryam: 62; al-mu’minun: 3; alfurqan: 72; al-qasas: 55; fussilat: 26; at-tur: 23; al-waqi`ah: 25; an-naba’: 35; and al-ghashiyah: 11. of these honorable verses, the 3rd honorable verse of the blessed surah of al-muminūn was selected for its closer connection to the concept under examination. there is a large congruence between this honorable verse and the subject of "futility". the search results in these software programs yielded no additional honorable verses using the derivatives of the word. the selected honorable verse was searched in all the dictionaries in the noor jami` al-tafasir 2 software (al-tahqiq, qamus al-quran, al-ayn, lisan al-arab, majma’ albahrain, and al-mufradat). translations and descriptions provided in these dictionaries with regard to the subject of "futility" were selected from the texts. arabic texts were translated. wherever there were doubts about the translation of a word or phrase, the original text and its translation were presented to an arabic language and literature professor and the translations were readjusted. results god almighty, in honorable verses 1-11 of the blessed surah of al-muminūn, reveals the attributes of believers. according to the 3rd honorable verse of the blessed al-muminūn surah, the second attribute of these meritorious servants is that they avoid being "idle": "prosperous are the believers, who in their prayers are humble, and from idle talk turn away"1. the thematic philology of the word "idle" in the dictionaries shows that it has several meanings. in this study, its closest meaning to the concept of medical futility was chosen as an example. according to the blessed surah of al-tahqiq, the word "idle" (laghw) denotes any insignificant speech or act that is of no benefit. it thereafter extends the examples of the word "idle" to more than the word and to external actions and matters. one of the instances that it subsequently provides for the word "idle" is an action from which no benefit ensues and goes on to cite any falsehood or any entertaining act as examples of "idle". in addition, it claims "idle" to be futile and against that which is right and stable (15). here, the author refers to honorable verse 3 of the blessed surah of al-muminūn ("and from idle talk turn away") as an example. he interprets the honorable verse as stating that, "a believer always proceeds with his life under the religion of the almighty god and acts according to divine directions and commands and prohibitions. he is an obedient servant to his lord who does not neglect his 1 qu´ran: 23: 1-3 http://www.parsquran.com/was) j med ethics hist med 9:1 april, 2016, jmehm.tums.ac.ir mohsen rezaei aderyani et al. page 4 of 7 duties of servitude even for a moment. he believes that the almighty god perceives his position and hears his words and the truth is nothing but that his good and bad deeds all get back at himself in this world and the hereafter. so how is it possible for him to do anything futile that stops him from devoting himself to the almighty god, that prevents him from fulfilling his duties of servitude and that acts as a barrier between him and his lord?"(15). by referring to honorable verses 52-55 of the blessed surah of al-qasas ("those to whom we gave the book before this believe in it ... when they hear idle talk, they turn away from it and say, 'we have our deeds, and you your deeds. peace be upon your we desire not the ignorant."), the author does not limit the avoidance of "idle" to the believers of islam and extends it to all followers of the book. based on honorable verses 71 and 72 of the blessed al-furqan surah ("and whosoever repents, and does righteousness, he truly turns to god in repentance. and those who bear not false witness and, when they pass by idle talk, pass by with dignity."), he claims the importance of avoiding "idle" as an important attribute for ibad al-rahman (the servants of the allmerciful), coming in the order after repentance and negating false testimony (15). by referring to honorable verse 25 of the blessed surah of al-waqi`ah ("therein they shall hear no idle talk, no cause of sin"), honorable verse 35 of the blessed surah of an-naba’ ("therein they shall hear no idle talk, no cry of lies"), and honorable verses 10 and 11 of the blessed surah of al-ghashiyah ("in a sublime garden, hearing there no babble"), the author claims that the inhabitants of paradise do not hear an idle word and considers this state one of the attributes of the inhabitants of paradise (15). ghamoos al-quran defines "idle" as useless speech and states that "laghiya" is a disagreeable speech and "loghat" (language) was given its name because it is useless for non-speakers. then, by referring to honorable verse 89 of the blessed surah of alma’idah ("god will not take you to task for a slip in your oaths; but he will take you to task for such bonds as you have made by oaths"), he claims that idle oath is an oath without an intention such as the expressions "wallah" (i swear to god) and "billah" (with god or through god), which are used habitually in speaking, and to take an oath is to strengthen it by an intention and to swear intentionally and consciously and the verse means that god will not punish you for what is unintentional in your oaths, but he will punish you for those oaths you have strengthened by your intention (16). by referring to the 3rd honorable verse of the blessed surah of al-muminūn, the author recognizes the meaning of "idle" as "apparently every futile word and action". he also refers to honorable verses 10 and 11 of the blessed surah of al-ghashiyah: "in an elevated garden, wherein they will hear no unsuitable speech". therefore, taking an unintentional oath not intertwined with the person's soul and not expressed with serious intent and out of faith is void and is considered idle, and any disagreeable, useless word and action will be also idle (16). the al-ayn dictionary also takes the word "idle" to mean falsehood and, by making reference to honorable verse 26 of the blessed surah of fussilat ("the unbelievers say, 'do not give ear to this koran, and talk idly about it; haply you will overcome'."), it recounts the words of the enemies of islam and defines "idle" in this verse as the raising of their voices so as to confuse the muslims (17). according to lisan al-arab, "idle" is interpreted as a useless, futile word or any other thing not worth paying attention to and not beneficial, or any speech that is irrelevant and off-topic. "idle" has also been taken to mean deviation from the right path and the state of getting disappointed (18). in trying to define the word "idle", majma’ albahrain refers to honorable verse 57 of the blessed surah of al-furqan and takes "idle" to mean the same concept as falsehood. subsequently, by referring to honorable verse 26 of the blessed surah of fussilat, in which non-believers advise one another, the author states that, in this verse, "and talk idly about it", the word "idle" can be defined as obsolete speech in which there is no benefit (19). al-mufradat fi gharib-e al-quran writes: "it is an insignificant speech and anything not derived from method and thought … and any disagreeable word is called idle. and it is used for anything insignificant" (20). discussion considering the findings from dictionaries, it seems necessary to examine whether or not the interpretations provided for the word "idle" in the dictionaries are related to medical ethics, in particular the issue of "futility". for this purpose, the present findings will be compared to cases that are their equivalent in a health service context, and their similarities and congruities will be discussed. based on tafsir al-jalalayn in the commentary of the verse “and from idle turn away”, idle includes speech and other things (21). it is also stated in the tafsir of qurtubi that idle includes any void and unseemly word or act, like ghena music, useless actions, erotic conversations, and other sins and obscenities (22). according to tabari, in arabic language, any void act or speech is known as idle (23). ibn kathir has mentioned in his quran’s tafsir that useless acts or words are called idle (24). the fact that the concept of idle is not restricted to speech and, as a general concept, includes acts too is so obvious that it is mentioned in non-interpretational works, too. for example, in his book, shu’ab aliman, ahmad ibn husain bayhaqi (d. 456) explains different instances of idle including in them wasting time in useless matters, revealing people’s secrets, j med ethics hist med 9:1 april, 2016, jmehm.tums.ac.ir mohsen rezaei aderyani et al. page 5 of 7 abuse, performance of magic, and composing hyperbolic poetry (25). this generality of meaning is so clear that the author of mashahir ‘ulama alamsar regards acts such as unlawful trade and perjury as instances of idle (26). a) having no significant benefit in al-tahqiq, ghamoos al-quran, lisan al-arab, and majma’ al-bahrain dictionaries (15, 16, 18, 19), the word "idle" is said to be any work that has no benefit or significant benefit. one of the four common ethical tenets of medicine in the world is the principle of beneficence, and in clinical decisionmaking, if a patient’s benefit is in conflict with other affairs, his benefit takes priority. thus, medical futility is wrong as it is not beneficial to the patient. the mentioned principle is not purely in contrast with religious doctrines; nevertheless, in religious morality, cases of benefit and harm and their domain are broader than what is perceived in a merely materialistic view. from the perspective of religious morality, man is an eternal creature who will not perish with death; rather, he sheds his skin (27). the comprehensive perspective of religion on the dimensions of human life necessitates that the determination of the individual’s benefits not be grounded only on bodily benefits and transient worldly life. these doctrines take other dimensions of human existence (such as the soul or divine breath) and man’s eternal life in the hereafter as the criteria for determining benefit and harm. if the treatment intended does not have a significant benefit for any of the dimensions of human existence, the provision of that treatment is wrong and impermissible in islamic morality and it is obligatory that it be avoided. it is now clear that the examples provided in the mentioned dictionaries for the word "idle" not only have no significant benefit for man, but are also harmful and damaging and should, therefore, be avoided. b) falsehood al-tahqiq examines the philology of the word "idle" and takes it to be falsehood and against that which is right, realized, and stable (15). in health service settings, if estimations indicate the unjustifiability and impossibility of any result being achieved through the intended treatment, the treatment is considered futile, false, and idle. another point is the interpretation supplied by almufradat fi gharib al-quran. the author defines the word "idle" as anything that is not derived from method and thought (20). medical science is an empirical science, and evidence-based medicine has become a valuable part of medicine. "futility" has been defined as a treatment not falling within the range of medical standards and, therefore, being deemed medical futility (28). accepted evidencebased treatments have been derived from a thoughtbased procedure; consequently, offering treatments outside the range of medical standards is considered "futile" according to this definition. the writer of lisān al-arab uses another signification for the word "idle" and says, "an irrelevant and off-topic speech … idle has also been taken to mean deviation from the right path." (18). this signification can be taken as physiologic futility, which is a type of futility. (9, 11, 29) c) unworthy of attention according to lisān al-arab, the word "idle" denotes pointless, useless speech and anything else that is not worth noting and has no benefits in it (18). this signification can be taken as evaluative futility, which is considered a type of futility in the available literature on the subject (9, 30). conclusion a) having no significant benefit one of the four tenets of medical ethics presented by beauchamp and childress, which are accepted and well-known in many countries, is the principle of beneficence. in addition, based on ethical policies such as the geneva declaration, in clinical decisions, the patient’s benefit is always a priority. in health service settings, any action that is not beneficial to the patient based on narrative or rational and empirical evidence is unacceptable and the patient and service providers need to cease pursuing it. accordingly, since medical futility is not beneficial to the patient, it is inconsistent with the two principles of beneficence and non-maleficence and is, as such, wrong. the following presents instances of measures which are not planned based on the prioritization of the patient’s benefit: simultaneously treating multiple differential diagnoses for the patient’s clinical status; administrating antibiotics for common colds, which are most likely viral; administrating injection drugs when non-injection drugs can be used instead; prescribing a test without checking the patient's history and performing a thorough physical examination; performing endoscopy without appropriate clinical criteria; and hospitalizing a patient who can be treated and followed up as an outpatient. in health settings, pursuing therapeutic-diagnostic measures without documented medical reasons (particularly with the sole motivation of financial gain or fame) is wrong. examples provided are instances of taking measures without a reason, which are unacceptable and impermissible according to both secular ethics and particularly from the perspective of religious ethics. a faithful physician with strong religious beliefs respects the command and prohibition dictated by the holy law (command and prohibition of the intellect, the book, and the tradition) based on observing the right of god, and respects the patients’ rights based on observance and accountability to the right of people, and envisions such a great right of self and honor that he avoids engaging in such activities and performing therapeutic-diagnostic measures without documented medical reasons (particularly for the sole motivation j med ethics hist med 9:1 april, 2016, jmehm.tums.ac.ir mohsen rezaei aderyani et al. page 6 of 7 of financial gain). b) falsehood the administration of antibiotics for viral diseases (such as most common colds) is ineffective in bringing health and is, therefore, futile and should be avoided from the perspective of islamic ethics. consequently, a treatment not included in medical standard, not derived from method and thought, not accepted through evidence-based medicine, and/or not having any physiologic effect on the improvement of man’s health is false, non-relevant, and, therefore, futile. when a patient visits a physician, one of the questions that need to be answered is whether the patient requires hospitalization or if he will recover through outpatient treatments without any serious complications. one of the cases that may be witnessed in health centers is the patients’ hospitalization without indication. the total costs of outpatient treatments are often less than the costs of hospitalization. the general culture in our country (as is the case in many asian countries) is familyoriented. the lack of human resources (particularly nurses) in addition to the family-oriented culture necessitates the presence of a relative of the hospitalized patient in the hospital as a companion. the costs of unnecessary hospitalization thus impose a heavy burden on the patient’s relatives, as well. when the patient does not benefit from hospitalization, his hospitalization is morally impermissible and wrong regardless of the motivations behind it. c) unworthy of attention whenever according to medical assessments, the considered treatment results in outcomes such as prolonged life for hours, days, months, and even years, but according to those estimates, the result is of no substantial value; this is evaluative futility. evaluative futility is one of the challenges of clinical cases. the patient and his family may regard the medical measure as a worthwhile action, whereas the medical practitioner, albeit aware of the possibility of increased longevity of the patient's life, may deem this longevity worthless. in this case, one of the major challenges is whose values and generally what types of values should constitute the criteria for action. in religious teachings, patience is a moral virtue. the holy quran commands the dear prophet of islam (pbuh) to give "good tidings to the patient" (albaqarah, 155). "allah loves the steadfast." (ali imran, 146). "indeed, allah is with the patient." (albaqarah, 153 & 249; al-ma’idah, 46 & 66). "patience during calamity", which is one of the types of patience, is acceptable and worthy, and disease is considered a test and a calamity. when in determining individual interests, the interests of the body and the spirit as well as the worldly life and the eternal life of man are taken into consideration, it can be perceived that requests for euthanasia take away the opportunity of practicing patience during illness from the patient/family. therefore, such measures are not beneficial to the patient/family and are morally wrong. from what was said, it can be concluded that there are several significations for the word "laghw" (idle) in the examined dictionaries. examples of these significations include any insignificant speech or thing, any action from which no benefit ensues, falsehood, entertaining act, anything wrong and against the right that is not stable or realized, useless speech, any disagreeable and useless speech and action, any speech that is irrelevant and off-topic, deviation from the right path, getting disappointed, and also anything not derived from method and thought. it can thus be concluded that despite superficial similarities, the religious thought (and in specific, islamic thought) is deeply different from secularism. believing in and adhering to the three basic principles of unity, prophethood, and resurrection is in apparent contradiction to the principles and values of secularism. it is necessary for muslim and shia scientists to collect their own set of moral principles and values for implementation in muslim communities after careful examination of the traditional resources of their culture (revelation and tradition of the infallibles) as well as their intellectual resources. they should then formulate medical guidelines and ethical charters for muslim communities based on these more harmonious principles and fundamental values. acknowledgments this paper is a part of a medical ethics phd thesis, entitled “medical futility: a comparative study from the perspective of secular and religious ethics”. this thesis was registered (#131) in the faculty of traditional medicine of shahid beheshti university of medical sciences. hereby, the authors would like to express their gratitude for the sincere cooperation and assistance of the professors and colleagues at the department of medical ethics, school of traditional medicine, shahid beheshti university of medical sciences; especially dr. parvaneh ghaffari that arabic-persian translations was under his supervisions. j med ethics hist med 9:1 april, 2016, jmehm.tums.ac.ir mohsen rezaei aderyani et al. page 7 of 7 references 1. chervenak fa, mccullough lb. ethics of research in perinatal medicine. semin perinatol 2009; 33(6): 391-6. 2. beauchamp tl, childress jf. principles of biomedical ethics, 6th ed. new york: oxford university press; 2009. xiii, p. 417. 3. thompson rj. medical futility: a commonly used and potentially abused idea in medical ethics. br j hosp med 2011; 72(2): 96-9. 4. moratti s. the development of "medical futility": towards a procedural approach based on the role of the medical profession. j med ethics 2009; 35(6): 369-72. 5. terra sm, powell sk. is a determination of medical futility ethical? prof case manag 2012; 17(3): 103-6. 6. de vos ma, seeber aa, gevers skm, bos ap, gevers f, willems dl. parents who wish no further treatment for their child. j med ethics 2015; 41(2): 195-200. 7. clark pa. medical futility in pediatrics: is it time for a public policy? j public health policy 2002; 23(1): 66-89. 8. larijani b. physician and ethical considerations, 1st ed. tehran: baraye farda; 2004. 9. whitmer m, hurst s, prins m, shepard k, mcvey d. medical futility: a paradigm as old as hippocrates. dimens crit care nurs 2009; 28(2): 67-71. 10. rubin sb. when doctors say no, the battleground of medical futility. bloomington: indiana university press; 1998, p. 191. 11. bagheri a. medical futility: a cross-national study. new jersey: imperial college press; 2013, p. 294. 12. enjoo sa, mosavat sh, heydari m. medical ethics in iranian traditional medicine, a review of qutb al-din alshirazi’s ethical code. j res hist med 2014; 3(3): 114-22. 13. aderyani mr, kiani m. a comparative study of the foundations of medical ethics in secular and islamic thought. j stud relig ideol 2015; 14(40): 27-46. 14. anonymous. the constitution of the islamic republic of iran, (1979). http://rc.majlis.ir/fa/content/iran_constitution (accessed in 2014) 15. al-mostafavi h. 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[mashahir ‘ulama al-amsar]. beirut: dar al-kutub al_ilmiyah; 1959. 27. anonymous. the difference between the religious and secular army is that the religious army believes that death brings a new life [internet]. esra. june 22, 2012. http://www.portal.esra.ir/pages/index.aspx?view=1&id=mtc5ma%3d%3dr9haw3stzos%3d&kind=1 (accessed in 2014) 28. weijer c, singer pa, dickens bm, workman s. bioethics for clinicians: 16. dealing with demands for inappropriate treatment. cmaj 1998; 159(7): 817-21. 29. madani m. ethical considerations of futile care. iran j med ethics hist med 2013; 6(2): 31-42. 30. petrova m, dale j, fulford b. values-based practice in primary care: easing the tensions between individual values, ethical principles and best evidence. br j gen pract 2006; 56(530): 703-9. http://rc.majlis.ir/fa/content/iran_constitution http://www.portal.esra.ir/pages/index.aspx?view=1&id=mtc5ma%3d%3d empathy ghazaleh ahmadi 170 16-8-94.docx journal of medical ethics and history of medicine original article surveying the attitudes of transsexual patients referring to tehran institute of psychiatry toward doctors’ empathy, iran, 2011-2012 ghazaleh ahmadi jazi1, mehrdad eftekhar*2, pezhman mobasher3, saeedeh saeedi tehrani4, khosro ahmadi5, maria rastgouy fahim6 1researcher, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran; 2associate professor, mental health research center, iran university of medical sciences, tehran, iran; 3skin and stem cell research center, department of dermatology, tehran university of medical sciences, tehran, iran; 4 medical ethics phd candidate, department of medical ethics, faculty of medicine, tehran university of medical sciences, tehran, iran; 5department of pediatrics, mashhad university of medical sciences, mashhad, iran; 6department of obstetrics and gynecology, shahid beheshti university of medical sciences, tehran, iran. corresponding author: mehrdad eftekhar address: mental health research center, tehran institute of psychiatry, school of behavioral sciences and mental health, shahid mansouri lane, niayesh st., sattarkhan ave., tehran, iran. postal code: 1443813444 email: eftekharardebili.m@iums.ac.ir tel/fax: +19495734549 received: 19 aug 2014 accepted: 10 dec 2014 published: 7 nov 2015 j med ethics hist med, 2015, 8:9 © 2015 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract physicians’ knowledge of therapy and counseling stands among the most important issues in the viewpoints of clients who refer to psychiatric centers. transsexual patients are very important in this regard. the goal of this research is to study their attitude toward doctors’ empathy. a group of transsexual patients who referred to the tehran institute of psychiatry, iran, answered the jefferson scale of empathy. the relationship of the patients’ age, gender, education level, and lifestyle with their attitude was measured. this study was conducted on 40 patients, including 16 women (40%) and 24 men (60%). in terms of education, 8 patients had a degree below high school diploma (20%), 9 had high school diploma (22.5%), and 23 patients were university students or of higher education level (57.5%). among these patients, 6 were unemployed (15%), 10 were students (25%), and the rest were employed. moreover, 8 participants lived alone (20%), 5 lived with their friends (12.5%), and 27 lived with their family (67.5%). gender had no influence on the average score of the questionnaires, yet level of education had some influence. lifestyle also had a significant influence on the patients’ attitude. on the other hand, patients whose problems began before the age of 12 had lower score than others. experienced psychologists in referential centers can express greater levels of empathy to specific diseases and this trend is very effective on the patients’ cooperation level. in order to create an effective relationship between physicians and patients, the efficiency of the health system and increasing satisfaction of specific patients should be considered. keywords: patients’ attitude, sexual identity disorder, transsexual, empathy mailto:eftekharardebili.m@iums.ac.ir j med ethics hist med 8:9 november, 2015 jmehm.tums.ac.ir ghazaleh ahmadi jazi et al. page 2 of 6 (page number not for citation purposes) introduction a good relationship between physicians and patients is the basis of a good medical care (1-3). researches indicate that most medical diagnoses and treatment decisions are based on information obtained from interviews and a good physician-patient relationship is the basis of medical interviews. an effective relationship between physicians and patients is a skill and physicians and patients should have an empathetic behavior to realize it (4). therefore, establishment of an empathetic relationship between physicians and patients is a key to success in a treatment process. more complaints against physicians have been related to the manner of their relationships with patients than their ability and skill (5). establishment of effective relationships not only increases patient satisfaction, but also has an important role in the enhancement of the result of medical action (6). empathy means sensitivity to the mental condition of other individuals and the ability to understand and know it. today, professional empathy is emphasized as a means of understanding the mental and emotional status of patients and its effect on success in clinical activities (7). empathy also greatly helps in increasing patients’ satisfaction and compliance, and therefore, facilitating treatment method by raising the patients’ confidence in physicians (8). therefore, empathy is required and necessary for a good relationship between physicians and patients, maintaining confidence in physicians, and having a professional behavior. in addition, having empathy is stated as a professional principle and obligations. this issue and its evaluation will greatly help in achieving health goals. evaluation of patients in terms of such empathy will also help in appraisal of health services. unfortunately, many physicians refuse to conduct such evaluations with the justification of not having enough time to establish a good relationship, and thus, to empathize with patients. this is observed more in specific diseases. previous researches have indicated the existence of serious problems in this regard in some countries (9) and that this weakness (physicians’ lack of empathy) has harmful effects on the physical, mental, economic, and social dimensions of health care (10). based on the diagnostic and statistical manual of mental disorders, 4th edition (dsm-iv) measures, annually 1 per 30,000 adult males and 1 per 100,000 adult females seek sex-reassignment surgery. based on statistics provided by clinics in amsterdam, this surgery is used for 1 per 10,000 males and 1 per 30,000 females. however, van kesteren et al. consider these figures to be higher (11). empathy is the easiest way of effectively taking care of patients, and understanding their emotional and verbal behaviors with an attempt to comprehend their emotions, desires, and words. the main key to improving the curative effect of the patient-doctor relationship is empathy. it has been proven that improving communications with patients based on empathy and correct comprehension can bring about higher quality care and treatment for patients. although the importance of empathy might be quite clear, its definition and influence on the patientdoctor relationship still needs to be explained. the first person who believed in the importance of empathy in the patient-doctor relationship was carney rogers. he proved the importance of empathy as a factor that promotes the curative influence. according to rogers empathy is the correct comprehension of another individual’s inner experience (12). truax also defined empathy as the correct understanding of the current client’s feelings and taking a structured path to having dialogue with patients (13). based on this definition, many people believe that empathy is a skill and an attitude, and the ability to comprehend the emotions of other people and the cause of such emotions (14). random information has indicated a relationship between empathy and routine behavior. the same information has also proven the beneficial effects of empathy on patients’ health, better cooperation of patients, reduction of legal problems concerning doctors, and higher levels of doctor and patient satisfaction (15). the relationship between empathy and empathetic and assisting behavior is defined in the 4 categories of sentimentality, morality, recognition, and behavior (16). sentimentality is the ability to experience the emotional state of another person. morality is necessary for the sense of humanity and practice of empathy. recognition is the ability to correctly understand and comprehend the attitudes of another person. behavior is the understanding the similarities in behaviors of the opposite individual. patterson has also described empathy in 4 steps the assisting individual’s talent to receive signals from another individual, to put oneself in place of another individual, mutual understanding, and patients’ understanding of the assistant’s perception. based on this definition, empathy falls into 4 categories of emotional, receptive, communicative, and relational (17). according to the internal medicine community, empathy means understanding the emotional state of an individual without really being in that situation. this definition shows that empathy is a mixture of the 2 components of intelligence and emotion. occupational empathy is a form of empathy which is mostly based upon intelligence and recognition aspects rather than emotional aspects. in a study, doctors were asked to define empathy. they defined it as: “putting myself in the patient’s shoes.” in that study, women emphasized the emotional aspect of empathy, while men focused their attention on the importance of empathetic behaviors (like accompanying the patient, the j med ethics hist med 8:9 november, 2015 jmehm.tums.ac.ir ghazaleh ahmadi jazi et al. page 3 of 6 (page number not for citation purposes) possibility of direct phone calls, prescribing cheaper medicines, and etc.) (18, 19). to our knowledge, no study exists that shows the prevalence of transexuality in the iranian population. yet, we cannot hide the problems these individuals have in various stages of their life. the patients usually treat their condition as a secret and hide it even from their close circle of friends. many of these patients do not even go to psychiatric and psychologist centers for treatment. among patients who come to psychiatric institutes for treatment and consultation, one of the most important issues is probably the level of understanding of responsible patients about issues of therapy and consultation. thus, we decided to study the empathy level of doctors from the view of transsexual patients in a psychiatric institute in iran. thus, the main goal of this study was to survey the attitude of patients referred to the tehran institute of psychiatry, iran, in 2011 toward doctors’ empathy. variables of age, education, unemployment, gender, sex reassignment, the age at which sex-associated problems began, and the rejection level from family were considered. therefore, evaluation of patients’ understanding of empathetic behavior and studying the rate of understanding and empathy between physicians and patients, especially patients with special conditions like transsexuals, can increase communication skills and change individuals’ attitudes. it can also be a type criterion for evaluation of physicians’ professional obligations and enhancement of health services in this area. materials and methods the present research was a cross-sectional study. statistical sample and population the statistical population of this study consisted of transsexual patients who referred to the tehran institute of psychiatry. tehran institute of psychiatry is one of the institutions to which forensic medicine organizations introduce some transsexual patients for more evaluation. all patients referring to the institute during 2011-2012 were included in the study using non-random simple sampling (based on convenient samples). a sample of 40-50 patients was selected. data collection tools and methods the data collection tool was a questionnaire designed by the researchers. it included questions about patients’ demographic information, such as age, employment status, lifestyle, education, and the age at which sexual problems started, and 5 questions concerning patients’ attitude toward doctors’ empathy (20). these 5 questions were adopted from the jefferson scale of empathy which was modified by hojat et al. (21). in the study by hojat et al., some changes were made to the jefferson scale of empathy so that it could be used by physicians and other therapists. thus, this modified version has been used for measuring the perception of patients about physician empathy level. reliability and validity of the questionnaire were confirmed by hojat et al. (21). moreover, in this study, cronbach’s alpha was used to ensure the reliability of the questionnaire. the cronbach's alpha of the research tool was 0.85 which confirmed its reliability. finally, the validity of the questionnaire was confirmed using content validity. data analysis the data were transferred to spss software (version 19, spss inc., chicago, il, usa) and analyzed. the average age of the patients was calculated. the average questionnaire score for patients in terms of variables of age, sex, occupation, and education level was calculated. chi-square statistical test was used to compare qualitative variables and analysis of variance (anova) was used to compare quantitative variables. the confidence level of the study was 95% and all p values of less than 0.05 were considered to be significant. results the present study was conducted on 40 patients, including 16 women (40%) and 24 men (60%) with the average of 24.32 ± 4.77. the average age of men in this study was 24.50 ± 5.6 years and the average age of women was 24 ± 3 years which did not differ significantly. on the other hand, the majority of patients were younger than 30. there were only 3 patients above the age of 30. figure 1 shows the age distribution of patients in this study. figure 1age distribution of patients in terms of education, 8 patients had a degree below high school diploma (20%), 9 had high school diploma (22.5%), and 23 were students or had degrees higher than high school diploma (57.5%). in addition, 6 patients were unemployed (15%), 10 were students (25%), and others had occupations such as teacher and barber. based on the answers to the questions, 8 people lived alone (20%), 5 lived with their friends (12.5%), and 27 lived with their families (67.5%). the average score of the jefferson scale of empathy including 5 five-point questions (25 scores in total) was 19 ± 2.13 for women and 19 ± 2.6 for men. j med ethics hist med 8:9 november, 2015 jmehm.tums.ac.ir ghazaleh ahmadi jazi et al. page 4 of 6 (page number not for citation purposes) hence there was no significant difference between the scores of the two genders. table 1 shows the frequency of the scores of the two genders (p < 0.94). table 1frequency of the scores of the two genders gender average range p-value female 19 ± 2.13 15-22.5 0.94 male 19 ± 2.6 13-25 total 19 ± 2.38 13-25 the average score of patients with a degree below high school diploma, high school diploma, and degree above high school diploma was 21.12 ± 1.95, 18.4 ± 2.46, and 18.5 ± 0.2.17, respectively. the difference was significant. table 2 shows the average frequency of scores for each level of education in patients (p < 0.02). table 2the average frequency of scores for each level of education level of education average range p-value below high school diploma 21.12 ± 1.95 9-25 0.02 high school diploma 18.4 ± 2.46 15-22.5 above high school diploma 18.5 ± 2.17 13-22.5 table 3 shows the frequency distribution of the average scores of the jefferson scale of empathy for each occupation. based on the occupation status, the average score for unemployed patients, students, and for employed participants was 17.8 ± 0.1.85, 18 ± 2.55, and 19.8 ± 2.3, respectively. the difference was significant (p < 0.03). table 3the frequency distribution of the jefferson scale of empathy score for unemployed participants, students, and employed participants occupational status average range p-value unemployed 18 ± 2.55 13-20 0.03 student 17.8 ± 1.85 15-20.5 employed 19.8 ± 2.3 16-22 in terms of lifestyle, those who lived alone, those who lived with their friends, and those who lived with their family obtained the scores 18.7 ± 0.2.6, 20.6 ± 0.2.77, and 18.8 ± 0.2.23, respectively. the differences observed among scores in terms of lifestyle were not significant. among the 40 transsexual patients studied, 25 patients (62.5%) said their problems started before the age of 12, and 15 patients (37.5%) said their problems started after the age of 12. the average score of jefferson scale of empathy for patients whose problems started before the age of 12 and after the age of 12 was 18.4 ± 0.2 and 20 ± 0.2.6, respectively. the difference observed here was significant (p < 0.038). discussion and conclusion the goal of the present study was to evaluate the empathy level of transsexual patients who referred to an iranian psychological center. the jefferson scale of empathy was used to study the empathy level of patients. based on the information gained from this scale, the majority of patients who referred to the tehran institute of psychiatry were less than 30 years of age. the majority of them were students and only a small percentage of them were unemployed. this shows that the population studied was mostly educated and independent. the results revealed that the majority of participants had education levels above high school diploma. the patients were asked to complete two sample forms, one for the institute’s psychiatrists and one for other physicians. this was used to evaluate the attitude of patients before and after attending institution. in previous studies, psychiatry residents showed high empathy levels compared to other residents (22). in this study, the patients gave an average score of 17.6 ± 3.6 to other institutions and 20.5 ± 2.6 to the tehran institute of psychiatry. in this study, 62.5% of the patients faced problems before 12 years of age, before puberty. this finding was in line with our hypotheses. the others faced problems after puberty. this showed the early and late symptoms of patients. thus, according to our expectation, the patients’ symptoms start earlier than 12 years of age and the status of other patients is doubtful. the patients with late symptoms need a different type of empathy. the important finding of this study was that the patients observed a higher level of empathy in the institute’s psychiatrists than their previous psychiatrists. as the subject conducting interviews in this study was not one of the therapists of the participants, reporting higher levels of empathy by the patients is unlikely to affect therapists’ satisfaction or their concern of therapy. this finding can be explained in terms of these psychiatrists’ higher experience of this disorder, as a result of which they can show their empathy better. thus, training health service providers on transsexualism is of great importance. the study results showed that there is no difference among genders regarding attitude toward empathy. this finding is consistent with the results of the study by owen-anderson et al. (22). their results showed that there is no difference regarding empathy between healthy girls and transsexual boys (22). the results of the investigation of empathy based on education showed that patients with low education level reported high empathy. this was due to the effortless communication between the physician and patient and the greater confidence of the patients in their physicians. it can be said that transsexual patients with high education level should be further studied, as they have different needs from others based on their more sociable behavior and higher j med ethics hist med 8:9 november, 2015 jmehm.tums.ac.ir ghazaleh ahmadi jazi et al. page 5 of 6 (page number not for citation purposes) expectation level. these needs should be taken into consideration during interviews with these patients. individuals with degrees below diploma have less expectation of empathy. moreover a difference was observed in the scores of the jefferson scale of empathy based on the patients’ occupation. however, no specific reason was found for this finding in terms of occupational differences and empathy. the job and income of patients should be considered in the proposed solutions and we should behave differently with each transsexual patient depending upon their job, social expectation, and income. the results showed that there was no difference between the patients living alone and the patients living with their family or friends in terms of empathy. this is because of various factors in patients’ attitude toward physicians’ empathy. it was found that the patients living alone have higher mean age than others (28 years vs. 23 years) and their lifestyle had no impact on their attitudes. the present research was appropriate in terms of the sample volume. transsexual patients have hardly been noticed in the world and not studied in terms of empathy level. this is due to these patients’ lack of confidence in health centers or social obstacles. a major strength of this research was the selection of these patients. another was the use of the jefferson scale of empathy in this study. this study has utilized parts of this scale and 2 sample forms (for institute’s psychiatrists and other physicians) were completed. the present study also measured the relationship between empathy level and individual factors of transsexual patients. it has been proven that questioning transsexual patients about their expectations of and satisfaction level with the health system will lead to a closer relationship with the therapist and increase the treatment pace (phone calls with patients) (23). since having a good relationship leads to enhancement of the quality of health services and increase in satisfaction of patients, understanding the attitude of patients toward physicians’ empathy rate and its relevant factors can greatly help in obtaining their satisfaction. in addition, knowing influential factors and how they influence empathetic behavior, would help professionals to communicate with patients more effectively. to name but a few restrictions of this research, we may refer to the use of questionnaires for data collection. mingling these ideas and comprehensions with biases, thoughts, and prejudgments might influence the research results. it is recommended that future researches adopt a qualitative approach or a mixture of qualitative and quantitative approaches to identify the attitudes of patients toward doctors’ empathy. in future researches, it is recommended that a questionnaire be given to the doctors so that they can also measure the patients’ cooperation level and compliance with treatments. furthermore, it is suggested that future studies be conducted with a greater sample volume based on other factors that influence empathy in the patient-doctor relationship. it also seems necessary to have an ethical guide for patients with mental disorders and for activists in this field to understand and know psychological issues in specific patients in order to have professional behavior in this regard. moreover, teaching communication skills to professionals in this field can be helpful and seems necessary. j med ethics hist med 8:9 november, 2015 jmehm.tums.ac.ir ghazaleh ahmadi jazi et al. page 6 of 6 (page number not for citation purposes) references 1. dorr goold s, lipkin m. the doctor–patient relationship challenges, opportunities, and strategies. j gen intern med 1999; 14(suppl 1): 26–33 2. zali mr. 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child psychiatry hum dev 2008; 39(1): 6783. 23. bockting w, robinson b, benner a, scheltema k. patient satisfaction with transgender health services. j sex marital ther 2004; 30(4): 277-94. journal of medical ethics and history of medicine p perception of iranian nurses regarding ethicsbased palliative care in cancer patients marjan mardani hamooleh 1 , leili borimnejad 2* , naimeh seyedfatemi 3 , mamak tahmasebi 4 1 phd candidate in nursing education, faculty of nursing and midwifery, nursing department, tehran university of medical sciences, tehran, iran; 2 assistant professor, faculty of nursing and midwifery, nursing department, iran university of medical sciences, tehran, iran; 3 associate professor, faculty of nursing and midwifery, nursing department, iran university of medical sciences, tehran, iran; 4 assistant professor, cancer institute research center, tehran university of medical sciences, tehran, iran. corresponding author: leili borimnejad address: nursing department, faculty of nursing and midwifery faculty, iran university of medical sciences, tehran, iran, p.o. box: 1419733-171 email: lborimnejad@tums.ac.ir tel: 98 21 66941669 received: 10 sep 2013 accepted: 12 oct 2013 published: 18 dec 2013 j med ethics hist med, 2013, 6:12 © 2013 marjan mardani hamooleh et al.; licensee tehran univ. med. sci. abstract palliative care is still a topic under discussion in the iranian healthcare system, and cancer patients require palliative care. moreover, nursing ethics has an important role in caring for these patients. the purpose of this study was to identify the perception of iranian nurses regarding ethics-based palliative care in cancer patients. this study was done with a qualitative approach and by using content analysis. in this study, 14 nurses were selected through purposive sampling, and a face-to-face semi structured interview was conducted with each of them. after data collection, all interviews were transcribed and reviewed, and categories were extracted. at first, similarities in meaning were reviewed and based on centralization arranged in sub-categories. then, relevant subcategories were arranged in a category after a second review. in general, original categories in the ethics-based palliative care in cancer patients encompass the following: “human dignity”, “professional truthfulness” and “altruism”. human dignity has 3 sub-categories consisting of ‘respecting patients’, ‘paying attention to patient values’ and ‘empathizing’. professional truthfulness has 2 subcategories consisting of ‘truthful speech’ and ‘truthful action’. lastly, altruism has 3 sub-categories consisting of ‘complete and multi-dimensional patient acceptance’, ‘supportive behavior’ and ‘responsibility’. content analysis of ethics-based palliative care in cancer patients revealed the required conditions for this type of care based on the perception of nurses. the results of this study suggest that in nurses’ point of view, human dignity, professional truthfulness and altruism all have important roles in ethics-based palliative care in cancer. the findings of this study will give nurses a greater knowledge about ethics-based palliative care in cancer patients, leading to a better understanding of the ethical needs of these patients, and may ultimately help improve the nursing practice. keywords: cancer, nursing ethics, nursing care, human dignity, palliative care mailto:lborimnejad@tums.ac.ir j med ethics hist med 6:12 sep, 2013 jmehm.tums.ac.ir marjan mardani hamooleh et al. page 2 of 8 (page number not for citation purposes) introduction cancer is one of the major causes of death in the world. it is estimated that more than 15 million people will suffer from cancer by 2020 (1). this illness is a progressing problem in middle eastern countries (2). in iran, cancer is the third important cause of death affected by factors such as genetics and the environment. cancer occurrence in adults and in different regions of iran is about 48 to 112 cases per million for females and 51 to144 cases per million for males (3). cancer causes physical and emotional malfunctions (4), and negatively affects the patients’ lives. in this situation, patients require palliative care. palliative care is offered for life threatening illnesses and is a comprehensive approach centralized on promoting life quality in its final phases. this type of care may prove helpful in confronting with chronic illnesses (5). palliative care is a humanitarian need among cancer patients throughout the world (2) and its aim is to lessen patients’ suffering by helping them figure out their pain, and physical, spiritual and ethical problems (6). palliative care is important as it helps create a structured method in offering care and making patients feel good through availability of nurses, who in turn try to accept the patient and his or her emotional pleas. factors such as focusing on professional laws in nursing highlight the importance of palliative care, and nurses’ perception of this type of care in their work environment (7). in fact, palliative care for cancer patients is of a comprehensive nature (8), and humane cares generally employ a holistic approach concentrating on all dimensions of the patient (9). while caring for patients, nurses are constantly challenged by ethical issues since ethics in nursing calls for behaviors that would prevent harm to the patients from different aspects (10). despite the emphasis on holistic, comprehensive and humane care, providing palliative care is really stressful for nurses (11) and results of a study show that from the viewpoint of nurses, adequate time is not allocated for this kind of care (12). moreover, nurses’ physical and mental fatigue is a burden to offering palliative care (13). however, the major problem of the nursing system in iran in offering palliative care to cancer patients is lack of a transparent framework for nurses, as palliative care does not receive serious attention in the formal education curriculum. it seems that one of the causes of this problem is lack of a comprehensive study in this field throughout the country, which restricts application of palliative care for these patients. the researcher’s clinical experience shows that palliative care centered on ethics is present in patient care programs, and nurses offer this type of care. although the researcher believes that the majority of nurses working in cancer wards take ethical aspects into consideration, more nursing care is needed for palliative care centered on ethics. reviewing texts, we found that there is a lack of studies on ethicsbased palliative care for cancer patients in iran, and that interpreting nurses’ viewpoints and studying the involved factors closely can pave the way for a better offering of such cure. it seemed suitable to perform such a research since identifying nurses’ perceptions about ethics-based palliative care for cancer patients can lead to achieving the basic knowledge for offering related foundations to ethical care in nursing. these foundations help design studies on care and codify scales in this regard. the purpose of this study was to explain nurses’ perception about ethics-based palliative care in cancer patients. method the present study is a qualitative study done through content analysis. this method is one of the approaches of qualitative research and also of qualitative data analysis (14). content analysis analyzes written, spoken or visual messages in which raw data are summarized and then categorized. in conventional content analysis categories and their names are taken from the data (15). in the present study, conventional content analysis was used. setting and participants participants were selected by purposive sampling method. in this research, sampling was done from nurses with maximum variation (sex, marital status, job experience) to the point of data saturation. the criterion to choose the nurses was having job experience in the adult cancer ward for at least two years. in this study, palliative care was not limited to a certain type of cancer or a certain phase of this illness, and participants were working in wards covering different ranges of cancer patients in different phases of the illness. from the 14 nurses participating in this study, there were 10 females and 4 males, whose ages ranged from 27 to 48. nine were married, and the rest were single. their job experience also varied from 4 years to 17 years. the research field was limited to centers related to tehran university of medical sciences such as cancer institute, palliative medical center and valieasr hospital. data collection deep semi structured and face-to-face interviews were conducted with 14 nurses. the interview time was about 30 to 45 minutes, and each of j med ethics hist med 6:12 sep, 2013 jmehm.tums.ac.ir marjan mardani hamooleh et al. page 3 of 8 (page number not for citation purposes) the nurses was only interviewed once. in general, 14 interviews were done. before the interview, both the researcher and the nurses agreed on the time and place of the interview. at the beginning of the interview, the nurses were asked a general question: what is your experience in ethics-based palliative care for cancer patients? in order to attain more information, the interview continued with probing questions. ethical considerations to respect ethical considerations, a letter of introduction was obtained from the research department of the tehran university of medical sciences. the interviews were recorded. the nurses were assured that all the information would remain confidential, and after implementation, all the audio files would be destroyed. if they wished, they could receive the audio files. they also were informed that they could abandon the study any time they wished, but no one did. data analysis the interviews were recorded, and written manuscripts were typed on the computer. implemented texts of the interviews were reviewed and broken down into smaller meaningful units. then, codes were unlocked to be placed in sub-categories based on their semantic similarities. finally, the researcher and the participants agreed upon a shared semantic about categories. the researcher did his best not to involve his presuppositions in the data analysis procedure. to determine data accuracy, criteria such as credibility, conformability, and dependability posed a permanent clash between the subject and the data (16). viewpoints of the research team professors were applied in the process of interviews and data analysis. interview manuscripts, extracted codes and sub-categories were discussed by some nurses and 2 people who have a phd in nursing. modulation was used in data gathering (interviews and notes from the field) to determine data dependability. furthermore, an outside observer, who was a researcher familiar with both clinical environments and qualitative research and was not the member of the research group, was used. there was an agreement on the findings. to determine conformability, all the activities are registered, and a report was prepared on the research process. to determine data transferability, data gathered from 2 nurses outside of the study who had conditions similar to those of the participants were discussed and verified. results three categories were derived from the deep descriptions of the participants. these categories consisted of eight sub-categories (table 1). table 1: categories and sub-categories sub-categories categories respecting patients paying attention to patient values empathizing human dignity truthful speech truthful action professional truthfulness complete and multi-dimensional patient acceptance supportive behavior responsibility altruism human dignity this category focuses mainly on ethics-based palliative care in the form of respect for patients, paying attention to their values, and empathizing. respecting patients: from the nurses’ viewpoint, respect for patients is very important in ethics-based palliative care. regarding aggressive patients, the way we look at them must be scrutinized. one of the nurses said: “some of the patients are nervous and aggressive, they curse at us and throw things at us, but we must ignore such things. we have to respect them because they cannot control their behavior, and accepting the illness is difficult for them.” [nurse 5] participants believed that they have to let the patients know that they are respected. one of the nurses said: “in my opinion, palliative care for cancer patients means that the nurse can calm the patient with the respect he or she offers and by inducing a good sense of respect to the patient.” [nurse 8] paying attention to patient values: nurses believed that human dignity is formed through respecting patients’ values. a participant said, “palliative care is not merely to lessen the physical pain…. no, there are other things such as respecting patients’ values. for example, a patient may believe in prayers and think they can calm him down, so an attendant may want to bring a prayer. as a nurse, i have to let them bring prayers, or if they cannot enter the ward, i have to take the prayer to the patient in the ward.” [nurse 4] another nurse clarified the necessity of constantly paying attention to the values of the in every moment of their lives: “i try to give the best care to the patients till their last breath, when there is no hope for improvement… i think every moment is important to these patients, and we as nurses have to be aware of that.” [nurse 2] empathizing: nurses believed empathy to lead to human dignity in ethics-based palliative care. “if we try to walk in the patient’s shoes or consider the patient j med ethics hist med 6:12 sep, 2013 jmehm.tums.ac.ir marjan mardani hamooleh et al. page 4 of 8 (page number not for citation purposes) as one of our relatives, empathy will be possible,” one nurse believed. “we have to walk in the patients’ shoes, patients who suffer from deformity because of chemotherapy, patients who suffer from metastasis, or patients who are going to have prosthesis operations. i’ve always said those being hospitalized are like my sister, father, mother or one of my relatives.” [nurse 11] another nurse highlighted the importance of empathy through unification with the patient’s feelings. “sometime, i go to medicate the patient, and it takes a rather long time. when my colleagues ask for the reason, i say i didn’t just medicate him. when he talked about himself, i cried with him, and i have no fear to say that i have cried with him because i think i helped him get relaxed.” [nurse 13] professional truthfulness this category concentrates on professional truthfulness, which is in the form of truthful speech and truthful action. truthful speech: nurses believed that patients also need verbal truthfulness in attaining ethics-based palliative care. a nurse said, “we try to honestly tell the patients about medicines which cause hair loss in the first session, and we spend time on it, because patients may be shocked after the hair loss. that’s why we pave the way for the patient from the beginning.” [nurse 10] one of the nurses emphasized the importance of not telling lies: “it is said: not to give information to the patients, but i don’t agree. i tell the truth as far as i can because nowadays everyone has access to the internet, and most of the patients are educated, so they can easily surf through the net…. i have to say that we must not tell lies to them.” [nurse 13] truthful action: nurses believed that ethics-based palliative care results from truthful action. one of them said: “all a cancer patient wants is to receive good care. and if we fail to do that and do not work honestly, for example, not give a drug dose to a chemotherapy patient, he has been mistreated, and the nurse must be responsible both in this world and the next, because this action can lessen the life of the patient for one year.” [nurse 9] one of the nurses emphasized the importance of truthfulness in action. she said: “we have patients in the cancer ward who receive especial care; cancer has spread throughout their body and we are almost sure that they will die in 2 or 3 days, but we ethically do not stop giving care and continue to work honestly for their well-being.” [nurse 3] altruism this category emphasizes altruism in ethicsbased palliative care, and is divided into the three sub-categories of complete acceptance, supportive behavior and responsibility. complete and multi-dimensional patient acceptance: one of the important aspects of ethics-based palliative care in altruism is complete acceptance. the nurse understands the patients, and accepts them with their special conditions. this is observed in one participant’s words: “i have accepted that cancer patients have a special condition and agreed to work with such patients. i mean i have been taught to consider all aspects of the patients. so, we accept the patients and their special conditions. if cancer nurses can’t accept these patients and their conditions, how can we expect other people of the society to accept them?” [nurse 5] focusing on services regarding complete acceptance in the patients’ final days, another nurse said: “i have accepted all the conditions in working with cancer patients wholeheartedly. i mean if all nurses pay thorough attention to the patients, we can better serve them.” [nurse 11] supportive behavior: another aspect of ethics-based palliative care that is related to altruism is supportive behavior. the nurse is the listener, advisor and confidante. supportive behavior is defined as the following from the nurses’ viewpoints: “sometimes a cancer patient is in search of a person to talk to, for example, a patient came and talked to me about his problem and asked me for a piece of advice. i can say my colleagues and i play a supportive role for cancer patients. the patients come to us not only as their nurse but also as a sister or a friend and ask for advice. i personally believe that i must protect cancer patients and give them the necessary guidance.” [nurse 9] being a good listener, based on another nurse’s viewpoint, is a sort of supportive behavior in ethical palliative care: “i feel when i listen to patients; they will know that somebody supports them, a person who can be a good listener for their problems. a cancer patient definitely needs support.” [nurse 6] responsibility: another aspect of ethics-based palliative care in altruism is responsibility, which is connected to nurses’ observance of ethical issues. according to one of the nurses, feeling responsible is so important that its absence may cause a sense of guilt: “in this ward, you can perform routine and ordinary work, write reports and then go home, and nobody will know. but if you’re not responsible for what you did for these patients, then what? ethically speaking, it is impossible to simply pass by…. if i don’t feel responsible in my job, i will feel guilty.” [nurse 12] j med ethics hist med 6:12 sep, 2013 jmehm.tums.ac.ir marjan mardani hamooleh et al. page 5 of 8 (page number not for citation purposes) one of the nurses asserted that the physical inability of patients is a stimulus for improving his sense of responsibility: ”you may want to take a short rest in the middle of your job, as is customary in other wards, but here you have to feel more responsible because seeing a physically powerless cancer patient provokes you not to rest and relax.” [nurse 1] discussion findings of this research showed that the nurses believed ethics-based palliative care for cancer patients can be divided into three categories: human dignity, professional truthfulness and altruism. participants believed human dignity to be possible through considerations such as respect for patients, paying attention to their values, and empathy. in this regard, baillie in england found that human dignity is an important concept in nursing which covers all human aspects and makes nurses see the patient as a thorough human. this concept is related to the values and social thinking of the people (17). in this respect, lam stated that the importance of human dignity in the nursing profession is to protect it in ethical codes as a duty and to consider it as a right in human rights framework, and it is the nurse’s responsibility to protect human dignity (18). furthermore, this finding agrees with the statements in the bagheri et al. study that human dignity is a central phenomenon in protecting patients, and is defined as being seen as a human being and respecting yourself and others (19). our findings seem to be in line with the mahmoodi shan et al. results that confirmed respecting patients is among important ethical concepts that should stand out in a nurse’s job (10). since individual expectations related to human dignity are formed based on a person’s viewpoints (20), if patients’ dignity is preserved, they feel more powerful with a positive mental picture (21). participants say that the patient must receive the best care till the last moment. this is in line with aramesh’s view that one of the prerequisites for human dignity is the right to live and die respectfully in the last phases of life (22). the findings of qualitative studies conducted by kvale and bondevik in norway and zagheri et al. in iran indicated that respecting the patient and promoting this respect is of high importance (23, 24). even in the case of aggressive patients, nurses in our study believed in respecting them because they thought that in ethics-based palliative care, it is possible to calm the patients through respecting them. moreover, they believed that palliative care is not just lessening physical pain but respecting patients’ values as a basic component of their human dignity. lacey and sanderson in australia and meran and spath-schwalbe in germany also have mentioned supportive roles such as respecting human dignity in cancer patients (25, 26). nurses believed that empathy has a key role in preserving human dignity in palliative care. they also believed that one must consider the patient as one’s relatives. empathy with the patients, considering them as one’s relatives and walking in their shoes is among important ethical concepts. qualitative studies done by mahmoodi shan et al., jo and doorenbos, and heijkenskjold et al. in iran, korea and england showed that considering the patient as one of your family members helps respect the patient’s dignity (10, 27, 28). empathy with patients is an ethical practice that can accelerate their recovery process (29) and lead to preservation of their dignity (30). despite all the attempts made to preserve human dignity, there are situations that can weaken or threaten human dignity, such as disrespecting patients and not considering them as human beings (27, 28). it seems as if palliative care is mixed with preserving patients’ dignity, and because the nurses in the present study believe in this ethical principle, they take it into consideration. another finding of the study showed that the nurses believed in professional truthfulness in ethics-based palliative care. they considered truthfulness in speech and action to be necessary for nurses, so much so that they believed in giving truthful information to the patients and explaining about the medication. the results of kvale and bondevik’s study in norway emphasized that giving truthful information to the patient is of high importance (23). in situations where telling the truth is vital to make the patient cooperate, although some disadvantages are probable, the truth must be told to suffer the fewest drawbacks (31). nurses believed giving truthful information to the patient may lead to a better confrontation with the illness. although learning that one has cancer is distressing and may initiate unpleasant reactions, giving correct information to the patient can help them better confront the cancer (32). some resistance may be seen upon revealing to the patient that they have cancer, but not telling the truth is disrespecting their rights and is considered deception (33). participants in the study declared that they spent time on giving truthful information to the patients and emphasized the importance of this ethical issue. listening to the patients and getting to know them is the consequence of giving information and makes one sensitive to the patient’s individual needs (34). nurses believed that actions such as not giving medicine to the patient are inconsistence with truthful action. in another study, one of the important ethical implications of the nursing profession was being truthful (10). participants believed even if the patient’s death is imminent, the nurses must continue to act truthfully. however, a study showed that in america, the offered care to dying patients such as cancer patients is not suitable, and some invasive http://www.ncbi.nlm.nih.gov/pubmed?term=kv%c3%a5le%20k%5bauthor%5d&cauthor=true&cauthor_uid=19000089 http://www.ncbi.nlm.nih.gov/pubmed?term=bondevik%20m%5bauthor%5d&cauthor=true&cauthor_uid=19000089 http://www.ncbi.nlm.nih.gov/pubmed?term=lacey%20j%5bauthor%5d&cauthor=true&cauthor_uid=20890152 http://www.ncbi.nlm.nih.gov/pubmed?term=sanderson%20c%5bauthor%5d&cauthor=true&cauthor_uid=20890152 http://www.ncbi.nlm.nih.gov/pubmed?term=meran%20jg%5bauthor%5d&cauthor=true&cauthor_uid=19786818 http://www.ncbi.nlm.nih.gov/pubmed?term=sp%c3%a4th-schwalbe%20e%5bauthor%5d&cauthor=true&cauthor_uid=19786818 http://www.ncbi.nlm.nih.gov/pubmed?term=kv%c3%a5le%20k%5bauthor%5d&cauthor=true&cauthor_uid=19000089 http://www.ncbi.nlm.nih.gov/pubmed?term=bondevik%20m%5bauthor%5d&cauthor=true&cauthor_uid=19000089 j med ethics hist med 6:12 sep, 2013 jmehm.tums.ac.ir marjan mardani hamooleh et al. page 6 of 8 (page number not for citation purposes) interventions are performed that are in vain, and threaten the patient’s quality of life in the remaining years (35). it seems that what makes ethicsbased palliative care more meaningful is that nurses mix their clinical function with a supreme humane concept such as truthfulness. they must try to preserve this ethical attribute and beware of vices such as lying to the patients. nurses’ explanations showed that altruism is one of the major aspects of ethics-based palliative care that is possible through the patient’s complete acceptance, supportive behavior and responsibility. the results of another study in iran showed that caring for patients is done with altruism (36, 37). as the nurses mentioned, they accepted and understood the patients and their special situation. a qualitative research conducted by ohlen et al. in germany also showed that for cancer patients, receiving palliative care is a process of a continual quest for understanding (38). with regard to complete acceptance, the participants pointed to the uniqueness of these patients’ situation. the results of a phenomenological study conducted by valente and teixeira in brazil showed that nurses consider caring for patients as something unique and especial (13). in the researcher’s viewpoint, what propels the participants to completely accept the patient is the essence of the nursing profession that views human beings holistically. nurses offer palliative care while considering this important issue. another finding of the study showed that nurses’ supportive behavior in ethics-based palliative care leads to altruism, in such a way that the patients consider them as their sisters, friends or advisors, as well as good listeners. in fact, palliative care is a basic supportive view of patients (34) as cancer patients need more care compared to other patients (39). the findings of qualitative studies conducted by valizadeh et al., chang and park, and rhondali et al. in iran, korea and the u.s. emphasized that supporting cancer patients is vital as it helps them better deal with their illness (40-42). as nurses in this study focused on supportive behavior, studies conducted in other cultures have verified these findings, too. we can therefore say that from the nurses’ viewpoint, supporting the patient is of great ethical importance in palliative care. another finding of the study showed that nurses consider responsibility as an important component of altruism in ethics-based palliative care. failure to fulfill one’s responsibilities will cause a sense of guilt, as seeing the patients’ inability makes nurses forget their own basic needs such as rest. responsibility is a fundamental concept in nursing that is reinforced through conscientiousness and a lack thereof can hurt the patient. responsibility calms the conscience and neglecting it arouses a sense of guilt (10). studies done in iran and england showed professional responsibility as an important factor in caring (24, 43). one of the factors in palliative care may be that nurses ethically and legally consider themselves responsible for the patients, and believe this responsibility to be very important. despite cultural diversity in the abovementioned studies, the results are almost the same; therefore, paying attention to ethical issues is a basic factor in palliative care that is observed internationally in nursing. what differentiates this basic factor in iranian culture from other cultures is the nature of human relations in the former, in that it considers all human beings as different organs of a single body who share prosperity and sorrow; this is intensified when somebody suffers from a severe illness. consequently, it seems as if the nurses in our study consider themselves as one with the patient. this view leads them to preserve human dignity, professional truthfulness and altruism. it is recommended to explain the ideas of other people involved in caring for patients. this study did not cover general palliative care for cancer patients. it is recommended that in further studies, ethicsbased palliative care be examined separately for cancer patients. conclusion this study depicted only a small portion of the broad world of ethics-based palliative care from the viewpoint of the nurses and showed that ethical concepts have a pivotal role in palliative care. although some concepts derived from this study can have different interpretations, the results showed that nurses care about concepts such as human dignity, professional truthfulness and altruism in ethics-based palliative care, and factors such as respect for patients, paying attention to patients’ values, empathy, truthfulness in speech and in action, supportive behavior, complete acceptance of patients and responsibility are important to nurses. on the other hand, because this is the first qualitative research done on ethicsbased palliative care for cancer patients in iran’s cultural context, the results may reveal some aspects of this kind of care in our society. acknowledgments the authors are grateful to all of the nurses who participated in this study. without their help and cooperation, this research could not have been conducted. this article was submitted as partial fulfillment of the requirements for the first author's phd thesis supported by tehran university of medical sciences. references http://www.ncbi.nlm.nih.gov/pubmed?term=chang%20h%5bauthor%5d&cauthor=true&cauthor_uid=23107511 http://www.ncbi.nlm.nih.gov/pubmed?term=park%20yh%5bauthor%5d&cauthor=true&cauthor_uid=23107511 j med ethics hist med 6:12 sep, 2013 jmehm.tums.ac.ir marjan mardani hamooleh et al. page 7 of 8 (page number not for citation purposes) 1. higginson ij, costantini m. dying with cancer, living well with advanced cancer. eur j cancer 2008; 44(10): 1414-24. 2. daher m. opioids for cancer pain in the middle eastern countries: a physician point of view. j pediatr hematol oncol 2011; 33(suppl 1): s23-8. 3. mousavi sm, gouya mm, ramazani r, dvanlou m, 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http://www.ncbi.nlm.nih.gov/pubmed?term=nikanfar%20ar%5bauthor%5d&cauthor=true&cauthor_uid=22462718 http://www.ncbi.nlm.nih.gov/pubmed?term=ferguson%20c%5bauthor%5d&cauthor=true&cauthor_uid=22462718 http://www.ncbi.nlm.nih.gov/pubmed/22462718 http://www.ncbi.nlm.nih.gov/pubmed?term=chang%20h%5bauthor%5d&cauthor=true&cauthor_uid=23107511 http://www.ncbi.nlm.nih.gov/pubmed?term=park%20yh%5bauthor%5d&cauthor=true&cauthor_uid=23107511 http://www.ncbi.nlm.nih.gov/pubmed/23107511 http://www.ncbi.nlm.nih.gov/pubmed?term=rhondali%20w%5bauthor%5d&cauthor=true&cauthor_uid=23302500 http://www.ncbi.nlm.nih.gov/pubmed?term=burt%20s%5bauthor%5d&cauthor=true&cauthor_uid=23302500 http://www.ncbi.nlm.nih.gov/pubmed?term=wittenberg-lyles%20e%5bauthor%5d&cauthor=true&cauthor_uid=23302500 http://www.ncbi.nlm.nih.gov/pubmed?term=bruera%20e%5bauthor%5d&cauthor=true&cauthor_uid=23302500 http://www.ncbi.nlm.nih.gov/pubmed?term=dalal%20s%5bauthor%5d&cauthor=true&cauthor_uid=23302500 http://www.ncbi.nlm.nih.gov/pubmed/23302500 http://www.ncbi.nlm.nih.gov/pubmed?term=%22walshe%20c%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22todd%20c%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22caress%20al%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22chew-graham%20c%22%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed/18494176 jmehm-9-16_r1_.docx journal of medical ethics and history of medicine review article does medical education erode medical trainees' ethical attitude and behavior? neda yavari phd candidate in medical ethics, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. corresponding author: neda yavari address: 23# 16 azar ave, keshavarz blvd, medical ethics and history of medicine research center, tehran, iran. email: ne.yavari@gmail.com tel/fax: 982166419661 received: 27 sep 2014 accepted: 19 nov 2016 published: 23 nov 2016 j med ethics hist med, 2016, 9:16 © 2016 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract in the last few years, medical education policy makers have expressed concern about changes in the ethical attitude and behavior of medical trainees during the course of their education. they claim that newly graduated physicians (mds) are entering residency years with inappropriate habits and attitudes earned during their education. this allegation has been supported by numerous research on the changes in the attitude and morality of medical trainees. the aim of this paper was to investigate ethical erosion among medical trainees as a serious universal problem, and to urge the authorities to take urgent preventive and corrective action. a comparison with the course of moral development in ordinary people from kohlberg’s and gilligan's points of view reveals that the growth of ethical attitudes and behaviors in medical students is stunted or even degraded in many medical schools. in the end, the article examines the feasibility of teaching ethics in medical schools and the best approach for this purpose. it concludes that there is considerable controversy among ethicists on whether teaching ethical virtues is plausible at all. virtue-based ethics, principle-based ethics and ethics of care are approaches that have been considered as most applicable in this regard. keywords: ethical erosion, medical trainees, medical education mailto:ne.yavari@gmail.com j med ethics hist med 9:16 november, 2016 jmehm.tums.ac.ir neda yavari page 2 of 8 introduction the incentive for this research project was provided by a personal encounter from some years ago, when i was a young intern in a prestigious iranian hospital. after visiting a patient, doing an accurate physical exam and studying her most recent lab results, i proceeded to record my findings in her chart as per my internship duties. the patient was an old obese woman. after a few moments, the ward resident came in and began to study the patient’s chart. while reviewing the chart, he took a degrading look at the patient and used a nickname related to her obesity. i was really mad at the resident and wanted to object to his unethical behavior. however, i found it safer to conceal my anger and save my friendly relationship with the resident at the moment. i was really disappointed at what i did. arguing internally, i remembered the same thing had happened a few years ago, when i was a first-year student. back then, i had voiced my objection to my superior’s unethical behavior, something that i am proud of to this day. contrasting these two experiences, i asked myself what had happened to me during those years? why had i so dramatically lost sensitivity to the ethical aspects of the job? had it happened to my friends too? and more importantly, what is the main culprit and how could we regain our ethical attitude, that moral perspective that encourages one’s commitment to ethical behavior? carole kleinman defines “ethical erosion” as “a gradual erosion of ethical behavior that occurs in individuals below their level of awareness” (1). although some subtle differences exist between this and other scholars’ definitions, most share a focus on gradual changes in medical students’ attitudes and behaviors, changes which present themselves through a halt or regression in moral development during the course of training. some scholars generalize this erosion to moral reasoning as well as ethical sensitivity, commitment and behavior. furthermore, some scholars believe this erosion does not happen unconsciously. unlike kleinman, they claim medical students are both aware of these changes and worried about their character (2). recent studies show that ethical erosion is one of the most challenging bioethical problems throughout the world. in fact, studies from different countries demonstrate the universality of the problem, which is part of its significance (2-4). moreover, due to the deep effect of students’ moral attitudes and behaviors on their characters as future practitioners, ethical erosion among medical trainees is worthy of evaluation. ethical breaches are intrinsically detrimental, and may deeply and sometimes even permanently affect students’ personality and their attitude toward patients, colleagues, and the profession. from the social point of view, loyalty to ethical principles directly aids physicians in practicing medicine. good clinical practice cannot be separated from professional and ethical behavior that is the result of moral maturity. therefore, any flaws in the ethical attitudes and behaviors of today’s students will directly affect their clinical performance as future practitioners and seriously challenge the health care system. jason liebowits elegantly demonstrates the importance of medical students’ morality (5). referring to german physicians’ extensive participation in the holocaust, he attempts to examine the circumstances that turned physicians from healers into accomplices of genocide in this terrible event. he persists in questioning these doctors’ training, looking for factors that turned them into the agents of genocide. the most important questions are probably his last when he asks if medical education potentially paves the way for moral erosion, and if physicians still are vulnerable to losing their ethical principles. he concludes by wondering what can be done to prevent this regression (5). in the same article liebowitz shows the personal and social consequences of disregarding ethical values. he refers to nazi doctors’ cruel behavior toward prisoners and claims that these tragedies happened because of the physicians’ disloyalty to ethical principles. the self-evident principles were gradually but so extensively ignored that, after a while, unethical behaviors turned from unacceptable deeds into norms. the misfortune started when some doctors lost their safeguards against harming patients and justified progressively greater breaches of professional conduct. as a cumulative result of such misbehavior, the medical community reached a point where there was no turning back: they had already transformed from healers to murderers. according to liebowitz, german physicians’ participation in the holocaust demonstrates that inattention to changes in the ethical attitudes and conduct of medical students may result in human tragedies at not only a personal but also a social level (5). another reason for the importance of discussions about ethical erosion among medical trainees lies in the possibility of resolving the problem and preventing its negative consequences through taking corrective action. the problem can be examined from several aspects. in this research, findings of studies from several countries will be presented to demonstrate that ethical erosion is a universal and serious problem among medical trainees. furthermore, the expected course of moral development in ordinary people from kohlberg’s and gilligan’s points of view will be introduced and compared with the moral development of medical students. subsequently, some important ethical approaches will be presented and the advantages and disadvantages of their j med ethics hist med 9:16 november, 2016 jmehm.tums.ac.ir neda yavari page 3 of 8 application to the ethical education of medical students will be discussed. the present study documents the ethical changes in medical students during the course of their education, and can therefore be used to enhance their moral development through preventive and therapeutic intervention programs. materials and methods for the purpose of investigating the changes in medical trainees' ethical attitude and behavior during the course of education, several websites including pub med, ovid and elsevier were examined. in order to validate the results, various resources and published research on the topic were studied as well. the keywords used for this aim were “medical education”, “ethical erosion” and “attitude change”. the hypothesis was that the growth of students’ ethical attitude and behavior is stunted, or even worse, degraded in medical schools throughout the world. results the scope of the problem in medical schools of different countries recent studies point to ethical erosion as a serious problem in medical education in countries such as the united states, the united kingdom, canada and scotland, while the author has seen it first-hand in the middle east as well. this article will examine recently published evidence of medical students’ moral status to show the universality and seriousness of the problem. in a 1989 study by philip hébert at the university of toronto, five clinical vignettes with seven to nine ethical issues each were developed. a randomly selected vignette was given to a first-, secondor third-year student who was asked to report the number of ethical issues in the vignette. each response was scored based on the number of ethical issues identified by the student, regardless of the content of the response. a statistical analysis of 281 responses showed that the second-year class identified the highest average number of issues, which was 3.13. the average numbers were 2.35 for first-year and 2.46 for third-year students. the increased number of identified ethical issues from first year to second year can be attributed to the fact that all of the students participating in this study passed a course on ethics in their first year of medical education (3). one year later, in 1990, hebert and his colleagues conducted a similar study with students in their fourth year. as they had expected, the findings showed a further decrease in ethical sensitivity. in other words, the percentage of issues identified by the subjects increased between the 1st and 2nd year and then decreased throughout the next two years, so that the 4th-year class identified the least number of issues in these vignettes after passing clinical training. it is notable that though the vignettes were slightly different in the two studies, the percentages are remarkably similar (6). these two studies suggest that as medical students progress in the course of their education, they are more likely to lose their sensitivity to ethical problems. in other words, their ability to recognize bioethical dilemmas – as the first step in a logical encounter with these problems – decreases gradually. this regression is considerable particularly after clinical training, and urges us to think about some aspects of clinical training as a probable root for the adverse effect on students’ ethical attitudes and behaviors. a 1992-1993 study by chris feudtner et al. involving 1853 thirdand fourth-year medical students in six pennsylvania medical schools showed that students were aware of and concerned about erosion of their ethical attitudes and behaviors. this study revealed that 67% of the subjects felt guilty about their behaviors, and 62% believed that at least some of their ethical principles had been lessened or lost. furthermore, 58% of the respondents had done something they believed was unethical, 52% had misled a patient during their practice, and 80% reported at least one of the two (2). in 2003 patenaude et al. published the results of studies conducted in canada that suggested a negative trend in students’ ethical growth during medical training. these studies demonstrated either decreased or inhibited development in the moral attitude and behavior of medical trainees (7). in one of these studies, students in quebec were invited to complete a questionnaire on moral reasoning once before their first year of medical school and once after their third. of the 92 entering medical students, 54 completed the questionnaire twice. the moral judgment interview (mji) scale (developed by lawrence kohlberg in 1958) was used to measure the changes in students’ moral reasoning. kohlberg believed that people gradually proceed through sequential stages of moral development, even though the rate of progress and the final stage they reach vary by individuals. after students’ responses were collected, they were coded according to parameters described by colby and kohlberg, and the answers for each question in the questionnaire were ascribed a score varying between 2 and 5. subsequently, the most frequent score was assigned to each respondent as his/her moral development stage, and if two scores had exactly the same frequency, an intermediate score was given. thus, two scores for moral development were attributed to each student for the first and third year of medical school. the students' stages of moral development in their first and third years of medical school were compared and they were divided into 3 groups: group 1: a total of 39 students (72%), who did not show any substantial changes in the stage of moral j med ethics hist med 9:16 november, 2016 jmehm.tums.ac.ir neda yavari page 4 of 8 reasoning from year 1 to year 3 group 2: a total of 8 students (15%), who showed progress in the stage of moral reasoning after 3 years group 3: a total of 7 students (13%), who showed decreases in the stage of moral reasoning (7). as the next step, two weighted average scores were defined for the firstand third-year questionnaires by calculating the average of all scores attributed to different questions in each questionnaire. the conclusion was that the differences in average changes in moral reasoning were not statistically significant. however, the mean changes in weighted average scores significantly declined. in fact, all seven students who had experienced a decrease in stages of moral development, and the 39 students who had undergone no change, showed significant decreases in weighted average scores. therefore, decreases in the weighted average score happened to 45 of 54 students. patenaude et al argue that, similar to some studies in the united states, they did not observe any progress in the development of moral reasoning among canadian students as might be expected. they concludes that the society needs some urgent action to provide students with an educational curriculum that enables them to keep their stage of moral development, if not increase it by medical education (7). recent studies show that a large number of medical students cheat on exams in medical schools (8, 9). in a study in scotland, roff and preece found that about a quarter of medical students had written ‘‘nervous system examination normal’’ in some patients’ notes even when they had not carried out the examinations (4). also, a significant number of residents in a u.s. training program had falsified their credentials when applying for fellowships (10). daniel sulmasy claims that a surprising number of students not only do not maintain their moral virtues, but also adopt some unethical behaviors in order to survive stressful clinical situations (10). the above-mentioned studies show the prevalence and importance of the problem of ethical erosion among medical trainees in several countries around the world. the course of moral development lawrence kohlberg and carol gilligan are two psychologists who have worked on young adults’ moral development. kohlberg classifies three general levels of moral development: preconventional, conventional, and post-conventional (11). he explains that for younger children – who are considered in the pre-conventional stage – “right” is what keeps them from punishment, and they are not able to generalize their findings to other situations. in the conventional stage, that is, later childhood and adolescence, individuals adjust their behaviors based on others’ approval and to exhibit loyalty. they try to fit the society by adopting behaviors that are in line with social norms. at this stage, people have a sense of self and are able to generalize their ethical findings to similar situations. in higher sub-stages of the conventional level, “individuals learn a more abstract understanding of their own roles, obligations, and customs as well as others” (11). the last stage, or the post-conventional level, is characterized by governing one’s behavior through moral principles. kohlberg describes an even higher sub-stage at the post conventional level, one that is achievable for only a limited number of individuals, when “the principles of human dignity and human rights are integrated into the personality and form the basis of a person’s action” (11). medical students and kohlberg’s concept of ‘moral maturity’ students are not all at the same developmental level, and therefore respond differently to the ethical challenges in clinical environments. medical students usually enter the university between the ages of 21 and 24, which is the age when individuals are expected to begin their passage to the postconventional level according to kohlberg’s classification. however, available data suggest that this progress is not fully accomplished in many students, and ethical dilemmas challenge their principles in many cases. as a result, some accept the conventional moral guidelines of the surrounding environment, whereas others express their discomfort at being assimilated into the ethical and social norms and the demands of the clinical climate, and strive to maintain their moral values. the latter group continues its moral development in spite of all adversity. nevertheless, in their descriptions of this conflict, students express concern about possible regression to the lower moral levels (12). as kohlberg suggests and other studies confirm, medical students react to this conflict differently. while many students struggle to accommodate their personal values within the scope of clinical training, others may be pressured to conform to the wards’ culture and give up those personal ethical values that are in contrast with their ability for rapid decisionmaking. however, the moral maturity of the latter is generally recognized as paused or even degraded (12-14). kohlberg describes the transition from the conventional to the post-conventional stage as the development of “moral reasoning”, which he claims to be only one component of ethical behavior. ethical behavior is in fact a combination of moral sensitivity (the ability to recognize ethical problems), moral commitment (a strong intention to do the right thing), moral behavior (skills at implementation), and moral reasoning (the ability to balance others’ rights against the principles at stake (12). in other words, ethical behavior is a combination of moral reasoning, moral sensitivity, moral commitment and moral behavior. the importance of moral reasoning should not impede our attention to those other aspects of ethical behavior. students are confronted in wards with demands for action, and j med ethics hist med 9:16 november, 2016 jmehm.tums.ac.ir neda yavari page 5 of 8 supporting all components of ethical behavior is therefore essential for their moral development (12). carol gilligan worked on kohlberg’s theory later and, unlike him, emphasized “connection, care and response” in moral development. she believes that these factors complete the kohlberg approach by focusing on “equality, justice, and rights”, because emphasizing mere justice as the index of morality results in impartiality and consequent indifference. thus, gilligan argues that caring and justice are both moral focal points and should therefore be promoted as complementary factors (15). branch et al. observed that students are more concerned about hindrances that pose a threat to their compassion and care rather than their reasoning abilities in confrontation with ethical issues. they usually place a high value on openness, sensitivity, and an understanding of patients and their problems. one can say that students generally pay more attention to the caring aspect of their job than their role as members of the clinical team. branch et al. state that caring, as opposed to moral reasoning, continues to remain the most important ethical issue for the typical medical student. thus, promotion of moral reasoning should not be the only goal in bioethical education, and medical students should be equipped with an integrated attitude toward morality (12, 16). is teaching ethics plausible at all? prior to discussing the most effective method for ethical training in medical schools, one needs to answer whether teaching ethics to medical trainees is plausible at all. edmund pellegrino believes that the teachability of virtues has been questioned since plato and socrates. he points out that aristotle's works have suggested a significant method for the development of students’ professional character: providing them with virtuous role models. aristotle states that the best practice for learning virtues is to follow the example of a virtuous person. in medicine, therefore, we need virtuous role models among physicians, as they are highly responsible for the characteristic traits that they exemplify for trainees. pellegrino asserts that even though medical students’ characters have been shaped to a certain extent prior to entering medical schools, they continue to remain impressionable even as they start their careers as physicians (17). thus he argues that “courses in medical ethics, the humanities, human values, etc., can sensitize, raise awareness and force critical reflection about the virtues of the good physician. [ethics] courses introduce students to a body of literature which gives evidence of the importance, depth and complexity of the moral issues commonplace in medical practice” (12). on the other hand, daniel sulmasy speculates whether ethics courses can help produce morally better doctors. simply put, he examines the teachability of virtues. contrary to those who argue that students enter medical schools “already morally packaged and incapable of change” (10), sulmasy believes that ethics courses can indeed be effective, and that it is essential to create a nurturing academic environment in which professional virtues receive real attention. it is possible, he states, to “consciencitize” students and provide them with the knowledge and skills necessary to deal with medical ethics issues. however, sulmasy argues, that these courses cannot change the individuals’ attitudes. as an example, he mentions a physician who has been educated on the principles of obtaining informed consent, but behaves in a disparaging manner that will not be reflected in a consent form. he concludes that teaching virtues can be considered only as a complement to ethical theories, not as a substitute for them (10). unlike sulmasy, william branch examines the data and concludes that changes in students’ attitudes are possible, but may happen in the wrong direction. these studies demonstrate that virtues such as compassion and altruism are unfortunately undermined due to the current trends in medical education (10). discussion many philosophers of ethics agree on the necessity of specialized courses in medical schools in order to minimize ethical erosion in trainees. the next step would be to select from different ethical approaches the best to be taught via the educational curricula in medical schools. in other words, the question is which theories will maximize medical students’ chances of adopting ethical behaviors in complicated situations. virtue-based ethics, principle-based ethics and ethics of care are approaches that have been considered as most applicable in this regard. virtue ethics, which can be followed in western thought to the works of plato and aristotle, emphasizes the character of the agent (18). sulmasy defines virtue as “the critical aspect of ethics that deals with character” (10), and believes this concept should guide medical students become the kinds of doctors they ought to be. he describes medical virtue as all characteristics of a good doctor including scientific competence, compassion, wisdom, courage and patience. a doctor committed to these virtues, in his view, is a trustworthy doctor even when left unsupervised (10). proponents of virtue-based ethics contend that medical students must be trained to perform moral acts because they possess certain virtues such as benevolence or generosity. the next step for the advocates of this approach is to determine which virtues are desirable and how they can be developed (18). scholars have emphasized the effect of virtues in providing the physician with a humane perspective on patients. pellegrino, for instance, claims that the virtue-based doctor is almost incapable of viewing j med ethics hist med 9:16 november, 2016 jmehm.tums.ac.ir neda yavari page 6 of 8 his patient as a “customer, consumer, insured life or any other commercialized, industrialized transformations of the ancient and respectable word ‘patient’. nor could he compromise his personal or professional integrity for political, economic, or social advancement. nor could the virtuous physician become a union member, go on strike, or engage in blatant self-promotion and advertising even though it is sanctioned by law. this would suit the ethics of professionalization but not of a true profession” (17). in a different approach, the deontologist is more concerned about the action to be performed in any given situation (18). lynn jansen believes that virtue ethics promotes medical ethics and can play a significant role in improving students’ moral development. however, when students face a moral conflict or dilemma, this approach does not support them in identifying morally correct actions or behaviors. it only shows whether the action possesses any moral worth or not. in order to adopt the right behavior, students depend on other concepts such as rules, duties and principles. jansen asserts that teaching virtue-based ethics to medical students poses two main problems. first, it is sorely difficult to determine a person’s motivation for taking an action. second, while the ultimate goal of medical education should be to preserve the interests of patients and their families, this approach places more value on the right motivation rather than a patientcentered practice. jansen declares that a good character is important as a means to good conduct, but due to the above-mentioned problems, it is a mistake to apply virtue ethics to medical practice (19). jansen claims that a worthy action has two components: decent motivation and rightness of behavior. the genuine role of virtue-based ethics is to teach medical students to do right things for good reasons. “by training virtuous characters in medical students we prepare them to do morally worthy actions in hard and complicated medical situations, not simply actions that are in line with what they ought to do” (19). principle-based ethics supports the rules or ethical principles that one may follow. this approach does not take into account the personality or intention of individuals. therefore, the right action is defined as the one conducted based on accepted principles (18). bioethicists have made several criticisms of principle-based theory. tom beauchamp and james childress, for example, believe that a pluralistic principle-based theory works best because it emphasizes a number of principles of obligation. in their opinion, single principle methods such as utilitarian ethics (the ethical theory with the aim of providing the most good for the most people) and kantian ethics (a single principle-based deontological model) may not be as effectual. unlike other theories that define a supreme or absolute principle that supports all other action guides in the system, the pluralistic approach offers several nonabsolute (prima facie) principles of equal importance, and entrusts ethical decision-making to the person applying these principles. furthermore, in contrast to utilitarian and kantian theories that rely on pure reason, the pluralistic principle-based theory relies on common sense morality. the principles in turn work as indicators for moral judgment in any particular case. any customary morality is accepted in this system only if it is in good balance with the other rules and principles of the theory. new attitudes and practices are evaluated in terms of compatibility with this theory through john rawls’s process of reflective equilibrium and, if coherent, are considered morally acceptable (20). beauchamp and childress’s principle-based theory defines four principles in the realm of medical ethics: autonomy, beneficence, non-maleficence and justice. critics of this theory assert that these principles are too general and ambiguous to be used as specific action guides. therefore, medical students may experience ambiguity and uncertainty when applying these ethical standards in particular cases. moreover, opponents of this model argue that the reliance of these principles on commonsense morality rather than pure reason, natural law or a special moral sense discredits the principles by creating a kind of ethical relativism. k. danner clouser and bernard gert believe that since each principle has its own logic and life, a number of internal conflicts leading to a kind of relativism are inevitable. they and other critics claim that defined principles in medical ethics at best work as a checklist of points to consider in the face of moral problems. by this critique they deny the value of guiding particular action by applying the pluralistic principle-based theory (20). considering these possible flaws in the pluralistic ethical model, it seems wise not to rely upon it as the only ethical theory to be taught in medical schools. the ethics of care is the next theory that has been widely considered in the moral training of medical students. this theory was derived from gilligan as a response to principle-based ethical theories. contrary to proponents of principle-based theories, gilligan dismisses impartiality or disregard for others’ values in moral reasoning and recommends moral judgment based on situation-attuned insight into each case instead. she encourages sensitivity to others’ needs and applying norms of responsiveness and responsibility in relationships. alisa carse, one of the pioneer advocates of care ethics in medicine, emphasizes the role of emotions in moral discernment and moral reasoning, and stresses that a timely and appropriate communication of the right emotions is a basic characteristic of moral agency (15). acknowledgement of emotions in ethical decision-making has turned care ethics into one of the most popular ethical theories for moral training j med ethics hist med 9:16 november, 2016 jmehm.tums.ac.ir neda yavari page 7 of 8 of medical students. after all, it seems that emotional attunement and sympathetic insight are essential to establishing a humane relationship between physicians and patients. conclusion the studies described here show the prevalence and importance of ethical erosion among medical trainees in several countries around the world. documenting the ethical changes in medical students during the course of their education, this work can be used to guide the moral training of medical students through preventive and therapeutic intervention programs. kohlberg and gilligan define three levels of moral development and believe that usually people develop toward higher levels as they get older. although medical students are often at an age when according to kohlberg and gilligan should progress toward the post-conventional level, available data suggest that this progress is not completed in many students. the challenging nature of ethical dilemmas forces a notable number of students to accept the conventional guidelines of the clinical environment and keeps them from developing their morality toward the expected higher levels. furthermore, there is considerable controversy among ethicists over the plausibility of teaching ethical virtues. william branch believes that in a nurturing environment where professional virtues receive real attention, medical students are able to develop their moral attitude and behavior. he contends that medical students would be able to transition to higher levels of moral development if they were exposed to a morally acceptable educational environment. virtue-based ethics, principle-based ethics and ethics of care are approaches that have been considered as most applicable in this regard. future studies might compare the ethical attitude and behavior of physicians to that of other serviceoriented professions such as lawyers or university professors. such a comparison might shed a more comprehensive light on effective factors in professional education and the corrective practices medicine might adopt. moreover, the studies discussed in this article were limited to medical students, and it is not clear if ethical erosion continues in working physicians or somehow stops when the new doctors take more responsibility as they start practicing medicine. therefore, one interesting subject for further study could investigate the possible changes in ethical attitude and behavior after residency. j med ethics hist med 9:16 november, 2016 jmehm.tums.ac.ir neda yavari page 8 of 8 references 1. kleinman cs. ethical drift: when good people do bad things. jonas healthc law ethics regul 2006; 8(3): 72–6. 2. feudtner c, christakis da, christakis na. do clinical clerks suffer ethical erosion? students' perceptions of their ethical environment and personal development. acad med 1994; 69(8): 670-9. 3. hebert p, meslin em, dunn ev, byrne n, reid r. evaluating ethical sensitivity in medical students: using vignettes as an instrument. j med ethics 1990; 16: 141-5. 4. roff s, preece p. helping medical students to find their moral compasses: ethics teaching for second and third year undergraduates. j med ethics 2004; 30(5): 487–9. 5. liebowitz j. moral erosion: how can medical professionals safeguard against slippery slope? med humanit 2011; 37(1): 53-5. 6. hebert pc, meslin em, dunn ev. measuring the ethical sensitivity of medical students: a study at the university of toronto. j med ethics 1992; 18(3): 142–7. 7. patenaude j, niyonsenga t, fafard d. changes in students' moral development during medical school: a cohort study. cmaj 2003; 168(7): 840-4. 8. baldwin dc jr, daugherty sr, rowley bd, schwarz md. cheating in medical school: a survey of second-year students at 31 schools. acad med 1996; 71: 267–73. 9. dans pe. self-reported cheating by students at one medical school. acad med 1996; 71(suppl): s70–2. 10. sulmasy dp. should medical schools be the school of virtue? j gen intern med 2000; 15(7): 514–6. 11. kohlberg l. stages and aging in moral developmentsome speculations. gerontologist 1973; 13(4): 497-502. 12. branch wt jr. supporting the moral development of medical students. j gen intern med 2000; 15(7): 503–8. 13. branch w, pels rj, lawrence rs, arky r. becoming a doctor: critical-incident reports from third-year medical students. n engl j med 1993; 329(15): 1130-2. 14. feudtner c, christakis da. making the rounds. the ethical development of medical students in the context of clinical rotations. hastings cent rep 1994; 24(1): 6–12. 15. carse al. the “voice of care”: implications for bioethical education". j med philos 1991; 16(1): 5-28. 16. branch wt jr, pels rj, hafler jp. medical students development of empathic understanding of their patients. acad med 1998; 73(4): 360-2. 17. pellegrino ed. professionalism, profession and the virtues of the good physician. mt sinai j med 2002; 69(6): 378-84. 18. lebreton c. virtue ethics and the medicine of the spirit. (2010) https://www.e-ostadelahi.com/eoe-en/virtue-ethics-andmedicine/ (accessed in 2016) 19. jansen la. the virtues in their place: virtue ethics in medicine. theor med bioeth 2000; 21(3): 261-76. 20. jecker ans, jonsen ar, pearlman ra. bioethics, an introduction to the history, methods, and practice. jones & bartlett publisher international; 1997, p. 141-146. https://www.e-ostadelahi.com/eoe-en/virtue-ethics-and ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ 1 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e case report volume 13 (suppl.) number 27 december 2020 copyright © 2020 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. confidentiality challenges surrounding plasma therapy during the covid-19 pandemic: a case discussion in iran *corresponding author mina froozandeh medical ethics department, no. 346, second floor, school of medicine, iran university of medical sciences, tehran, iran. tel: (+98) 21 86 70 33 46 email: foruzandeh.m@iums.ac.ir received: 25 oct 2020 accepted: 1 nov 2020 published: 21 dec 2020 citation to this article: saeedi tehrani s, hashemi a, madani m, forouzandeh m. confidentiality challenges surrounding plasma therapy during the covid-19 pandemic: a case discussion in iran. j med ethics hist med. 2020; 13(suppl.): 27. saeedeh saeedi tehrani1, akram hashemi1, mansureh madani2, mina forouzandeh1* 1.assistant professor, department of medical ethics, school of medicine, iran university of medical sciences, tehran, iran. 2.researcher, phd in medical ethics. abstract maintaining confidentiality, both in national and international codes of ethics, is considered an important principle in healthcare and the medical profession for both patients and physicians. this case-report article focused on a real case. based on the request of the iranian blood transfusion organization (ibto) for plasma donation from recovered covid-19 patients, we asked the names and personal information of those patients from hospitals affiliated with iran university of medical sciences (iums) and arranged for the subjects to be referred to the medical ethics department of iums for consultation during the covid-19 pandemic. various ethical and legal aspects of this case were discussed in a special meeting, and practical solutions were then provided considering the limits of confidentiality and conditions for ethical access to patients’ information during a pandemic. since plasma therapy is not a definitive cure for covid-19 and considering the ethical and legal points presented in this article, it is not recommended to announce the names of patients in the early stages. given the potential impacts of the procedure and the possibility of patients being cured, however, their consent should be obtained in different situations and, if necessary, providing information to patients or educating them should be considered. keywords: confidentiality; confidentiality breach; covid 19; plasma therapy. confidentiality challenges surrounding plasma therapy during … 2 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 27 december 2020 case introduction to conduct research and provide treatment using plasma therapy, the iranian blood transfusion organization (ibto) requested the names and personal information of the recovered covid-19 patients from hospitals affiliated with iums. the ibto also asked the ethics authorities of the university to propose the best ethical way to obtain information, given the existing laws and instructions and the current conditions and needs. moreover, hospital authorities consulted the medical ethics experts in iums about the ethical aspects of the request. introduction in the medical and health-care system, patient confidentiality and privacy of personal data is among the fundamentals of therapeutic relationships and professional ethics. confidentiality of medical information, a significant aspect of the doctor-patient relationship, has a long history in medical ethics from the hippocratic oath to the current codes of professional conduct (1). muhammad ibn zakariya al-razi, an iranian physician, also stated in his treatise that doctors, as confidants, must keep patients’ secrets. in iran (as in other parts of the world), at the time of graduation from medical schools, medical students take an oath and declare, “i swear by god almighty, the holy quran and my conscience that i will never reveal patients’ secrets” (2). furthermore, maintaining confidentiality is a prominent ethical virtue emphasized in islamic ethics. according to imam sajjad (pbh) and imam sadegh (pbh), failure to maintain confidentiality is a moral vice that can violate others’ rights, and breach of confidentiality can adversely affect all human interactions (3). the four common principles of medical ethics are beneficence, non-maleficence, respect for autonomy, and justice, and the obligation to maintain patient confidentiality is justified by the first three principles (4, 5). respect for autonomy means that patients should be free to make decisions about their issues and problems, including choosing a confidant to keep their personal secrets. with regard to confidentiality, the principle of nonmaleficence requires physicians to avoid disclosing patients' information. furthermore, breach of confidentiality can damage the doctor-patient relationship and patients’ trust in doctors, as well as the society’s faith in the medical and health-care community over time. the principle of beneficence seeks to provide maximum benefit to patients. hence, patients should be able to disclose all relevant information to their doctors with confidence so that the doctors can use the patients’ entire information and history to correctly diagnose and treat their condition. therefore, patients as well as the medical and health-care community should have protection against the consequences of saeedi tehrani s., et al. 3 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 27 december 2020 disclosure of confidential information. according to the abovementioned principles, the necessity of maintaining confidentiality is obvious to physicians, and they should make their maximum effort in this regard. preservation of human dignity is a significant ethical principle that should be considered in all human actions and behaviors. furthermore, due to the special nature of the doctor-patient relationship (patients need to trust their doctors to express their pain and suffering), doctors are required to be highly sensitive to confidentiality as a fundamental principle in doctor-patient interactions. the concept of “secret” in the medical and health-care field in health-care providers’ interactions with patients, the following information is considered as secret: (i) all information revealed by patients to doctors for correct diagnosis and treatment, and (ii) information that health-care providers accidentally obtain while delivering patient care (6). during the diagnosis or treatment process, information from patients' private life, including their physical and mental states, is provided to the medical and health-care team members. part of this information is so private that even people close to the patient are not aware of it, despite knowing the patient or cohabiting with him/her for many years. however, physicians have access to this information because of their professional circumstances (7). if such information is disclosed or made public, a group of individuals may face stigma or discrimination. therefore, various philosophical reasons make maintaining confidentiality imperative in the medical and health-care system including respecting patient's autonomy and avoiding damage to the doctor-patient relationship, which is founded on trust. confidentiality forum, legal perspective and international laws in most guidelines and codes of medical ethics, confidentiality is highlighted, and in some countries, enacted as laws such as the health insurance portability and accountability act of 1996 (hipaa) (8). in the united kingdom, breach of confidentiality is only permitted with the patient’s consent, in response to court orders, or in case of certain public interest requirements. in the united states (9), regulations allow hospitals to provide the patient's information to insurance companies and relevant organizations without the patient's written permission if that information is directly related to health service provision. the personal information protection and electronic documents act (pipeda) in canada and the european union privacy directive in european countries support data privacy and protection (10 12). the laws in iran article 648 of the islamic penal code stipulates, “health-care staff are confidants and secret keepers. with the exception of legal cases, if personal secrets are disclosed, confidentiality challenges surrounding plasma therapy during … 4 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 27 december 2020 the liable staff member is sentenced to the stated punishment”. according to article 106 of the penal code, doctors are responsible for keeping patients' secrets due to the nature of their profession. in cases other than those required by the law, if doctors violate confidentiality, they are sentenced to lashes, imprisonment and fines. article 19 of the law regarding the prevention of communicable and infectious diseases, approved in 1941 and amended in 1968, obliges doctors to inform the ministry of health and medical education immediately when observing one of the following infectious diseases: cholera, plague, yellow fever, typhoid, exanthematous typhus, smallpox, scarlet fever, rubella, diphtheria, dysentery, malaria, polio and plague. in addition, if pertussis, leprosy, rubella, tuberculosis, pneumonia, trachoma, typhoid dermatitis, chickenpox, viral hepatitis or food poisoning is found in denselypopulated centers (e.g., schools, factories, etc.), the doctor in charge must report it to the local health department (13). according to article 3 of the law on the prevention of infectious and sexually transmitted diseases, approved in 1941, all physicians who treat sexually transmitted diseases are required to store relevant information and keep such information safe (13). according to article 1 of the law on compulsory registration and reporting of cancer, approved in 1984, to study and research epidemiological cancer diseases, if relevant institutions, in sampling from the human body for diagnosis and treatment, encounter cancer or suspected cases, they must send the test results confidentially to the ministry of health’s designated centers (14). furthermore, in articles 76 to 80 of section 7 of the general guide to the professional ethics of medical professionals and affiliates of the medical council of the islamic republic of iran, the necessity of maintaining confidentiality is highlighted, and disclosure of information is subject to the request of a court or a written legal article (15). ethical conflicts in maintaining confidentiality as mentioned above, the aim of confidentiality is to maintain patient’s autonomy and respect for human dignity; it also is in line with the principles of bioethics: autonomy, nonmaleficence, beneficence, and justice. however, what approach should we take if fulfilling one principle is at the cost of dismissing other principles, or if fulfilling any of these principles for one patient leads to other people losing them? for example, when benefiting a patient is in conflict with benefiting a larger group of people or maximizing profits for others, or preventing harm to a patient is in conflict with protecting another person or a group of people in the community from harm. as another instance, respect for autonomy or dignity of one patient may be in conflict with respect for autonomy or dignity of others. such questions indicate that confidentiality is not absolute and has exceptions that need to be addressed per case (16). saeedi tehrani s., et al. 5 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 27 december 2020 therefore, since medical confidentiality is not absolute, doctors are allowed and even obliged to disclose patients' private health information under several conditions: (i) in case of patient’s awareness and consent to release information; (ii) to prevent harm to the patient or others (e.g., when one’s health or life is danger); and, (iii) to meet legal requirements or in response to court orders (17). for breach of confidentiality, the following conditions must be met: (i) the danger must be definite, serious and imminent; (ii) disclosure is the only way to prevent harm to the third person; (iii) the damage caused by disclosure is insignificant and tolerable; and, (iv) disclosure must only be made to the responsible authorities or people at risk and in the minimum amount required (18). method the reported case was considered as an ethical challenge. in a two-hour group meeting of the medical faculty of iums, various aspects of the reported case were thoroughly discussed, and different viewpoints were expressed. using the gathered data based on the ethical decisionmaking model and the four principles of bioethics, practical and logical solutions were presented for the raised problems considering the current conditions of the society during the covid-19 pandemic. discussion in the reported case, respect for human autonomy and dignity require that people have the right to control and manage their personal information. furthermore, respecting patient’s autonomy is an ethical principle in heath, treatment and care. hence, if patients do not wish to disclose personal information, medical and health officials are not allowed to breach confidentiality unless under several conditions: (i) legal requirements: the clauses and legal provisions in iran do not apply to the reported case, that is, covid-19 cannot be regarded in accordance with the existing legal prose. it should also be noted that from a legal standpoint, disclosure of information is allowed only to the relevant official mentioned. (ii) patient’s consent: because prior consent to participation in research had not been obtained in the reported case, disclosure of information was not possible without obtaining the recovered patients’ consent and their willingness to volunteer for participation. (iii) danger of harm to a third person: currently, covid-19 does not have a standard and definitive cure, and various studies are still evaluating treatment options. therefore, plasma therapy is considered neither a standard and definitive treatment nor the only method to save patients’ lives according to the confidentiality challenges surrounding plasma therapy during … 6 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 27 december 2020 available scientific documents. therefore, recovered covid-19 patients’ refusal to donate their plasma would not pose a definite danger to other patients’ lives. consequently, in the reported case, abandoning the act (not saving lives) does not cause definite harm to patients, and hence the recovered covid-19 patients cannot be forced to donate plasma. despite the abovementioned arguments, scientific research may prove in the near future that plasma therapy is definitely effective in treating covid-19; in fact, some articles have mentioned that it may be, as it has been used to improve patients’ survival rate in the case of sars, the 2009 influenza a (h1n1) pandemic, the avian influenza a (h5n1) pandemic, ebola, mers, and other viral infections (19 24). hence, given the sanctity of life and the exigency of saving lives, considering the potential benefits of plasma therapy is a sensible choice. from an ethical perspective, it should be discussed whether human beings have a duty to take a course of action that will probably benefit others. according to various moral schools of thought, both minimalistic and maximalistic, no human being should have to bring a probable benefit to others. instead, they unanimously emphasize not harming others. for example, for patients with rare blood types in dire need of blood, hospitals cannot receive information from the ibto without donors’ initial consent, and they usually adopt other solutions. in such cases, a request to donate is made to the patients’ family members who have the same blood type, or to the ibto's blood donors who expressed their consent to be contacted in special circumstances. islam emphasizes human life preservation so strictly that in shiite jurisprudence, if survival is exclusively dependent on committing an act that is not allowed (haram), that act becomes obligatory (25). with similar emphasis, if human life is dependent on usurpation of another person’s property, usurpation will be permissible and even obligatory. for example, food, medicine or sutures can be taken by force from those who own them and do not need them, but refuse to give them to persons in need (26). however, such actions are allowed if they are the only way to save human life, are definitely effective in saving life, and do not harm the owners’ lives. in the reported case, the plasma method has not yet been proven effective in treatment of covid-19, and in terms of effectiveness is equal to other suggested methods, and no more. in this case, as mentioned before, disclosing patients' private health information and transforming data to ibto are not recommended based on ethical, legal and islamic principles. conclusion during the covid-19 pandemic, the iranian blood transfusion organization (ibto) requested the information of the recovered covid-19 patients from several saeedi tehrani s., et al. 7 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 27 december 2020 hospitals for plasma therapy and related research. based on the above ethical arguments and legal considerations, providing such information to the relevant organization is not recommended. however, during the covid-19 crisis, the interest of the society should also be considered. to manage the ethical challenges during the covid-19 pandemic, practical solutions and provisions should be sought to achieve maximum benefit and dismiss potential loss, which mainly revolve around different methods of obtaining consent. although plasma therapy is still in the research phase and is not a definitive cure for covid-19, ongoing studies may prove its effectiveness in the near future. therefore, various practical solutions can be proposed to resolve the abovementioned issues. clearly, it is necessary to find solutions that will provide the conditions for acquiring sufficient volunteers to donate plasma without disclosing patients' secrets. some of these solutions are briefly mentioned in table 1, and can be divided into two groups. the first group aims to provide therapists with the necessary information or training to justify the importance of confidentiality and patient information management methods; the second group comprises policy-making for public culture, media education, and the definition of an appropriate consent process. for example, plasma therapy can be discussed before admitting patients to the hospital or even before their release from the hospital to obtain their informed consent for research. if the initial consent has not been obtained, calling for volunteers or advertisements in various forms and communities could be used to raise awareness and attract participation. such measures would both prevent the risk of losing the trust of individuals due to breach of confidentiality and encourage participation of the recovered covid-19 individuals to save other patients’ lives. finally, regarding the advisory action taken by the relevant organization with the relevant ethics experts, the following solutions have been suggested to resolve the issue. the proposed operational solutions:  informed consent regarding plasma donation should be obtained from patients upon arrival or discharge from the hospital.  necessary information should be given to hospital patients to contact ibto themselves.  hospitals can directly contact patients to obtain permission regarding plasma donation.  voluntary participation in plasma donation programs should be announced publicly in central hospitals. a public call for voluntary participation of recovered patients in plasma donation programs should be announced and advertised. confidentiality challenges surrounding plasma therapy during … 8 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 27 december 2020 table 1proposed solutions for maintaining confidentiality during the covid-19 pandemic policy making and management education and raising awareness  developing culture at the macro level of the society and raising awareness  calling for volunteers and advertisement in various forms and communities  developing a suitable protocol to obtain informed consent upon patients’ diagnosis and admission  offering education through mass media to raise public awareness and understanding of the benefits of plasma donation for the community  educating the medical and health-care staff about patient information management  raising awareness regarding the consequences of mismanaging patient information  teaching physicians and patients how to manage patient information and maintain confidentiality in interactions with the mass media  raising the ethical sensitivity of physicians, especially regarding the consequences of inappropriate information disclosure for the profession  raising awareness regarding the benefits of maintaining patient confidentiality both to patients and the community acknowledgments the authors would like to express their appreciation to the department of medical ethics, school of medicine of iran university of medical sciences. conflict of interests none. saeedi tehrani s., et al. 9 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 27 december 2020 references 1. imran m, samad s, maaz m, qadeer a, najmi ak, aqil m. hippocratic oath and conversion of ethico-regulatory aspects onto doctors as a physician, private individual and a clinical investigator. j midlife health. 2013; 4(4): 203-209. 2. ryan cj, callaghan s, large mm. communication, confidentiality and consent in mental health care. med j aust. 2014; 200(1): 9. 3. tavaokkoli sn, nejadsarvari n, ebrahimi a. analysis of medical confidentiality from the islamic ethics perspective. j relig health. 2015; 54(2): 427-34. 4. page k. the four principles: can they be measured and do they predict ethical decision making? bmc med ethics. 2012; 13: 10. 5. saeedi tehrani s, madani m. bioethical principles and medical futility. medical ethics and history of medicine. 2015; 7(6) :1-14. [in persian] 6. asemani o, ebrahimi s. medical confidentiality. medical ethics and history of medicine. 2014; 6(6): 64-76. [in persian] 7. sankar p, mora s, merz jf, jones nl. patient perspectives on medical confidentiality: a review of the literature. j gen intern med. 2003;18(8): 659-69. 8. hardiman m, edwards t. clarifying the confusion about hipaa-compliant texting. [cited 2020 december]; available from: https://www.perfectserve.com/whitepapers/hipaa-complianttexting/ 9. josefson d. new rules announced on confidentiality of us patient records. bmj. 2002; 325(7361): 408 10. gershon as, tu jv. the effect of privacy legislation on observational research. cmaj. 2008; 178(7): 871-3. 11. anonymous. the personal information protection and electronic documents act (pipeda). [cited 2020 december]; available: https://www.priv.gc.ca/en/privacy-topics/privacy-laws-incanada/the-personal-information-protection-and-electronic-documents-act-pipeda/ 12. thorogood a. canada: will privacy rules continue to favour open science? hum genet. 2018; 137(8): 595-602. 13. milanifar a, larijani b, paykarzadeh p, ashtari g, akhondi mm. breaching confidentiality: medical mandatory reporting laws in iran. j med ethics hist med. 2014; 7: 13. 14. etemadi a, sadjadi a, semnani s, nouraie sm, khademi h, bahadori m. cancer registry in iran: a brief overview. arch iran med. 2008; 11(5): 577-80. 15. noroozi m, zahedi l, bathaei fs, salari p. challenges of confidentiality in clinical settings: compilation of an ethical guideline. iran j public health. 2018; 47(6): 875-83. 16. nazari tavakoli s, nejadsarvari n. confidentiality: a comparative study between medical ethics principles and islamic ethics. medical ethics and history of medicine. 2013; 5(7): 40-54. [in persian] 17. yarmohammadian mh, raeisi ar, tavakoli n, nansa lg. medical record information disclosure laws and policies among selected countries; a comparative study. j res med sci. 2010; 15(3): 140-9. 18. kadivar m, jannat makan z. moral dilemmas and realistic vision in the field of health with regard to confidentiality. medical ethics and history of medicine. 2014; 6(6): 56-63. [in persian] 19. salazar e, perez kk, ashraf m, et al. treatment of coronavirus disease 2019 (covid-19) patients with convalescent plasma. am j pathol. 2020; 190(8): 1680-90. 20. salazar e, christensen pa, graviss ea, et al. treatment of coronavirus disease 2019 patients with convalescent plasma reveals a signal of significantly decreased mortality. am j pathol. 2020; 190(11): 2290-303. confidentiality challenges surrounding plasma therapy during … 10 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 27 december 2020 21. hung ifn, to kkw, lee ck, et al. hyperimmune iv immunoglobulin treatment: a multicenter double-blind randomized controlled trial for patients with severe 2009 influenza a(h1n1) infection. chest. 2013; 144(2): 464–73. 22. stockman lj, bellamy r, garner p. sars: systematic review of treatment effects. plos med. 2006; 3(9): e343. 23. cheraghali a m, abolghasemi h, eshghi p. management of covid-19 virus infection by convalescent plasma. iran j allergy asthma immunol. 2020; 19(s1):3-6. 24. wooding dj, bach h. treatment of covid-19 with convalescent plasma: lessons from past coronavirus outbreaks. clinical microbiology and infection. 2020; 26(10): 1436-46. 25. islam a, rafiq s, karim s, laher i, rashid h. convalescent plasma therapy in the treatment of covid-19: practical considerations: correspondence. int j surg. 2020; 79: 204-5. 26. madani m. ethical considerations of futile care. medical ethics and history of medicine. 2013; 6(2): 31-42. [in persian] ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ original article copyright © 2021 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e the role of narrative medicine program in promoting professional ethics: perceptions of iranian medical students *corresponding author nikoo yamani address: medical education research center, medical education development center, isfahan university of medical sciences, hezar jarib ave., isfahan, iran. postal code: 81746-73461 tel: (+98) 31 36 68 87 89 email: yamani@edc.mui.ac.ir received: 16 feb 2021 accepted: 1 nov 2021 published: 6 dec 2021 citation to this article: daryazadeh s, adibi p, yamani n. the role of narrative medicine program in promoting professional ethics: perceptions of iranian medical students. j med ethics hist med. 2021; 14: 21. saeideh daryazadeh1, payman adibi2, nikoo yamani3* 1.researcher, medical education research center, isfahan university of medical sciences, isfahan, iran. 2.professor, gastroenterology research center, isfahan university of medical sciences, isfahan, iran. 3.professor, medical education research center, isfahan university of medical sciences, isfahan, iran. abstract narrative medicine (nm) is an educational tool that can be used to promote the professional competencies of medical students. this study aimed to investigate iranian medical students’ perceptions of the first nm program offered in 2019. the study was conducted on 69 medical interns who participated in the weekly nm program that was part of the professional ethics course for two months. we used a questionnaire to determine medical interns' perceptions and personal attitudes toward nm. three experts confirmed the validity of the questionnaire in persian, and its reliability was verified by internal consistency (α = 0.879). the independent t-test was used to compare the differences in the total scores of students' perceptions. data analysis was conducted using spss 23 software (p < 0.05). the response rate to the questionnaire was 95.65%. the results showed overall students' perceptions of the program were found to be positive. furthermore, the scores showed a significant difference in terms of gender (p = 0.014), but none in terms of marital status (p = 0.936). according to the results, nm was effective in improving students’ reflections and their empathy with patients. therefore, it is recommended to include nm in professional ethics education. keywords: narrative medicine; empathy; professional ethics. the role of narrative medicine program in promoting professional ethics … 2 j med ethics hist med. 2021(december); 14:21. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e introduction one way to enhance understanding and the interactions between patients and doctors or other health-care professionals is interdisciplinary medical education through combining art and literature (1). many universities have used a narrative approach to teach humanities, with the goal of helping medical students to understand the concerns and illnesses of patients (2). narrative medicine (nm) makes it possible to comprehend the relationship between doctors and patients and assists physicians in identifying, analyzing and solving others' difficulties. moreover, nm can increase trust and understanding while helping doctors to recognize the dilemmas people encounter. reading, writing and listening to narratives through reflective exercise can develop narrative skill and reflective capacity, which promotes perception and recognition in medicine (3). the importance of nm is strongly emphasized, because its goals are in line with two of the core competencies endorsed by the accreditation council for graduate medical education, that is, "professionalism”, and “interpersonal and communication skills". therefore, in order to gain professional competencies, it is necessary to include this approach in the curriculum (4, 5). effective communication between physicians and patients, associates and the community will foster empathy and therefore promote more suitable clinical care (3). a review of the literature shows that empathy can be enhanced through education, and nm is one method to improve reflective capacity and empathy (6, 7). moreover, nm as an educational intervention can enhance students' narrative competence and help them to make better treatment decisions (2, 8). to investigate the impact of nm on learners' affective domain, the results of a comprehensive study showed that the use of narratives improves communication skills and promotes empathy and medical ethics in students (9, 10). numerous studies have investigated the effects of the nm program (6, 11-16). for example, in iran, a narrative medicine program was offered for medical students and it was shown to be effective in promoting reflection and empathy (12). although the importance of perceptions has been investigated in different cultures (for instance in western and chinese medicine), it is necessary to explore other cultures’ acceptance for optimal use of the program (3, 17). so far, no study has examined learners' perceptions of nm in iran. due to the novelty of using the narrative approach in this context, this study was conducted to determine iranian medical students’ perceptions of the nm program as a means to promote professional ethics. methods this was a quantitative and cross-sectional study to assess the nm program offered as an educational intervention in isfahan university of medical sciences in iran for the first time (12). the study was performed to identify medical daryazadeh s., et al. 3 j med ethics hist med. 2021(december); 14: 21. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e interns’ perceptions of the nm program. the subjects participated in the nm program as part of the professional ethics course. this program was presented in weekly sessions for two months with the purpose of improving communication with patients, reflection and empathy (12). this twomonth course was intended to include theory classes for interns in the internal medicine department. we considered the department of internal medicine and the selected medical interns as the target group for the first implementation of the nm program. the research sample included medical interns of the internal medicine department selected during the study period using the census method. sixty-nine medical interns participated in the nm program and a total of 66 participants completed the questionnaire. due to the fact that nm was offered as part of the professional ethics training course for medical interns, the internal medicine department was chosen for educational intervention. practicing narrative writing and reflection training sessions were conducted in 5 small groups by trained clinical teachers. the focus of these meetings was on writing reflective narratives with the theme of empathy. the clinical teacher and narrative analyst in each small group gave the students feedback on their reflective narratives. this program was first introduced in isfahan university of medical sciences and it was necessary to evaluate the learners' perceptions and reactions to the program. for this purpose, we asked the subjects to complete the ten-item self-reported questionnaire about their perceptions of nm at the end of the program. this questionnaire was made available to all interns who participated in the program, but its completion was optional. in order to determine students' perceptions of nm, we used a 10-item questionnaire with 5-point likert scale responses (completely disagree to completely agree) designed by chen et al, to examine healthcare providers’ perceptions of nm. this tool was developed to examine the two domains of "perceptions" and "personal attitudes" with regard to the program (6). the face and content validity of the questionnaire were confirmed, and its reliability was verified by measuring internal consistency and cronbach’s alpha, which was reported to be 0.934 (3). in order to use this ten-item questionnaire in our study, in addition to mentioning it in the references, we asked permission from one of the authors of the article too (3). first, we translated the questionnaire into persian and then had the persian version translated back into english by an english translator. the two english versions were compared and showed an accurate match. finally, the persian version of the questionnaire was confirmed. the face and content validity of the questionnaire were confirmed by three specialists in medical education, and its reliability was verified by measuring internal consistency. statistical analysis frequency, percentage, standard deviation the role of narrative medicine program in promoting professional ethics … 4 j med ethics hist med. 2021(december); 14:21. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e and the mean values of descriptive data were obtained. the reliability of the test tool was measured by internal consistency and through cronbach's alpha coefficient. the independent t-test was used to compare the differences in the total scores of students' perceptions considering their gender and marital status. data analysis was conducted using spss 23 (ibm, armonk, ny, usa) and statistical significance was set at p < 0.05. result sixty-six medical interns completed the questionnaire (response rate = 95.65%). the age of the participants ranged from 23 to 28 years (24.97 ± 0.98). other demographic characteristics are listed in table 1. table 1demographic characteristics of medical interns (n = 66) characteristics n percent (%) gender male 35 53.0 female 31 47.0 marital status single 47 71.2 married 19 28.8 cronbach’s alpha coefficient of the questionnaire was measured at 0.879 for the persian version. the frequency of medical students' perceptions of the nm program for each item of the questionnaire is reported in table 2. the results in the two domains of the questionnaire is presented below. perceptions six items in the domain related to participants’ perceptions were identified. reviewing the frequency of students' responses to each questionnaire item showed that almost all participants in this study (98.5%) believed that nm is effective in improving empathy, and many also believed that reflection (97%) and communication skills (89.4%) can be improved through nm. although more than 50% of students agreed on the necessity of nm in medical care and its role in reducing stress and anxiety, some other participants doubted its effectiveness. table 2medical interns’ perceptions of narrative medicine (n = 66) domain item n (%) completely-disagree and disagree no idea completely-agree and agree perceptions nm* soothes my grief while i am providing medical care. 4 (6.1) 25 (37.9) 37 (56.1) nm relieves the pressure while i am offering medical care. 4 (6.1) 11 (16.7) 51 (77.3) nm is necessary for medical care. 2 (3.0) 22 (33.3) 42 (63.7) nm is useful for physician-patient communication. 1 (1.5) 6 (9.1) 59 (89.4) nm is useful for reflection. 0 2 (3.0) 64 (97) nm is useful in improving empathy. 0 1 (1.5) 65 (98.5) personal attitudes i will continue to use narrative writing in my future practice. 6 (9.1) 19 (28.8) 41 (62.1) i am interested in nm. 3 (4.5) 16 (24.2) 47 (71.2) i will inform my colleagues about the principles of nm. 2 (3.0) 10 (15.2) 54 (81.8) generally, i have a good feeling about nm. 0 5 (7.6) 61 (95.2) *nm: narrative medicine daryazadeh s., et al. 5 j med ethics hist med. 2021(december); 14: 21. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e personal attitudes four items in the questionnaire were related to personal attitudes. many participants (95.2%) stated that they had a good feeling about nm, and a large number (81.8%) stated that they would share the concepts of nm with their colleagues. furthermore, although a large number of participants (71.2%) stated that they were interested in nm, some (9.1%) mentioned that they would not use this approach in the future and would not continue the narrative writing. also, the overall scores of medical students' perceptions were compared considering their gender and marital status. the comparison of the scores of students' perceptions of nm showed a significant difference in terms of gender because the mean score of females was higher than male students. however, there was no significant difference in students’ perception of nm in terms of marital status (table 3). table 3comparison of students' perceptions of gender and marital status (n = 66) demographic factors n (%) perceptions independent samples t-test mean std. deviation minimum maximum t df p gender male 35 (53.0) 39.46 5.736 27.00 50.00 2.539 64 0.014 female 31 (47.0) 42.58 3.973 28.00 50.00 marital status single 47 (71.2) 40.96 5.473 27.00 50.00 .081 64 0.936 married 19 (28.8) 40.84 4.561 28.00 50.00 discussion the purpose of this study was to investigate iranian medical students’ perceptions of the nm program. the results of this study showed that in general, medical students had high or medium perceptions of the nm program, and their overall perceptions was found to be positive. our findings showed that the mean score of female students was higher than male students and that there was a significant difference between the two groups. therefore, it can be stated that females have a more positive personal attitude to the nm program and show more acceptance. however, there was no significant difference between the mean scores of single and married students, so it can be stated that marital status was not a determining factor in perceptions of the nm program. previous studies have reported nm to be useful in engaging physicians and reflecting on patients' stories and clinical experiences through narrative writing. from the viewpoint of medical students, nm is also an effective tool for explaining cultural differences and enhancing interactions to improve interpersonal communication, collaboration and professional development (3, 4, 18). moreover, in arntfield et al, study, medical students reported that narrative is an important means for the role of narrative medicine program in promoting professional ethics … 6 j med ethics hist med. 2021(december); 14:21. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e improving communication skills, interpersonal collaboration and professionalism (4). in charon et al, study, learners stated that they enjoyed narrative writing and found it a useful experience in the clinical field (19). in winkel study residents reported that reading, writing and sharing their experiences with their peers promoted reflection (14). in addition, nm workshops have been shown to help decrease burnout among residents of obstetrics and gynecology (20). chen et al, study showed that most participants had a positive view of the nm program in medical practice (6). also, the highest percentage of disagreement pertained to "nm relieves the pressure while i am offering medical care", and the highest percentage of agreement to "nm is useful for reflection" (6). in our study, the highest percentage of disagreement was expressed in relation to the sentence "i will continue to use narrative writing in my future practice", followed by the impact of nm on medical care. also, most students agreed on the usefulness of nm in promoting empathy and reflection, and in the next rank, they stated that they had a good feeling about the program. our study is consistent with chen et al. study (6) in terms of participants' perceptions about the effectiveness of nm in promoting empathy and reflection. the rate of agreement on the other items of the questionnaire also conforms to chen et al study, and while the agreement percentages are different, they are basically within the same range. based on our findings, some medical students were unwilling to practice narrative writing in the future. this may be because they had only recently been familiarized with narrative writing, or it could be due to the priority of treatment over education in our clinical education system. hence, the gradual introduction of a new approach such as nm can be helpful in changing the educational system. a lot of the experiences expressed by students as narratives come from informal interactions and the hidden curriculum in medical school and improve their understanding of professionalism (21). wesley et al. investigated the experiences of internal medicine residents about nm sessions and extracted three themes: mindfulness, physician well-being, and professionalism. in general, residents had a good overall understanding of nm and satisfactory participation in the program (5). huang et al. compared the participation of two groups of medical students in the nm course; students in the first group were studying western medicine, and those in the second group were studying chinese medicine. students' perceptions of nm as an approach to learning empathy and professionalism were examined, and the results showed that cultural differences were effective in accepting nm, in that the students studying traditional chinese medicine showed better acceptance of nm. however, gender was not shown to affect the students’ acceptance of nm in either group. in this study, three factors were extracted from the questionnaire: personal attitude, self-development/reflection, and emotional benefit, and the advantages of daryazadeh s., et al. 7 j med ethics hist med. 2021(december); 14: 21. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e nm training were found to be improvement of "reflection, empathy and interpersonal relationships". with regard to acceptance of nm, the difference between the chinese and western cultures is that in chinese medicine the emphasis is on the emotional characteristics of communicating with the patient, while in western medicine the focus is mainly on evidence. also, in chinese medicine clinical teachers are role models who focus on patient-centered care and paying attention to patients' emotions, and this has played an important role in the acceptance of nm by students. therefore, clinical teachers have a formative influence in the chinese curriculum and can be mentioned as an example of the effect of different learning cultures on the understanding and acceptance of nm (3). studies show that 50% of medical students in western societies are women and make up the largest workforce, but in eastern societies such as taiwan, women comprise a small percentage of physicians. additionally, results from previous studies showed that women behaved more appropriately and were more involved in providing health-care services. although these findings have yet to be verified in other eastern countries as well, gender may also be influenced by culture (3). similarly, the results of a study showed that there is a greater willingness to do teamwork and help others among female medical students in tunisia (3, 22). however, huang et al did not report a significant difference in the acceptance of nm among male and female students, but rather identified cultural influences as the dominant factor (3). there are various ethnicities and cultures in iran, but we did not examine those issues in the present study, although we found a significant difference between male and female students' perceptions. it seems that repeating this program and examining learners’ perceptions in other target groups may help to discover other influential factors in this regard. in columbia university, miller et al investigated what medical students learned in the nm curriculum as well as a framework for professional development (18). students' educational experiences were presented in focus groups and then analyzed. nm was taught to medical students with the aim of improving "reflection, curiosity, perspective taking, ethical awareness, tolerance of uncertainty, and empathy". the students expressed "attention, representation and affiliation" as a valuable process to develop professional identity. they also stated that nm is useful in promoting critical thinking and improving reflective capacity, and described narrative writing as a pleasant experience (18). in our study, although the students had a positive perception and attitude about the nm program, there were still doubts and disagreements regarding the acceptance of nm as an effective tool in clinical care and one with the potential to reduce stress in physicians. it seems that some students' reluctance to write narratives or their hesitation to choose the narrative approach in future activities is due to various factors that need to be investigated in future qualitative studies. it should be added that in the role of narrative medicine program in promoting professional ethics … 8 j med ethics hist med. 2021(december); 14:21. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e order to optimally implement the narrative medicine program, a framework has been developed that departments in other medical universities can also use to implement this training approach (23). the educational level of students and their preferences in academic needs can be effective factors in their perceptions of the nm program. therefore, medical students’ perceptions of the program may be different at other educational levels and in other departments. therefore, among the limitations of this study were small sample size and the geographical limitation. qualitative studies in the future can help to improve the effectiveness of the program in different cultures for more purposeful and accurate implementation. our study was conducted only on medical interns, and since this survey was the first implementation of nm and students' perceptions were very dependent on how the program was managed, the results may be different in subsequent surveys. on the other hand, innovative programs sometimes receive negative feedback due to individual’s resistance to change, which may have been the case in the present study. nevertheless, these results can be considered as a general guide to identify students' perceptions of the nm program in iran. conclusion considering the students' perceptions of the reported outcomes of nm on improving reflection and empathy with patients, it is recommended that this program be included as part of the professional ethics training course and in the formal medical curriculum. on the other hand, cultural differences are not restricted to eastern and western cultures, but can be found among the various ethnic groups in iran, for instance in kurdish or turkish communities. thus, further studies may be required to investigate the cultural acceptance of nm among iranians from different ethnic backgrounds. however, this did not seem to have a significant effect on our study because most of the medical interns were of persian ethnicity. also, other related curricula could use nm as an effective teaching method in humanities depending on the intended educational purpose. in addition, investigating the outcomes of the program on health-care services and clinical performance seems to be useful. ethical considerations this research was part of a project conducted under the ethics code ir.mui.research.rec.1399.530 in isfahan university of medical sciences, iran. informed consent was received from the subjects prior to participation in the study. conflicts of interests no potential conflict of interests was reported with regard to this article. acknowledgements this study was funded by the isfahan university of medical sciences, isfahan, iran under grant no. 299137. the authors would like to thank all the participants in the study. daryazadeh s., et al. 9 j med ethics hist med. 2021(december); 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34(6): 438-41. 8. charon r, dasgupta s. narrative medicine, or a sense of story. lit med. 2011; 29(2): vii-xiii. 9. daryazadeh s. application of narrative in medical ethics. j med ethics hist med. 2019; 12: 13. 10. barber s, moreno-leguizamon cj. can narrative medicine education contribute to the delivery of compassionate care? a review of the literature. med humanit. 2017; 43(3):199-203. 11. coret a, boyd k, hobbs k, zazulak j, mcconnell m. patient narratives as a teaching tool: a pilot study of first-year medical students and patient educators affected by intellectual/developmental disabilities. teach learn med. 2018; 30(3): 317-27. 12. daryazadeh s, adibi p, yamani n, mollabashi r. impact of narrative medicine program on improving reflective capacity and empathy of medical students in iran. j educ eval health prof. 2020; 17: 3. 13. olds s. narrative poetry and narrative medicine rounds. lit med. 2011; 29(2): 227-45. 14. winkel af. narrative medicine: a writing workshop curriculum for residents. mededportal. 2016; 12: 10493. 15. gowda d, curran t, khedagi a, mangold m, jiwani f, desai u, et al. implementing an interprofessional narrative medicine program in academic clinics: feasibility and program evaluation. perspectives on medical education. 2019;8(1):52-9. 16. rian j, hammer r. the practical application of narrative medicine at mayo clinic: imagining the scaffold of a worthy house. cult med psychiatry. 2013; 37(4): 670-80. 17. tsai sl, ho mj. can narrative medicine training improve osce performance? med educ. 2012; 46(11): 1112-3. 18. miller e, balmer d, hermann n, graham g, charon r. sounding narrative medicine: studying students' professional identity development at columbia university college of physicians and surgeons. acad med. 2014; 89(2): 335-42. 19. charon r, hermann n, devlin mj. close reading and creative writing in clinical education: teaching attention, representation, and affiliation. acad med. 2016; 91(3): 345-50. 20. winkel af, feldman n, moss h, jakalow h, simon j, blank s. narrative medicine workshops for obstetrics and gynecology residents and association with burnout measures. obstet gynecol. 2016; 128 suppl.1: 27s-33s. the role of narrative medicine program in promoting professional ethics … 10 j med ethics hist med. 2021(december); 14:21. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e 21. karnieli-miller o, vu tr, holtman mc, clyman sg, inui ts. medical students' professionalism narratives: a window on the informal and hidden curriculum. acad med. 2010; 85(1): 124-33. 22. nabli ajmi t, bougmiza mi, mtiraoui a. attitudes of tunisian medical students to medical practice: gender differences. east mediterr health j. 2008;14(3):686–96. 23. daryazadeh s, yamani n, adibi p. development of a checklist to validate the framework of a narrative medicine program based on gagne’s instructional design model in iran through consensus of a multidisciplinary expert panel. j educ eval health prof. 2019;16: 34. ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ original article copyright © 2021 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e moral distress among iranian neonatal intensive care units’ health care providers: a multi-center cross sectional study *corresponding author maliheh kadivar address: department of neonatology, children’s medical center, no. 62, gahrib st., tehran, iran. postal code: 1419733151 tel: (+98) 21 66 91 76 48 email: kadivarm@tums.ac.ir received: 24 jan 2021 accepted: 1 sep 2021 published: 3 nov 2021 citation to this article: tajalli s, rostamli s, dezvaree n, shariat m, kadivar m. moral distress among iranian neonatal intensive care units’ practitioners: a multi-center cross sectional study. j med ethics hist med. 2021; 14: 12. saleheh tajalli1, somayeh rostamli2, nazi dezvaree2, mamak shariat3, maliheh kadivar4* 1.researcher, nursing care research center, school of nursing and midwifery, iran university of medical sciences, tehran, iran. 2.researcher, department of pediatrics, children’s medical center, tehran university of medical sciences, tehran, iran. 3.professor, maternal and fetal and neonatal research center, family health research institute, tehran university of medical sciences, tehran, iran. 4.professor, department of pediatrics, children’s medical center, tehran university of medical sciences, tehran, iran. abstract due to the unique nature of the neonatal intensive care unit (nicu) and its moral distress, this study aimed to investigate moral distress in the nicu. this cross-sectional study was conducted on 234 physicians and nurses working in the neonatal wards of eight hospitals. the corley’s moral distress scale was used to collect data. findings showed that 25 of the participants were physicians and 209 were nurses. the intensity and frequency of distress among physicians and nurses were assessed as moderate. the mean intensity and frequency of moral distress among nurses and physicians were 48.3%, 41.5% and 46.46%, 15.62% respectively. the results showed that the mean intensity and frequency of distress were higher, however not significantly, among nurses. the intensity and frequency of moral distress had a statistically significant and direct correlation with the intention to leave and the number of staff in each working shift among the nurses. moral distress in the nicu practitioners was moderate, so addressing this issue and trying to alleviate it was important. identifying the causes behind moral distress can help adopt appropriate measures to prevent and reduce them. keywords: ethical conflict; moral distress; moral dilemmas; neonatal intensive care unit; mental health; iran. moral distress among iranian neonatal intensive care units’ health care providers: a multi-center … 2 j med ethics hist med. 2021(november); 14: 12. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e introduction advances in technology have overshadowed the healthcare settings and have created more tension among the treatment team in recent decades. treatment team members face a variety of tensions in their work environment, causing numerous problems; one of the most important of which is moral distress (1). moral distress is an emotional and mental pain and discomfort, in which the person makes moral mistakes due to real or mental limitations while having the necessary awareness and ability to make moral judgments (2, 3). moral distress is a concept that people experience in different professions. nursery and medicine are among the professions encountering morally distressing situations from the beginning of their study to their retirement due to the unique nature of the job (4). from among the members of the care and treatment teams, nurses have the longest and deepest human connections with the patients (1). as a result, they are more likely to experience moral distress than other treatment team members (5). moral distress occurs when nurses are unable to put their ethical choices into practice (6). the pressure imposed on the nurses by the health organizations and institutional policies, working with incompetent colleagues, poor management, high workload, lack of facilities and manpower are factors that can contribute to moral distress. additionally, the inability to make decisions, compulsion to carry out orders, and taking unnecessary actions in end-of-life care are other possible factors (7). moreover, various factors such as race, nationality, social, and cultural factors can affect the intensity of moral distress (8). moral distress exposes nurses and patients to adverse consequences. the experience of moral distress by the pediatric intensive care unit and neonatal intensive care unit (nicu) caregivers affects the quality of care (9, 10). that causes several problems for the patients, including increased pain intensity, inadequate care, and increased length of hospital stay (11, 12). experiencing moral distress also exposes nurses to emotional exhaustion, burnout, disappointment, withdrawal, job dissatisfaction, resignation, leave, and turnovers (13, 14). moral distress is associated with negative effects on mental health in the form of anxiety and failure in the professional life of the treatment team members. in the case of incompatibility, its negative effects are manifested in feelings of worthlessness, anger, depression, shame, and unhappiness in professional life. the results of studies suggested that the personal life of individuals will surely be affected by the negative effects of moral distress (15). in fact, when the caregivers are not able to support the patient, they will have an uncomfortable and hurtful feeling, which if repeated, will disrupt their adaptation, selfesteem and ability to provide care. in this situation, they may use negative adaptive methods that can affect the quality of patient care and cause secondary complications (1). a study conducted in italy reported moderate moral distress in nurses but failed to find any association between their education, age, and work experience and the tajalli s., et al. 3 j med ethics hist med. 2021(november); 14: 12. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e intensity of their moral distress (6). another study in the southwestern us state of colorado reported high levels of moral distress among intensive care unit (icu) nurses (1). in swedish nurses, low intensity of moral distress was reported (16). studies conducted in iran have indicated moderate to high levels of perceived moral distress among nurses (17-19). in recent years with the advancements in neonatology, perinatology, and infertility treatments, there have been more expectations from the family and treatment team members to help infants survive despite their poor prognosis, being premature, having very low birth weight, and being sick. the goal is not just to keep these infants alive and short-term and long-term complications are inevitable. enduring to care for these infants with such an unfavorable prognosis is itself a predisposing factor, which causes moral distress in nurses or physicians, placing them under numerous moral pressures. therefore, identifying the causes, having a better understanding of these factors, and examining moral distress in nicu nurses or physicians enable health policymakers and managers to take appropriate measures to prevent and reduce this distress. this issue has been studied to some extent in other countries. similar studies in the sociocultural context of iran can, therefore, provide information to reduce moral distress and improve working conditions for health care providers. thus, we have investigated the moral distress among iranian neonatal intensive unit health care providers. methods study design this cross-sectional study recruited nurses and physicians from level ii or iii nicus of eight hospitals affiliated to tehran university of medical science, shahid beheshti university of medical science, and iran university of medical sciences in tehran, iran from december 2020 to early march 2021. all of the nurses (bachelor and/or master of science) and physicians (neonatologists, fellowships in neonatology and pediatricians) who worked at nicus of arash, shariati, bahrami, children’s medical center, akbarabadi, ali-asghar, valieasr, and mofid hospitals were recruited for 12 months. these are teaching hospitals with level ii and ш referral nicus and 30 to 50 nicu beds, which admit infants with all medical and surgical and neurosurgical problems, except for cardiac surgery, from all over the country. also, they have facilities for sophisticated procedures, imaging evaluations or consultation services for pediatric subspecialties, metabolic disorders, congenital malformations, hypoxic-ischemic encephalopathy (hie), and neonatal seizure, the common causes of the referral of infants to these hospitals. participants were selected via convenience sampling. the sample size was determined as 134 nurses and physicians, with a significance level of 0.05, power of 0.8, and moral distress among iranian neonatal intensive care units’ health care providers: a multi-center … 4 j med ethics hist med. 2021(november); 14: 12. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e an effect size of 0.24. considering the attrition rate (10%), a total of 234 nurses and physicians were asked to participate in the study. six of the participants who did not complete the questionnaires fully or six of the participants who did not complete the questionnaires fully were excluded. finally, the data of 234 questionnaires were analyzed. the inclusion criteria were being involved in care at neonatal intensive care for more than 12 months. data collection data were collected with the cooperation of one researcher trained on the research objectives and completing the questionnaires. the research objectives and procedures were explained to all the participants and their written informed consent was obtained. the participants completed the questionnaires in a quiet place. questionnaires took 15-20 minutes to complete and the sampling period lasted from december 2020 to early march 2021. the following data collection tools were used: demographic and job characteristics questionnaire included 12 items of age, gender, marital status, educational degree, hospital name, experience, experience in nicu, employment status, work shift, job satisfaction in nicu, and intentions to leave the service. the moral distress was assessed using corely et al. moral distress questionnaire with 21 items. its reliability was determined by test-retest to be 0.86 (20). it measures an individual’s perceptions of a situation based on the intensity of moral distress and the frequency of the encountered situation. the moral distress scale-revised (mds-r) includes two subscales: (1) frequency ranging from 0 (never) to 4 (very frequently) and (2) intensity ranging from 0 (none) to 4 (great extent). the total score of each question is obtained by multiplying the intensity score by that of frequency, summing up to a 0-16 score. moral distress is accordingly scored as low (0-96), moderate (97-192), and high (193-288). mds-r has been translated to different languages and proved valid and reliable (21, 22). it has also been translated to persian by soleimani et al. who reported the threefactor structure of the persian version of the tool and a cronbach's alpha of 0.71 for the whole tool and 0.685-0.853 for its subscales (23). in the present study, the reliability of mds-r using cronbach’s alpha coefficient for the whole tool was 0.85. data analysis data were analyzed using spss-23 (spss inc., chicago, il, usa) software by descriptive statistics (mean, frequency and percentage). to determine the data distribution, the one-sample kolmogorovsmirnov test was used. comparison of normal data was done using test-re-test and one-way anova. moreover, pearson test were used for assessing the quantitative variables. the power and significance levels were set at 0.8 and α = 0.05, respectively. ethical approval all ethical considerations of the study were approved by the institutional review board tajalli s., et al. 5 j med ethics hist med. 2021(november); 14: 12. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e and the research ethics committee at tehran university of medical sciences, tehran, iran (ir.tums.vcr.rec.1395.403). all participants in the study were informed of the study objectives and signed a written informed consent form and were assured of the confidentiality of their personal information and the voluntary nature of participation. result findings indicate that out of 234 participants, 25 (10.7%) were physicians and 209 (89.3%) were nurses, and 215 (91.9%) were female. sixty-nine of the participants (29.4%) had less than or equal to 5 years of experience working in hospitals. sixteen (5%) had the intention to leave the service soon and 129 participants (56%) planned to do so sometime in the future. from the other point of view, eighty-nine and 16 of participants had no intention to leave the service. the mean intensity and frequency of moral distress among nurses were 48.36 ± 17.27 and 41.5 ± 16.13 respectively. as for the physicians, they were 46.46 ± 16.3 and 36.56 ± 15.62, respectively. the intensity and frequency of distress among physicians and nurses were assessed as moderate with no statistically significant difference (table 1). table 1intensity and frequency of moral distress in physicians and nurses moral distress (mean) frequency mean (sd) intensity mean (sd) physicians 36.56 (15.62) 46.46 (16.3) nurses 41.5 (16.13) 48.36 (17.27) total 46.96 (16.10) 48.18 (17.13) *p value 0.249 0.656 there was a significant correlation between the intensity and the frequency of nursing moral distress and some demographic factors between nursing staff. (table 2) table 1relationship between intention to leave the service and the intensity and frequency of moral distress among study participants moral distress frequency mean (sd) intensity mean (sd) emminent intention to leave the service 50.37 (13.66) 53.28 (11.25) possible intention to leave the service, but were still working 44.16 (14.59) 52.29 (15.24) no intention to leave the service 35.46 (17.46) 40.62 (19.35) *p value 0.002 0.004 *anova test as shown in table 3, a direct correlation was observed between the frequency of moral distress and the number of staff in the morning and evening shifts, suggesting a surge in the frequency of moral distress with the increase in the number of working personnel (tables 3). moral distress among iranian neonatal intensive care units’ health care providers: a multi-center … 6 j med ethics hist med. 2021(november); 14: 12. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e table 1correlation between frequency and intensity of moral distress and demographic variables of the study participants moral distress frequency intensity morning staff correlation(r) p. value* 0.290 0.001 0.158 0.100 evening staff correlation(r) p. value* 0.239 0.006 0.161 0.840 work experience in nicu correlation(r) p. value* .137 .129 .180 .055 overall work experience correlation(r) p. value* .047 .599 .084 .368 overtime working correlation(r) p. value* -.057 .625 .026 .832 number of daily working hours correlation(r) p. value* -.013 .903 -.063 .569 *pearson correlation test discussion we found the mean intensity and frequency of distress between nurses and practitioners was high and moderate respectively. this was higher, among nurses compare to practitioners, however not significantly, among nurses. the high level of technology and the unknown outcomes of nicu newborns have made the care and treatment in this ward associated with moral distress for physicians and nurses (24). once nurses and physicians are faced with a critical situation, they experience a great deal of moral distress and caregiver feels the provided care is not in the best interest of the infant (25). infants are a vulnerable population and caring for them can cause various forms of moral distress, and their caregivers are exposed to unique moral distress. therefore, identifying the causes of moral distress may improve not only the working environment but also the quality of care for the patients (26). studies in the nicu have repeatedly revealed long-term and aggressive treatment in neonates as the main source of moral distress among the medical professions. moral distress is also a cause of dissatisfaction among nurses and physicians (27). in 2016, janvier et al. conducted a systematic study that identified disproportionate usage of technologies, not perceived to be in a patient’s best interest and powerlessness to act as the most important cause of moral distress in the nicu (27). in our study, the mean scores were higher among females compared to males. the findings of trotochaud et al., a study in atlanta are consistent with our study. they found that moral distress among medical staff in the canadian nicus was moderate, with nurses experiencing higher distress than physicians and other care team members. moral distress was also higher among women than men, with a rate reaching up to 17 times more distress in nicu (26). dryden-palmer et al. conducted a study to identify the causes of moral distress among the clinicians in the canadian pediatric and tajalli s., et al. 7 j med ethics hist med. 2021(november); 14: 12. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e neonatal icus. they concluded that neonatal physicians and nurses experience high levels of moral distress (28). st ledger et al. conducted a qualitative study to assess moral distress following end-of-life decisions perceived by the physicians and nurses in the neonatal intensive care units in belfast. they reported moral distress to be significant (29). dodek et al., in a study from vancouver, identified that the icu nurses face critical conditions requiring important decisions, and these situations make the experience of moral distress among them more likely. therefore, nurses suffer from higher rates of moral distress compared to physicians in icu (30). in several studies, moral distress was more prevalent among nurses. in a systematic review by yektakooshali et al., the intensity and frequency of moral distress among nurses were reported to be moderate in 2018 (12). hally et al. concluded that the nicu nurses who scored high in measure of moral distress for health care professionals are more likely to leave their work (31). in the present study, there was no significant relationship between the intensity and frequency of moral distress among physicians and the demographic factors. while in nurses, a statistical significant and direct relationship was found between the moral distress and intention to leave and the number of personnel in each working shift. higher intensity and frequency of distress was reported among individuals with the intention to leave, either now or later. there was a direct correlation between the frequency of moral distress and the number of personnel working in the morning and evening shifts, i.e., the higher was the number of staff in each shift, the higher was the frequency of moral distress. the findings of the present study are consistent with previous studies. joolaee et al. reported moderate levels of moral distress among nurses in iran in 2012. they also found no significant statistical relationship between moral distress and nurses’ desire to continue working in the nursing profession (19). berhie et al. reported that nurses repeatedly suffer from moral distress, with a rate of as high as 83.7%. a significant relationship was also found between moral distress and poor communication between physicians and nurses, manpower shortage, low work experience, lack of effective and specialized care, and poor decision making (32). another study by molloy et al., found a significant inverse relationship between perceived moral distress and a person’s age and years of service, whereas moral distress was significantly correlated with the ward type (33). it seems that, firstly, having more work experience reduces certain stresscausing factors, and secondly, individuals use different methods to adapt and resolve the intensity of moral challenges. yeganeh et al. found a significant direct relationship between moral distress and the degree of professional autonomy (17). in this regard, molloy et al. found that one of the most important factors affecting moral distress among nicu nurses is their perception of moral distress. not believing in having a prominent role in decision-making for neonatal resuscitation can cause moral moral distress among iranian neonatal intensive care units’ health care providers: a multi-center … 8 j med ethics hist med. 2021(november); 14: 12. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e distress (33). gallagher et al. found that nicu nurses and physicians in their professional role as caregivers for infants face issues, not previously encountered or completely defined in practice; these situations result in moral distress (34). moreover, strandas et al., reported that caregivers of vulnerable infants are constantly trying to make a balance to protect their patients; as a result, they experience moral distress (35). boss et al., found that in the neonatal and pediatric wards, medical interns experience moral distress following contact with the infant’s parents, other physicians, and members of the health care team (36). in general, based on the findings of the present study and previous studies, moral distress is moderate among nicu nurses in the university hospitals in tehran, so addressing this issue and alleviating it would have a significant impact. by identifying the causes of moral distress, appropriate measures can be taken to prevent and reduce them. strengths and weaknesses the study aimed to evaluate the level of moral distress among health care providers in the iranian neonatal intensive care units. being multi-centric and sampling from several hospitals affiliated with different universities is the strength of the study, and increases the generalizability of the results. in our study, the use of self-reporting scales is the main limitation. although we guaranteed the information to be kept confidential, some physicians and nurses may not have provided truthful answers. conclusion the mean levels of moral distress among nicu physicians and nurses and its direct relationship with the number of people present in each working shift points out the need for more attention of the policymakers. in this regard, we should try to raise awareness of moral distress, its causes and correlational factors through strategies such as setting up training workshops and establishing related ethical committees in clinical settings. furthermore, raising awareness of positive adaptation strategies and mechanisms can help reduce burnout and turnover in this sector. the causes of moral distress could be minimized through designing solutions to improve the working condition of medical staff, especially nurses and physicians, the key elements in treatment and care, and consequently increase the quality of care. to generalize the results, a study with larger sample size and using locally designed tools are recommended. acknowledgements the authors of this study would like to offer special thanks to the staff of the nicu in selected hospital. moreover, we are grateful to dr. arash bordbar, dr. farhad abolhasan choobdar, mojdeh mansourzadeh msc, fariba nouri msc, and amenh abroon bsc for their cooperation conflicts of interests there are no conflicts of interests. tajalli s., et al. 9 j med ethics hist med. 2021(november); 14: 12. jo u rn a l o f 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sciences, shiraz, iran; 2professor, department of medical ethics and philosophy of health, shiraz university of medical sciences, shiraz, iran; 3health policy research center, shiraz university of medical sciences, shiraz, iran; 4department of sociology, shiraz university, shiraz, iran; 5research center consultation (rcc), shiraz university of medical sciences, shiraz, iran; 6professor, health policy research center, shiraz university of medical sciences, shiraz, iran. corresponding author: ahmad kalateh sadati address: health policy research center, shiraz university of medical sciences, shiraz, islamic republic of iran. email: asadati@sums.ac.ir tel: 98 711 2309615 received: 10 nov 2015 accepted: 18 apr 2016 published: 23 apr 2016 j med ethics hist med, 2016, 9:2 © 2016 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract the doctor-patient relationship (dpr) is one of the most important subjects in medical sociology and health policy. due to mutual understanding, undistorted dprs not only result in satisfaction of both doctors and patients, but also help to reduce financial burdens for patients and the health care system. the purpose of this research was to identify a dpr based on the qualitative paradigm model which is called the grounded theory (gt) methodology. the data were collected from 3 focus groups, the participants of which consisted of 21 faculty members of shiraz university of medical sciences, shiraz, iran. the content of the interviews, following the transcription stage, was organized based on open, axial, and selective coding. results showed that dpr was distorted which was the consequence of an inefficient structure in the healthcare system which is related to several cultural barriers. in this situation, agency is determinant so the doctor's personality determines the direction of dpr. consequences of such scenarios are the patient’s distrust, patient's dissatisfaction, lack of mutual understanding, patient suppression, and patient deception. therefore, the health care system should emphasize on reforming its inefficient infrastructures, so that, besides being controlled and surveyed, physicians are socialized ethically. keywords: doctor-patient relationship, patient satisfaction, paradigm model, iran mailto:asadati@sums.ac.ir j med ethics hist med 9:2 april jmehm.tums.ac.ir ahmad kalateh dati et al. page 2 of 11 introduction the doctor-patient relationship (dpr) is the main subject of medical ethics, health policy and management. the doctor-patient relationship (dpr) is the keystone of care (1). its meaning, although seemingly simple, is complex (2) and poorly defined (3), and has uncertain features (4, 5). although the debate on dpr began in hippocrates’ era, it has remained a central topic in medical discourse over the past decades (6, 7). dpr is a controversial topic because it is an interaction between two human beings with distinct values and characteristics. a dynamic and mutual relationship not only can lead to satisfaction of both parties (8-11), but also helps to reduce financial burden for patients and the health care system. moreover, dpr is an important topic in medical ethics (12). from this perspective, dpr is not simply a matter of professionalism, but it has philosophical dimensions (13). since the 1950s, two different sociological paradigms have addressed dpr (6, 14). on the one hand, parsons’ functionalist theory (15) has concentrated on the patient’s role, recognizing 4 roles as the patient’s responsibilities toward his/her illness and toward doctors’ medical instructions (16). on the other hand, certain critical theories have been proposed including habermas’ critique on modern specialization (17, 18), and criticisms on knowledgepower relations established by modern medicine from foucault’s viewpoint (19). in addition, there have been extensive ethnographic studies criticizing modern medicine (20, 21). due to the importance of dpr, it has been studied in different disciplines such as psychiatry (22), dermatology (23), somatic symptom severity (sss) (24), cerebral aneurysm surgery (25), pharmaceutical care (26), and chronic illness (27). while good dpr can lead to better clinical outcomes (2, 28) and patients' satisfaction, poor dpr can negatively affect quality of healthcare services (2). therefore the purpose of this study was to identify the quality of dpr, based on the views of shiraz university of medical sciences faculty members. to achieve this goal, this study tried to explore paradigm model of the dpr; a model which is capable of showing phenomenon, context, intervening conditions, and action/interaction strategies to consequences. this is an inductive study which explores the codes in three phases and a paradigm model according to grounded theory method. method this qualitative study was conducted between april and september 2014, among faculty members of shiraz university of medical sciences. to maximize participation and collect different viewpoints (29), the focus group discussions (fgds) method was applied. during each interview, at least 6 faculty members were present and the interviews were recorded digitally after obtaining a verbal consent. data were transcribed after each discussion. data collection and theme analysis were performed simultaneously. when data saturation was achieved (30, 31), sampling finalized. our method was grounded theory included two main phases: exploring codes in three phases and presenting findings in paradigm model. initially, coding process was conducted in three main phases: open, axial and selective coding. open coding is the first stage of analysis as well as comprehensive analysis. according to glaser, open coding is the initial stage of comparative analysis. at this stage, analysis was performed through a line-byline analysis of data. there are many data coding methods including writing memos about the conceptual and theoretical ideas that emerged throughout the analysis (32). in this stage we interpreted the meaning units. axial coding was the second stage. the purpose of axial coding is to put the fractured data together in new ways “by making connections between a category and its subcategory” (33). during axial coding, we tried to understand categories observed in relation to other categories and their subcategories (34). based on axial coding we tried to explore the phrasal code which presented the phenomena in higher level of abstraction. at the third stage, called selective coding, data were integrated to shape a central theme, hypothesis, or story to generate a theory (35). selective coding is the highest abstraction of coding. in this level code is explored according to meaning units, and other previous codes and also based on previous theoretical frameworks about the subject. one practical sample of coding in three phases about code called distorted dpr is showed in table 1. after exploring the codes, another important part of the study was presenting findings in a paradigm model based one strauss and corbin’s (32) approach to gt. based on strauss and corbin’s approach, a paradigm model should distinguish between causal conditions and intervening conditions and there is a very strict linear model for causal conditions via phenomenon, context, intervening conditions, and action/interaction strategies to consequences. after the analysis of data, differences between them were found using the paradigm model. for the presentation of the paradigm model, we used theoretical sampling through inductive and deductive approaches. to this end, we developed through with a reflexive comparative analysis of data and codes for a better understanding of the theory produced. since, this article was based on a sociological study, to observe ethical principles of research, the codes of the american sociological association were applied throughout different stages of this research. the criterion sampling was finalized after data saturation was reached (34, 35). research validation was conducted through member check. j med ethics hist med 9:2 april jmehm.tums.ac.ir ahmad kalateh dati et al. page 3 of 11 table 1an example of three phases coding process about distorted dpr meaning units open codes axial codes selective code there are several patients which you or your assistant do many works for them, but because you don’t have relationship with them, they don’t benefit from them or they don’t satisfy, patient deson’t understand doctors’ efforts. unappeasable patient distorted dpr after public system, condition is worse, some physician work until 4 in the morning, because we don’t know what we want from this interaction. doctors just work without interaction. ignorant and irregular relationship. in our country there is a different form of relationship in comparison with other countries. somehow the doctor believes himself to have the right to treat his patient any way he/she sees fit. relationship depends on doctor’s desires. one day a patient whose pathology results were positive for malignancy came to me with his wife. his wife worried and was about to faint. they asked me to tell them the facts, but i did not tell them everything. i asked them go to their doctor and just ignore them. doctors do not reply appropriately to patients ignorance of patent’s psychological need it has occurred numerous times; the patient does not communicate some main points of his/her illness, due to the doctor’s week interaction. patient does not present a complete history of his/her illness. incomplete relationship. results dpr has had an important role in the treatment process, to such an extent that it is called “the key to treatment” (surgeon of fgd1)). as a result of lack of good dpr, doctors fail to appropriately practice medicine. yet, the dpr within the context of this study was specifically leaning towards doctors’ benefits, while patients and their concerns were disregarded. under these circumstances, the conditions governing the consultations in clinics and hospitals did not allow for a suitable means of communication. this means that doctors practice medicine without establishing any kind of mutual interaction, but mainly a one-sided relationship. this type of interaction is called distorted dpr. distorted dpr every relationship is initiated with interaction and dialogue. in contrast, a distorted relationship is onesided. in the distorted relationship, little or no communication takes place between the doctor and patient. in such interactions, not only the scientific principles of diagnosis and treatment, but also meaningful action are disregarded. the consultation is conducted within a few minutes, and then, the patient leaves the office with only a written prescription. the participants’ statements showed that a distorted drp, within the context under study, had turned into a norm and was based on doctors’ autonomy. [even today, there are still some physicians, even good ones, who do not even talk to their patient (nephrologist of fgd3). in governmental hospitals, verbal communication has sharply declined. the situation is such that the doctor performs an examination, and then, makes a decision without any verbal communication.] (psychologist of fgd3) “do not even talk” indicates a total absence of verbal contact between the doctor and patient. in such situations, diagnosis and treatment are mainly based on the doctor’s experiences or para-clinical data. when no dialogue takes place, no message is conveyed, and as a result, no meaning (patient’s feeling and experience) is transferred. in extreme cases, the doctor disregards the patient’s existence as a human being and the patient leaves the office feeling perplexed. a distorted relationship is a mechanical and passive one. consequently, the doctor does not gain any understanding of the patient’s perception of and attitude toward the illness. [a mechanical relationship means that no attention is paid to the patient’s psyche; the person in front of you is called a human being whose soul and psyche should also be taken into account. by considering his/her psychological issues, you can treat many of them. the patient’s psychological aspects should not be ignored or suppressed, and he/she should not be treated like an object. treating a patient should not be like repairing a car. the doctor does not look at the patient, but looks at the lab test papers.] (psychologist of fgd2) in other words, one-sided or mechanical relationships are generally unequal. there is even a higher level of inequality in doctors’ conduct and their patterns of questioning, shaping an interrogatordefendant-style dialogue. [doctors are not supposed to act like interrogators. some doctors are just like that and when a person sits in front of them, they start asking questions in this manner.] (psychiatrist of fgd1) in an interrogative style interaction, the patient faces numerous closed questions which should only be answered with yes or no. yet, if the patient wishes to change the direction of the consultation by asking a question about the diagnosis or therapy, the question is simply suppressed. if the patient insists, he/she may receive an unpleasant answer. a distorted dpr is an interrogative interaction which includes weak, mechanical, and unequal communication. j med ethics hist med 9:2 april jmehm.tums.ac.ir ahmad kalateh dati et al. page 4 of 11 inefficient infrastructure inefficient infrastructure was the chief issue observed in relation to the shaping of distorted relationships. one aspect of this issue is the inability to respond to a large number of patients, including clinical and hospitalized patients, due to poor accessibility. doctors are forced to consult a great number of patients on a daily basis. [when i have to visit 100 patients in the hospital, i cannot even understand what the thirtieth or fortieth patient says, or i simply refer him to my resident. how strong do you think i am to visit more than 100 patients!?] (nephrologists of fgd3) this statement shows that a doctor has limited capacity in providing services. for instance, a psychotherapist “has to spend at least thirty minutes on each patient” (psychiatrist of fgd1), although those in charge of the clinic have a different expectation. [the biggest obstacle is the system. in fact, our flawed health system forces the attending physicians to visit 50-60 patients a day, while visits are heavily dependent on interaction, and without it, even in case of emergency, no matter how much i try to help, it will not work. the clinic manager encourages me to visit 70 patients, but i need to spend at least 0:30 minutes on each visit. on the contrary, if i do this it has negative implications for me. it means that i am not a doctor, but more like a money-making machine.] (psychiatrist of fgd1) poor accessibility to physicians has led the health system to focus on quantitative services rather than qualitative services. meanwhile, a quantity-oriented service could affect the quality of consultations and relationships. the health system has focused on quantity not only in case of providing services, but also in case of science and knowledge. in such a condition, the criterion for professors’ promotion is simply the number of papers they have published rather than their performance. [in professors’ promotion form, there is no item for quality, and the whole thing is about the number of papers published. the best professor i have seen with numerous papers allows half a dozen patients at a time in his office, and never lets them talk, because for his promotion, quality is not considered, and only the number of papers is important. i wonder how much these papers will help patients.] (internist of fgd2) since the criterion for doctors’ evaluation is the number of their papers and not the quality of their performance, they pay no attention to active interaction. another characteristic of inefficient infrastructure is poor control/supervision, or even lack of supervision, which is a shortcoming that has direct impact on dpr. [i just wanted to say that we are not satisfied ourselves; there is not even a system to put us within a framework, and this is a serious obstacle.] (surgeon of fgd1) when there is no framework and there are economic demands prompting the doctor to compete against other doctors, medicine is practiced without considering quality and active interaction with patients as a critical issue is simply marginalized. another aspect of inefficient infrastructure is reflected upon one-dimensional education system, which creates one-dimensional medical logic. this education system encourages mechanical and instrumental relations. such structures neglect to teach the ethics and philosophy of medicine. in this structure, dpr skills are not taught and ethical problems are not explored. [in our time, there was no course or workshop for medical ethics, and now, even at our residency stage, there still are no such courses! so, teaching such issues is not important and professors do not expect students to know about these things.] (psychiatrist of fgd2) clearly, students neither receive medical ethics awareness nor communication skills training, and this framework reinforces distorted dpr, as a hidden curriculum. [when students come to motahari clinic to be trained, they learn how to interact from their professor. when they see a professor visits 70-80 patients per day, the students, too, learn this.] [pediatrician of fgd2] in addition to “hidden curriculum”, medical students are faced with the education/treatment paradox. this creates a struggle between educational departments and treatments. [education and treatment are in conflict with each other. you sit in the department and see 4 protocols for the education of medicine with some orders. then, you see 10 protocols for providing services to patients which are in conflict with the previous protocols.] (nephrologist of fgd3) finally, inefficiency in the infrastructure can lead to inefficiency in the student admission screening process system which is performed without any protocols or plans. [at this point, medical students are not screened when they are entering medical colleges. often, university graduates are even worse than the new entries (new students), because some of the students are not even cut out for the job.] (internist of fgd2) as a result, university graduates are not familiar with ethical principles; thus, in reality they cannot be expected to act accordingly. cultural barriers data revealed that a number of the themes in distorted relationships were in fact rooted in culture. one of the related cultural values is patient's obedience, which refers to patients’ attitudes that encourage them to yield to doctor’s dominance. this cultural attitude contributes to doctors’ imposition of power, and there seems to be a relationship between this attitude and doctors’ tendency for dominance. apparently, acting congenially on the part of the j med ethics hist med 9:2 april jmehm.tums.ac.ir ahmad kalateh dati et al. page 5 of 11 doctor may convey the impression that he/she is not competent enough. [in iran, due to our culture or basically our iranian personality, if a doctor allows us to have an active interaction with them during our visit, we feel that he/she does not have sufficient knowledge.] (surgeon of fgd1) one of the participants believed that this tendency was rooted in the cultural and social settings of middle eastern countries. [in middle eastern societies, patients still assume that a doctor must preserve and practice his authority.] (psychiatrist of fgd2) as a result, culture and cultural values demand from doctors to refrain from practicing the ethics of interaction. there is another side to this coin of cultural obedience; if a patient feels that the doctor has allowed him to communicate, the patient creatively tries to direct the dialogue towards his/her points of view. this is called patient's manipulation which is another cultural characteristic which can lead to the misuse of the doctor’s position by the patient. [some patients do not have the capacity to accept this courtesy and when you bring yourself to their level, they somehow try to manipulate you. if you want your patient to “buy” and cherish your words, you must create some sort of difference and you should talk from a higher status.] (anesthesiologist of fgd1) doctor’s paternalism is another value that is reproduced in this context. medical culture is itself a patriarchal and suppressive culture in which the doctor regards himself as “the guardian” of the patient. in this culture, doctors, as they think they deserve to practice medicine, regard themselves as experts in every aspect of treatment and disregard patients’ experiences. [a patriarchal medical culture is one in which the doctor considers himself as the custodian and somehow he allows himself to treat the patient as he wishes.] (dentist of fgd2) another cultural issue is poor health literacy. the most challenging concerns are individuals’ attitudes toward illness and therapy, inability to present their illness and the inappropriate structure of communication with the doctor. [some patients come, let me tell you precisely, and i ask them, “what’s wrong with you?”, and in response they say, “how do i know! you’re the doctor here!” i then ask about their illness, but feeling shameful about their problem, such as rectal bleeding, they may say they have stomachache. they hide the truth and say something else instead.] (surgeon of fgd1) another aspect of cultural barriers is related to the growth of materialistic doctors in iran. under such circumstances, a patient is disregarded as a human being in need of quality services and is viewed as a source of financial benefits. this perspective toward patients may, in some cases, encourage the doctor to deceive patients. [the society is increasingly becoming materialistic and people are seen as dollar signs. this could be your child when he/she wants to go to private class with a teacher, a customer for a salesperson, the police, or a judge.] (ophthalmologist of fgd2) the more materialistic the relationship becomes, the more intensified the distorted dpr will become. this is because symbolic mediators turn to financial benefits instead of ethics and human dignity. accordingly, doctors distance themselves from the ethics and philosophy of their profession and stay in limbo, hanging between human responsibility and materialistic benefits. [the problem is that we do not know what we want from this relationship with our patient. do we seek inner satisfaction, money, or social status? i know a person who makes $ 500.000 uds per month and is still not satisfied. this physician has hired 10 surgeons as assistants to work for him and has told them they will not have any professional identity for the next 10 years, since they are operating under his name.] (surgeon of fgd1) lack of openness to criticism and lack of freedom of opinion were other problems found in the context of the study, and they contribute to doctors' authoritative personality. thus, doctors treat patients according to the cultural settings they were raised and educated in; that is, to be dominant over subordinates and to be submissive to their superordinates which generally disregard human dignity. [there is something called human dignity which in my opinion is genetic. although it might seem insignificant, the whole story emerges from this point. to do this, a person should know what human dignity is, and this goes back to his/her childhood, the ages 1-6, and not necessarily the university system, where they have acquired their behavior.] (pediatrician of fgd3) the incomplete educational system leads to the formation of distorted drp. in this educational culture, instead of an analytical qualitative outlook, a quantitative and test-achievement approach which overlooks other issues has become dominant. [from secondary school, or lower education levels, students go to school to learn how to answer tests, but they do not learn much about thinking or communication. they only think about how to get good and better grades without any analytical approach. finally, this person becomes a doctor who cannot communicate properly with his/her clients.] (pediatrician of fgd3) consequences a distorted dpr with the above characteristics will have certain consequence in the interaction. the first outcome of incorrect diagnosis and distorted dpr is patients distrusting the doctor. j med ethics hist med 9:2 april jmehm.tums.ac.ir ahmad kalateh dati et al. page 6 of 11 [does the fact that patients should wait for a long period of time to visit a doctor lead to their mistrust or discouragement? should they wander about for 23 months and follow wrong orders before you [doctor] may finally make a correct diagnosis?!] (surgeon of fgd1) patient's dissatisfaction with consultation and lack of mutual understanding are other consequences of distorted dprs. [i can see in the eyes of some (patients), when they are leaving, that they think: “what a stupid idea it was to see this doctor; it’s as though i’m talking to a wall.” they feel that i do not understand them, or i feel they do not understand me.] (psychiatrist of fgd1) suppressing patients is yet another outcome of distorted dpr. the doctor fails to establish a good relationship with the patient and does not understand him/her, and thus, reprimands the patient’s attitude and action, suppressing them. in focus group 2, one of the psychotherapists retold a story of a gynecologist’s encounter with a patient, who due to illness had to have an abortion. [first the doctor started out well and said that it was not a big deal and that only 1 out of 270 cases would need an abortion. at this point, the patient started to cry, to which the doctor responded offensively, asserting she had not said anything wrong and if the patient would not stop she had to leave.] (psychologist of fgd2) deceiving patients is another consequence of dpr. patients’ lack of adequate information about their health conditions is the cause of their concern and apprehension. under such circumstances, the doctor can easily deceive the patient in order to acquire financial benefits. some participants talked about “patient deception” in such fields as gynecology, ophthalmology, and dentistry. [the art of deception is so prevalent!!! for example, the patient is advised to do a transvaginal ultrasound test and without any examination, the doctor tells her that she has uterine prolapse and should be operated on right away. this is very prevalent in iran. the patient starts crying, saying that the doctor told me, if i do not treat this issue, it may lead to cancer.] (gynecologist of fgd2) one of the participants claimed that due to the high patient turnover in governmental hospitals, doctors are not motivated to participate in patient deception, but she stated that in the privatized sector, the patient deception is more prevalent. therefore, deception is closely tied to doctors’ financial incentives; this is a tragic issue in medicine. [yeah, exactly, and it is tragic. in the field of women’s studies, you can simply see an endless number of cases. i myself do not dare visit a gynecologist!!!] (gynecologist of fgd2) doctors’ personality distorted dprs are also related to another factor; the doctor’s personality. how the doctor communicates and how he/she views the patient is a matter of personality, which is both psychological and educational. from this perspective, doctors’ personality has an important function in dprs and through their unselfish individual character they can establish a more active interaction and the opposite is also true. [i think the most important issue is the individual personality of doctors. some individuals are not mature enough to respect or value patients’ selfexpressions and see the patient as a mechanical object to be given a simple prescription. this is what they believe a dpr should be.] (psychologist of fgd2) therefore, the extent to which the doctor thinks about personal and financial benefits or resists suppressing or deceiving the patient is related to his personality and the family setting that he/she was raised in. paradigm model the paradigm model is a holistic framework that explains social phenomena, specifically the condition which has created them. such an explanation includes causal conditions, the context, intervening conditions, core phenomenon, action/interaction strategies, and consequences. to reach the paradigm model of this research, the factors observed were conceptually grouped. this was conducted based on data, memos, and the themes that were extracted, and through the establishment of a reflexive manner between the factors and the data. figure 1 illustrates the paradigm model of distorted dpr. as figure 1 illustrates, the core phenomenon in the model is distorted dpr, which is affected by causal conditions (inefficient system), context, and intervening conditions. the inefficient system is a context incapable of meeting patients’ needs and is characterized by inaccessibility, quantity-orientated service, poor control/supervision, one-dimensional education system, education/treatment paradox, and lack of planning. in addition to inefficient structure, the context also contributed to the reproduction of distorted dprs. as the model illustrates, cultural attributes have led to the reproduction of certain values, both in case of doctors and patients. patients' obedience is accompanied by the exploitation of patients, and doctors’ paternalism, self-interest, and authority. such attributes have led to the reproduction of some values in the society, inclining distorted dprs. the result of these attributes is the reproduction of a value that legitimizes doctors’ unequal and dominance-regulated relationships. for instance, the fact (as confirmed by participants in this study) that the doctor should dominate the relationship was both a tendency in patients’ behaviors and in doctors’ paternalism. j med ethics hist med 9:2 april jmehm.tums.ac.ir ahmad kalateh dati et al. page 7 of 11 figure 1 a paradigm model of distorted doctor-patient relationship (dpr) in such conditions, the main question is as to why a patient seeks consultation, when there is no hope for a suitable interaction. it seems that the determining factor is the doctors' personality and not the code of ethics. thus, this is a double-edged sword that can play either a positive or a negative role. the only reason this type of interaction continues is the hope for a positive interaction that can ultimately lead to deception and a distorted dpr. hence, when there is a lack of appropriate infrastructure, everything depends on the doctors' personality and character. based on the results of this study, we can conclude that, since the majority of physicians are financially motivated, it is evident that all dprs are distorted. in this context, action/interaction strategies were passive, one-sided, and power-regulated consultations based on the doctor’s authority. passive interaction takes place when the doctor does not establish an appropriate interaction and the doctor normally relies on para-clinical data and sometimes physical examination rather than a dialog with the patient. one-sidedness also means that in the interaction the doctor is the final decision-maker. finally, the consequences of distorted dpr are patient’s distrust, patient’s dissatisfaction, lack of mutual understanding, patient suppression, and patient deception. discussion the present study revealed that dpr in the context of the study was not suitable which, in this text, was called distorted dpr. this means that there is no communicative relationship between the doctor and patient. thus, both the doctor and patient, especially the patient, are dissatisfied. the paradigm model revealed that the inefficient structure was the main reason behind the formation of distorted dprs. poor accessibility, a dominant quantity-oriented approach to providing services, poor control/supervision, and a glaring inconsideration of communicative skills training for doctors and medical students were all the fundamental specifications of this inefficient structure. this shows that the system does not have an effective function, control, and surveillance. causal condition: inefficient structure poor accessibility, quantity-oriented service, poor control/supervision, one-dimensional education system, hidden curriculum, education/treatment paradox, and inefficiency in the student admission screening process system core phenomena: distorted dpr context: cultural barriers patient's obedience, patient's manipulation, doctor’s paternalism, poor health literacy, materialistic doctors, lack of openness to criticism, and incomplete educational system action and interaction strategy: passive, one-sided, and power-regulated consultations consequences: patient’s distrust, patient’s dissatisfaction, lack of mutual understanding, patient suppression, and patient deception intervening conditions: doctor’s personality j med ethics hist med 9:2 april jmehm.tums.ac.ir ahmad kalateh dati et al. page 8 of 11 furthermore, cultural values contribute to a distorted dpr. under such circumstances, personal characteristics of doctors could serve as an intervening factor in generating distorted dprs. this ultimately means that if a doctor is good, the interaction is also good and vice versa. thus, dpr is heavily dependent on social and personal character of the doctor rather than systems rational. the study by mishler revealed that doctors and patients had two opposing and unharmonious voices that lead to conflict, and the cessation and disintegration of consultations. it was concluded that there were two voices in dpr; the voice of the life world and that of the system (36, 37). the voice of the life world preferred a technical interpretation of matters, listening, open-ended questions, negotiation, and power distribution. nevertheless, the voice of doctors was regulated by concentration and preservation of knowledge and asymmetric power relations. in the life world voice of patients, there was a coherent and sensible report, whereas in the voice of doctors, there was suppression, dismantling, and incoherence. finally, medical care was only effective and humanistic in the life world voice, but in the voice of doctors, it was inhumane and ineffective (38). following mishler’s work, fairclough dealt with a discursive evaluation of doctors’ tendency to control the interaction. his study showed that doctors used linguistic strategies to control the interaction with the patient (39). the research by atkinson and atkinson also showed that doctors did not necessarily use a specific language (medicine) in their interaction with patients, but they used different languages, each of which played a specific function in the interaction (40). barry et al. revealed that the nature of an interaction depends on the type of voice used by doctors and patients. it is also related to the nature of the illness. for example, the worst outcomes occurred when patients used the voice of the life world, but were disregarded (life world disregarded) or blocked (life world blocked) by doctors' use of the voice of medicine (chronic physical complaints) (38). a recent critical study was conducted on dpr as a phd dissertation in the same context under study here (41). the findings of the study revealed that dialogues and dprs involved a special political economy of medicine which reproduced doctors’ interests within a scientific discourse (14). furthermore, this confirms our findings that doctors are becoming increasingly materialistic. another study showed that the medical field was governed by power iniquities in which doctors could finalize their interaction with patients or suppress them whenever they saw fit (6). the comparison of findings of the present study to those of the researches reviewed revealed that each of them unfolded a portion of dpr realities, which can be divided into two general subcategories of ontological and structural. although the mentioned researches mostly revealed ontological and epistemological aspects of dpr, the present study mainly identified the malfunction of the health system structure within the cultural context in case of distorted dprs. generally, it can be said that the most important finding in this study is that inefficient infrastructure plays a central role in the continuity of distorted dpr. under these circumstances, dpr occurs in a chaotic state which is totally dependent on doctor's personality. as was mentioned, better organization of the health care system can limit the number of cases of corruption between doctors and patients (42). in this regard, it was suggested that e-health system should monitor and evaluate the observance of ethics by physicians (43). an important limitation of this study was that it was conducted with views of faculty members. however, the views of patients, patients’ relatives, and managers of hospitals and clinics are also important to develop the subject. we suggest that future studies follow the subject with regard to the views of these individuals. furthermore, further studies with emphasis on quantitative approach are required to evaluate our findings. moreover, another limitation was that there were no similar studies with which to compare the results of the present study. conclusion our results show that distorted dpr is a natural phenomenon in our context. even though others have stated that distorted dpr is part of modern medicine, this issue in our context is related to inefficient infrastructure of the health care system. this inefficient infrastructure does not teach doctors social and medical ethics and does not have appropriate supervision over their behavior. thus, dpr is completely dependent on the individual character of the doctors rather than the rationality of the system. therefore, this leads to ignorance of patients’ rights which ultimately results in inappropriate dpr and brings about deception, dissatisfaction, and cost burden. this illustrates the necessity of a real change in policymakers’ approach and the way they view the health care system in order to improve its infrastructure. therefore, medical ethics has to be thought in a way that physicians are socialized ethically, in addition to being controlled and surveyed. acknowledgment this research was supported by department of medical ethics and philosophy of health (grant no. hp 49-90) at shiraz university of medical sciences, shiraz, iran. the researchers would like to thank for dr sz tabei and all of participants. also, the authors would like to thank the research consulting center of shiraz university of medical sciences (rcc) for their assistance in editing this article. j med ethics hist med 9:2 april jmehm.tums.ac.ir ahmad kalateh dati et al. page 9 of 11 ethical issues the article was conducted considering ethical codes of the american sociological association. the ethics committee of shiraz university of medical sciences confirmed ethical aspects of the study. in respect to ethical considerations and the research ethics, the names of all physicians and patients in this study are fictional. also, privacy of patients was taken into consideration. competing interests the authors declare that they have no competing interests. j med ethics hist med 9:2 april jmehm.tums.ac.ir ahmad kalateh dati et al. page 10 of 11 references 1. dorr goold sd, lipkin m jr. the doctor–patient relationship. j gen int med 1999; 14 (suppl 1): s26-33. 2. 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[in polish] 43. sadati ak, iman mt, lankarani kb, derakhshan s. a critical ethnography of doctor–patient interaction in southern iran. indian j med ethics. published online on april, 2016. ______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ original article copyright © 2021 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. journal of m edical ethics and h istory of m edicine experience of indonesian medical students of ethical issues during their clinical clerkship in a rural setting *corresponding author raditya bagas wicaksono address: jalan, dr. gumbreg, nomor 1, mersi purwokerto, 53112, banyumas, jawa, tengah, indonesia. tel: (+62) 85 74 77 68 695 email: r.bagas.wicaksono@unsoed.ac.id received: 29 aug 2020 accepted: 1 jun 2021 published: 13 jul 2021 citation to this article: wicaksono rb, ferine m, lestari dwd, hidayah an, muhaimin a. experience of indonesian medical students of ethical issues during their clinical clerkship in a rural setting. j med ethics hist med. 2021; 14: 6. raditya bagas wicaksono1*, miko ferine1, diyah woro dwi lestari1, arfi nurul hidayah1, amalia muhaimin2 1.lecturer, department of bioethics and humanities, faculty of medicine, universitas jenderal soedirman, purwokerto, indonesia. 2.lecturer, department of bioethics and humanities, faculty of medicine, universitas jenderal soedirman, purwokerto, indonesia; researcher, department of ethics, law, and humanities, amsterdam university medical centres, university of amsterdam, the netherlands. abstract although ethics is an essential part of medical education, little attention has been paid to ethics education during the clerkship phase, where medical students observe how physicians make decisions regarding various ethical problems. specific nuances and cultural contexts such as working in a rural setting can determine ethical issues raised. this phenomenology study aimed to explore ethical issues experienced by indonesian students during clinical clerkship in a rural setting. in-depth interviews were used to explore students’ experiences. participants were ten students, selected on gender and clerkship year variations. data saturation was reached after eight interviews, followed by two additional interviews. thematic analysis was used in this study, and trustworthiness was ensured through data and investigator triangulation, member checking, and audit trail. three main themes found in this study were limited facilities and resources, healthcare financing and consent issues, as well as unprofessional behavior of healthcare providers. many ethical issues related to substandard care were associated to limited resources and complexities within the healthcare system in the rural setting. early exposure to recurrent ethical problems in healthcare can help students prepare for their future career as a physician in a rural setting. keywords: ethical issue; medical students; clinical clerkship; indonesia. experience of indonesian medical students of ethical issues during … 2 j med ethics hist med. 2021(july); 14: 6. journal of m edical ethics and h istory of m edicine introduction ethics has been considered an essential part of medical education in developed countries (1,2). this concern is currently the case in developing countries, including indonesia, where competencies in ethics are stated clearly in the standar kompetensi dokter indonesia (skdi), competency standards of medical doctors. however, ethics education was overlooked during clinical clerkship phase, where medical students may encounter various ethical problems and authentic learning experiences throughout their clinical training (3,4). teachers and healthcare providers may have different perspectives and standards when managing ethical issues, causing challenges and difficulties for students in understanding and mastering skills in ethics (5). moreover, when confronting ethical issues, medical students often feel hopeless and powerless, perceiving themselves as the lowest in the hierarchy (6). throughout the world, ethical issues faced by medical students during their clerkship phase vary from profession-related issues (e.g., inappropriate physician behavior, physician-patient and physician-peer relationship) to issues surrounding end-oflife care, privacy and confidentiality, and informed consent (7–11). nevertheless, issues related to financing difficulties and justice emerged in some studies (7,8). other studies reported issues regarding uncertainty of students’ roles and responsibilities in healthcare, leading to dissatisfaction with how they manage ethical concerns during the clerkship (11–13). different healthcare settings with particular nuances and cultural contexts in each area can determine the type of possible ethical issues (14). this nuance includes remote and rural areas where human resources and healthcare facilities are scarce and access to healthcare is limited, making it challenging for patients (15,16). not many studies focused on ethical issues reported by the medical students in the areas with the scarcity of healthcare resources in indonesia. therefore, this study aimed to explore ethical issues encountered by the medical students working in a rural setting in indonesia. methods study design, participants, and setting this phenomenology study used purposive sampling and collected data through indepth interviews (17). medical students involved in this study had their clinical clerkship in banyumas, central java, indonesia. participants eligible for this study were medical students who had attended six months of clinical clerkship. medical students in indonesia must undergo two years of clinical clerkship; hence, participants were categorized into the first year and final year. as a part of data triangulation, a wide variety of students were chosen considering gender and clerkship year variations. participants were added until data saturation was reached. data saturation has been an important part of the qualitative research methodology where new data tend to be redundant (18). after eight interviews, data saturation stage was reached, and two additional interviews were conducted to ensure that no new data or code would appear. bagas wicaksono r., et al. 3 j med ethics hist med. 2021(july); 14: 6. journal of m edical ethics and h istory of m edicine data collection data was collected in september-october 2019, and participants were informed about the study goals. interviews were conducted by rbw, dl, and mf in bahasa indonesia based on the following questions: • during your clinical clerkship, have you ever encountered any ethical issue? • can you tell us the most notable cases you have experienced? • are there any other cases that you still remember? additional questions were asked according to the participants’ responses to these base questions. the duration of interviews ranged from 32 minutes to 76 minutes (average of 45 minutes). due to familiarity of participants with the interviewers, establishing relationship and trust was straightforward, which was required to ensure the honesty of participants’ answers (19, 20). data analysis thematic analysis was employed to identify, analyze, and report the patterns and themes that emerged from the data (21). interviews were transcribed verbatim by two members of the research team (rbw and dl). transcriptions of the interviews were initially coded and analyzed by rbw and mf, and further discussed with all investigators to review the codes. two team members, anh and am, did not conduct the interviews and were involved in data analysis, to enhance study’s credibility. involving different investigators from various backgrounds –notably medical physicians, medical educators, and psychologists – is a part of investigator triangulation to enhance study’s credibility (21,22). all research team members discussed all findings and codes to have a general understanding of the data. after the refinement and removal of the overlapping codes, the team classified the codes into eight categories and three themes. discussions were done iteratively until consensus and data saturation were reached. study trustworthiness the trustworthiness of this study was ensured through several validation strategies such as data and investigator triangulation, member checking, and audit trail. the credibility of the study was maintained through the member checking process by sending data, interpretations of transcripts, and conclusions to the participants. this process was done to ensure their meanings and perspectives were correctly translated and represented (23). some of the participants suggested minor adjustments; therefore, adjustments were made accordingly. all participants responded well and agreed with interviews’ translation and interpretation. the first author kept the records of raw data, transcripts, and reflexive journals to ensure a clear audit trail and increase credibility (21). ethical and research approval this study was approved by the health research ethics committee of the faculty of medicine, universitas jenderal soedirman (application no. 3533/un23.07.5.1/pp.1/ 2019). in accordance with the declaration of helsinki, permission for audio recording and experience of indonesian medical students of ethical issues during … 4 j med ethics hist med. 2021(july); 14: 6. journal of m edical ethics and h istory of m edicine field-note taking was obtained in written consents before the interviews. the interviewer explained that all data would be kept anonymized and unidentifiable to ensure the privacy and confidentiality of participants, patients, physicians, and other healthcare providers result ten students were interviewed with a balanced distribution of gender. participant's characteristics are presented in table 1. in this study, twenty-eight codes were found, classified into eight categories: substandard care, lack of privacy, students’ exploitation and less prioritized education, financial difficulties, issues of consent, fraud, harassment, and inadequate interprofessional collaboration. all categories were then classified into three themes: (i) limited facilities and resources, (ii) healthcare financing and issues of consent, and (iii) unprofessional behavior of healthcare providers. table 1participants’ characteristics p articipants gender clinical clerkship’s year interview duration (minutes) 1 male first-year 58:23 2 female final year 41:09 3 female final year 47:47 4 female final year 38:07 5 male final year 32:13 6 female first-year 35:57 7 male first-year 47:10 8 male final year 38:13 9 female final year 38:22 10 male first-year 76:46 table 2 delivers an outline of ethical issues experienced by students during clinical clerkship in a rural setting. the classification of ethical issues was arranged based on their relevancy with certain areas in bioethics, healthcare, and education. table 2ethical issues observed by students during clinical clerkship codes categories themes under time consultation physician interrupting patient overload emergency department slow response of the supervisor determining the patient’s medical plan without further examination rushed examination hasty operation substandard care limited facilities and resources discussing patient’s diagnosis in front of other patients examining more than one patient in a room lack of privacy unnecessary task which was unrelated to education excessive workload patient care relied on student’s existence students did procedures without supervision limited time for clinical coaching students’ exploitation and less prioritized education limited medication choice in national health insurance formularies inadequate therapy due to limited insurance coverage patient’s accommodation not covered by insurance financial difficulties healthcare financing and issues of consent delayed life-saving procedure directive informed consent issues of consent falsifying patients’ medical condition making up cpr scenes doctor brags to cover up futile operation fraud unprofessional behavior of healthcare providers verbal humiliation among healthcare providers sexual harassment of medical students bullying in the clinical clerkship harassment nurse disobeying physician’s order physician refusing to consult a nutritionist for diet therapy inadequate inter-professional collaboration bagas wicaksono r., et al. 5 j med ethics hist med. 2021(july); 14: 6. journal of m edical ethics and h istory of m edicine limited facilities and resources participants in this study often shared cases of substandard care due to limited facilities and resources, which negatively affected the quality of care. a participant shared her experience witnessing a physician who has 100 to 150 patients a day. the physician requested the student to type the prescription long before the consultation started, to accelerate the patient flow. “in one of the outpatient clinics, there were hundreds of patients every day. before the patient came inside the examination room, the physician already prescribed the medications. this happens every day! so, the patient only met the physician for one or two minutes. i mean, just like that?” [participant no. 3] other participants also observed limited contact time between the physician and the patients. in some cases, the physician did not respond to the patients’ complaints regarding their health condition. several examinations and medical procedures were done carelessly and in a rushed setting. even when a surgical procedure was needed, the physician did not explain thoroughly to the patient. hence, the patient’s hopes and expectations while visiting the physician could not be fulfilled. limited healthcare resources led to other issues related to privacy and confidentiality. some participants witnessed how patient’s privacy was neglected, for instance, when a specialist simultaneously examined more than one patient in the outpatient clinic. “patients were called into the physician’s room, and they were sitting next to each other, in front of the specialist. all of this happened in less than 5 minutes. patients came in, the physician checked the medical records for previous diagnosis and treatment, and the physician asked, “what’s your name?” then, “all right, this is the prescription, go out,” without any proper examination.” [participant no. 6] she felt that this practice was inappropriate in any medical case, especially when patients have a severe condition or suffer from a terminal illness. patients were also not allowed to ask any questions, let alone to make an informed decision. other participants also witnessed a specialist instructing a patient to unbutton her shirt in the presence of other patients. patients were mostly startled, but they hesitated to refuse the order. students also stated issues surrounding the training system in clinical clerkship. one prevalent issue was the exploitation of medical students. students complained that their time was mostly used to help provide care to the patient while not receiving adequate supervision from their supervisors (medical specialists), especially when facing shortage of healthcare workers. a participant described those students often received instructions from nurses to perform tasks unrelated to medical training. “tasks without any relation to clinical knowledge are not supposed to be given. i disagree on this matter. for instance, we have to transport the patient from the emergency delivery room in the front part (of the hospital), to the neonatal ward way experience of indonesian medical students of ethical issues during … 6 j med ethics hist med. 2021(july); 14: 6. journal of m edical ethics and h istory of m edicine back there… i think we should use our energy efficiently since we have many things to do….” [participant no. 10] the participant thought that tasks given to medical students should have clinical relevance not to cause unnecessary fatigue, affecting their work performance in the department. healthcare financing and issues of consent ethical issues regarding substandard care also involved by the healthcare financial complexities or were caused by them. participants observed difficulties and dilemmas faced by physicians when deciding on the treatment plan. disparities were observed between treatment in the medical guidelines and the jaminan kesehatan nasional, or jkn national health insurance formulary. “physicians often told us that the jkn formulary is inaccurate. but still, we follow the formulary... since most patients are jkn patients, so we have to follow the jkn rule to get the insurance claim... ‘it’s very limited, we can’t give therapy based on the guideline’... these are complaints from physicians...” [participant no. 8] a participant observed a case of delayed treatment on an emergency patient due to issues of consent. “the internist ordered emergency hemodialysis for him, but it was not performed. there was no guardian or family member who could sign the consent form. the emergency physician, internist, and hospital staff were all reluctant to perform the hemodialysis… as far as i know, there is no need for consent for life-saving medical procedures. why did the hospital refuse to do the hemodialysis?” [participant no. 4] the participant believed that informed consent was not needed in an emergency setting. nevertheless, the hospital and medical team were doubtful to perform emergency hemodialysis in this case, as there was nobody available to give consent and funding guarantee. unprofessional behavior of healthcare providers the participants shared cases of unprofessional behavior from healthcare workers, including fraud and harassment. a participant, witnessed how a healthcare worker manipulated a patient’s condition while reporting to the specialist on duty. the student knew the patient’s real condition and was aware of the invalid data in medical reporting. “she (the healthcare worker) didn’t want to wait as it was rather a long observation to go. usually, they report it (the patient’s condition) as worsening. just like now… she called the specialist, ‘the patient is now vomiting.’ in this patient’s case, vomiting is a subjective emergency symptom that may become an indication for operation.” [participant no. 7] the specialist eventually gave instructions for operation, which would be performed by a resident in the department. the patient was then transferred to the emergency operation room. according to the student, this was not the only case related to the manipulation of data. he encountered multiple similar cases while undergoing his clinical clerkship. bagas wicaksono r., et al. 7 j med ethics hist med. 2021(july); 14: 6. journal of m edical ethics and h istory of m edicine another student, witnessed what he called a “fake” cardiopulmonary resuscitation (cpr) since it was only done superficially or incompletely. he was annoyed and tried to make suggestions on how to perform a qualified cpr to the available nurse in the ward, which was ignored and thereby created one of the most memorable ethical issues for him. students sometimes became an object of harassment by the medical team, and a male student witnessed how his female colleagues were verbally harassed in the operation theatre. “from what i saw by myself and what my friends experienced...it was more or less harassment, mostly done by (male) nurses... verbally, starting from ‘have you ever done breast self-examination (sadari)? where did you do that? come here, let me do that to you’...also physical (harassment) like... grabbing one’s shoulder and hip… even hugged from behind... sadly, sometimes, the physician also joins the conversation by asking simple questions like… ‘do you have a boyfriend? what things have you done together?” [participant no. 5] he thought that such behavior is unacceptable, especially in an academic setting. he felt upset to see the same practice repeatedly. other unprofessional conduct occurred in collaboration between physicians and other healthcare workers. for instance, a student, reported a physician who deliberately discarded patient’s meal provided by the hospital nutrition unit because it was considered unhealthy. the patient was startled. the physician hesitated to talk directly to the hospital nutritionist because he believed his dietary plan was better than that of the hospital. another case of collaboration difficulty among healthcare providers was also shared by another student, who shared his experience regarding patient transfer from the emergency department to the clinical wards. he observed a delay in therapy due to the patient being referred and transferred back and forth, from one department to another. “so, this patient was unconscious. we assumed it was a uremic case because he had chronic kidney failure. but we also realized that it could be a hemorrhagic stroke caused by heparin during hemodialysis. anyway, the emergency room (er) physician referred him to internal medicine. from internal medicine, the patient was referred to neurology and referred back to internal medicine. eventually, a ct scan was performed, and it was indeed a hemorrhagic stroke. so, we consulted the neurology department. unfortunately, the patient died before therapy was given” [participant no. 1] he thought this case might be caused by ineffective communication among the medical team members, including inadequate information reported by the student and er physician during the referral consultation process. discussion issues regarding substandard care due to limited facilities and resources were also found in previous studies in indonesia (24– 26). this finding was consistent with those experience of indonesian medical students of ethical issues during … 8 j med ethics hist med. 2021(july); 14: 6. journal of m edical ethics and h istory of m edicine of another study, where problems of justice and quality of care were ubiquitous in indonesia, compared to the netherlands (24). the same concern was also observed by medical students who took an international health elective rotation in lowresource countries such as nepal, india, ghana, kenya, south africa, and others (11,14). patient overload, as found in the present study, is closely related to disparities in the number of healthcare providers between urban and rural areas in indonesia. the shortage of physicians in rural areas is influenced by multiple factors, such as low population and limited healthcare infrastructures, closely related to the geographical factors (15, 27). banyumas region is located in the rural area of the central java province where reaching the capital city of central java takes five to six hours by car or train. around 1.8 million population live in banyumas, who are mostly low educated and graduated from elementary school. the general physician to patient ratio in banyumas is 17.8 per 100.000, below the national standard; 43 per 100,000. however, medical practice nowadays should focus on patient-centered care, instead of the old-fashioned one-way consultation style. physicians should have a holistic view of the patients, including psychological and social aspects, instead of only focusing on the disease (28). a study from china shows that physician’s high patient load has negatively affected patient-centered care (29). the government’s policy regarding physician distribution is needed to resolve this systemic problem of health inequality. however, limited healthcare resources might be associated with other issues related to privacy in this study. patient’s privacy and confidentiality should be maintained in healthcare service. a previous study showed that not every patient in developing countries might have the same degree of privacy. physicians might not be aware of patient rights, including protecting privacy and confidentiality (30). patients from south east asia mostly agreed to all physician’s actions, due to their paternalistic relationship (31). however, the situation might differ between patients in cities and urban and rural areas, mainly due to differences in the level of knowledge and how they perceive their rights and responsibilities within the physician-patient relationship. patients coming from a low level of education and low socio-economic class might not be aware of their rights, and most of them have no courage to request further (32, 33). such lack of awareness results from an emergent social distance between physician and patient (34). in addition, limited healthcare resources might have both positive and negative impacts on medical training. students may have more experience in managing ethical dilemmas in patient care due to this limitation. however, as shown in previous studies, inadequate number of healthcare workers may lead to the exploitation of medical students and their burnout (35, 39). bagas wicaksono r., et al. 9 j med ethics hist med. 2021(july); 14: 6. journal of m edical ethics and h istory of m edicine burnout might affect students personally and professionally, including decreased empathy and increased dishonest behaviors (37). medical students may experience emotional exhaustion, symptoms of depression, and low sense of personal accomplishment when compared to residents and early career physicians (35). several factors associated with students’ burnout were as follows: (i) poor learning environment, (ii) inadequate support from faculty staff and colleagues, and (iii) limited opportunities for clinical coaching recieved from supervisors (37). nonetheless, while mentally and physically exhausting for students, medical clerkship should be designed to improve students’ experience and knowledge. financial issues remain a crucial part of the healthcare system. financial difficulties were uncommon in similar studies from western countries, but were observed by medical students from indonesia and india (7,24). indonesia has implemented jkn as a national health insurance scheme since 2014 to bridge disparities of healthcare access. however, jkn faced a financial deficit, resistance from health professionals, and suspected management failure since its release (40). the financial deficit might be caused by catastrophic diseases covered by jkn, such as cardiac diseases, cancer, thalassemia, and others. unethical practices such as bloody discharge, upcoding, and unnecessary readmissions could further increase the deficit. through indonesia case-based groups (ina-cbgs), the indonesian ministry of health has regulated a pathway for health providers to improve cost-effectiveness. the system of inacbgs includes the rate of every service in patient care (e.g., physician consultation, workups, and treatment) based on a national drug formulary. nevertheless, meticulous budget control might negatively affect the quality of care. balancing the quality of care and costeffectiveness is challenging for medical practice (41, 42). extensive and intensive discussions among insurance representatives, hospital management, and attending physicians can help plan and budget medical care as well as find solutions when funding is limited. delayed emergency treatment due to issues of consent was a case found in the present study. a body of evidence confirms that issues related to respecting patient autonomy, including informed consent, are recurrent ethical problems encountered by medical students in their clinical training (7, 9, 10, 12). however, informed consent in an emergency setting was complicated as multiple factors were involved. in this case, no family member or guardian were available to give consent, leading to obscurity of the patient’s funding. hospital staff may face difficulties in determining who will guarantee patient’s medical bill payment. although the indonesian government had stated that every patient in an emergency condition should have firstaid regardless of funding, such experience of indonesian medical students of ethical issues during … 10 j med ethics hist med. 2021(july); 14: 6. journal of m edical ethics and h istory of m edicine implementation is challenging. in rural areas where health funding is limited, financial uncertainty would be problematic for hospital management. some hospitals also faced delays in insurance claim payments, which further increased their financial burden (43). government and healthcare providers should discuss and find appropriate solutions for such dilemmatic conditions. in indonesia, the implementation of informed consent is not always ideal. informed consent is an indispensable part of respecting patient autonomy. nevertheless, informed consent is sometimes perceived as a legal protection for the physician against potential lawsuits. hence, the focus changes from respecting patient autonomy to obtaining patient’s signature. unfortunately, patients often sign the consent form without fully understanding the procedure they are going to experience (44). regarding informed consent, indonesia’s ministry of health has published a specific regulation stating that informed consent is not needed during an emergency and life-saving procedure4. while physicians are required to uphold beneficence and prioritize patient’s interest in emergency cases, they might hesitate to perform an emergency procedure without written consent – even though it is permitted by law – due to potential risks of being reported for malpractice. lately, physician criminalization and lawsuits regarding medical malpractice in indonesia escalated due to increased awareness of patient rights and self-determination . various issues related to professionalism were prevalent in previous studies, such as inappropriate or rude behavior of healthcare personnel and dishonesty (5, 7, 24). professionalism is related to clinical competence, communication skills, and ethical and legal understanding (45, 46). as part of honor and integrity, physicians are expected to be faithful and truthful; however, dishonesty and fraud are not uncommon in healthcare settings (47). falsifying medical records is an example that is also predominant in other regions in indonesia, as well as in other countries (48, 49). in some cases, specific working environments might force healthcare workers to falsify medical records (49, 50). issues regarding fake cpr were also found in other countries, in form of slow code, defined as less rigorous resuscitative efforts or prolonged cpr than usual (51). it was more of a symbolic gesture than an effective medical intervention. families want to be involved, engaged in patient care, and treated respectfully during cpr (52); however, slow code is still ethically debatable (51). issues of student harassment were also found in the present study. harassment in medical school is not unheard and still exists (53, 56). a study from pakistan reported that around 28% of medical students were exposed to varieties of harassment, such as verbal, sexual, or physical abuse. supervisors were reported as the most frequent offender (56), whereas they are bagas wicaksono r., et al. 11 j med ethics hist med. 2021(july); 14: 6. journal of m edical ethics and h istory of m edicine expected to offer students an excellent example of behavior as part of the hidden curriculum (57). however, reporting harassment was dilemmatic for students, let alone confronting the offender directly. significant obstacles to reporting harassment in workplaces include fear of retaliation from the abuser and shame (58). although considered less powerful, medical students could discuss their problems and difficulties during training with their peers and reachable supervisor. bullying and harassment awareness should be increased through open discussions and consultation. other vital aspects of professionalism required in qualified health care are interprofessional collaboration and effective communication. a previous study showed improvement in at least one outcome following inter-professional collaboration (59). decent quality of teamwork and coordination among healthcare providers from different disciplines can lead to better understanding of patients’ problems, thus preventing mistakes and unnecessary disadvantages in health care (60). collaborative clinical reasoning and shared decision-making of different health professionals are two core processes needed to solve patients’ medical conditions (61). effective communication among healthcare workers is also crucial in emergency cases involving several specialties (62). emergency physicians should know which specialist should be consulted and prepare sufficient medical information before the consultation. they are expected to be professional, pertinent, and anticipative (63). however, emergency physicians might face difficulties due to conflicting values, beliefs, and perspectives with their colleagues (64). medical students also experienced issues regarding termination of life such as euthanasia and ending of life’s support devices (9, 10, 24, 65). however, these issues were not emphasized by the present study’s participants. indonesian patients and their families are less likely to request life support termination due to predominant social-cultural-spiritual context that differs from that of western countries. moreover, euthanasia is not legally permissible in indonesia as it is forbidden by the current law and regulations (66). thus, the participants hardly experienced such issues, especially in indonesia’s rural area. strengths and limitation this phenomenology study provided a better understanding of medical students’ experience in managing ethical issues during their clinical rotation. however, more studies with larger sample sizes are needed to investigate ethical issues encountered by medical students during their clerkship in other rural settings, as well as urban settings, in indonesia. future research, using mixed quantitative and qualitative studies, can provide a more robust understanding of ethical issues observed by medical students. experience of indonesian medical students of ethical issues during … 12 j med ethics hist med. 2021(july); 14: 6. journal of m edical ethics and h istory of m edicine conclusion ethical issues observed by medical students in this study were related to limited facilities and resources, healthcare financing and issues of consent, as well as unprofessional behavior of healthcare providers. many ethical issues related to substandard care were strongly associated with limited resources and complexities within the healthcare system. early exposure to recurrent ethical problems in healthcare can help students prepare for their future career as a physician in a rural setting. to provide more real examples of ethical issues, new strategies in ethics education are needed to provide students with a deep understanding. however, this study’s results may or may not be limited to specific rural areas, as no similar studies have been conducted in urban settings in indonesia. acknowledgements the funding of this study was from research grant “riset peningkatan kompetensi” from lembaga penelitian dan pengabdian masyarakat universitas jenderal soedirman (grant number b/53/un23/14/pn/2019). conflict of interests the authors declare no conflict of interests related to the study, and they are exclusively responsible for the content and writing of this article. authors’ contribution the research proposal was developed by mf. interviews were performed by rbw, mf, and dl. rbw, mf, dl, and anh analyzed the data and discussed it further with am. manuscript writing was led by rbw and further developed by mf, dl, and am. all authors have read and approved the final manuscript. bagas wicaksono r., et al. 13 j med ethics hist med. 2021(july); 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________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ 1 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e original article volume 13 number 20 december 2020 copyright © 2020 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. barriers of students’ adherence to dress code policy in clinical settings: dental students’ viewpoint nafiseh momeni1 fariba asghari2* 1.phd candidate in medical ethics, department of medical ethics, school of medicine, tehran university of medical sciences, tehran, iran; researcher, dental research center, dentistry research institute, tehran university of medical sciences, tehran, iran. 2. associate professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. abstract medical universities have called for a professional dress code to preserve the dignity of the medical profession, creating a sense of respect, tranquility, and trust in healthcare recipients and improve patient safety. this study aims to explain the reasons behind poor adherence to the professional dress code by students of the dentistry school. a qualitative study was conducted to explain the viewpoints of dentistry students of tehran university of medical sciences (tums). twenty-three in-depth interviews with dentistry students of different genders, study years, living in different accommodations, and having different tuition payment status were conducted. conventional content analysis was used to analyze the data. one hundred and twenty initial codes were extracted. they were categorized into common causes of non-adherence to the tums dress code and specific causes of not following a specific section of the dress code (hygiene, jewelry, and makeup sections). the codes of common causes were categorized into 4 main categories including defects in education, management shortcomings, changes in societal culture, and personal factors. all components of the educational system must be aligned with each other to overcome the barriers against the students’ adherence to professional dress and put forward appropriate interventions at the policymaking, regulatory and educational levels. keywords: dental student; guideline adherence; clothing; dress code. *corresponding author fariba asghari no. 21, medical ethics and history of medicine research center, 16 azar st., tehran, iran. tel: (+98) 21 66 41 96 61 email: fasghari@tums.ac.ir received: 2 jun 2020 accepted: 1 nov 2020 published: 5 dec 2020 citation to this article: momeni n, asghari a. barriers of students’ adherence to dress code policy in clinical settings: dental students’ viewpoint. j med ethics hist med. 2020; 13: 20. barriers of students’ adherence to dress code policy … 2 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 20 december 2020 introduction the doctor-patient relationship plays a central role in providing high-quality health services (1). in the educational-clinical setting of the dentistry schools, this relationship is established between the patients and undergraduate or postgraduate students. evidence shows that when both sides of a relationship (in this case the patients and dental students) do not know each other, they use the available information to form their judgment (2); therefore, the verbal and nonverbal elements of the patientdoctor relationship are of particular importance (3). the clinicians’ appearance and wardrobe choices are parts of their non-verbal behavior. clothing in the clinical settings not only provides physical security at the individual level, but also acts as an important means of transmitting personal and social messages at the social level (4), and reflecting the traditions, values, and beliefs of the professional community (5). studies have also shown that patients value their doctors’ appearance and even consider it as a measure of their competence and trust ability (6, 7). since professional dress codes can help to develop a successful doctor-patient relationship (8) and may be considered as a subset of the professionalism concept, many medical universities around the world have regulated dress codes (9, 10). in tehran university of medical sciences (tums), the dress code was approved at the university council (11) and was delivered to all the schools. in this guideline, the articles are categorized under three sections of clothing, jewelry and makeup, and hygiene. previous studies have indicated that while the majority of students appreciate the importance of professional dress code (7), they don’t adhere to it (12, 13). kaveh et al. studied the factors influencing students’ adherence to the dress code based on the theory of reasoned action. they did not take into account the students' views on the noncompliance reasons (12); while, their viewpoints can point out the barriers to adherence to dress code in the clinical setting. knowing these barriers can help with improving the students’ professional conduct. thus, this qualitative study aims to explain the barriers to adherence to professional dress code based on the students of the tums dentistry school viewpoint. method the qualitative approach using conventional content analysis (14) technique was used to study students’ viewpoints on non-adherence to professional dress code. the study subjects were selected from among the undergraduate and postgraduate students of the dentistry school of tums, from october 2018 to march 2019. the inclusion criteria were studying in the clinical phase of dental education and signing informed consent to enter the study. the following variables were taken into account in the convenience sampling method to guarantee maximum diversity:  study year: undergraduate/postgraduate student  gender: male/female momeni n., et al. 3 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 20 december 2020  living condition: living with family or in student house/university dormitory  tuition fees: yes/no the information was collected mainly through a semi-structured in-depth interview in a quiet, stress-free location, preferably selected by the interviewees. the interviews were guided by a list of questions including “have you ever read the “university dress code”?” “what do you think about the dress code?” “in your opinion, do your peers follow the dress code in the clinical settings of dental school?” and “what are the barriers against adherence to the dress code in the clinical settings?” interviews were conducted on 23 students and recorded. after each interview, the record was transcribed verbatim; which was repeated as needed. after the initial codes were extracted, the main categories were identified based on similarities. the analysis of the last two interviews indicated data saturation. the length of the interview sufficient time was dedicated to interviews to increase the acceptability of the study and the reliability of the interviews and attempts were made to establish good communication with the participants. in addition, respondents were assured that their information would remain confidential and that the individual results would not be declared to any authority. it is noteworthy that in 10% of the interviews, the coding process was performed for a second time independently by a ph.d. student of medical ethics with good knowledge of the subject, and the results were compared with the researcher’s codes. the agreement was obtained after discussions on the points of disagreement. although the generalizability of qualitative studies is inherently impossible (15), attempts were made to use alternative approaches for this purpose. for example, the maximum diversity was considered in sampling and the researcher tried not to interfere with the interview process, for instance by avoiding playing the role of a consultant. during the interviews, the researcher balanced between her roles of being an interviewer and a researcher. ethical considerations written informed consent was obtained from all participants after they were clearly informed of the research objectives. their right to leave the research was also considered during the study. their personal information was kept confidential. this study was reviewed by the ethics committee of tums and approved with the code ir.tums.vcr.rec.1395.1651. results twenty-three students participated in this study. their demographic characteristics are presented in table 1. they were asked about their prior knowledge of the dress code policy of tums in the clinical settings. only 1 participant had never heard about the policy, 4 had heard about it but had never read it carefully, 5 had read it but were unable to barriers of students’ adherence to dress code policy … 4 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 20 december 2020 remember its contents, and the remaining 13 were familiar with its contents. table 1the demographic characteristics of the participated students number % gender female 13 52/56 male 10 48/43 study level undergraduate 16 57/69 post graduate 7 43/30 living status with family 10 48/43 student house 4 39/17 university dormitory 9 13/39 tuition fees yes 4 39/17 no 19 6/82 except for one participant who believed that the dress code was not respected by students and four others who believed that a few students respect the dress code, the other participants stated that the dress code policy was relatively followed by most students. all the participants mentioned that the lack of cleanliness of the white coats was more noticeable than other articles of dress codes, pointing out the reasons for not following the guidelines. in the content analysis of the interviews, 60, 45, and 15 initial codes were extracted about the causes of non-adherence to the clothes, jewelry, and makeup, and hygiene sections of the tums dress code, respectively. further study of the codes showed that most of them were common between the three sections. therefore, the codes were categorized in to common and section specific causes of non-adherence. the matching codes in different categories were merged. finally, 27 codes were extracted from the common causes and classified into 4 main categories. the specific causes were related to causes of non-adherence to hygiene, jewelry, and makeup, which will be described. the main categories of common causes are described below. a. defects of education (table 2 shows the subcategories, codes and participant quotes in this category.) 1. lack of understanding of the dress code policy basis. several respondents mentioned that the basis for the code was unclear to them. three main codes leading to these viewpoints were inadequate training, inappropriate training time, and lack of understanding of their own professional duties. some pointed out that rules for professional dress codes are officially taught to the students before they enter the clinical wards, momeni n., et al. 5 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 20 december 2020 which is why they do not understand the importance of the subject and forget about it. some argued that students did not find themselves responsible to adhere to their duties as dental and medical professionals and obtaining patients' trust. 2. inappropriate role models. everyone emphasized that students are mainly influenced by role models, and their nonadherence to the dress code is the reason the students don’t see the need for it as well. 2-1. academic professors. some students mentioned that they look into the faculties who do not adhere to the dress code themselves, and therefore these students did not take the subject seriously. 2-2. postgraduate and senior students. 2-3. dentists. some respondents mentioned that students follow dentists’ wardrobe choices in private clinics. 2-4. social network: some interviewees pointed out the effect of images and videos of iranian and foreign dentists in the media, adding that their clothing was different from the one accepted by the university. table 2the common causes of students’ non-adherence in “defects of education” category subcategory code participant quote lack of understanding of the dress code policy basis inadequate training scientific reasons to justify dress code adherence have not been explained to the students. inappropriate training time a single-session about the dress code was held when the clinical practice had not yet been initiated. lack of understanding of their professional duties the students do not know their position in the medical profession, so they do not strive to preserve dignity and respect for the medical profession. inappropriate role models academic professors the students follow their instructors' wardrobe choices because they consider it as a sign of their success and wealth. postgraduate and senior students residents' attire, which is often not in accordance with the dress code attracts the attention of undergraduate students. dentists dentists' dress in private practice is very different from the “university dress code” and since many students work during their training, they consider that attire as the custom of the dental profession. social network students' perceptions of the dentist attire are what they see in movies and social media advertisements, which is modern and appealing and differs from the “university dress code”. barriers of students’ adherence to dress code policy … 6 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 20 december 2020 b. management shortcomings some of the discussed reasons pointed out the management shortcomings in the field. table 3 shows subcategories, codes and participant quotes in this category. 1. lack of clarity of the dress code 2. lack of supervision: although all the interviewees disagreed with the strict regulations and coercion regarding dress and appearance, most of them pointed out a lack of proper supervision in this regard in the clinical environment. 3. failure to take appropriate measures. some pointed out that the management has taken no measures to improve adherence to the dress code. others attributed the problem to a lack of communication. some others mentioned non-addressing adherence to the dress code in the final evaluation of students. a group of students also reported bad planning for washing the white coats at the school, as the reason behind poor hygiene and nonadherence to the dress code. table 3the common causes of students’ non-adherence in “management shortcomings” category subcategory participant quote lack of clarity of the dress code it's not clear what the dress code wants from us. do our sleeves matter? what about the color. lack of supervision compliance with other rules and guidelines is supervised, but no one cares about the dress code. failure to take appropriate measures. the dress code poster at the entrance of each clinical ward is small and does not attract people's attention. a certain time is set for students to take their clothes to the laundry. this time overlaps with their classes. c. changes in societal culture (table 4 shows the subcategories, codes and participant quotes in this category.) 1. cultural effects: all respondents, both male and female, considered non-adherence to be influenced by the societal culture of clothing. they argued that the dental school and the clinical environment is a small part of the community, adding that the new clothing culture contradicts the professional dress codes in some subcategories. 2. patients: two codes were extracted from the interviewees’ comments, indicating how patients are influenced by societal culture. 2-1. lack of reaction to inappropriate appearance. some students pointed out that patients do not react to the inappropriate appearance of those responsible for their treatment, mainly due to their lack of awareness of their rights and/or concerns about the possible impact of their reaction on the treatment process. 2-2. inappropriate reaction to choices in accordance with the dress code. some students believed that their patients' image of momeni n., et al. 7 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 20 december 2020 a good physician was influenced by what they have seen in private practice and social media, and therefore may not respect the students who adhere to the guidelines. table 4the common causes of students’ non-adherence in “changes in societal culture” category subcategory code participant quote cultural effects change in dress culture intuitively, young women and girls in our society wear more makeup compared with the europeans. the same view can be seen in clinical settings. the definition of beauty has changed in modern society. patients lack of reaction to the inappropriate appearance patients usually do not object to students who dress inappropriately because they are worried about their treatment. inappropriate reaction to choices in accordance with the dress code my friend had no makeup, so her patient thought she was not a dental student. if patients have the right to choose a dental student, they will choose the more beautiful ones. d. personal factors (table 5 shows the subcategories, codes and participant quotes in this category) 1.age requirements: the following codes were extracted from the students' comments and are in accordance with their age. 1-1. sense of self-determination: some claimed that they did not follow the guidelines in order to maintain and show their identity, thereby practice their autonomy. 1-2. focus on beauty: many participants noted that they preferred to appear in the clinical wards wearing dresses that they find beautiful. however, their definitions of beauty and fashion were different from the model presented by the “university dress code”. 1-3. attracting others’ attention. 1-4. love of comfort: the interviewees claimed the love of comfort was a strong contributor to non-adherence. they believed that their peers were too lazy and comfortloving to wear the right dress, id badges, and proper shoes, or to wash their white coats. 2. habits: some respondents linked nonadherence to the dress code to being used to opposing behaviors, arguing that the training provided in this regard was not adequate to change habits and create correct behaviors. 3. lack of familiarity with social skills: some believed that family and school have not prepared the students to enter the community, stressing that many of those who did not adhere to the dress codes have never learned social life skills such as respecting others and laws. barriers of students’ adherence to dress code policy … 8 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 20 december 2020 table 5the common causes of students’ non-adherence in “personal factors” category subcategory code participant quote age requirements sense of selfdetermination young people want to express themselves in every way possible focus on beauty the behavior of young people is affected by their love of beauty and they wear clothes that they find most beautiful. they use makeup for the same reason. attracting others’ attention they are wearing attractive clothes and makeup since they need more attention. love of comfort some students prefer cool casual and informal dresses to be comfortable. habits i know someone who is always a messy student and his character is also seen in his clothing. lack of familiarity with social life skills some students do not know the skills of respecting others and so they don't care to win respect for the medical profession. lack of acceptability lack of feedback from students about the dress code, we were never asked to make it easier to execute. considering the dress code stringent this code is too stringent for women and many of its comments are not necessary for clinical practice. disregard to the dental education environment considering the nature of the activities, the dental students’ clothing gets dirty easily and he/she can't wash the white coat during the day. therefore, a dental student should be expected to have a clean white coat in all sections. the unacceptability of the material and style proposed by the school i don't like the model of the white coat proposed in my school, and i never wear it. lack of interest in the field of study we have no incentive to adhere to the codes in the university. patients have to accept us. false pride she/he is proud of her/his education in dentistry and does not follow the rules. instrumental view towards patients sense of irresponsibility students look at the patients as a course they have to pass, and the mentors' satisfaction with their clinical performance is more important than the patients. lack of motivation we have no incentive to adhere to the dress code in the university. patients have to accept us. 4. lack of acceptability: some respondents claimed that some students did not adhere to the guidelines as they did not accept it. 4-1. lack of feedback from students: some believed that as the students’ opinions had not been taken into account during the code momeni n., et al. 9 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 20 december 2020 development and revision, they did not accept and hardly adhere to its terms. 4-2. considering the dress code stringent 4-3. disregard to the dental education environment: some students believed that because some terms of the code did not take into account the dental education requirements, it was unacceptable and unimportant to students. 4-4. the unacceptability of the material and style proposed by the school. the participants mentioned that they were given a white coat by the school, which its style and fabric did not fit them. moreover, while no particular color was assigned for the women’s scarf in the “university dress code”, the dentistry school has considered a particular color for undergraduate students. this was not acceptable for some students. 5. lack of interest in the field of study: some respondents believed some of their classmates had chosen their field of study because of its prestige and future income. they were not interested in the tasks of this job. therefore, they did not care about the goals of adherence to professional dress. 6. false pride: according to some interviewees, being accepted and studying in the field of dentistry and related specialties has led to pride and selfishness among students. therefore, they do not accept or follow the laws. 7. instrumental view towards patients: some interviewees stated that patients were considered as an educational tool. therefore, students did not care about certain goals mentioned in the dress code such as stimulating a sense of respect, tranquility, and trust in the service recipients. they again pointed out the negative influence of their role models, specifically the faculty members, in reinforcing this perspective. according to them, some academics paid more attention to their patients in their private offices and behaved differently in educational settings. some participants pointed out that since students played no serious role in patient management and the residents and professors were responsible for the treatment and students’ mistakes, they felt no responsibility other than learning. therefore, they regarded the patients only as a training model. this feeling was also the reason behind their lack of interest in trying to stimulate their trust by adhering to the professional dress codes. specific causes of lack of cleanliness as noted earlier, all interviewees acknowledged that non-adherence to the cleanliness of the white coats was more evident than other sections of the “university dress code” in the dentistry school. the reasons behind this behavior were similar to many of those mentioned earlier, such as lack of understanding of the basis and importance of the code, inappropriate role models, lack of sense of responsibility toward patients, lack of motivation, inadequate administrative planning, lack of supervision, lack of barriers of students’ adherence to dress code policy … 10 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 20 december 2020 patients’ reaction, love of comfort or laziness, habits and lack of familiarity with social life skills. however, some students stated two extra points: 1. stress from the educational environment: for example, one interviewee said, “stress for passing the course sometimes does not let one care about having a clean white coat and even paying attention to his/her bad dress choice.” 2. fatigue from heavy educational tasks: some stated that they did not use the university’s washing system, and as they were tired from the heavy educational tasks, they did not clean their white coats themselves. this was more common among students who were away from their families. specific causes of non-adherence to makeup and jewelry articles lack of recreational programs in the education system. some respondents believed that facial make-up for women or specific hairstyles for men was fun, and dentistry students used these easy and accessible tricks to blow the steam off their heavy curriculum. they complained about the lack of excitement, cheerfulness, and appropriate recreational programs in their school’s program, considering it as one of the causes of inappropriate appearance in some students. discussion the barriers against adherence to the professional dress code, based on the results of this study, can be summarized in 4 main categories, namely defects of education, management shortcomings, changes in the societal culture, and personal factors. the proper implementation of any policy in a system requires apt training. however, according to the students of dentistry, little effective training in this field, whether formal or informal, has been provided so far. previous studies have shown that various factors influence adherence to the dress code (12), then it is not sufficient just to raise awareness of the issue (13), and even having a positive attitude toward it may not be a sufficient factor for adherence to it (2). so it seems that more attention should be paid to professional dress education to transform the knowledge and attitude into appropriate behavior. lack of understanding of professional duties is a sign of an educational deficit. lorestani et al. (16) in 2010 also introduced this factor as one of the barriers to the internalization of adherence to professional dress code by the medical students of tums (16). this shows that the efforts in professional behavior training have failed to meet the goals. the impact of role modeling in professional behavior training is more important than formal training (17, 18). bramstedt et al. found that teaching ethics and dress code rules had little effect on students’ perception of professional dress; rather, students were more influenced by their educators in clinical settings, which is in line with the findings of the present study (19). in fact, the inactive behavioral role modeling, which is an integral momeni n., et al. 11 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 20 december 2020 part of the education process, occurs unconsciously. indeed, students generate their attitudes and behaviors based on various conditions they are exposed to; this might have a debilitating effect on the formal training of professional behavior (20). from the students’ point of view, the problems at the management level also act as a barrier against students’ adherence to the dress code. asaju attributed this nonadherence to the lack of leaders' tendency toward implementation of the dress code (13). he believed that different components of the educational system should plan a single proper intervention and coordinate with each other to achieve the final goal. in addition, establishing communication between the executive authorities and the students can help to take and implementing appropriate measures in this regard (21). however, the managers should be careful about unnecessary or discriminatory interventions and prevent stress in the educational setting. the results of this study confirm that personal wardrobe choices are influenced by the social environment (22) and peers (12, 23). when people understand social support for the dress code, they will be more likely to adhere to it (12). because of the changes in fashion trends over the years, the present study shows a lack of social support for the dress code, building a barrier against its adherence. patients’ opinion reflects the viewpoints of the community. bahrami et al. studied the professional dress choices of the dentists from the patients’ perspective (24). they reported that more than 50% of the patients did not support the dress code. in the present study, similarly, the participants mentioned that most patients do not support the dress code. although 80% of the iranians believe the wardrobe choice influences one's trust in physicians (5, 6), their definition of professional clothing is a narrow definition. whiteness, cleanliness, and formality of a professional dress are three components considered important by the patients (6, 24). therefore, it seems that in reviewing the dress code in clinical settings, it is good enough to emphasize more on what is stated as the primary purpose, namely infection prevention, and patient and clinicians safety as well as the creation of a sense of respect, tranquility, and trust in service recipients; that is, the additional cases should be addressed in other regulations or guidelines. interviewees also found that personal factors may also result in non-adherence to the professional dress codes. some of these factors result from the students’ pre-college education, or requirements of youth, or their educational experience. the rapid social and technological changes in recent years have reformed the preferences of the new generation (7). the youth’s preferences may be in conflict with professional appearance guidelines; so those who are expected to adhere to those guidelines may find it unacceptable. this is not specific to the school investigated in this barriers of students’ adherence to dress code policy … 12 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 20 december 2020 study; similar results have been reported in studies conducted in other schools (7, 25). as a result, a dress code designed in the past would not be acceptable for the thirdmillennium generation now entering university, as they may consider it old, outdated, and not acceptable. urging students to follow guidelines that they do not accept causes frustration and stress (25). as a result, it would be more acceptable if the policymakers achieve the adherence to dress code goal by planning for students' education on the effects of proper clothing on the doctor-patient relationship or prevention of possible infection/contamination. in line with the heidarzadeh et al. study, most of our participants believed that adherence to dress code is at an appropriate level (8). it seems that alteration in social culture and personal preferences have changed the participants' view towards considering the proper wardrobe the same as common clothing. it is noteworthy that while this study was conducted in the dentistry school and the clinical environment of that school is different from general and specialized hospitals, it seems that the mentioned students’ perspective is not specific to this context. however, it must be taken into account that although the media have made similarities in clothing in different geographical parts, cultural differences are still effective in clothing. this point should be considered in generalizing the results of this study to the students across iran. conclusion based on the findings of this study, all components of an educational organization must be aligned with each other to overcome the barriers against the students’ adherence to the professional dress code. on the one hand, by taking into account the social evolution and the morale of the youth, transparent policies and proper planning should be adopted. on the other hand, there should be a maximum will to internalize belief in dress code through appropriate educational methods. therefore, a review of the dress code contents as well as its teaching, and evaluation methods are needed to improve formal education in this field. the training should also be performed at the correct time in order to maximize the effect. moreover, by raising the academic staff’s awareness of their inspiring role in this field and providing the students with appropriate feedback, we can use the benefits of the informal curriculum to enhance formal education. conflict of interests there are no commercial or associated interests that represent a conflict of interest in connection with the submitted manuscript. momeni n., et al. 13 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 20 december 2020 references 1. goold s, lipkin m. the doctor-patient relationship: challenges, opportunities, and strategies. j gen intern med. 1999;14 (suppl. 1): s26-33. 2. kayode a. assessment of students’ perception of dress code in tertiary institutions in nigeria: a study of federal college of education. iosr journal of research & method in education (iosr-jrme). 2013; 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[cited 2020 november]; available from: https://aisel.aisnet.org/bled2010/40 23. kiran a, riaz a, malik nh. factors affecting change in the clothing patterns of the adolescent girls. international journal of agriculture & biology. 2002; 4(3): 377-8. 24. bahrami m, memarian m, tamaddon h, kharrzi fard m j. survey of dentist’s professional appearances from patients’ point of view at tehran university of medical sciences. journal of dental medicine. 2018; 31(2) :109-18. 25. oxtoby k. what should medical students wear? bmj. 2017; 358: j3207. jmehm-9-10physrelation 124.docx journal of medical ethics and history of medicine original article the doctor-patient relationship: toward a conceptual re-examination hamidreza namazi1, kiarash aramesh2, bagher larijani3* 1phd candidate in medical ethics, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran; 2associate professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran; 3professor, medical ethics and history of medicine research center, and endocrinology and metabolism research institute, tehran university of medical sciences, tehran, iran. corresponding author: bagher larijani address: medical ethics and history of medicine research center. 23# 16 azar ave, keshavarz blvd, tehran, iran. email: larijanib@tums.ac.ir tel: 982166419661 fax: 982166419661 received: 28 jun 2016 accepted: 2 jul 2016 published: 28 aug 2016 j med ethics hist med, 2016, 9:10 © 2016 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract the nature of the doctor-patient relationship as a keystone of care necessitates philosophical, psychological and sociological considerations. the present study investigates concepts related to these three critical views considered especially important. from the philosophical viewpoint, the three concepts of "the demands of ethics “,” ethical phenomenology and "the philosophy of the relationship" are of particular importance. from a psychological point of view, the five concepts of "communication behavior patterns" (including submissiveness, dominance, aggression, and assertiveness), "psychic distance", "emotional quotient", "conflict between pain relief and truth-telling", and "body language" have received specific emphasis. lastly, from the sociological perspective, the three notions of "instrumental action", "communicative action", and "reaching agreement in the light of communicative action" are the most significant concepts to reconsider in the doctor-patient relationship. it should be added, however, that from the sociological point of view, the doctor-patient relationship goes beyond a two-person interaction, as the moral principles of doctors and patients depend on medical and patient ethics respectively. the theoretical foundations of the doctor-patient relationship will finally help establish the different dimensions of medical interactions. this can contribute to the development of principles and multidisciplinary bases for establishing practical ethical codes and will eventually result in a more effective doctor-patient relationship. keywords: doctor-patient relationship, philosophy, psychology, sociology, orbital parameters mailto:larijanib@tums.ac.ir j med ethics hist med 9: 10, august, 2016 jmehm.tums.ac.ir hamidreza namazi et al. page 2 of 6 introduction the doctor-patient relationship plays an essential role in ordering the health care system and medical ethics, and since it is a form of communication, it necessitates ethical, philosophical, psychological, and sociological considerations. the present paper aims to evaluate the essence of the doctor-patient relationship in order to re-examine its conceptual framework. in the first part, the philosophical, psychological and sociological significance of this relationship is explored, and in the final section, the theoretical implications will be discussed. it seems that despite the imbalance in the relationship between doctors and patients resulting from the greater significance of the physicians’ ethics, organization of this relationship is not possible without enhancing patient ethics. simultaneous consideration of sociological, psychological and philosophical dimensions of the doctor-patient relationship can contribute to developing theoretical foundations and multidisciplinary bases for establishing practical ethical codes. the result will eventually be a more effective interaction between the two. a) the philosophical essence of the doctorpatient relationship in investigating the philosophical essence of the doctor-patient relationship, three points should be taken into consideration. first, ethical demands in doctor-patient interactions must have distinct definitions and terms; second, the phenomenological ethical debates on this issue need to be explored; and third, modern topics in the philosophy of the relationship should be considered, and relationships with the others should be analyzed from different perspectives. ethical demands various organizations and professions differ in their attitudes towards ethical demands, recommendations, norms, values and judgments. the three components of inclusion, priority and severity are presented below as the criteria for judgment in ethical issues. 1. inclusion: the main questions to answer in regard to this component are: "what are the ethical limits?” and “should all of our actions be judged ethically or only some of them are included in the scope of ethical judgment?" in other words, is it enough to avoid doing the wrong thing, or is doing right among our moral duties too? it seems that the doctors’ moral duties include doing the right thing as well. this important matter is embedded within the principles of beneficence and non-maleficence. 2. priority: the component of priority relies on the answers to the following questions: "if what morality is demanding is in conflict with our personal interests (for example it concerns our self, family, friends and so on), which side should we take? should we always take the ethical side and forget about our personal interests? or personal interests could have priority over moral obligations?" nigel and stalker explain that autonomy and our personal integrity have priority over what morality is demanding from us, or as kagan (1) and singer (2) say, demandingness of morality can even affect autonomy and our personal integrity. it seems that on the one hand the altruism of a practitioner as a professional should be based on the priority of patients’ interests, and on the other hand it should safeguard the practitioner’s own autonomy. 3. severity: the main questions here are: can ethics press extreme and costly demands from us? or are the obligations of morality lighter and easier in the way that most people could overcome?" apparently if ethics are founded on costly demands, we will be more likely to fail to fulfill our ethical duties. based on the above-mentioned considerations and classifications, three macro-positions emerge in the ethical relationship, including: maximal ethics, ordinary ethics, and minimal ethics. maximal ethics: maximal ethics include all the three components discussed above. in this type of ethics, ethical inclusion does not have any limits and covers all human actions. extremist moralities consider ethical inclusion to be an absolute matter that covers all life styles and signify that no human action should be outside of this infinite circle. ordinary ethics: this is the sort of ethics that most people believe in, and because of its affinity to the contemporary human life, it is also referred to as “common ethics”. here what ethics demands from us are boundaries. in other words, moderate ethics often state that after performing our obligations and moral duties, in a relatively wild range of personal interests we can start selecting. thus, our actions are not always subject to moral judgment. minimal ethics: this type of ethics is contradicted with maximal ethics. according to minimalists, the only forbidden action is intentional harassment. followers of minimal ethics believe in a wide range of choices and selection areas; they recognize only a limited range of constraints and are in favor of acting upon personal interests (3). it is a growing concern in medical ethics that the doctor-patient relationship is not approached in a sufficiently broad way and that this overly narrow medical perspective leaves doctors, nurses and other health care professionals badly equipped to deal with ethical dilemmas (4). phenomenology could broaden this perspective and serve as a strong basis to understand moral sensitivity. two notions in phenomenology have a central role in understanding the concept of the doctor-patient relationship: intentionality and first-person point of view. j med ethics hist med 9: 10, august, 2016 jmehm.tums.ac.ir hamidreza namazi et al. page 3 of 6 intentionality and first-person point of view one of the basic concepts of phenomenology is attainment of phenomenal intentionality, which occurs when a person recognizes earlier assumptions and adopts a perspective (5). some thinkers like franz brentano believe that intentionality and the phenomenological approach can be applied to the first-person point of view (6). for instance the first sighting of a beautiful landscape elevates us in a way that may not happen in later encounters. the reason is that later encounters are accompanied by presuppositions of the observer, who will be more used to the landscape. it seems that the phenomenological approach can be applied to the doctor-patient relationship. doctors must reexamine and restrict assumptions toward patients, and at the same time value intentionality in order not to fall into habits. moral sensitivity moral sensitivity may be enhanced in two ways. first, through reinforcing the phenomenological approach by renewing the first sight experience, that is, in each re-identification (of the patient for instance), priorities should be observed. second, since any situation could come to a fork and ethical conflicts may rise, the adverse impacts should be considered and every situation must be regarded from an ethical perspective. although at commencement moral sensitivity appears to overlap with maximal ethics, it is of particular importance especially in heterogeneous communications such as the doctor-patient relationship. it may be added that enhancing moral sensitivity even seems to be the target of the phenomenology of ethics in the doctorpatient relationship (7). communication with others the term “communication” can be defined through the philosophical approaches of great thinkers such as levinas, marcel and buber who set their philosophical arguments in the relationship between “me” and “the other”. levinas insists on the maximum responsibility of any other; marcel assists on turning the me-that relationship to the me-you relationship and replacing absence with presence; buber finds god in "thou”. b) the psychological essence of the doctorpatient relationship in terms of psychology, the doctor-patient relationship is imbalanced as the doctor has superiority over the patient. such imbalanced relationships may give rise to various patterns of communication behavior. psychologists (8) have distinguished the following four communication behavior patterns based on components such as honesty, perspicuity, respect and inhibition: 1) submissiveness submissive persons are shy, and although they speak honestly, they are usually taciturn and cannot express themselves perspicuously. they are also afraid of being judged or offending others, so they are incapable of making eye contact while speaking. their voices are weak and unsteady, and they speak hesitantly. submissive people avoid conflict rather than try to resolve it. they speak indirectly and in general terms because they cannot express themselves openly and may quickly feel depressed and vulnerable. people with this behavioral pattern admittedly let others abuse them and treat them disrespectfully. these patterns work both for doctors and patients. patients who evade their responsibilities and encourage physicians to patriarchy in the process of therapy, or doctors who are not able to say “no" to patients easily consent to inappropriate and ineffective treatments. 2) dominance domineering people feel insecure and believe that they do not possess good qualities. accordingly, they try to deceive others and take advantage. domineering persons do not have the perspicuity and honesty necessary for earning their wishes. they express themselves in general terms and sometimes their voices shake. these people use others to achieve their goals and make light of this inhibition and deception, so they take away another person’s autonomy and freedom. this behavioral pattern is often seen in doctors and sometimes among patients as well. doctors who prefer patient satisfaction to authority thus create a false autonomy for the patients and will eventually be dominated by them, and patients with this behavioral pattern impair the healing process by inhibition and deception. 3) aggressiveness the target of aggressive and domineering people is very similar and that is exploitation and domination of others. their difference is that a domineering person achieves this aim by secrecy and cheating, while an aggressive person follows it frankly and openly. unlike the domineering type, aggressive people are honest and straightforward; they are horrible listeners, always accuse others, get angry soon, get confused by criticism, and are usually grim in appearance. they have loud voices and look hostile, and in conflicts, they tend to destroy their opponents. this pattern is seen among both physicians and patients. impatient physicians that do not listen, shout all the time and sometimes make irreparable mistakes during the healing process, or patients with lower anger thresholds who create tension in medical environments belong in the category of aggressive people. 4) assertiveness assertiveness is the most creative behavioral pattern of communication. assertive people respect themselves and others, and observe the authority of all sides. they are both honest and frank, and do not accuse themselves or others. their approach to matters is problem-oriented, that is, when dealing with a problem, instead of accusing themselves and others, they think of a solution. they listen j med ethics hist med 9: 10, august, 2016 jmehm.tums.ac.ir hamidreza namazi et al. page 4 of 6 effectively and speak appropriately and understandably. during conflict they emphasize conversation. their arguments are clear, specified, objective, fair and respectful, and eventually they are the most successful communicators. issues such as breaking bad news, wasted treatments and medical mistakes are easy and solvable with this type of behavioral pattern. while submissiveness, dominance and aggression lead to lose-lose situations in long term, assertiveness, is a helpful behavioral pattern and finally results in win-win solutions (9). based on the above-mentioned notions, the following practical hints should be outlined: 1. psychic distance: an important topic in aesthetics and artistic criticism that is also related to ethics is psychic distance. in aesthetics, this refers to the distance that should exist between a work of art and the viewer, so that aesthetic entente is created and art is not confused with reality. omitting the psychic distance and forming deep sympathy and psychological identification with the work of art obstructs artistic judgment and aesthetic approach. in medical ethics, the concept seems to be important while encountering patients. reduction of psychic distance and excessive sympathy with patients prevent an effective doctor-patient relationship as a fundamental element of treatment. 2. body language: nonverbal communication skills are referred to as body language. this type of communication is very important in the doctorpatient relationship due to factors such as the limited visiting time, and linguistic and discourse differences. 3. truth-telling versus pain relief: one of the oldest ethical challenges is the pain and suffering that can be caused by telling the truth. on the other hand, we can bring comfort and relief to patients by lying to them. physicians can employ various methods at their discretion, but it seems that health care systems are more inclined toward telling the truth, and doctors must try to maintain a balance between the two. 4. emotional quotient (eq): unlike intelligence quotient that does not improve after the second decade of life, emotional quotient can continue to improve till the end. emotional quotient refers to the ability to control emotions, sentiments and unwanted desires. people with high intelligence quotient dealing with people with lower intelligence quotient are susceptible to reckless, impulsive behavior and may gradually lose their eq (10). in order to improve the doctor-patient relationship, health providers must be instructed in techniques to promote their emotional quotient. c) the sociological essence of the doctor-patient relationship unlike the psychological approach, the sociological approach to the doctor-patient relationship examines the essence of this (individualistic) relationship in a social context. in other words, the sociological approach regards the doctor-patient relationship beyond a merely mutual connection and therefore external elements are considered particularly important. in order to investigate this relationship from the sociological perspective, communicative actions serve as a valid basis. they have been included among the most important sociological criteria in the last few decades as a set of social actions oriented towards reaching entente. the target of communication action theory is to subvert a single prophetic and patriarchal individualism in human interactions. jürgen habermas has developed this notion in his famous book the theory of communicative action, and his ideas are quite often presented in ethical manuscripts and medical ethics books. in this book habermas distinguishes and characterizes his theory by drawing a distinction between instrumental action and communicative action. instrumental action jürgen habermas states, “we call an action oriented to success instrumental when we consider it in the light of following the rules of rational choice and assess the efficiency of influencing the decisions of a rational opponent. by contrast, i shall speak of communicative action whenever the actions of the agents involved are coordinated not through egocentric calculations of success but through acts aiming at reaching an understanding. in communicative action the participants are not primarily oriented to their own individual successes; they pursue their individual goals under the condition that they can harmonize their plans of action on the basis of common situation definitions. in this respect, negotiating the definitions of the situation is an essential element of the interpretive accomplishments required for communicative action” (11). reducing an individual to only one of the functions of his or her integrity is called instrumentalism. the function of a ticket seller in a bus station is just like that of a machine and therefore his human dimension could easily be overlooked. in the doctor-patient relationship both sides (especially the doctor) are susceptible to perceive others as mere instruments. the power that is practiced over patients by "medical gazing" makes them abject by reducing them to bodies that are examined simply to locate illness. three fundamental concepts in sociology and philosophy have been purposed to deal with instrumentalism: 1) teleological view of others by emphasizing the task: in his works on the golden rule, kant argues that instrumental action is inconsistent with socialization and human dignity, and proposes to regard others as an acme, not an instrument. the universal version of j med ethics hist med 9: 10, august, 2016 jmehm.tums.ac.ir hamidreza namazi et al. page 5 of 6 this rule is that you should like for others whatever you like for yourself and vice versa. one concrete technique for applying this rule is that human beings constantly put themselves in other people’s positions and see the world from their perspectives. 2) the distinction between mysterious looks and issue makers: martin buber and gabriel marcel emphasize the difference between the i-thou and i-it relationship. in the former, a human is a mystery that unfolds and in the latter, an issue that resolves (12). 3) maximum responsibility toward others: emmanuel levinas states, "we are responsible for each other, and me more so…" (13). this approach considers responsibility toward others as an unconditional matter, but does not require others to be equally responsible in return. communicative action communicative action is allegedly an action focused on entente. whoever wants to be successful in reaching entente should be prepared to bring up claims. habermas states that the communication between a speaker and a listener is constituted by the existence of three universally valid claims: the claims for truth, rightness and truthfulness (11). the terms of these claims in the doctor-patient relationship accurately reveal the sociological essence of this relationship. doctors should speak understandably and beware of ambiguity and opacity in their speech. on the other hand, they should make true statements and propositions, scientific and other. they should be honest and have faith in what they say, and ultimately they can use their discretion to determine the content of their relationship with patients. analysis to clarify the concept of relationship and connectedness, we used a hybrid concept analysis including: identifying essential attributes, critiquing the existing definitions, examining boundaries and identifying antecedents (14). on the basis of the comparative concept analysis, the doctor-patient relationship is an interdisciplinary notion and a mono-disciplinary approach will reduce this relationship to communicative skills. discussion and conclusion the doctor-patient relationship has greater impact on the health system than it may seem at first. in this paper, three novel dimensions of the doctor-patient relationship were deeply explored. the philosophical approach emphasizes the importance of promoting moral sensitivity. communicating with others entails considerations rooted in the human soul that provoke great philosophical concerns. the psychological approach emphasizes learning about behavioral patterns, enhancing the intelligence quotient, and creating a balance between truth-telling and pain relief. finally, the sociological approach demonstrates that the doctor-patient relationship is part of a macro social relationship in a community and discovers various aspects beyond the two-person relationship. the re-examination of the doctor-patient relationship in this paper can have several important implications. attention to the philosophical, sociological and psychological dimensions provides a basis to evaluate the doctor-patient relationship both quantitatively and qualitatively. two wellknown examples of such qualitative and quantitative evaluations may be seen in the development of native questionnaires and conversion of random considerations to systemic approaches. as a final word, a re-examination of the doctorpatient relationship requires an interdisciplinary approach that should take into account the legal as well as juridical essence in addition to the three approaches discussed in this paper. j med ethics hist med 9: 10, august, 2016 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[marzhaye akhlagh]. tehran: ney publication; 2012. [in persian] 4. svenaeus f. the phenomenology of suffering in medicine: explorations in the baltic sea region [dissertation]. sӧdertӧrn university, 2015. https://www.sh.se/p3/ext/content.nsf/aget?openagent&key=projekt_page_eng_ 1413378035391 (accessed in 2016) 5. kriegel u. moral phenomenology: foundational issues. phenom cogn sci 2008; 7(1): 1-19. 6. pasquerella l. phenomenology and intentional acts of sensing in brentano. south j philos 2002; 40(s1): 269-79. 7. morton kr, worthly js, testerman jk, mahoney ml. defining features of moral sensitivity and moral motivation: pathways to moral reasoning in medical students. j moral educ 2006; 35(3): 387-406. 8. buss ah. social behavior and personality. l. erlbaum associates; 1986. 9. gharamaleki af, nochefallah r. [mavanege roshde akhlaghe herfehey dar sazmanha]. tehran: din pajohy boshra cultural institute; 2007. [in persian] 10. birks yf, watt is. emotional intelligence and patient-centred care. j r soc med 2007; 100(8): 368-74. 11. mccarthy t. reason and rationalization of society. in: habermas j. the theory of communicative action: lifeworld and system: a critique of functionalist reason. boston: beacon press; 1984. 12. keen s. gabriel marcel. carey kingsgate press; 1966. 13. olia m. [kashfe digari hamrah ba levinas]. tehran: ney publication; 2009. [in persian] 14. phillips – salimi cr, haase je, kooken wc. connectedness in the context of patient provider relationships: a concept analysis. j adv nurs 2012; 68(1): 230-45. https://www.sh.se/p3/ext/content.nsf/aget?openagent&key=projekt_page_eng_ journal of medical ethics and history of medicine rhazes viewpoints about causes, diagnosis, treatment and prognosis of gout seyed mahmoud tabatabaei1*, seyed mohammad ali tabatabaei2 , mohammad mahdi zamani3, nastaran sabetkish3, farnaz roshani4 1.professor of psychiatry, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. 2.dentist, yazd, iran. 3.scientific students of pediatric urology research center, tehran university of medical sciences, tehran, iran. 4.master of psychology, mashhad, iran. *corresponding author: seyed mahmoud tabatabaei address: no.23, 16 azar st., keshavarz blvd., tehran, iran. tel: (+98) 21 66 41 96 61 email: smtabataba_md@yahoo.com received: 15 jan 2012 accepted: 18 feb 2012 published: 03 mar 2012 j med ethics hist med. 2012; 5:3. http://journals.tums.ac.ir/abs/20744 © 2012 seyed mahmoud tabatabaei et al.; licensee tehran univ. med. sci. abstract keywords: gout, rhazes, history of medicine, iranian traditional medicine. introduction rhazes in his medical encyclopedia (alhawi) has explained about most of diseases and illnesses which are well-known today. we have published rhazes’ statements about ophthalmology [1], bell’s palsy [2] and cancer [3] in previous articles. in this article, we study his viewpoints about gout. gout is one of the most common inflammatory joint disorders in which patients experiences recurrent attacks. these patients may have more co-morbid conditions such as cardiovascular and kidney problems [4]. hyperuricemia, which is known as the classic feature of gout, is an inde gout, a medical condition of acute inflammatory joint disorders, has been recognized from the antiquity. however, the name of rhazes, a persian historic physician who has described the etiology, signs, symp toms, epidemiology, treatment and prevention of this malady more than a thousand year ago, hasn’t been taken into consideration appropriately. in this article, we studied and reported several chapters of alhawi which is considered the most important rhazes’s medical textbook, focussing on his hypotheses because he has described this disease more manifestly. his original manuscripts are originally written in arabic and they hadn’t been translated to persian until 1998. we intend to compare rhazes opinions about gout with those of the literature in the area of rheumatology. according to our findings, rhazes documented the symptoms of gout and categorized them scientifically. his insights about the treatment of gout, side effects of pharmacotherapy and management of the patients are so interesting and wonder ful. generally most of rhazes viewpoints about gout are correct and compatible with recent findings. more investigation on rhazes’ viewpoints can guide us to propose more reliable hypothesis and schema tize cost effective studies by delving into past medical records. j med ethics hist med 2012, 5:3 seyed mahmoud tabatabaei et al. page 2 of 4 (page number not for citation purposes) pendent risk factor that can cause hypertension [5]. nowadays, this malady is treated with non steroidal anti-inflammatory drugs (nsaids), steroids, colchicine and some urate-lowering agents such as allopurinol and probenecid [6]. the history of gout comes across with the annals of scientific knowledge. the first documentation of it dates back to 2600 bc when egiptians described the arthritis of the big toe which is known as podagra today [6]. the second documentation of the disease dates 400 bc when hippocrates noted its absence in eunuchs and premenopausal women in his aphorisms. aulus cornelius celsus, around 30 ad described its linkage with the use of alcohol and its later onset in women. around 200 ad, galen described tophi [6]. however, it seems that we have missed an important name in the history of gout; a physician who has described it in details [7]. ancient scientists have proposed numerous interesting and even wonderful methods for diagnosing, differential diagnosis and treatment of gout but unfortunately they have been neglected because of the usage of archaic words, abundant mistakes in scripts, non-current and unclear expressions, unfamiliarity of the contemporary intellectuals with their method of writing and heedlessness of sages to this precious heritage. rhazes is one of the most famous iranian tradi tional physicians (865 925 ad) whose compila tions such as his great medical encyclopedia [8], alhawi, written in 25 volumes, are amongst our most invaluable medical heritages. he has discussed medical subjects in alhawi in which he has described the majority of known diseases in that period of time, one of the most important of them being gout. he has described its diagnostic criteria, treatment and several ways to soothe the pain [9]. in this article, we aim to familiarize readers with his opinions and suggestions by comparing his points of view with recent studies. description of gout rhazes described the disease as a condition in which a joint is affected and he proposed to cure the disease as soon as possible in order to prevent the ensuing chronic arthritis, in which more than one joint is affected, in acute form [10]. nowadays we know that without an effective treatment in the primary stages in which the patient suffers from monoarthritis, the disease turns from acute chronic form that means that other joints may also be affected [11]. epidemiology rhazes pointed out that gout is less common in women and children in comparison with men [10]. it is written in different literatures that the age of its onset in women is later than men [12] which can be defined by the role of estradiol in lowering the level of serum urate in females [13]. he also alluded that the incidence of this disease in rich people is considerably higher than other socioeconomic classes [9]. etiology rhazes claims that the cause of this malady is a kind of abnormal humor that reaches the joints via blood circulation [9]. today, reliable researches confirmed that the main cause and the classic feature of gout is hyperuricemia [6]. recent studies indicate that high levels of uric acid, especially levels higher than 7 mg/dl (416 mmol/l), tend to significantly increase the risk of bouts and tophi formation [14]. lifestyle rhazes indicated that some lifestyles and habits like gluttony, hyperactivity and drinking wine can aggravate the pain [9]. recent studies have confirmed his claim by demonstrating its strong association with dietary regimens which contain high levels of purine [15] and consumption of alcohol [16]. he emphasized that consumption of any kind of meat can be prejudicial [9]. results of several studies have demonstrated that increased intake of meat and seafood is associated with hyperuricemia [17, 18]. he has also observed that the disease becomes more severe in some seasons such as spring and autumn [10]. some studies have corroborated his findings. however, this has been ascribed to personal changes in diet and physical activity in different seasons [19]. presentations it was written in alhawi that the affected joints gradually become rigid and turn to a stony structure at times [9]. current studies indicate that the final metabolite of purine is crystallized in synovial fluid in the form of monosodium urate [20]. these tophaceous deposits provide the best diagnostic criteria. computed tomography (ct) scan is now employed to evaluate the size of these deposits [21]. rhazes has illustrated that the state of swelling, edema and pain which is often commenced from the big toe is one of the most common presenta tions of gout [9]. there are many studies and articles that validate his conviction [22]. he mentioned that the affected patient may feel a twinge in his leg, knee and testis [9]. treatment rhazes mentioned that gout is a chronic and complicated disease which needs long term treatment and holistic approach [10]. he has proposed that one of the best medications for this disease is suranjan [9] which is the traditional j med ethics hist med 2012, 5:3 seyed mahmoud tabatabaei et al. page 3 of 4 (page number not for citation purposes) name of colchicum automnale [23]. this herb is known as colchicum in most of herbal medicine text books [24]. rhazes claimed that suranjan can cause a wide array of gastrointestinal and general side effects [9]. a considerable number of articles have acknowledged his opinion by declaring that the renal and gastrointestinal complications of the medicine, limit its usage [25]. as supported by european league against rheumatism (eular), its intense regimens have dramatically fallen out of use [26]. he especially recommended that in order to reduce the gastrointestinal side effects of the medication, it is better to consume it with ginger, pepper or cumin [9]. he asserted that the use of suranjan can soothe the pain and it is effective for prevention of the attacks [9]. there is evidence indicating that this suggestion is justified [27]. rhazes suggested another treatment option instead of colchicum automnale with benefits similar to suranjan but without the side effects [9, 9]. discussion rhazes started his medical education in rey, a suburb of modern tehran (the capital of iran) [28]. he has demonstrated significant points about gout in his main manuscript. by comparing them with today knowledge, we conclude that he recorded the symptoms and categorized them scientifically. he also provided detailed information about its epidemiology and etiology which is principally in accordance with the findings of modern medicine. it can be suggested that generally, his viewpoints are compatible with the recent scientific findings. this should motivate us to give more notification of the rest of his points of view. therefore, further investigation into rhazes’ viewpoints can lead us to propose more reliable hypotheses and conduct cost effective studies by delving into past medical records. acknowledgement while appreciating honest cooperation of heads , managers and nurses of the three mentioned hospitals and also each of the participants in the present research, i seize the opportunity to express my sincere thanks to dr. fariba asghari and dr. pooneh salari for their critical review, ms. heidarian for performing interviews, ms. karimi for carrying out typing affairs and pagination and also ms. aqaii for following up necessary measures for realization of objectives of the present research paper. page 4 of 4 (page number not for citation purposes) j med ethics hist med 2012, 5:3 seyed mahmoud tabatabaei et al. references 1. tabatabaei sm, kalantar-hormozi aj, sedaghat mr. ophthalmology in al-hawi of rhazes, comparing to modern medical literature. pajouhesh dar 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23(11): 1225-6. 26. wortmann rl. the management of gout: it should be crystal clear. j rheumatol 2006; 33(10): 1921-2. 27. zhang w, doherty m, pascual e, et al. eular evidence based recommendations for gout. part i: diagnosis. report of a task force of the standing committee for international clinical studies including therapeutics (escisit). ann rheum dis 2006; 65(10): 1301-11. 28. tabatabaei sm. synopsis of rhazes alhawi, “ continens of rhazes”, encyclopedia of medicine. vol 1. mashhad: mashhad university of medical sciences; p. 39-48. ______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ original article copyright © 2021 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. journal of m edical ethics and h istory of m edicine the relationship between managers’ ideal intelligence as a hybrid model and employees’ organizational commitment: a case study in tehran university of medical sciences *corresponding author hossein dargahi address: school of public health, tehran university of medical sciences, ghods ave., poursina st., tehran, iran. tel: (+98) 21 88 98 91 29 email: hdargahi@sina.tums.ac.ir received: 10 nov 2020 accepted: 1 jul 2021 published: 13 jul 2021 citation to this article: dargahi h, veysi f. the relationship between managers’ ideal intelligence as a hybrid model and employees’ organizational commitment: a case study in tehran university of medical sciences. j med ethics hist med. 2021; 14: 8. hossein dargahi 1*, fereshteh veysi 2 1.professor, department of management sciences and health economics, school of public health, health information management research center, tehran university of medical sciences, tehran, iran. 2.researcher, school of allied medical sciences, tehran university of medical sciences, tehran, iran. abstract high ideal hybrid intelligence of managers is among the factors that can improve employees’ organizational commitment. therefore, this study aimed to determine the relationship between managers’ ideal hybrid intelligence and employees’ organizational commitment in the vice chancellors’ headquarters of tehran university of medical sciences. this was a descriptive-analytical and crosssectional study conducted in 2017 2018. the research sample size consisted of 86 senior and middle-level managers selected through census method, as well as 181 employees, selected using the kerjecie and morgan table. the research tool was an ideal hybrid intelligence questionnaire consisting of 102 questions on cultural, moral and spiritual intelligence, and also meyer and allens’ organizational commitment questionnaire including 24 questions. face validity and reliability of each questionnaire were confirmed by an expert panel and chronbach’s alpha method. the data were analyzed by spss software, and descriptive results were shown through mean and standard deviation, and analytical results by inferential tests. the results showed that the ideal hybrid intelligence of the vice chancellors’ headquarters managers and employees’ organizational commitment were at a desirable level. also, there was a significant correlation between cultural, moral and spiritual intelligence as constituents of the ideal hybrid intelligence of managers and employees’ organizational commitment. we found that ideal hybrid intelligence may affect employees’ organizational commitment, but it should be mentioned that other forms of intelligence may also affect organizational commitment. keywords: ideal; hybrid; intelligence; managers; employees; organization; commitment. the relationship between managers’ ideal intelligence as a hybrid model and … 2 j med ethics hist med. 2021(feb); 14: 8. journal of m edical ethics and h istory of m edicine introduction there are certain factors that either directly or indirectly impact successful projects. reduced productivity is one of the most important factors that cause projects to fail due to increased frustration in employees (1). findings reveal that several factors play a significant role in productivity (2). today, more organization managers are asking, “how can we get more out of our employees?” the answer is to devise strategies to develop and increase employees’ organizational commitment (3). in this regard, organizational commitment is one of the most important motivational factors through which the employees will have more organizational participation and better performance (4 7). allen and mayer investigated the application of organizational commitment to occupational commitment. for this purpose, they developed measures of emotional constancy, as well as normative commitment to the occupation. these measures were then used to examine hypotheses about their differential relationships with antecedent and consequence variables (8). emotional commitment demonstrates the emotional link of employees with organizational values and goals, and continuous commitment means continuing activities and feeling the need to stay and work in the organization. also, in normative commitment, employees consider working in the organization with moral commitment (9 14). on the other hand, in the new management approach, the writers recommend promoting the ideal hybrid intelligence, which is comprised of cultural, spiritual and moral intelligence. high ideal hybrid intelligence of managers improves commitment (15). this type of intelligence emphasizes thinking in the present, although it is no stranger to the past (16). lomov and venda reported hybrid intelligence to be the adaption of a social system to achieve intellectual resonance in the process of communicating information (17). therefore, the hybrid model may be the ideal type of intelligence for information analysis and problem solving for managers, allowing them to analyze and react to every situation (18 22). cultural intelligence, as a dimension of ideal hybrid intelligence, is the ability to understand the appearance and reality, and demonstrates managers’ understanding of cultural similarities and differences (23 25). spiritual intelligence predicts people’s adaptability and gives managers capabilities to solve problems and achieve organizational goals (26). also, moral intelligence describes managers’ tendency and capability to organize dynamic and stable rules for adhering to moral beliefs that can affect organizational performance (27 29). this study aimed to determine the relationship between manages’ ideal hybrid intelligence and employees’ organizational commitment in the vice chancellors’ headquarters of tehran university of medical sciences. methods this was a descriptive-analytical and crossdargahi h., et al. 3 j med ethics hist med. 2021(feb); 14: 8. journal of m edical ethics and h istory of m edicine sectional study conducted in 2017 2018. the research statistical population included all employees and managers of the vice chancellors’ headquarters of tehran university of medical sciences. 112 senior and middle-level managers were selected based on census method, as well as 181 employees, and sample size was determined based on the kerjecie and morgan table. after referring to the vice chancellors’ headquarters and explaining the purpose of the study, the researcher distributed the questionnaires among the participants, and after several visits at different intervals, collected the completed questionnaires. as a result, 181 questionnaires related to the employees and 86 questionnaires related to the managers were completely filled out and returned. the response rate was 100% for the employees and 86% for the managers. it seems that due to the high workload of managers, they could not complete all the relevant questionnaires. the research tool in this study was an ideal hybrid intelligence questionnaire including 102 questions on cultural, moral, and spiritual intelligence dimensions. demographic details were also collected through a separate questionnaire. for managers, the inclusion criteria consisted of a minimal 5 years of work experiences and willingness to participate in the study, and the exclusion criteria was the delivery of incomplete questionnaires to the researcher. the cultural intelligence constituent dimension of this research instrument consisted of four components in 20 items developed by dyne et al. (30). all items were measured based on a five-point likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree). face validity of this questionnaire was confirmed by the cultural managers and professionals of tehran university of medical sciences. the experts were asked to assess the questions in terms of quality and see if they covered the entire content of the study, and to confirm the validity of the questionnaire. in order to evaluate the reliability of the questionnaire, cronbach’s alpha was used to calculate internal consistency and stability. therefore, first the variance of scores of each item and then the total variance were calculated using the relevant formula, and the cronbach’s alpha coefficient was 0.85. the moral intelligence constituent dimension of the questionnaire included ten components developed by lennick and kiel (31). the validity and reliability of this questionnaire was confirmed by martin and austin, arasteh et al., raisi et al. and nasiri valikbani et al. (32 35). the scoring style of this questionnaire was based on a fivepoint likert scale of always = 5, often = 4, sometimes = 3, rarely = 2 and never = 1. moreover, the reliability of this questionnaire was calculated by cronbach’s alpha test with a coefficient of 0.77. the spiritual intelligence constituent dimension of the questionnaire included 42 questions in four components, used and developed by king and decicco (36). ahmadi et al. reported this part of the questionnaire to have a reliability of 0.94 the relationship between managers’ ideal intelligence as a hybrid model and … 4 j med ethics hist med. 2021(feb); 14: 8. journal of m edical ethics and h istory of m edicine using cronbach’s alpha (37), and dadras and nouhi reported its reliability to be 0.88 (38). the face validity of this section was confirmed by 5 cultural and theology experts of the university, and cronbach’s alpha was 0.87. the scoring range of this part of the questionnaire was based on a five-point likert scale of very correct = 5, correct = 4, to some extent = 3, incorrect = 2 and completely incorrect = 1. in this research, meyer and allen’s three components model of organizational commitment questionnaire was used to evaluate employees’ organizational commitment in 24 questions and three dimensions. allen and meyer confirmed the reliability of this questionnaire by cronbach’s alpha method with a coefficient of 0.85, 0.79 and 0.83 for each dimension, respectively (8). also, the reliability of this questionnaire was measured in the present research with a coefficient of 0.80, 0.78 and 0.85 for each dimension. the scoring style of this questionnaire was based on a fivepoint likert scale from 1 to 5 including strongly agree = 5, agree = 4, no idea = 3, disagree = 2, and strongly disagree = 1. moreover, the face validity of this questionnaire was confirmed by a panel consisting of 5 health-care management experts. the data were analyzed by spss software version 21 and the descriptive results were shown through mean and standard deviation. also, the kolmogrov-smirnov test was used to determine the normality of data distribution. due to the significance of this test in the spss software (p < 0.05), it was found that data distribution is not normal and nonparametric tests were used to analyze the data. consequently, the inferential results, including wilcoxon sample t-test, two-sample independent t-test, mann-whitney, anova, kruskal-wallis and pearson regression tests were used to show analytical results result the majority of the managers were female (56, 65.1%), 27 (31.4%) had more than 20 years of experiences, 42 (48.8%) were aged 40 50, and 55 (64%) had a bachelor’s degree. also, most of the vice chancellors’ headquarters employees were female (109, 60.2%), 62 (34.4%) had 5 10 years of experiences, 97 (53.6%) were aged 30 40, and 79 (43.6%) had a bachelor’s degree. table 1 shows the mean of the spiritual intelligence dimension of the managers’ ideal hybrid intelligence was at a desirable level. table 2 showed the mean of the cultural intelligence constituent dimension of the managers’ ideal hybrid intelligence was 40.81, which was a desirable score. table 3 showed that the mean of the moral intelligence constituent dimension of the managers’ ideal hybrid intelligence was 86.69, which seems to be at a desirable level. dargahi h., et al. 5 j med ethics hist med. 2021(feb); 14: 8. journal of m edical ethics and h istory of m edicine table 1descriptive findings related to the spiritual intelligence constituent dimension of the managers’ ideal hybrid intelligence spiritual intelligence dimensions mean median mode standard deviation minimum maximum existence of critical thinking 24.3 24 26 3.97 14 35 creation of personal meaning 17.44 17.5 20 3.18 8 25 transcendental consciousness 23.78 23 25 4.18 15 35 expanding of the consciousness state 14.46 14.5 15 3.24 7 25 spiritual intelligence 79.99 80 72 12.51 47 120 table 2. descriptive findings related to the cultural intelligence constituent dimension of the managers’ ideal hybrid intelligence cultural intelligence components mean median mode standard deviation minimum maximum metacognitive 13.5 14.5 14.5 0.90 4 20 ccognitive 14.24 15 15 1.50 4 20 motivational 12.88 13 12 1.20 4 20 behavioral 13.69 14 12 1.20 4 20 cultural intelligence 40.81 40.05 38 0.95 12 56 table 3. descriptive findings related to the moral intelligence constituent dimension of the managers’ ideal hybrid intelligence moral intelligence components mean median mode standard deviation minimum maximum performance based on values, beliefs and principles 11.6 12 12 1.89 4 15 truthfulness 7.51 8 8 1.48 2 10 perseverance and persistence with regard to truth 10.01 10 10 2.31 4 15 keeping promises 19.8 20 20 2.85 12 25 accepting responsibility for personal decisions 7.21 7 7 1.33 2 10 admitting failures and mistakes 3.56 4 4 0.95 1 5 taking responsibility to serve others 11.95 12 12 1.97 7 15 showing active interest in others 3.71 4 4 0.81 2 5 ability to forgive mistakes 3.89 4 4 0.78 2 5 ability to forgive others’ mistakes 7.43 8 8 1.67 3 10 moral intelligence 86.69 87 79 11.89 50 111 the relationship between managers’ ideal intelligence as a hybrid model and … 6 j med ethics hist med. 2021(feb); 14: 8. journal of m edical ethics and h istory of m edicine table 4 shows considering the favorable condition of cultural, moral and spiritual intelligence as the constituent dimensions of ideal hybrid intelligence in this study, it seems the senior and middle-level managers of tehran university of medical sciences have a desirable level of ideal hybrid intelligence. table 5 shows that the mean of organizational commitment among the vice chancellors’ headquarters employees was 76.12, which was at an upward average level. table 4. descriptive findings related to the constituents dimensions of ideal hybrid intelligence of the vice chancellors’ headquarters managers type of intelligence mean median mode sd minimum maximum cultural intelligence 40.81 40.05 38 0.95 12 56 moral intelligence 86.69 87 79 11.89 50 111 spiritual intelligence 79.99 80 72 12.51 47 120 table 5. descriptive findings related to organizational commitment and its dimensions among the vice chancellors’ headquarters employees organizational commitment dimensions mean median mode standard deviation minimum maximum emotional 26.83 27 30 5.22 12 38 continuous 25.43 26 26 4.23 15 35 normative 23.86 24 24 3.58 14 34 organizational commitment 76.12 76 75 10.12 49 104 using the kolmogorov-smirnov test to determine data distribution normality, and considering the significance level of this test (p < 0.05), the data were not normal, and consequently, we used nonparametric tests for data analysis (table 5). the results of the anova and kruskal-wallis test showed that there was no significant correlation between the managers’ ideal hybrid intelligence and its different constituents dimensions, and gender, academic degree, age and work experience. however, there was a significant relationship between employees’ organizational commitment and their work experiences and education level, so that employees with lower education and more work experience showed higher organizational commitment. moreover, there was no significant relationship between employees’ organizational commitment and their age and gender. the results of pearson’s correlation test showed a significant relationship between cultural, spiritual and moral intelligence, which constitute the dimensions of ideal hybrid intelligence (p < 0.001, p = 0.001) [table 6]. pearson’s correlation analysis proved the relationship between cultural, moral and spiritual intelligence as constituents of the ideal hybrid intelligence, and the relationship between these variables was provided for other analyses such as regression analysis. dargahi h., et al. 7 j med ethics hist med. 2021(feb); 14: 8. journal of m edical ethics and h istory of m edicine table 6. the pearson’s correlation analysis between cultural, moral, and moral intelligence as constituents dimensions of ideal hybrid intelligence variable spiritual intelligence cultural intelligence moral intelligence ideal intelligence spiritual intelligence correlation 1 0.36 0.55 0.64 p-value < 0.001 0.001< 0.001< cultural intelligence correlation 0.36 1 0.54 0.61 p-value 0.001 0.001< 0.001< moral intelligence correlation 0.55 0.54 1 0.76 p-value 0.001< 0.001< 0.001< ideal hybrid intelligence correlation 0.64 0.61 0.76 1 p-value 0.001< 0.001< 0.001< table 7. the pearson’s correlation analysis between cultural, moral and spiritual intelligence as constituents dimensions of ideal hybrid intelligence, and organizational commitment variable organizational commitment emotional continuous normative 86=n 86=n 86=n 86=n spiritual intelligence correlation 0.15 0.14 0.003 0.17 p-value 0.018 0.018 0.008 0.012 cultural intelligence correlation 0.04 0.06 0.130.16 p-value 0.007 0.005 0.024 0.013 moral intelligence correlation 0.22 0.25 0.25 0.3 p-value 0.04 0.02 0.04 0.004 according to table 7, the results of pearson’s correlation test showed that there was a significant correlation between managers’ spiritual, cultural and moral intelligence (as constituents dimensions of ideal hybrid intelligence) and employees’ organizational commitment (p = 0.012, p = 0.013, p = 0.004). table 8. the effect of managers’ cultural, moral and spiritual intelligence as constituents dimensions of ideal hybrid intelligence on the organizational commitment of employees variable regression coefficient (b) standard deviation error standardized regression coefficient (β) t statistic pvalue spiritual intelligence 0.17 0.14 0.18 1.21 0.02 cultural intelligence 0.1 0.24 0.4 0.42 0.035 moral intelligence 0.27 0.16 0.3 1.69 0.04 r2= 0.52 regarding table 8, results of the regression analysis showed that spiritual, cultural and moral intelligence (as constituents dimensions of ideal hybrid intelligence) affect employees’ organizational commitment significantly with an intensity of 0.18, 0.4, and 0.3 respectively. also, managers’ ideal hybrid intelligence affected employees’ organizational commitment with an intensity of 0.52 when the other variables were fixed. the relationship between managers’ ideal intelligence as a hybrid model and … 8 j med ethics hist med. 2021(feb); 14: 8. journal of m edical ethics and h istory of m edicine discussion the findings showed that the mean of the constituents dimensions of ideal intelligence (that is, spiritual, cultural and moral intelligence) of the vice chancellors’ headquarters managers in tehran university of medical sciences (tums) was higher than expected. some studies that have reported high scores of spiritual intelligence include: karimi et al. among 250 nurse directors in mashhad teaching hospitals in iran, malik and tariq among 300 bank managers in malaysia, and haj ali et al. among muslim managers in malaysia (39 41), and soebyakto and ming (42). all the above-mentioned studies confirm the current study results. on the other hand, the following studies reported cultural intelligence scores that were over medium or desirable level, which also confirms the current study results: ahmadi et al. among iranian healthcare organizations managers, and rahmanzadeh et al. among fars news agency managers, and ahmadi et al. (43, 44). some studies that have reported desirable levels of moral intelligence among managers and thus confirm the results of the current study are: bahrami et al. among faculty members and staff of schools of public health and allied health medicine (45), hosseini et al. among the managers of an industrial company in iran (46), and motlaghi et al. among islamic azad university, tabriz branch physical education experts (47). moreover, it was observed that the mean of the ideal hybrid intelligence of tums vice chancellors’ headquarters managers was at a desirable level. this was similar to the findings of dargahi and veysi et al. (2020) who had reported a desirable level of hybrid intelligence in tums managers (48). the current study results showed that the mean of organizational commitment among the vice chancellors’ headquarters employees of tehran university of medical sciences was at a desirable level. moreover, the status of organizational commitment was average to desirable in a study by dargahi and sadat tehrani (2012) on the vice chancellors’ headquarters employees of tehran university of medical sciences (49), and a re-study by rajabnezhad et al. (2017) (50). in addition, raadabadi et al. reported an average level of organizational commitment among tehran university of medical sciences employees in 2017 (51). however, dargahi and morshedi found the organizational commitment of the nurses employed in hospitals of tehran university of medical sciences to be moderately desirable (52). this seems that the organizational commitment level of employees has been relatively stable in this university in recent years. other findings of this study showed that there was no significant relationship between the spiritual, cultural and moral intelligence as constituents dimensions of ideal hybrid intelligence, and managers’ academic degree, age and work experiences (p > 0.05). rajabnezhad et al. did not report any significant relationship between tums managers’ spiritual intelligence and academic degree (50). however, dargahi et al. (53) and dargahi and sadat tehrani (49) dargahi h., et al. 9 j med ethics hist med. 2021(feb); 14: 8. journal of m edical ethics and h istory of m edicine reported a significant and negative relationship between spiritual intelligence and academic degree. the difference in the relationship between spiritual intelligence and the academic degree of tums managers may be due to the time of research and type of population studied. the results of this research showed a higher rate of cultural intelligence in men than women. a study by ahmadi et al. on the managers of healthcare organizations, as well as a study by hosseini nassab and ghaderi and templer et al. showed no significant relationship between cultural intelligence and gender or age (43, 54, 55). no adaptable positive relationship can be observed between cultural intelligence and gender among employees in iran or other countries because of the higher presence of men in managerial positions especially in cultural domains, and the differences in the cultural conditions of various countries. dargahi and sadat tehrani stated there was a significant relationship between the moral intelligence of managers and their gender. they found that moral intelligence was higher in male managers (49), which is in line with the results of this study. in the current study, there was no significant relationship between organizational commitment and gender and age among the vice chancellors’ headquarters employees. however, a significant relationship was found between their organizational commitment and education level and work experience. results of studies by rajabnezhad et al. (2017), yaghoubi et al. (2010) and delgoshaei et al. (2008) showed no significant relationship between employees’ organizational commitment and their age, gender and education level (50, 56, 57). incompatibilities between the results of various studies may be due to differences in populations and research times. findings about the correlation between ideal hybrid intelligence and its different constituents dimensions indicated a significant relationship among these dimensions (p < 0.001). a study by fawcett et al. on 500 companies showed that managers’ spiritual intelligence and the organizations’ spiritual environment affect the organizational culture of companies (58). also, graham et al. stated that cultural intelligence can affect organizational values, and managers’ judgments and moral intelligence (59). poursoltani et al. showed that algorithms of measurement’s model of all the indicators of spiritual intelligence and cultural intelligence had been approved and was in acceptable level (60). similarly, faghihi aram et al. found a direct and meaningful relationship between cultural intelligence and spiritual intelligence (61). bahrami et al. also confirmed the relationship between spiritual intelligence and cultural intelligence among the nurses of birjand teaching hospitals (62). other studies that have reported a significant relationship between spiritual and moral intelligence as dimensions of ideal hybrid intelligence include: sotoodeh et al. among nurses of bojnourd hospitals in north-east of iran (63), asgari sharabjani et al. among senior the relationship between managers’ ideal intelligence as a hybrid model and … 10 j med ethics hist med. 2021(feb); 14: 8. journal of m edical ethics and h istory of m edicine high school students in bostanabad among ministry of petroleum employees (64), and golipour et al. among emergency response volunteers in tehran, iran (65). a positive correlation was found between moral intelligence and cultural intelligence among the women of west islam abad in kermanshah province and among the employees of a public organization in tehran (66). also, presbitero and tengcalleja found that moral intelligence strengthens cultural intelligence (67). according to dargahi et al., in the present century, hybrid managerial intelligence is needed to direct organizations (48). also, mosadeghrad and abbasi wrote that managers performance manly depends on their intelligence. managerial hybrid intelligence is vital for hospital managers’ success. they also reported a meaningful statistical correlation was observed between intelligence quotient and emotional intelligence and political intelligence as constituents of hybrid intelligence (68). dale believed that when joined with other types of intelligence, emotional intelligence plays a key role in solving problems at the time of climate change and geopolitical conflict (69). the present study demonstrated the relationship among all constituents dimensions of ideal hybrid intelligence, which has also been confirmed by other studies. in this study, a significant relationship was found between cultural intelligence as a constituent dimension of ideal hybrid intelligence and organizational commitment. dolatshah and ghorban hosseini in arman financial institute in tehran and rockstuhl et al. in a sample of 126 swiss military officers defined cultural intelligence as a constituent dimension of hybrid intelligence was a strong predictor of organizational commitment and leadership effectiveness (70 , 71), which is in line with the results of this study. aebdeen et al. in their study in lahore and renala khurd (pinjab) in pakistan on banking sector employees, chun et al. in their study on 3821 employees of 130 companies in korea, and clandia et al. stated that moral intelligence was correlated with organizational commitment (72 , 73). moreover, parandeh et al. emphasized that spiritual intelligence had a vital effect on employees’ organizational commitment (74). it can therefore be concluded that the findings of the above studies are in line with current study results, that is to say, a combination of cultural, moral and spiritual intelligence as ideal hybrid intelligence affects organizational commitment in employees (75). finally, the results of this study showed that there was a significant relationship between cultural, moral and spiritual intelligence as constituents dimensions of ideal hybrid intelligence and employees’ organizational commitment. sternberg, mirdamadi and rezaeian, and also sagharvani and zabihi found that there was a relationship between hybrid intelligence and organizational commitment, which is compatible with our results (20 22). therefore, different dimensions or components of intelligence need to be developed in managers so that they can achieve individual, organizational dargahi h., et al. 11 j med ethics hist med. 2021(feb); 14: 8. journal of m edical ethics and h istory of m edicine and managerial success (48, 68). moreover, the results of the current study showed that when the other variables were fixed, managers’ ideal hybrid intelligence including cultural, moral and spiritual intelligence affected employees’ organizational commitment with an intensity of 0.52. dargahi et al. showed that there was a significant relationship between hybrid intelligence in managers of clinical laboratories and transformational leadership, management skills, moral considerations, and other job variables such as organizational commitment and job satisfaction (53). despite advantages such as its new features and examination of many variables, the present study had some limitations. first, it was conducted using the self-assessment procedure. second, it was a cross-sectional study, and it is likely that the results will be different if it is done at another time. third, it was performed on the vice chancellors’ headquarters managers and employees of tehran university of medical sciences, and therefore the findings cannot be generalized to the whole country. conclusion the results of the present study have different aspects in terms of conclusion. first, considering the remarkable developments and numerous changes in organizational culture and environment in the present century, managing organizations relies on the use of a new model called ideal hybrid intelligence; this is made of different constituents dimensions including spiritual, cultural and moral intelligence, which are all essential to the development of employees’ organizational commitment. existence of all these various dimensions constitute ideal hybrid intelligence, which will give managers capabilities and capacities that will enable them to improve employees’ organizational commitment and work ethics. some measures that may facilitate the process include: testing ideal hybrid intelligence at the time of employment; socialized training and on the job training of managers to be appointed in different managerial positions; evaluating managers’ ideal hybrid intelligence at different times; and establishment of empowerment trainings. however, we found that managers’ ideal hybrid intelligence may affect employees’ organizational commitment with an intensity of approximately 52%. this shows that employees’ organizational commitment may influence other forms of intelligence, including emotional quotient (eq), political quotient (pq), intelligence quotient (iq) and other organizational variables. however, intelligence is just one of the factors that determine managers’ meritocracy when selecting and appointing them to managerial levels and positions. acknowledgements the authors of this article sincerely appreciate the help and collaboration of all vice chancellors’ headquarters managers and employees of tehran university of medical sciences in this research. this the relationship between managers’ ideal intelligence as a hybrid model and … 12 j med ethics hist med. 2021(feb); 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[cited on july 2021]; https://iconline.ipleiria.pt/handle/10400.8/3678?locale=en abstract references microsoft word 2 journal of medical ethics and history of medicine chronic pain and voluntary euthanasia mojtaba rismanchi medical student, department of medical ethics, shiraz school of medicine, shiraz university of medical sciences, shiraz, iran. *corresponding author: mojtaba rismanchi address: zand ave., shiraz school of medicine, shiraz university of medical sciences, shiraz, iran. tel: (+098) 91 73 07 30 27 e-mail: rismanchi@sums.ac.ir received: 19 jul 2008 accepted: 24 aug 2008 published: 19 oct 2008 j med ethics hist med. 2008; 1:2. © 2008 mojtaba rismanchi; licensee tehran univ. med. sci. abstract keywords: chronic pain, emotion, decision making, voluntary euthanasia. introduction voluntary euthanasia (ve) is the act of requesting deadly medical practices in order to terminate one’s life (1). the process of decision making (like that for ve) is composed of two interwoven brain based components (2). one is the conscious power of analyzing the condition and utilizing algorithmic like strategies, which is known as cognition (2, 3). the other part is the emotional background of the individual (2). this part is important since it affects the person’s ability of seeking in the condition (4), estimating the parameters of a situation (5) and finally deciding (2). chronic pain patients (cpps) develop disappointing emotional backgrounds, which affect their mental power of decision-making (6). this article argues about the mental incompetence relating decision-making that accompanies chronic pain in such patients. theoretical concepts chronic pain and emotion based decision making (exemplifying approach): a cpp is under the torture of his/her illness. this can be considered as equal to the historically known conditions of torturing a person and wanting him/her to accept or confess something in return for relieving pain (7). in case of ve, the agent is the internal mental burden of a disease and the thing wanted in return for reliving the pain is “dying acceptance”. therefore, in this condition the stimulator of emotional status and its brain bases change in a chronic pain patient and this change affects his/her decision making ability. moreover, it is accepted that a mentally disturbed individual is not competent to make critical decisions. according to these bases, this article demonstrates that such patients are not entitled to request voluntary euthanasia. mailto:rismanchi@sums.ac.ir j med ethics hist med 2008, 1:2 mojtaba rismanchi page 2 of 3 (page number not for citation purposes) accepting death is the emotion of escaping from pain in return for anything. this is the exaggerated form of the normal emotion of fearing and escaping from painful situations (8). in fact, a cpp fears from experiencing excess pain. according to this outlook and having in the mind that emotions -in the way it is described in the literature (9) are the most important determinants of the alternative to be chosen (10), here it is proposed that cpps are emotionally and hence mentally incompetent for making critical decisions. chronic pain and emotion based decision making (experimental approach): studies using mri technology have shown brain deficits in cpps (11 14). more specifically in the state of chronic pain it is stated that the orbitofrontal part of the brain cortex is preferentially involved. this part functions as a link between multiple brain regions with distinct roles in the emotional assessment. these regions include lateral prefrontal areas which handle memory, effector components of the brainstem which are responsible for producing emotional responses and those parts that are considered as the brain substrates of feelings like insula and amygdale (6). according to these findings a cpp does not have a biologically healthy brain for providing the accuracy of the act of choice-making especially when he/she wants to do so for emotion laden alternatives like that of whether to escape or cope with the pain. discussion the central concept of this article is that a person who is under the mental pressures is not capable of making critical decisions. the same concept is already accepted for the other categories of people who cannot think well such as drunken individuals (15). the fact that mentally under pressure patients cannot think well is also indirectly accepted by all societies that refuse to obey a mentally ill patient’s will in the light of labeling the patient unqualified for making a will according to the judgment of court. with the same bases, this article’s concept can be accepted by the court and become a law in such societies. conclusion a cpp is mentally incompetent to make critical decisions. therefore, the patient’s will of terminating his/her life must not be accepted like that of a drunken person. deciding to undergo euthanasia is the most critical decision of a person (not only a patient) since this decision leads to the end of making other decisions. in this respect, deciding to die is different from deciding to buy a car because the latter is reversible or can be compensated in the future and does not violate the right of making other decisions, something that the former intrudes in. therefore the ability of making the decision of undergoing euthanasia must be considered as something different from just a right. in this regards the inclusion of this ability among other rights must be investigated more. mental incompetence is the common quality in both conditions of chronic pain and will rejection in the court. therefore the accepted rules for both of these two conditions must be the same. this means that any nation that rejects the will of a mentally incompetent individual must do the same about the request of a cpp for ve. j med ethics hist med 2008, 1:2 mojtaba rismanchi page 3 of 3 (page number not for citation purposes) references 1. anonymous, (2008). url: http://www.vesq.org.au/definitions.html 2. martin p, paulus mp. neurobiology of decision-making: quo vadis? cognitive brain research 2005; 23(1): 210. 3. anonymous, (2008). url: http://www.floridainstitute.comresourcesglossary1.html 4. kahnand be, isen am. the influence of positive affect on variety seeking among safe, enjoyable products. j consum res 1993; 20 (2): 257–270. 5. nygren te, isen am, taylor pj, dulin j. the influence of positive affect on the decision rule in risk situations: focus on outcome (and especially avoidance of loss) rather than probability. org behav human decis process 1996; 66 (1): 59– 72. 6. apkarian av, sosa y, krauss br, et al. chronic pain patients are impaired on an emotional decision-making task. pain 2004; 108 (1-2): 129–136. 7. durant w. the story of civilization, 1939; vol 4. 8. keefe fj, lumley m, anderson t, lynch t, studts jl, carson kl. pain and emotion: new research directions. j clin psychol 2001; 57(4): 587–607. 9. anonymous. emotions in decision making, (2008). url: ttp://en.wikipedia.org/wiki/emotions_in_decision_making 10. anonymous. emotion and decision, (2008).url: http://changingminds.org/explanations/emotions/emotion_decision.htm 11. apkarian av, grachev id, krauss br. imaging brain pathophysiology of chronic crps pain. in: harden r, janig w, baron jc, eds. complex regional pain syndrome. seattle, wa: iasp press; 2001a. pp. 209–27. j med ethics hist med 2008, 1:2 mojtaba rismanchi page 4 of 3 (page number not for citation purposes) 1. apkarian av, krauss br, fredrickson be, szeverenyi nm. imaging the pain of low back pain: functional magnetic resonance imaging in combination with monitoring subjective pain perception allows the study of clinical pain states. neurosci lett 2001; 299 (1-2): 57–60. 2. apkarian av, thomas ps, krauss br, szeverenyi nm. prefrontal cortical hyperactivity in patients with sympathetically mediated chronic pain. neurosci lett 2001; 311 (3): 193–7. 3. baliki mn, geha py, apkarian av, chialvo dr. beyond feeling: chronic pain hurts the brain, disrupting disrupting the default mode network dynamics. j neurosci 2008; 28(6): 1398-403. 4. george s, rogers rd, duka t. the acute effect of alcohol on decision making in social drinkers. psychopharmacology 2005; 182 (1): 160–9. journal of medical ethics and history of medicine original article from good to great physician: a critical ethnography based on patients' views ahmad kalateh sadati 1 , mohammad taghi iman 2 , kamran bagheri lankarani 3* , najmeh ebrahimzadeh 4 1 assistant professor, department of social sciences, yazd university, yazd, iran; 2 professor, department of sociology and social planning, shiraz university, shiraz, iran; 3 professor, health policy research center, shiraz university of medical sciences, shiraz, iran; 4 ma, health policy research center, shiraz university of medical sciences, shiraz, iran. corresponding author: kamran bagheri lankarani address: health policy research center, shiraz university of medical sciences, shiraz, iran. email: lankaran@sums.ac.ir tel/fax: 98 711 2309615 received: 8 feb 2016 accepted: 14 dec 2016 published: 20 dec 2016 j med ethics hist med, 2016, 9: 18 © 2016 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract the doctor-patient interaction (dpi) plays an important role in the way patients view physicians. thus, response to the question of ''who is a great physician?'' is related to dpi experiences of patients. the aim of this qualitative study was to explore patients' views regarding this subject. based on critical ethnography in one educational hospital in shiraz, iran, the study was performed based on 156 clinical consultations, 920 hours of participant observations, and 6 focus groups with patients and their relatives. the results revealed that asymmetrical power relationships exist in this context. based on the general views of participants and their recent dpi experiences, a great physician should be kind, empathetic, friendly, and a good listener. considering the presence of an asymmetrical power relationships in this context, results showed that doctors do not participate in an active interaction. based on sociological theories, it can be concluded that the concept of a great physician is not only limited to obligations as in the parsonian view, but is also related to active communication between both sides which is presented in the critical view. through active communication‎, asymmetrical power relationships can be reduced. thus, if a physician wants to become a great physician, he/she must strengthen his/her humanistic dimensions and communicative skills alongside his/her medical skills. keywords: doctor-patient interaction, empathy, great physician j med ethics hist med 9: 18 december, 2016 jmehm.tums.ac.ir ahmad kalateh sadati et al. page 2 of 9 introduction numerous characteristics have been attributed to a good doctor. a good doctor is expected to be attentive, analytical, authoritative, accommodating, a good adviser, approachable, assuring, and etc. (1). however, it seems that a good doctor differs from a great doctor, but no deep scientific research has been conducted on this difference. sir william osler stated that the good physician treats the disease, while the great physician treats the patient who has the disease (2). this means that the great physician pays attention to the patient, while the good physician emphasizes the disease. a patient who was diagnosed with diabetes in 1960 stated that finding a great doctor is not easy, because some doctors do not listen to the patient (3). this means that a great doctor should be a good listener. most doctors are great doctors in the eyes of the most patients (4). if a physician facilitates a great relationship and meets his/her patient's expectations, the patient feels that he/she is a great doctor. it seems that a high quality relationship is essential from patients' point of view. the doctor-patient interaction (dpi) is the main subject of the present study. although dpi dates back to the hippocratic oath, it has been considered to be an important subject in the late 20 th century and onward (5, 6). overall, there is unified global view of characteristics of a great doctor. however, a patient's point of view toward a great doctor is contextual and it is also related to patient‎s' dpi experience. moreover, within each social and cultural context, there is a different view toward values and norms of medicine‎and‎doctors’‎behaviors.‎this‎means‎that‎the‎ values of each society regarding the position of doctors and medicine are dependent upon that society’s‎historical‎context. in iran, due to considerable social and behavioral changes, medicine has been dramatically commercialized, and as a result, the humanistic aspect of this trade is fading away. in addition, the present‎ increase‎ in‎ individuals’‎ knowledge‎ is‎ remarkable compared with two decades ago. this leads to a fluctuation in dpi, so that patient's expectation of a great physician is related to his/her experience‎ of‎ relationship.‎ therefore,‎ the‎ patient’s‎ dpi experience has an important influence on his/her view of a great physician. generally, patients have expectations of their doctors. if a patient has a bad dpi experience, he/she will most likely start to judge doctors’‎ behaviors‎ based‎ on‎ his/her‎ expectations.‎ here, the physician will be judged based on the characteristics that he/she does not have. in sociology there are two opposing views of dpi. one is parsons' theory which is also known as the sick role. this view has a functional approach; a doctor must perform his/her duties by curing patients until order returns to the social system (7, 8). the second view is a critical one, which has a humanistic outlook on dpi. in this view, dpi should not be distorted and there should be appropriate communication between doctors and patients based on a mutual understanding (9). even though there have been an ample number of studies on the good physician in other countries, the great physician has been not been well understood. because of this and due to extensive social changes in iran, this study focused on the subject of the great physician. the goal of this study was to explore the characteristics of a great doctor according to patients' views and their recent experiences of dpi. thus, the main question of the present study was: "who is a great physician?" method this critical ethnographic study was conducted on patients admitted to an educational hospital in shiraz, iran, based on critical ethnography method. for data collection and analysis, triangulation method was applied. for this purpose, 156 clinical consultations, which were daily visits of admitted patients by faculty members and their students, were recorded digitally. before this, verbal consent was obtained from each participant by researchers. in total, 156 consultations by 8 faculty members in cardiology, internal, and neurology wards were recorded digitally. in addition, 920 hours of participant observations were conducted by the researcher in all wards of the hospital. for participant observations, the researcher worked as a clinical supervisor by hiding his researcher identity. he observed the consultations, and in some cases, he conducted in-depth interviews with patients (n = 5). in these interviews, the patients were asked about their views of dpi, and data were recorded manually for analysis. in total, 6 focus group discussions were conducted with patients in internal, urology, general surgery, cardiac surgery wards, and the coronary care unit (ccu). focus group research involves organized discussion with a selected group of individuals with the aim to gain information about their views and experiences of a topic. this research method is suitable for obtaining different perspectives about the same topic (10). after explaining the aims of the study to patients and their families, those who were willing to participate were enrolled in the focus groups (table 1). j med ethics hist med 9: 18 december, 2016 jmehm.tums.ac.ir ahmad kalateh sadati et al. page 3 of 9 table 1the participants information no. ward number of participants female male patients family members duration of interview (hour) 1 internal 6 2 4 5 1 1:10 2 urology 11 5 6 5 6 1:28 3 ccu 16 7 9 13 3 1:15 4 general surgery no. 1 5 5 0 4 1 1:20 5 cardiac surgery 5 3 2 0 5 1:12 6 general surgery no. 2 8 1 7 7 1 0:42 total 51 23 28 34 17 7:07 the‎questions‎in‎the‎focus‎groups‎were:‎“how is the dpi in this hospital?”; “what is your opinion with regards to this type of dpi?”; and “from your point of view, who is a great physician?”. the collected data were then transcribed. data analysis was performed based on critical ethnography methodology which was introduced by carspecken.‎ he‎ called‎ this‎ method‎ “reconstructive analysis” (11). in this method, the cultural norms that shape people's behaviors are taken into consideration. these cultural norms which include values‎regarding‎people’s‎behaviors‎are‎explored‎in order to interpret social contexts. statements were analyzed according to three main validity claims; subjective, objective, and normative/evaluative. subjective claims are those that represent perception of an interaction. objective claims represent certain objects and events which occur during an interaction. normative/evaluative claims are those which represent judgment (11, 12). in this study, simultaneous to exploration of claims, the main themes of dpi were also explored. themes that explained a great physician were discussed according to sociological dpi theory. the validity of this research was evaluated and confirmed through triangulation method (13, 14). in addition, trustworthiness was also confirmed in every phase of the analysis process, including preparation, organization, and reporting of the results (15, 16). this study was conducted based on the ethical codes of the american sociological association (17). based on these considerations and the ethical principles of research, all participants' names were kept‎ confidential.‎ moreover,‎ patients’‎ privacy‎ was‎ taken into consideration. furthermore, the study was approved by the ethics committee of shiraz university, iran. results our results showed that some patients were not satisfied with dpi, although most of them believed that their physicians were experts in their specialties. this finding was confirmed by other observations in our studies. observations showed that some physicians did not visit their patients in the ward, even though patients and their relatives had been waiting for hours. generally, residents (not sfms) are‎ responsible‎ to‎ answer‎ patients’‎ worries.‎ in‎ addition, the clinical consultations showed that much of the conversations were between faculty members and their medical students. dialogues with the patients were very rare, and generally, doctors talked with the patient about date of discharge and nothing more. however, in some cases, the doctor explains everything for patients. thus, generally, patients and their families experienced negative dpi. negative dpi is a form of interaction which cannot satisfy the patient, despite the‎patient’s‎satisfaction‎with‎treatment.‎in‎negative‎ dpi, patients were faced with some ambiguities about their illness as well as disorder in daily visits. for example, one patient stated: [i was admitted to this hospital four days ago, but i do not know who my physician is. if anyone comes and says that i am dr. ma'roof, i will believe him]. (woman with urology problem) in different wards, specifically in the surgery wards, some patients did not recognize their physicians, because they were never visited by the faculty member prior to the operation. some cases, specifically female patients, had concerns about their privacy during treatments. [when i was taken to the operation room, 5 or 6 physicians examined my breasts, is this right? i am a woman, i would only let my physician handle the dressing, but i will not let anyone else do this at all. do you think it is right that a woman be examined by several male physicians?] (woman with breast cancer) in addition, the duration of the clinical consultations that took place in wards was very short. of the 156 consultations that took place in different wards, some only took 1 minute. for instance, the resident would say that this patient is ok and they would move on to the next patient without any form of communication. therefore, the definition of a great physician is related to the quality of the relationships. analyses of all data in triangulation method showed that a great physician must be kind, emphatic, friendly, and a great listener. j med ethics hist med 9: 18 december, 2016 jmehm.tums.ac.ir ahmad kalateh sadati et al. page 4 of 9 kindness kindness is a theme that was heavily emphasized by the participants. this refers to patient's desire to see a doctor with at least a pleasant behavior such as a smile on his/her face. observer’s comments: during daily visits, rarely did any type of dialogue occur between the doctors and their patients. doctors merely read reports, listens to medical students‎'‎ reports about the patient's condition, patient's vital signs, and paraclinical data such as magnetic resonance imaging (mri), computerized tomography (ct) scan, or lab data, and what was prescribed. under these conditions, if a patient asks a question, usually it is ignored or a simple answer is provided. after a few such encounters, the patient usually feels it is better not to ask any questions, as he/she feels that doctors are generally moody and they are not kind in the least. another issue that instigates this matter is when family daily visits are coming to an end and usually security guards force visitors to leave the room immediately with disrespect. this is what doctors want because they do not want to answer any questions‎of‎the‎patients’‎family. a son of a patient with cancer told: [the doctor‎'s‎ kindness gives us energy; when you speak to a patient in a great manner, he/she will recognize your kindness and accept what you have said, even if the patient has cancer.] a women with multiple sclerosis said that [when a physician speaks with kindness, i feel i can trust him.] as validity claims show, kindness is a vital part of being a great physician, and it is any patient's expectation (figure 1). figure 1. horizon analysis; possible validity claims of patients' view about kindness by a great doctor sfms: scientific faculty members empathy patients have physical and psychological issues and these disabilities may result in financial burden which puts more pressure on the family as a whole. hence, they expect the physician to pay attention to every aspect of their illness. their expectation is that doctors‎ be‎ empathetic‎ towards‎ their‎ patients’‎ circumstances and to put themselves in the place of their patients. observer’s comments: due to poor interactions, patients and their families sense that their doctors do not empathize with them. doctors do not actively speak with their patients and their families, and do not listen to their concerns. as a result, patients feel that their worries are unimportant for their physician. specific field note: family members of an old man who had passed away the night before in the surgical intensive care unit (icu) were very upset. they were saying that they were going to file a complaint to the coronary office, because they felt that the doctor did not care enough for their patient. the doctor arrived and explained that he had tried his best to resuscitate the patient. he said: "i tried my best, i called my mentor (sfm) about your patient, our team tried for several hours, but unfortunately he passed away". after his explanation the family was convinced, and they even apologized to the doctor and thanked him for his efforts. in this case, if the doctor had provided them with these explanations the night before, the family would not have had concerns and complaints. possible subjective claims quite foregrounded, quite immediate: kindness has postive effects. less foregrounded, less immediate: kindness gives positive energy. kindness leads to trust. possible objective validity quite foregrounded, quite immediate: if sfms are moody, patient will be under more stress. less foregrounded, less immediate: i feel i can trust the doctor. possible normative calims less foregrounded, less immediate: doctors have to be kind. doctors should not be moody. less foregrounded, less immediate: kindness is an essential part of being a doctor. j med ethics hist med 9: 18 december, 2016 jmehm.tums.ac.ir ahmad kalateh sadati et al. page 5 of 9 a woman with multiple sclerosis said that [great doctors will empathies with their patient.] the other patients told: [a physician should be compassionate. they should put themselves in their patients’ shoes, so that they can understand what/how the patient is feeling.]; [a great doctor should ask his/her patients about their problems, and should sympathize with them.] as this horizon analysis showed, patients like compassionate doctors. this means that patients expect their doctors to talk to them and be sympathetic towards their issues (figure 2). figure 2horizon analysis; possible validity claims of patients' view about a great empathetic doctor friendliness friendliness refers to a relationship between doctors and patients, where both sides feel that they are communicating as friends. being friendly means warm, face to face dpi while smiling, in a way that both sides feel as though they are interacting with their family members. if this form of interaction ever occurs, patients are surprised. observer comments: in daily visits, patients watch doctors generally and did not have conversation. if patients have any question, the doctors respond rarely and usually they refer the patient to their residents. because of this patients do not feel any connection in this relationship. they think that doctors are robotic and no friendly interaction is possible with them. the sister of a patient with renal problem told: [the doctor-patient relationship should be based on friendship. doctors should act as a friend. when visiting a patient, the doctor should behave in a way that the patient feels the doctor is his/her friend. this gives the patient's hope and energy. the doctor should be friends with the patient and not act as a father figure. however, these relationships are not based on friendship, because friends usually converse with one another]. a patient with surgical problem insists: [doctors should act as a friend. i disagree that dpi should be based on father-child relationship, because in that type of friendship there will never be any hurt feelings between friends]. horizon analysis shows that the main criteria for a great doctor are his/her friendliness with a patient (figure 3). this means that a friendly doctor should not only have empathy, but also try to solve patients' problems as a friend. being a good listener this characteristic refers to doctors' patience when listening to patients' conversations. every patient is concerned about his/her condition and also has questions and worries about the condition. a good listener is someone who listens well. observer’s comments: some patients and their families were annoyed by the doctor's disregard for them. they believed that doctors did not listen to them and they did not allocate any time to listen. observation of clinical consultations showed that scientific faculty members (sfms) always speak with their medical students about pathophysiology of the diseases. sometimes they speak about the recovery of the disease. they rarely speak with patients and their family members, particularly when they ask their doctor about their illness. a man with inflammatory bowel disease believed that [doctors must listen to patients' conversations.] the sister of a patient with urinary problem confirms that [doctors should be patient and talk to their patients.] a patient with urology problem told that [doctors should not only work in operation rooms, but also possible subjective claims quite foregrounded, quite immediate: patients have several needs. a great doctor considers the patients' needs. less foregrounded, less immediate: emphaty means that the doctor puts him/herself in the patients' postion. possible objective validity quite foregrounded, quite immediate: the doctor had not explained the sitiuation before the family members became upset. less foregrounded, less immediate: the doctor did not empathize with his patient. possible normative calims less foregrounded, less immediate: doctors have to sense patients' needs and problems. less foregrounded, less immediate: doctors have to empathize with their patients. https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0cb4qfjaaahukewieh8lkquthahvixbqkhudydpk&url=http%3a%2f%2fwww.mayoclinic.org%2fdiseases-conditions%2finflammatory-bowel-disease%2fbasics%2fdefinition%2fcon-20034908&usg=afqjcnerzyz7it0ffxoaqgpqvfyyhuwe6a&sig2=snccym3hh7gqv6mmc6epjq j med ethics hist med 9: 18 december, 2016 jmehm.tums.ac.ir ahmad kalateh sadati et al. page 6 of 9 must allocate at least 5 minutes to each patient daily. in this way, the doctor will provide the patient with energy.] as figure 4 shows, doctors should be great listeners as well as great communicators. thus, the patient can present his/her worries and concerns to the doctor, and the feedbacks show that these types of doctors are good listeners. figure 3. horizon analysis; possible validity claims of patients' view about a friendliness doctor figure 4horizon analysis; possible validity claims of patients' view about a doctor who should being a good listener discussion few studies have been performed on the characteristics of a great physician. thus, the main question that was investigated in this study was: "what do patients demand from their physicians?" although it seems that both technical and communicative skills are important (4), our findings showed that communicative skills are more important. the results showed that the participants demand that their physician to be kind, friendly, a good listener, and show empathy. among all the participants, only two participants emphasized the importance of technical skills; a father of a girl with tetralogy of fallot (tof) who was faced with complications after heart surgery and a woman with multiple sclerosis (ms) who was admitted with surgical problems. none of the other participants referred to technical skills. patients may have been generally satisfied with the skills of doctors, although this could be due to the fact that possible subjective claims quite foregrounded, quite immediate: the doctor-patient friendship is proposed. less foregrounded, less immediate: dpi should be different from other forms of intraction. possible objective validity quite foregrounded, quite immediate: the doctor should act as a friend. less foregrounded, less immediate: the doctor-patient relationship should be based on friendship. possible normative calims less foregrounded, less immediate: doctors must act like a friend. less foregrounded, less immediate: a friendly relationship is a must. possible subjective claims quite foregrounded, quite immediate: patients need to be listened to. less foregrounded, less immediate: listening to patients converstion is an important part of dpi. possible objective validity quite foregrounded, quite immediate: doctors should not only work in operation rooms. less foregrounded, less immediate: the doctor empowers the patient by speaking to him/her. possible normative calims less foregrounded, less immediate: doctors should be patient and speak with the their pateints. less foregrounded, less immediate: doctors have to listen to their patient. j med ethics hist med 9: 18 december, 2016 jmehm.tums.ac.ir ahmad kalateh sadati et al. page 7 of 9 they were unaware of what great skills are or they were forced to refer to an educational hospital due to financial issues. although this should be evaluated in future studies, the important point was that there was no significant dissatisfaction regarding skills. based on our findings, it seems that a great physician in this context is someone who can communicate and interact well. from another aspect, it can be noted that patients in this hospital were faced with a specific form of interaction which was more linear and technical and refers to poor dpi. instrumental interaction shows that doctors only interact with patients according to scientific findings, which is a deep rooted issue in biomedicine (5). in this approach, health and disease are defined in a simple and one-dimensional path. since the human body is a complex entity, the diagnosis of disease and treatment should be performed through a nonlinear method. additionally, patients have souls which need dialogue, attention, and empathy. among the four themes which were extracted, empathy plays a central role. this theme was emphasized more than others by the patients. empathy is the capacity to understand or feel what an individual is experiencing, i.e., the capacity to place oneself in another's position (18). many studies have shown the importance of empathy in clinical experiences (19-21). a study showed that empathy significantly influences patient satisfaction and compliance through mediating factors, such as perceived expertise, inter-personal trust, and partnership, and this can lead to patient satisfaction and compliance (19). physicians who can empathize during visits through effective interactions can diminish irritation and hindrance and increase their therapeutic‎impact‎(21).‎it‎seems‎that‎doctors’‎sense‎ of empathy with their patients can facilitate a great relationship based on listening, kindness, and friendliness. in addition, these points lead us towards other new concepts in medicine which are called professionalism and patient-centeredness. in the concept of professionalism, it is an obligation to be a great listener, have empathy, and be kind which are considered to be important communication skills (22). generally, we can say that our participants were in pursuit of a great physician rather than a good physician. sir william osler distinguished between a great physician and a good physician by stating: “the‎ good‎ physician‎ treats‎ the‎ disease;‎ the‎ great‎ physician‎treats‎the‎patient‎who‎has‎the‎disease”‎(2).‎ accordingly, we believe that a great physician should not only pay attention to the patient's physical and mental problems in the context of the illness, but should also consider the patient's soul, family, and socio-economic status. thus, a great physician always tries to cure patients holistically. it seems that the ultimate concern was to find a great doctor, rather than someone who can only cure the illnesses. other dimensions of dpi can be discussed based on sociological theories. in this context, a great physician is someone who should comply with his/her professional obligations which is referred to a "functional view" in the parsonian view (8). in this view, illness is defined as a social deviant, and the role of the physician is to return the society to a normal condition. in this approach, illness is considered to be a fundamental part of what may be called the motivational economy of the social system (8). correspondingly, the therapeutic process must also be treated as part of that same motivational balance. this view presents the function of physicians as good physicians. hence, a physician fixes the malfunctions of the social system with his/her medical knowledge. on the other hand, critical theory explores the quality of dpi from different view. according to communication action theory (23), in the context of this study, patients encountered a distorted relationship. thus, there is a huge gap between doctors and patients. while, patients were in need of a doctor who communicates well, these physicians were mute without any active verbal and non-verbal communication. thus, as mishler has mentioned, there is a separation between the voice of modern medicine and the voice of patients' lifeworld (24). as a result, physicians do not recognize patients' expectations and desires. therefore, doctors think that they are great doctors, while patients seek great doctors. this is a divergence condition which cannot lead to the two parties' mutual understanding. this claim was confirmed by other studies in this context. results of a study by sadati et al., based on the opinion of faculty members of shiraz university medical sciences (iran), showed that dpi in this context is distorted due to the disorganization of health care management and cultural barriers (25). furthermore, it was shown that patients in the context of the study were faced with an unexpected interaction with unequal, unprofessional, instrumental, and non-cooperative features (26). therefore, dpi in this context needs the communicative action approach in order to attain the great physician. another view of critical theory showed the existence of power-knowledge relations between doctors and patients (27). according to this view, the doctor's domination can suppress patients. thus, based on this view and our interpretation of the findings, patients seek a great physician in order to escape this suppression. thus, when a doctor is kind, friendly and emphatic the possibility of suppression will decrease. another study in a similar context showed different forms of domination and suppression in clinical consultations (28). thus, it can be concluded that the desire for the good and great physician is related to communication between doctors and patients with the minimum level of unequal power j med ethics hist med 9: 18 december, 2016 jmehm.tums.ac.ir ahmad kalateh sadati et al. page 8 of 9 relationships. one of the limitations of this study was the way in which the conversations were recorded. in fact, recording affects doctor's manner of consultation and dialogue. however, the researchers did not find another alternative for collection of the data. this is an important and basic restriction of qualitative studies, where the participants are aware of the recording and data collection, considering the fact that the researcher did not interfere with the natural course of the dialogues between the physician and the patient. conclusion being a good physician in general terms means knowing how to use appropriate medical techniques. nevertheless, a great physician is someone who is not only a professional in using appropriate medical techniques, but who also has excellent communicational skills. the results of this study showed that in this context patients had experienced bad dpi. thus, it is their desire for their physician to be kind, friendly, empathetic, and a good listener. based on sociological theory, the results are more in favor of critical theory than functional theory. thus, if a physician wants to become a great physician, he/she must strengthen his/her humanistic dimension and communicative skills in addition to his/her medical skills. conflict of interests the authors declare that they have no conflict of interests. acknowledgment this study was extracted from the phd dissertation of ahmad kelateh sadati in sociology titled critical narrative analysis of doctor-patient interaction in shahid faghihi hospital approved (no. 1069353) at shiraz university. the research was conducted to develop knowledge and does not seek to question the efforts of physicians who are working against the clock to serve patients in this hospital. the researchers wish to thank all of the participants of the study. the authors would like to thank the research consultation center (rcc) of shiraz university of medical sciences for their invaluable assistance in editing this article j med ethics hist med 9: 18 december, 2016 jmehm.tums.ac.ir ahmad kalateh sadati et al. page 9 of 9 references 1. rizo ca, jadad ar, enkin m.‎what’s‎a‎good‎doctor‎and‎how‎do‎you‎make‎one. doctors should be good companions for people. bmj 2002; 325(7366): 711. 2. centor rm. to be a great physician, you must understand the whole story. medgenmed 2007; 9(1): 59. 3. schwartz s. the difference between a good doctor & a great doctor. https://www.diabetesdaily.com/blog/2015/06/thedifference-between-a-good-doctor-a-great-doctor/ (accessed in 2015). 4. coulter a. patients' views of the good doctor: doctors have to earn patients' trust. bmj 2002; 325(7366): 668–9. 5. kalateh sadati a, iman mt, lankarani kb. 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2016; 9: 2. 26. sadati ak, lankarani kb, hemmati‎s.‎patients’‎description‎of‎unexpected‎interactions:‎a‎critical‎ethnography‎of‎the‎ quality of doctor-patient interactions in one educational hospital in shiraz, iran. shiraz emed j 2016; 17(7-8): e38269. 27. armstrong d. bodies of knowledge/knowledge of bodies. in: jones c, and porter r eds. reassessing foucault. power, medicine and body. london: routledge; 1998, p. 17-27. 28. sadati ak, lankarani kb, enayat h, kazerooni ar, ebrahimzadeh s. clinical paternalistic model and problematic situation: a critical evaluation of clinical counseling. j health sci surveillance sys 2014; 2(2): 78-87. http://ethics.iit.edu/ecodes/node/4978 journal of medical ethics and history of medicine original article evaluation of pediatric residents’ attitudes toward ethical conflict: a crosssectional study in tehran, iran maliheh kadivar 1 , marjan mardani-hamooleh 2 , shiva shayestefar 3* 1 professor, division of neonatology, department of pediatrics, children’s medical center, tehran university of medical sciences, tehran, iran. 2 assistant professor, department of psychiatric nursing, iran university of medical sciences, tehran, iran. 3 pediatrician, children’s medical center, tehran university of medical sciences, tehran, iran. corresponding author: shiva shayestefar address: children’s medical center, 62 gahrib street, 1419733151 tehran, iran. email: shivashayestefar@yahoo.com tel/fax: +98 21 66920983 received: 16 mar 2016 accepted: 01 jan 2017 published: 28 feb 2017 j med ethics hist med, 2017, 10:2 © 2017 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract ethical conflicts are recognized as critical aspects in assessing competence in clinical communication. moreover, pediatrics residents may face more problems, compared to other disciplines; due to the specific characteristics of the age group receiving services as well as the presence of their families. this study has been conducted with the aim of determining the attitude and perspective of pediatric residents toward ethical conflicts in the field of pediatrics. this descriptive, cross-sectional study was carried out on all residents of tehran university of medical sciences (90 residents), selected through census method, in 2014. the data collection tool was a 32-item research-based questionnaire. its validity and reliability were confirmed by the researchers and the medical faculty members. to analyze data, descriptive and inferential statistics were used. however, based on the results, lack of an advanced directive and written procedure for withdrawing life-sustaining treatment of an incompetent or critically-ill child (4.38 ± 0.80), lack of provision of sufficient information on obtaining informed consent (4.12 ± 1.10), and the absence of a legal written process for doing not resuscitate (dnr) orders (3.98 ± 0.95) were the most salient causes of ethical conflicts in pediatrics. furthermore, in accordance with the linear regression analysis of demographic characteristics, there was a significant relationship (p = 0.04, r = 0.046) between residents’ year of education and attitude toward ethical conflict; however, this relationship was not observed in other demographic characteristics. taking the priorities of ethical conflicts in pediatrics into account may help improve the designing of medical ethics education programs in hospitals for residents, thereby reducing the conflicts related to the issues of medical ethics. keywords: children, education, ethical conflict, pediatrics, resident mailto:shivashayestefar@yahoo.com j med ethics hist med 10: 2, february, 2017 jmehm.tums.ac.ir maliheh kadivar et al. page 2 of 8 introduction conflict is defined as an interpersonal or intrapersonal discord potentially causing serious harms (1). our ethical experiences are riddled with a range of conflicts most human beings have gone through regardless of the precepts and code of ethics, so that they find themselves on the horns of dilemma and confusion in both discerning and practicing it. the concept of ethical conflicts was first introduced in plato’s ideas and different views on this issue emerged in the post-platonic era (2). moral conflicts are intertwined with our daily life and all human beings grapple with such situations (1). although ethical conflicts are potentially possible across various areas and do occur within the field of medicine, they should be viewed according to the different medical disciplines in which they occur. pediatric residents might encounter more problems than other disciplines in this area due to the specific characteristics of the age groups under their supervision along with the presence of the children’s families (3). in the field of pediatrics, the refusal of the provision of treatment, order to discontinue resuscitation in the event of cardiorespiratory arrest, measures such as resuscitation of premature or newborn infants in severe conditions, children’s privacy, obtaining consent for treatment or intervention, parental disapproval of the necessary treatment, and child abuse or neglect by guardians are of the most important issues facing residents. these issues are the main causes of ethical conflicts in pediatric residents’ clinical practice (4). another factor involved in the occurrence of ethical conflicts for residents is providing care for seriously ill children or at the end of life condition; the care of such children for the residents are associated with ongoing conflicts and further tensions (5). furthermore, most pediatricians have experienced difficulties in interacting with critically ill children (4). in this regard, the results of a study in england encompassing medical conflicts showed that decision-making processes for patients and communication between employees were the main ethical challenge in pediatric oncology from the perspective of professionals (6). in addition, a study was carried out with participation of the pediatric residents in the united states of america (usa) to expound their experiences in the neonatal intensive care unit (nicu) (5). analysis of the participants’ experiences showed that the most common theme in this regard was conflict which further materialized in the relationships with families and other physicians. furthermore, according to the residents, working in the nicu was fraught with distress because of their exposure to infant deaths (5). according to the results of a research conducted in iran on the quality of medical ethics curriculum from the perspective of iranian students, the program had an unfavorable condition (7). the results of another study in iran suggested that one of the most significant clinical challenges cited by the medical students centered on issues related to informed consent (8). moreover, physicians participating in an iranian study believed that sometimes their efforts are not in line with their clinical commitments, have no benefit for their patients, and are considered futile (9). the trend of educating medical ethics in medical schools has had rapid progress. however, residency training has been focused more on the development of clinical skills, and most of the teaching hospitals have failed to either hold medical ethics education classes for the residents or dedicate far less hours to this end. furthermore, the educational programs for residents do not cover the relationship between medical ethics and ethical decisions revolving around physicians and human values which are focused by both the teaching hospitals and the educational curricula (10). therefore, given the importance of the moral concepts of pediatrics, a study was carried out in the usa to investigate the educational programs of pediatrics in terms of codes of ethics and professionalism policies by experts who supervised the program (5). it was found that although these programs pursue to implement ethical approaches; this issue does not represent a clear structure in the curriculum of pediatrics, and consequently, needs to be structurally revised (5). in this regard, the results of a study in iran found that medical ethics rounds might be a helpful approach to teaching medical ethics to medical students (11). unfortunately, topics related to ethical conflicts of pediatricians are rarely argued in current medical ethics courses. in other words, although some researches have been performed to address the most common ethical challenges of medical ethics in iran (9, 11-13), less attention has been paid to ethical conflicts in the pediatric field. therefore, it seems that by identifying ethical conflicts in the field of pediatrics from the residents’ viewpoint, it is feasible to ameliorate the quality of treatment by residents in addition to their efforts toward upgrading the healthcare service delivery trend by timely interventions, while reducing the conflicts. method in this cross-sectional study, the research population included all pediatric residents studying in 3 teaching hospitals affiliated to tehran university of medical sciences (tehran, iran) (imam khomeini hospital, bahrami hospital, and the children’s medical center) for 9 months in 2014. subjects were selected through census method (n = 90). the researchers, taking into account the ethical considerations, attempted to perform the study by gathering data using questionnaires filled out by the residents once obtaining permission from the ethics committee of j med ethics hist med 10: 2, february, 2017 jmehm.tums.ac.ir maliheh kadivar et al. page 3 of 8 tehran university of medical sciences and the consent of residents. the studied variables included demographic variables and residents’ attitudes toward ethical conflicts. the demographic variables studied included age, gender, marital status, years of residency, training hospital, and previous medical ethics course track records. first, the relevant literature, including theses, articles, and electronic databases (pubmed, scopus, science direct, and proquest), were reviewed for an appropriate questionnaire. the used keywords were medical ethics, medical education, conflicts, challenges, and pediatric. the questionnaire used was made by the research group. for this purpose, during 3 sessions, the items were reviewed and revised using the views of 13 experts (10 pediatricians and 3 medical ethics professionals). finally, the items were applied according to the latest comments and received the final approval of the panel of experts. then, the final questionnaire was designed with 32 items. each item was assessed based on a 5-point likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). the validity and reliability of this tool were justified by the researcher using content validity and test-retest methods. the content validity of this tool was measured by 10 faculty members of the department of pediatrics and department of medical ethics of tehran university of medical sciences and their comments were applied. to verify the reliability of the mentioned tool, test-retest was conducted; 10 members of the sample group took the test 1 week apart. results of the two tests were calculated using pearson’s correlation coefficient to the accuracy of 0.78. the data were analyzed using descriptive (mean and standard deviation) and analytical (linear regression) statistics in spss software (version 16; spss inc., chicago, il., usa). all p values < 0.05 were considered significance. results the findings related to the demographic characteristics of the participants are given in table 1. table 1the demographic data of residents demographic data number (%) age (year) 25-35 58 (64.4) over 35 32 (35.6) gender female 72 (80) male 18 (20) marital status married 68 (75.5) single 22 (24.5) year of residency first 29 (32.6) second 30 (33.7) third 31 (34.4) teaching hospitals* a 17 (22.4) b 41 (53.9) c 18 (23.7) previous participation in medical ethics education yes 72 (80) no 18 (20) *the hospitals are presented as capital alphabetical letters for the purpose of confidentiality. evaluation of the attitude of pediatrics residents toward moral conflicts indicated that lack of a formal and written process to withdraw life-saving treatments of seriously ill children toward the end of life (4.38 ± 0.80), lack of provision of adequate information in attaining informed consent (4.12 ± 1.10), and absence of a written procedure for do not resuscitate (dnr) orders for children (3.98 ± 0.95) are the primary causes of moral conflicts in the domain of pediatrics. the mean and standard deviations related to other priorities are presented in table 2. table 2percentage, and mean of residents’ perspective toward ethical conflicts items strongly agree agree moderate disagree strongly disagree mean ± sd lack of a formal and written process to withdraw life-saving treatments of seriously ill child toward the end of life 24 22 20 18 16 4.38 ± 0.80 lack of provision of adequate information to attain informed consent 20 22 20 20 18 4.12 ± 1.10 absence of a written procedure for dnr orders for children 20 33 22 13 12 3.98 ± 0.95 lack of maintenance of respect and dignity of sick children and their family 20 31 22 12 15 3.96 ± 0.84 j med ethics hist med 10: 2, february, 2017 jmehm.tums.ac.ir maliheh kadivar et al. page 4 of 8 violation of child’s privacy 18 30 24 16 12 3.92 ± 0.78 violation of children’s rights as an educational subject 20 29 21 19 11 3.88 ± 1.20 inappropriate method of conveying bad news to a sick child or parents 19 30 22 12 17 3.86 ± 0.62 inappropriate professional behavior in communication between physicians and other health-care team members 20 28 23 16 13 3.84 ± 1.10 conflict between hospital rules and professional ethics (code of ethics) 22 27 21 18 12 3.78 ± 0.68 lack of respect for cultural and religious beliefs of sick children and their families 21 28 24 16 11 3.76 ± 0.46 lack of pain control for the child 21 27 22 17 13 3.64 ± 0.82 violation of rights of children as research subjects 22 24 26 11 17 3.61 ± 0.84 inappropriate attitude toward decision-making conflicts between the sick child and his/her family 19 22 30 17 12 3.52 ± 0.68 failure to establish the minimum physical requirements for continued mother-child intimacy 22 27 24 16 11 3.48 ± 0.72 poor decision-making regarding colleagues’ misconduct 20 22 24 16 18 3.36 ± 0.44 failure to establish parents’ right of staying with their sick child 18 21 29 20 12 3.23 ± 1.10 inappropriate attitude toward sick child/family’s inappropriate request for futile treatment 18 22 30 17 13 3.18 ± 0.78 inappropriate attitude toward or refusal of treatment by the sick child or his/her legal guardian 12 12 33 24 19 2.68 ± 0.66 lack of suitable management of one’s medical error or that of colleagues 15 11 31 22 21 2.65 ± 0.76 lack of appropriate action in cases of child abuse 12 11 30 27 20 2.62 ± 0.44 implementation of physical limitations for sick children 11 16 28 24 21 2.56 ± 0.28 inappropriate attitude toward the family’s misconduct toward their children 20 11 28 22 19 2.54 ± 0.38 lack of a formal and written procedure for selection of ill children for allocation of limited resources 13 20 28 22 17 2.54 ± 0.42 lack of integration of caring for sick children between different hospital units 13 15 29 21 22 2.52 ± 0.28 breach of confidentiality of the child or parents 9 22 27 22 20 2.48 ± 0.66 discrimination between sick children in terms of provision of services 13 18 27 18 20 2.46 ± 0.68 euthanasia 13 18 27 20 22 2.46 ± 0.48 lack of access of sick children and their families to an efficient system for handling complaints 11 15 24 30 20 2.42 ± 0.36 j med ethics hist med 10: 2, february, 2017 jmehm.tums.ac.ir maliheh kadivar et al. page 5 of 8 intervention in areas lacking competency 11 17 27 24 21 2.36 ± 0.72 lack of supervision over the safety of invasive procedures for patients 6 18 28 28 20 2.28 ± 0.48 unnecessary referrals and measures for more financial benefits and personal gains 9 19 23 28 21 2.24 ± 0.38 inappropriate appearance and clothing of medical staff 9 17 23 29 22 2.18 ± 0.46 a p value < 0.05 was considered significant. dnr: do not resuscitate, sd: standard deviation furthermore, according to the linear regression analysis of demographic characteristics, there was a significant relationship between the residents’ years of education and their attitudes toward ethical conflict, but this relationship was not seen in any other demographic characteristics. the linear regression analysis results are presented in table 3. table 3results of linear regression test demographic data ethical conflicts p r age 0.68 0.089 gender 0.59 0.059 marital status 0.78 0.067 year of residency* 0.04 0.046 various teaching hospitals 0.88 0.025 previous participation in medical ethics education 0.72 0.036 *significant relationship discussion assessing pediatrics residents’ attitudes toward ethical conflicts illustrated the lack of an enacted and written process to withdraw life-sustaining treatment toward the end of the child’s life, provision of adequate information for an informed consent, and an established procedure for dnr orders as the most important causative factors of ethical conflicts in the field of pediatrics according to the residents’ point of views. by the same token, the findings of a study in the netherlands showed that pediatricians face challenges regarding the issue of life-sustaining treatment for children, and therefore, they have focused on feeding medical information to their families (14). another study was carried out in canada to evaluate the attitudes of physicians toward the ethical challenges to life-sustaining treatments for children which, according to the findings, the most salient ethical challenge was related to fear of failure in the face of uncertainty (15). a study was conducted with the participation of pediatricians in the netherlands on the end-of-life decision-making for children (16). according to the results, all participants believed that it was best to discuss the matter with colleagues before talking to parents. in 50% of cases, experts declared that trying to expand parents’ awareness about their decision and seeking their permission are necessary. in 25% of cases, specialists commented that information should be presented to the parents without requiring their permission. in addition, 66 experts underlined the importance of pain management for children before their death. according to this study, the decisionmaking approach regarding the end-of-life in children is deeply influenced by the nature of decision and type of treatment (16). however, it must be consisted that facing the death of children in the final stages of life is, by its very nature, a crucial factor shaping conflict in pediatricians. in this regard, the results of a research in the usa revealed that the factors playing a supportive role for pediatric residents in facing children’s death and helping them to reduce their perceived conflicts are teamwork and high quality end-of-life care provision (17). the findings of this study and the results of other studies in this field suggest that life-sustaining treatment and dnr at the end stage of life are still challenging issues for which there is no legallypronounced and written mandate. this issue is potentially harmful as far as ethical conflicts in pediatrics are concerned. therefore, taking the fact into account that physicians encounter many conflicts at the final stage of children’s life, it is essential to use the right strategies of conflict resolution. in iran, no approved clinical and ethical directive document and guideline exist to determine when and how dnr orders are assigned, and in some cases, this was communicated orally without the knowledge of the patient or his/her family. these ambiguities about dnr caused much controversy and confusion among the health staff about their course of action when managing a clinical situation. the fact of the matter is that making comments on the continuing treatment of patients in the terminal phase is a fundamental skill required by physicians and has given rise to scientific, ethical, and legal challenges. other results of this study showed that neglecting to provide enough information on obtaining informed consent is another effective factor in clinical conflicts in pediatrics. in this context, it should be acknowledged that although pediatricians play an j med ethics hist med 10: 2, february, 2017 jmehm.tums.ac.ir maliheh kadivar et al. page 6 of 8 important role in informing the patient about the consequences of disease (18), children’s eligibility in terms of giving informed consent depends on factors such as developmental age, the influences of parents and peers, quality of information provided, life experiences, and further medical decisions (19). it is clear that factors such as the impossibility of child's giving consent, and in some cases, surrogates’ incorrect decision-making (proxy decision-making), are issues that make appropriate ethical approaches toward sick children challenging. so that sometimes parents decision as to how to treat the child and follow treatment, from the standpoint of medical ethics, face the ethical challenge, and the accuracy of parents’ decision gets questionable. frankly, there is currently no officially written plan designed for the iranian families on decision-making in pediatrics in iran, specifically on chronicle and life-threatening child diseases. thus, in some cases, the child’s family is doubtful as to the appropriate decision. results revealed that lack of respect for children and families, violation of children’s privacy and rights as an educational issue, and the improper process of breaking bad news to a sick child or parents are considered to constitute other important ethical conflicts in the field of pediatrics. these findings were also supported by a research carried out in canada concerning this field of study (15). as believed by the researcher, breaking bad news is an integral part of the pediatricians’ duties this key element throws into stark relief the focus on ethical ingredients related to the profession for pediatricians. therefore, regarding medical ethics and ethical requirements, on which relies the upholding of human values, and through taking advantage of a protectionist approach, the expression of truth is underlined to avoid aggravating the reality of ethical challenges. as a matter of fact, health-care providers in the field of pediatrics, in most cases, do not involve the patient and his/her family in the treatment decisionmaking process. as a result, they fall short of the patient’s values, concerns, preferences, and barriers perceived by them to follow up on the treatment regimens, and in this way they in fact disrespect them. in contrast, addressing the issue of participative decision-making can boost satisfaction with care and quality of life (qol) for the child and his/her family, and thus, help decrease the existing conflicts (20). in fact, based on clinical experiences, since the biggest concern of a sick child’s family is the suffering of their child, they expected experts and professionals to exert an attitude with maximum respect. accordingly, it is essential that this humanitarian issue be addressed more profoundly by all pediatric subspecialists in the future. on the other hand, educational programs in the health-care systems should be capable of training dexterous specialists. therefore, patients need to be involved in medical education programs (10), yet the child’s privacy should be protected in this regard. similarly, other researchers stated that despite the frequent access to patient records by medical students for educational purposes, broad questions are raised about ethical conflicts in this regard including maintaining patients’ data, issues related to autonomy, protecting privacy, and seeking their permission (21). as such, taking advantage of an ethical approach in establishing an educational communication with patients is necessary (22). a study conducted in sweden in collaboration with pediatricians in the field of cancer, illustrated that their biggest concern was the labels they allegedly received as messengers of life-threatening conditions and the breakers of bad news (23). this finding confirmed the results of the present study. according to this study, decision-making in difficult situations and breaking bad news are an integral part of pediatrics which emphasizes the importance of the ethical aspects related to the profession for pediatricians (23). other ethical conflicts considered important in this study were inappropriate professional behavior of physicians toward other health-care team members, and hospital rules and regulations which are in conflict with professional ethical principles. the results of a study in the usa indicated that negative factors related to professional behavior associated with the workplace that affect the work quality of pediatricians included the absence of professional autonomy, interpersonal challenges, poor communication among colleagues, non-supportive climate, and feeling of powerlessness (24). these findings emphasize the need to address the concept of professional ethics in pediatrics. one of the main concerns in the health services field is to respect values and ethical principles across interprofessional collaborations. to this end, a framework has been formulated in iran which emphasizes the dire need of doctors in the field to observe the professional ethics principles, pay attention to the individual and social values, and manage ethical challenges in relation to a variety of intra-professional and inter-professional problems (25). in addition, lack of respect for cultural and religious beliefs of the sick children and their families was another ethical conflict of great importance from the viewpoint of the residents in this study. in a more realistic context, the process of both care and treatment of sick children is affected by cultural and social factors which are often misconceived by both the medical staff and families (26). therefore, disdaining the cultural beliefs of the child and his/her family might give rise to ethical conflicts in the domain of pediatrics. this is a critical issue that must be addressed by the relevant specialists. lack of complete and appropriate control and management of children’s pain, lack of respect for children’s rights as a research subject, dealing with a j med ethics hist med 10: 2, february, 2017 jmehm.tums.ac.ir maliheh kadivar et al. page 7 of 8 decision-making conflict between sick children and their families in an awkward way, and failure to provide suitable physical facilities for the continued presence of the mother in the hospital were other issues recognized as responsible for emergence of ethical conflict in this study. generally speaking, complementary education could be cited as one of the strategies that can assist residents in logically dealing with ethical conflicts. however, the findings of the study in canada showed that medical ethics education is of very high value among residents, and familiarizing residents with moral conflicts during residency training is also important (27). in addition, moral counseling helps solve clinical challenges and results in better ethical clinical decision-making (28). it is clear that pediatric residents cannot avoid facing ethical conflicts, but they should be capable enough to prevent these conflicts through receiving appropriate training. in this study, improper appearance and clothing of medical staff were the least important factor in the area of ethical conflicts. it seems that more studies should be conducted in this regard. according to other findings, among the demographic characteristics, there was a significant relationship between year of residency and their attitude toward ethical conflict, but this relationship was not seen in any other demographic variable. this means that as residents proceeded to higher academic years, they may have developed a deeper understanding of the ethical conflicts related to their career. this finding may be explained in that the importance of ethical conflicts for residents has become more prominent with the passage of time along with further professional experiences. this study had the following limitations. the pediatrics residents’ attitudes toward ethical conflicts regarding children were evaluated. the study findings, however, cannot be generalized to ethical conflicts in other specialized medical disciplines. furthermore, another limitation of this study was that the perspective of pediatrics residents was evaluated in only one university of medical sciences, which is the largest university in the country with the highest population of residents in the field of pediatrics. therefore, it is recommended that the opinions of residents from other medical specialties regarding ethical conflicts be evaluated in future studies to provide better comparisons in this regard. it is also suggested that a relevant national survey be conducted in iran. on the other hand, comparison of the current research findings with those of other studies was limited due to the poverty of similar studies in iran. conclusion based on the results, formulation of clinical ethics standards and relevant educational methodology and their institutionalization into health centers, determination of strategic plans for clinical ethics education, identification of methods, the need to expand clinical ethics, and ultimately, its institutionalization into a comprehensive health-care system constitute the most important issues which must be considered for pediatrics residents’ ethical conflicts. this may help reduce the conflicts related to issues of medical ethics for them. in addition, it seems that formal medical ethical education should be incorporated in the formal curriculum of pediatrics in the country and the importance of these issues should be emphasized during the education of pediatrics residents. acknowledgment the authors wish to express their appreciation and special thanks to all pediatrics residents of tehran university of medical sciences who kindly participated in this study. conflict of interest the authors have no conflict of interest. j med ethics hist med 10: 2, february, 2017 jmehm.tums.ac.ir maliheh kadivar et al. page 8 of 8 references 1. bahrami m, faramarz gharamaleki a. conceptual analysis of moral dilemmas. iran j med ethics hist med. 2012; 5(2): 32-44. 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[in persian] 26. stenmarker m, hallberg u, palmérus k, márky i. being a messenger of life-threatening conditions: experiences of pediatric oncologists. pediatr blood cancer. 2010; 55(3): 478-84. 27. tataw db. provider perceptions of the social work environment and the state of pediatric care in a downsized urban public academic medical center. j evid based soc work. 2011; 8(3): 275-93. 28. van mccrary s, green hc, combs a, mintzer jp, quirk jg. a delicate subject: the impact of cultural factors on neonatal and perinatal decision making. j neonatal perinatal med. 2014; 7(1): 1-12. journal of medical ethics and history of medicine original article correlation between moral sensitivity and self-esteem in nursing personnel farideh rahnama1, marjan mardani-hamooleh2*, marjan kouhnavard3 1msc, education development center, saveh university of medical sciences, saveh, iran. 2assistant professor, department of psychiatric nursing, iran university of medical sciences, tehran, iran. 3children’s medical center, tehran university of medical sciences, tehran, iran. corresponding author: marjan mardani-hamooleh address: faculty of nursing and midwifery, iran university of medical sciences, zafar st., vanak sq., tehran, iran. postal box 1419733171. email: mardanimarjan@gmail.com tel: :( +98) 21 88201978 received: 6 may 2017 accepted: 23 dec 2017 published: 30 dec 2017 j med ethics hist med, 2017, 10:16 © 2017 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract nurses are continuously involved with ethical problems in their area of practice and need to possess a satisfactory level of moral sensitivity in order to be able to offer moral care. additionally, they act as agents for proper management of ethical dilemmas and are therefore required to have high self-esteem. this study aimed to determine the correlation between moral sensitivity and self-esteem in nurses. in this descriptive-correlational research, sample study included 204 nursing personnel working in hospitals affiliated with iran university of medical sciences. participants were selected by convenience sampling. the data were collected using a demographic form, lützén’s moral sensitivity questionnaire, and rosenberg’s self-esteem questionnaire. then, the data were analyzed using descriptive and analytical statistics. written informed consent was obtained from each subject who participated in the research. the mean score for moral sensitivity of the samples was 69.15 ± 5.70, and 20.01 ± 4.76 for their self-esteem. pearson’s correlation coefficient test indicated a meaningful and positive relationship between the two variables under study (r = 0.472 and p = 0.001). there was no correlation between the participants’ demographic data and moral sensitivity (p > 0.05), but a significant relationship was found between the participants' level of education and the variable self-esteem (p < 0.05). since there was a positive and significant relationship between moral sensitivity and self-esteem among the nursing staff, nursing managers should focus on improving the quality of patient care by promoting nurses’ moral sensitivity inspired by high self-esteem. keywords: moral sensitivity, nurse, nursing ethics, self-esteem j med ethics hist med 10: 16, december, 2017 jmehm.tums.ac.ir farideh rahnama et al. page 2 of 8 introduction the ethical principles shape the ethical framework emphasizing what counts as true or false according to a set of rules and behaviors considered as right or wrong. ethics is a spawn of values formed by human beings. moral sensitivity, on the other hand, is an individual’s skills and ability to interpret the reactions and feelings, take the necessary actions or decisions, examine the effect of possible consequences on the people, and accept responsibility for these decisions, actions and outcomes (1). as a matter of fact, nurses are invariably bound up with ethical concepts and problems in their work environment. among the ethical challenges that nurses face are issues such as working with patients at the end of life, observing patients’ suffering and illness, lack of organizational support, and working stints to meet organizational demands (2). therefore, it is essential for them to bring the concept of moral sensitivity into focus because their ethical performance in providing patients with nursing care depends on it (3). on the other hand, nurses encounter a broad range of ethical ambiguities as they go about their professional interactions with others. how they behave under these conditions as well as a plethora of professional decision-making shows that they require moral sensitivity in order to properly work these ambiguities out; otherwise, they would act inefficiently in difficult situations when providing care to patients (4). however, the current research results suggest that moral sensitivity in nurses is at a moderate level of 42 58% (4 6). the findings of iranian studies shows that high moral sensitivity among nurses increases nursing leadership and reduces moral distress (7, 8). these findings emphasize the importance of addressing the issue of moral sensitivity in nursing practice and the fact that it ensures a wide range of positive ethical implications in the profession. now the question that comes to mind is: what components could potentially be associated with nurses’ moral sensitivity? one of the variables that seems to have potential in this regard is self-esteem. it is a personality trait that plays an important role in the mental health of individuals. self-esteem is a measure of approval, acceptance, and a feeling of selfworth toward oneself. there is an undeniable relationship between self-esteem and the ability to establish interpersonal contacts as an integral component of the effective care process (9). relevant studies conducted in the nursing context show that self-esteem of 46 55% of nurses is at an intermediate level (10 13). high self-esteem facilitates interpersonal relationships and has a positive effect on the thinking, feeling and practice of nurses in providing care. nurses with high self-esteem are capable of providing better care services to patients and less likely to suffer burnout (14). additionally, these nurses consider the changes that creep into their career, such as structural reforms that lead traditional nursing to teamwork nursing, as fruitful challenges (15). on the other hand, the lower nurses’ self-esteem is, the lesser their professional success will be (9). nurses with low self-esteem consider changes that occur in their career as challenges that impose colossal pressure while wreaking havoc on them (14). nurses must therefore beware of factors that reduce their self-esteem while providing moral care. thus, moral sensitivity is considered as a feature that causes nurses to fully recognize the ethical challenges of the clinical environment and have a good understanding of their work situation. therefore, by controlling the clinical challenges faced by nurses, the pressure that is imposed on them due to low self-esteem will also be reduced. this emphasizes the need to examine the relationship between the two variables under study even more closely. it should be acknowledged that ethics is an integral part of nurses’ professional life. it lends sense to their working lifestyle. nurses are in long-term contact with patients and other healthcare staff. therefore, the shadow of ethics should be constantly extended to all their professional practices. accordingly, it is important to consider the various ethical dimensions of the nursing profession, as neglecting this part of nurses’ professional life will cause irreparable harm (16). on the other hand, since nursing ethics encompasses a wide area, a comprehensive look at ethical concepts would reveal the possible relationship between these and other concepts, including psychological variables. utilizing an interdisciplinary approach will help nursing ethics specialists enhance the richness of this area. therefore, given that moral sensitivity is a cornerstone of professional ethics in nursing (17), and self-esteem as a personality trait affects nurses’ professional performance, the investigation of the relationship between these two variables is essential. as agents for the correct management of ethical issues, nurses seem to require both moral sensitivity and high self-esteem. considering the ethical problems encountered by nurses in hospitals and the different attitudes that they adopt, as well as the importance of high self-esteem in the profession, it may be concluded that perhaps there is a correlation between the two variables of moral sensitivity and self-esteem. studies have already been carried out throughout the world to examine these two variables separately or against other variables, but the researchers could not access any studies that have directly investigated the relationship between them. however, several studies have been conducted in iran and elsewhere that examined each of these two variables alone or in relation to other variables. therefore, considering the importance of the subject and the effect of these variables on the behaviors of nurses as well as their potential impact on the quality of nursing care, the present study aimed to determine j med ethics hist med 10: 16, december, 2017 jmehm.tums.ac.ir farideh rahnama et al. page 3 of 8 the correlation between moral sensitivity and selfesteem in nurses. method this study is a descriptive-correlation research. in the beginning 3 hospitals affiliated to iran university of medical sciences were chosen by simple random method in 2016. the study population consisted of all the nursing staff employed in these hospitals, which by implication included all the nurses of the selected hospitals with a minimum of one-year work experience. it should be noted that due to the nature of the concept of moral sensitivity in nursing, the employees experience it as a result of working in the clinical environment; therefore, the researchers considered at least one-year work experience as the criterion for the participants to enter the study. other iranian studies on moral sensitivity in nurses have also considered one year as the minimum work experience for selection of their participants (2, 7). participants were selected by convenience sampling. the sample size was estimated at 200 for the confidence interval of 95%, and power to test 80%, assuming the correlation coefficient between moral sensitivity and self-esteem among the nurses was 0.2, so that the relationship between the two variables could be considered statistically significant. given the possibility of a lack of cooperation on the part of the study samples, 220 nurses were selected for the research. it should be added that 9 subjects opted out of the study for personal reasons, and 7 questionnaires were defaced. as a result, this study was conducted with the participation of 204 nurses. in this study, ethical approval was first received from saveh university of medical sciences (ir.savehums.rec.139506), and the necessary coordination with hospital managements was then achieved through a letter of introduction from the university. written informed consent was obtained from each subject prior to participation in the research. furthermore, the participants received the necessary information on the research process, and they were assured that their participation in the research was completely voluntary and they had complete freedom in this regard as well. in addition, the participants were assured that their information would be protected and confidentiality of the data would be maintained. the researchers collected the data over the course of 3 months by meeting the participants in their working departments. a demographic information form, a moral sensitivity questionnaire, and a self-esteem questionnaire were used for data collection. the demographic information form examined age, gender, marital status, work experience, education level, shift work and the workplace ward of the participants. the moral sensitivity questionnaire was constructed by lützén et al. in 1994 and contained 25 questions (18). this questionnaire measures moral sensitivity on a five-level likert scale: strongly agree, relatively agree, relatively disagree, strongly disagree, and neutral, each receiving a score of 0, 1, 2, 3, and 4 respectively. the total scores range from 0 to 100. scores of 0 50, 50 75 and 75 100 represent low, moderate and high levels of moral sensitivity respectively. this questionnaire has been used in a variety of researches on nurses and its validity and reliability have been confirmed (4 5, 18). the self-esteem questionnaire was designed by rosenberg in 1965 (19), and consisted of 10 items on a 4-point likert scale with the following response options: fully agree, agree, disagree and strongly disagree, scored from 0 to 3. the overall scope of the score was 30; scores higher than 25 indicated high, 15 25 moderate, and less than 15 low self-esteem. this questionnaire has also been used in many studies on nurses and its validity and reliability have been confirmed (11, 20, 21). iranian studies reported the questionnaire reliability 8083% using the cronbach's coefficient alpha (22, 23). validity and reliability of both questionnaires were confirmed by the researchers using content validity and test-retest methods, respectively. in order to obtain content validity, the viewpoints of 7 professors of the nursing faculty of iran university of medical sciences were used and their corrective comments were applied in the questionnaires. it should be noted that in order to adapt the english version of the tools to their persian format, in addition to the persian version previously used by iranian scholars, the english version of the tools was also available to the above-mentioned professors. the reliability of the questionnaires was confirmed by test re-test in two weeks by participation of 10 nurses. the results of the test (2 times) using the pearson’s correlation coefficient were calculated to be 0.92 for the moral sensitivity questionnaire and 0.88 for the self-esteem questionnaire. statistical data analysis was performed using spss 18 and descriptive statistics (determining frequency, percentage, mean and standard deviation) and analytical statistics (chi-square test, pearson’s correlation coefficient test and linear regression). in analyzing the data, p-value less than 0.05 was considered statistically significant. results in this study, the nurses were between 27 and 48 years of age, with an average age of 34 ± 3.8. in terms of work experience, the lowest and highest experiences were 2 and 21 years, with an average of 12 ± 2.5 years. in this study, the majority of the research participants were female (182, 89.2%) and married (178, 87.2%). other demographic findings are presented in table1. j med ethics hist med 10: 16, december, 2017 jmehm.tums.ac.ir farideh rahnama et al. page 4 of 8 table1. distribution of demographic data percentage number demographic data 22.6 46 less than 35 age (year) 77.4 158 more than 35 14.7 30 less than 10 job experience (year) 85.3 174 more than 10 94.1 192 bachelor’s degree education level 5.9 12 master’s degree 11.8 24 fixed shift work 88.2 180 rotational 20.6 42 internal ward 23.5 48 surgical 19.6 40 pediatric 16.7 34 emergency 19.6 40 intensive care the average score for the moral sensitivity of the samples was 5.70 ± 69.15, and 4.76 ± 20.01 for their self-esteem. pearson’s correlation coefficient test indicated a significant and positive relationship between the two variables under study (r = 0.472 and p = 0.001) (table 2). table2. mean score and standard deviation of moral sensitivity and self-esteem in nursing personnel standard deviation mean variable 5.70 69.15 moral sensitivity 4.76 20.01 self-esteem pearson’s correlation coefficient test: p = 0.001, r = 0.472 the distribution of moral sensitivity and self-esteem is represented in table 3. table 4 illustrates the relationship between demographic profiles and the two main variables according to the linear regression test. in the data analysis, a p-value less than 0.05 was considered statistically significant. table3distribution of moral sensitivity and self-esteem in nursing personnel self-esteem moral sensitivity high moderate low total severe 20 (9.8%) 12 (5.9%) 0 (0%) 32 (15.7%) moderate 30 (14.7%) 125 (61.2%) 2 (1%) 157 (76.9%) mild 0 (0%) 8 (3.9%) 7 (3.5%) 15 (7.4%) total 50 (24.5%) 145 (71%) 9 (4.5%) 204 (100%) table4relationship between demographic data and main variables main variable demographic data moral sensitivity self-esteem p r p r gender 0.190 0.063 0.245 0.082 marital status 0.115 0.045 0.189 0.055 age 0.137 0.073 0.294 0.062 work experience 0.156 0.046 0.188 0.074 education level 0.148 0.081 *0.001 0.033 shift work 0.196 0.018 0.264 0.057 ward 0.162 0.022 0.144 0.028 j med ethics hist med 10: 16, december, 2017 jmehm.tums.ac.ir farideh rahnama et al. page 5 of 8 discussion the results of the study revealed that there is a positive and significant correlation between the moral sensitivity and self-esteem variables among nurses. in other words, nurses who enjoy a higher moral sensitivity have greater self-esteem. although we could find no studies in the available literature on the correlation between the two variables of sensitivity and self-esteem specifically, the relationship between other moral variables and self-esteem has been investigated. the results of one study in the united states suggested that high self-esteem in nurses would nurture a positive understanding of personal dignity, which is an ethical concept (13). similarly, another study in the united states illustrated that as nurses understand their professional values, their self-esteem increases (24). in this regard, the findings of a study in iran indicated that the perceived support as a moral variable increases nurses’ self-esteem in the workplace (25). in another study the relationship between moral sensitivity and psychosocial work environment factors was measured in iranian nurses, and significant correlations between the psychosocial work environment factors and the moral sensitivity in nurses was found (26). the findings of the present study and the studies mentioned above confirm the fact that moral variables can be related to psychological variables. current study results showed that the moral sensitivity score of the majority of the nurses under study was of moderate level. these findings align with those obtained from other relevant studies as well (5 6, 20, 27). studies conducted in the area of moral sensitivity suggest that this moral trait stands as a cognitive ability for nurses (28) and is useful for both patients and nurses, in that it can promote the quality of patient care through encouraging cooperation with health professionals (1). also, the results of one study in sweden revealed that nurses with higher moral sensitivity experience less moral stress (4). research findings in iran indicated that enhanced moral sensitivity in nurses leads to job satisfaction (26), and the results of a research in korea also showed that nurses who possessed higher moral sensitivity scored better on the application of the code of ethics (6). in this regard, the results of studies conducted in iran on moral sensitivity in the nursing profession are negotiable. iranian researchers have demonstrated that moral sensitivity is a part of the professional competence of nurses and improves their moral performance (29). other iranian researchers have identified the concept of moral sensitivity in nursing as containing elements such as sensitivity to care, sensitivity to work errors and sensitivity in care decisions (8). in addition, another study suggested that having high moral sensitivity in nurses leads to an increase in moral self-concept (5). overall, studies that conceptually evaluate moral sensitivity in nurses emphasize the need to improve the level of moral sensitivity in this particular group of medical staff. since ethical issues may spell trouble in the workplace at the individual, organizational and societal levels (1), and nurses need moral knowledge in order to cope with a number of ethical challenges, high moral sensitivity can further help them in this regard. therefore, with respect to the merits of developing high moral sensitivity in nurses, the concept of moral sensitivity in the nursing profession should be considered more closely, and nurses need to be trained up from medium to high level by professors of clinical ethics. incidentally, a study in china demonstrated that lack of ethical knowledge in nurses prevents the promotion of moral sensitivity in the clinic (30). likewise, paying attention to the moral sensitivity of other members of the healthcare team such as physicians has been a topic of research. while the moral sensitivity of nurses was moderate in this study, another research in iran found a high level of moral sensitivity in physicians using the same questionnaire (31). the reason for the higher level of moral sensitivity in physicians can be attributed to their difficult professional conditions. in fact, doctors carry out their duties in an atmosphere that requires high moral sensitivity in patient-related therapeutic decision-making, especially in critical situations. as a result, it can be stated that physicians have higher moral sensitivity levels than nurses. therefore, it seems necessary to consider ethical education measures for nurses in order to achieve a more satisfactory level of moral sensitivity. the present study also showed the self-esteem of the majority of nurses to be at a moderate level. similarly, the results of a study in iran also indicated that the majority of hospital staff had moderate self-esteem, and the higher the self-esteem of the staff was, the higher their organizational commitment would be (32). the researchers’ clinical experiences suggest that self-esteem in nursing is interspersed with concepts such as the feeling of self-worth, professional socialization and understanding professionalism; and that high self-esteem serves as a basis for improved professional performance. the findings of other studies set forth the advantages of high self-esteem for nurses. according to the results of a research in south korea, self-esteem is one of the factors that help nurses develop clinical skills (33). a research in nepal also indicated that high self-esteem in nurses is associated with a more effective use of coping strategies (34). the enhanced efficiency resulting from high selfesteem on the part of nurses has been explicitly stated in other studies. research in taiwan illustrated that it promotes greater job satisfaction and thus bolsters a sustained career (8). similarly, a study in china demonstrated that high self-esteem in nurses encourages them to stay at their jobs and gain more professional success (35). a study in iran also showed that high self-esteem would add to nurses’ professional independence (36). j med ethics hist med 10: 16, december, 2017 jmehm.tums.ac.ir farideh rahnama et al. page 6 of 8 a broad range of benefits resulting from high selfesteem in nurses reminds us that this important personality trait needs to be raised from medium to high; otherwise, nurses may be plagued with a problem that might cause their low level of selfesteem to decline even further. with respect to this dilemma, studies have been conducted whose results could worry the authorities. nurses with low selfesteem have experienced bullying to a great degree in spain (11), and in taiwan, they have not attained the required emotional sophistication in their work place and self-sabotaging behavior tends to be extremely high (12). therefore, it is essential to enhance selfesteem in nurses by implementing educational and psychological interventions. the findings of the research did not yield any relationship between the demographic data of the research participants and the moral sensitivity variable. in terms of self-esteem, there was a positive and significant relationship only between education level and this variable, so that the higher the nurses’ degree was, the higher their self-esteem would be. similar findings were obtained about nurses in germany as well (21). it can be inferred that promoting the continuation of advanced education among the nursing staff will contribute to their improved self-esteem. it should be mentioned that there were limitations to this research, for instance we were unable to get all the distributed questionnaires back, and some that we did were defaced. another issue, which was beyond our control, was that the nurses could have developed different perceptions of the main variables of the study at the time they were completing the questionnaires due to specific conditions encountered in the workplace. furthermore, we could not find any studies on the correlation between the two variables of moral sensitivity and self-esteem, and therefore it was impossible to compare and contrast the findings of the current study with other similar works. conclusion considering the medium level of moral sensitivity and self-esteem in the majority of the participants in this study, it seems necessary to focus on the moral and personal characteristics of nurses. based on the results of this study, there is a significant and positive relationship between moral sensitivity and selfesteem in nurses. consequently, in order to strengthen the moral sensitivity of nurses, it is recommended to implement psychological educational interventions focusing on improving their self-esteem. other interventions may include implementing strategies such as periodic and regular training in the field of clinical ethics, and improving nurses’ knowledge on clinical ethics. in addition, current study results will help nursing managers and hospital authorities plan and offer training courses to promote nurses’ moral sensitivity and self-esteem, which will eventually lead to empowering them both morally and psychologically, and providing quality care to patients. acknowledgements the authors would like to extend their sincere thanks and appreciation to all the nurses participating in the study. conflict of interest the authors declare that there is no conflict of interest. j med ethics hist med 10: 16, december, 2017 jmehm.tums.ac.ir farideh rahnama et al. page 7 of 8 references 1. kulju k, suhonen r, leino-kilpi h. ethical problems and moral sensitivity in physiotherapy: a descriptive study. nurs ethics. 2013; 20(5):568-77. 2. shoorideh fa, ashktorab t, yaghmaei f, alavi mh. relationship between icu nurses' moral distress with burnout and anticipated turnover. nurs ethics. 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http://www.ncbi.nlm.nih.gov/pubmed/?term=valizadeh%20l%5bauthor%5d&cauthor=true&cauthor_uid=26586259 http://www.ncbi.nlm.nih.gov/pubmed/?term=zamanzadeh%20v%5bauthor%5d&cauthor=true&cauthor_uid=26586259 http://www.ncbi.nlm.nih.gov/pubmed/?term=gargari%20rb%5bauthor%5d&cauthor=true&cauthor_uid=26586259 http://www.ncbi.nlm.nih.gov/pubmed/?term=ghahramanian%20a%5bauthor%5d&cauthor=true&cauthor_uid=26586259 http://www.ncbi.nlm.nih.gov/pubmed/?term=tabrizi%20fj%5bauthor%5d&cauthor=true&cauthor_uid=26586259 http://www.ncbi.nlm.nih.gov/pubmed/?term=keogh%20b%5bauthor%5d&cauthor=true&cauthor_uid=26586259 http://www.ncbi.nlm.nih.gov/pubmed/?term=pressure+and+protective+factors+influencing+nursing+students'+self-esteem%3a+a+content+analysis+study. jmehm-8-1 journal of medical ethics and history of medicine original article ethical challenges in the neonatal intensive care units: perceptions of physicians and nurses; an iranian experience maliheh kadivar1, ziba mosayebi2, fariba asghari3, pari zarrini4 1professor, department of pediatrics, division of neonatology, children’s medical center, tehran university of medical sciences, tehran, iran; 2associate professor, department of pediatrics, division of neonatologychildren’s medical center, tehran university of medical sciences, tehran, iran; 3associate professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran; 4neonatologist, department of pediatrics, division of neonatologychildren’s medical center, tehran university of medical sciences, tehran, iran. corresponding author: pari zarrini address: mdchildren's medical center, 62 qarib st., keshavarz blvd., tehran 14194, iran email: dr.zarrini@yahoo.com tel: 98 9123076211 fax: 98 21 66920983 received: 5 aug 2014 accepted: 24 jan 2015 published: 4 feb 2015 j med ethics hist med, 2015, 8:1 © 2015 maliheh kadivar et al.; license tehran univ. med. sci. abstract the challenging nature of neonatal medicine today is intensified by modern advances in intensive care and treatment of sicker neonates. these developments have caused numerous ethical issues and conflicts in ethical decision-making. the present study surveyed the challenges and dilemmas from the viewpoint of the neonatal intensive care personnel in the teaching hospitals of tehran university of medical sciences (tums) in the capital of iran. in this comparative cross-sectional study conducted between march 2013 and february 2014, the physicians’ and nurses’ perceptions of the ethical issues in neonatal intensive care units were compared. the physicians and nurses of the study hospitals were requested to complete a 36-item questionnaire after initial accommodations. the study samples consisted of 284 physicians (36%) and nurses (64%). content validity and internal consistency calculations were used to examine the psychometric properties of the questionnaire. data were analyzed by pearson's correlation, t-test, anova, and linear regression using spss v. 22. respecting patients’ rights and interactions with parents were perceived as the most challenging aspects of neonatal care. there were significant differences between sexes in the domains of the perceived challenges. according to the linear regression model, the perceived score would be reduced 0.33 per each year on the job. the results of our study showed that the most challenging issues were related to patients’ rights, interactions with parents, communication and cooperation, and end of life considerations respectively. it can be concluded, therefore, that more attention should be paid to these issues in educational programs and ethics committees of hospitals. keywords: ethical issues, neonatal intensive care unit (nicu), nursing ethics, hospital ethics committee mailto:dr.zarrini@yahoo.com j med ethics hist med 8:1 feb, 2015 jmehm.tums.ac.ir maliheh kadivar et al. page 2 of 9 (page number not for citation purposes) introduction today, the whole health system is faced with issues such as the rapid advancement of technology, economic changes, resource constraints, and problems in health care delivery (1). due to the nature of their career, health team members are constantly exposed to ethical issues and challenges such as abortion, end of life care, and medical errors (1, 2). there are fundamental differences between adults and children, and therefore the issues related to children and infant care and ethical decision-making are quite different. although neonatal wards are always filled by moral conflicts, amazing advances in the care of critically ill neonates have led to challenging established standards and clear procedures in neonatal care (3 , 4). these advances have caused more conflicts in ethical decision-making and developed more ethical challenges. in a study on 70 physicians and caregivers, 210 ethical problems were reported, which means an average of three problems per person. in other words, each caregiver was confronted by more than one ethical problem on a regular basis (5). it is clear that a single person or group of people cannot make the right decisions without proper training, and therefore hospital ethics committees and ethics consultation were created (3 , 6). the latter has been introduced as a mechanism approved by ethics experts to help in situations of moral conflict (6 , 7). similarly, important decisions are made by ethics committees based on the long established practices in developed countries (8). however, ethics committees and ethics consultation have only been introduced to the iranian health system in recent years. although some studies have been conducted to identify the most common ethical issues of the medical system in iran (9), less attention has been paid to issues in the field of neonatology. this survey evaluated these matters from the viewpoint of the neonatal intensive care personnel in the teaching hospitals of tehran university of medical sciences (tums) in the capital of iran. the role of the hospitals’ ethics committees and ethics consultation were also assessed in the present study. materials and methods this was a comparative cross-sectional study conducted between march 2013 and february 2014. the study population consisted of physicians (including neonatologists, fellows of neonatology, and residents of pediatrics) and nurses of the neonatal care units level ii and iii of the teaching hospitals affiliated with tums. the samples were collected from the neonatal units of seven teaching hospitals using convenience sampling method. the first phase of the study was to design a valid and reliable tool for assessing the ethical issues in neonatal units. first, related sources of data, including theses, dissertations and electronic databases (pubmed, science direct and proquest) were examined for a suitable questionnaire. the used keywords were ethical, issues, dilemmas, challenges, neonatology, and nicu. the research team designed a new questionnaire for the purpose of this study. common ethical issues and challenges were extracted through interviews with experts in the field of ethics and neonatology, and literature review, and the results were gathered together as a questionnaire. after six revisions of the questionnaire by the research team and consultations with ethics experts, the first draft was designed with 60 items. an expert panel consisting of two neonatal care professors, two medical ethics experts and three members of the research team revised the questionnaire further and omitted, modified or merged some questions. the final instrument included 36 questions related to ethical issues and consultation. in the pilot phase, a sample of 20 nurses and physicians completed the questionnaire and the final adjustment was performed accordingly. in the main phase of the study a three-part questionnaire was prepared as reported above. the first part contained demographic questions, including variables such as age, gender, and work experience. the main part consisted of the first 36 questions of the developed questionnaire, designed to assess the ethical issues and challenges in neonatal care. ethical issues were divided into four domains: communication and cooperation, patients’ rights, end of life considerations, and interaction with patients. the questions are presented in table 1. the next 10 questions examined the participants’ viewpoints regarding hospital ethics committees and ethics consultation. the questions of this part are presented in table 2. j med ethics hist med 8:1 feb, 2015 jmehm.tums.ac.ir maliheh kadivar et al. page 3 of 9 (page number not for citation purposes) table 1 the ethical issues in neonatal intensive care units domain item no. items c om m un ic at io n an d c oo pe ra tio n 2 variation of medical opinions on different shifts 3 declining of physicians’ decisions by nurses 8 absence of senior authorities in nicu 17 inappropriate behavior among medical staff 18 improper management of medical errors on neonates 19 unreported ethical issues 24 lack of coordination between nicu and other wards pa tie nt s’ r ig ht s 1 patient confidentiality in nicu 14 interest in some patients leading to unfair services to others 22 neglecting to obtain informed consent 23 lack of respect for patient privacy (such as taking pictures without consent) 25 lack of respect for the rights of infants during residency training 26 lack of respect for the rights of infants in medical research in te ra ct io n w ith pa re nt s 4 improper parent requests that are contrary to medical advice 5 disagreement between parents in choosing the treatment 6 refusal of parents to give correct information about the infants’ conditions 7 parents’ failure to understand the infants’ conditions 16 discharge against medical advice (dama) due to financial problems 20 differences in language, culture and religion 21 lack of parental competency in decision making e nd o f l if e c on si der at io ns 9 lack of decision-making protocols (such as do not resuscitate order, dis-charge against medical advice, etc.) 10 futile care 11 treatment of neonates with congenital abnormalities or poor prognoses 12 decisions based on the type and severity of illness, age and birth weight 13 devoting the resources to children with poor prognoses 15 using infants’ prognoses as a basis for nicu admission nicu= neonatal intensive care unit. table 2 the main strategies in confronting ethical issues item no. items 27 formulating decision-making protocols (such as do not resuscitate order) 28 providing the necessary information and proper communication 29 caregivers’ accountability 30 helpfulness of hospital ethics committees 31 functions of hospital ethics committees 32 use of hospital ethics committees 33 helpfulness of hospital ethics committees’ comments 34 helpfulness of hospital ethics committees on the occasion of conflicts between patients’ families and hospital staff 35 helpfulness of hospital ethics committees in reducing ethical issues in nicu 36 attending related courses nicu= neonatal intensive care unit. each question had a 5-point likert assessment. to achieve a score of 100, the sum of each domain’s question scores were divided by the maximum attainable score in that domain and then the result was multiplied by 100. the content validity of the questionnaire was assessed by an expert panel of twelve bioethicists and neonatologists. the cronbach's alpha coefficient was calculated for internal consistency (α = 0.89 and α = 0.77 respectively). inclusion criteria were at least three months’ experience of working in neonatal intensive care units (nicus) and agreement to complete the questionnaire. the main researcher visited all selected nicus and asked physicians and nurses to complete the questionnaire in person. after a full explanation of the study purpose, the participants were asked to complete the questionnaire carefully. participation in the study was voluntary and a written consent was obtained after the initial briefing. j med ethics hist med 8:1 feb, 2015 jmehm.tums.ac.ir maliheh kadivar et al. page 4 of 9 (page number not for citation purposes) two hundred and eighty six nurses and physicians out of a total of 350 completed the questionnaire. the response rate was 81.71 percent. the questionnaires were completed anonymously, and all personal data were removed. the researcher assured all participants that the data was confidential and would only be used for research purposes. data were entered into spss software v. 22. means and standard deviations of each question score and domain were reported. data were analyzed by pearson's correlation, t-test, anova, and linear regression. results the results showed that the majority of subjects were female, married and muslim. the majority of nurses had a bachelor's degree and most physicians were residents of pediatrics. most of the participants had formerly participated in an ethics education program, and the most common educational method had been the workshop. the demographic characteristics of the study subjects are presented in table 3. table 3 demographic characteristics of study participants variable value number (percentage) or mean ± sd sex female 259 (91.2%) male 25 (8.8%) age 34.14±6.57 marital status married 187 (66.1%) single 96 (33.9%) religion muslim 280 (98.9%) other 3 (1.1%) job physician 102 (36%) nurse 183 (64%) education bachelor 160 (55.9%) master of science 23 (8%) resident 51 (17.8%) pediatrician 29 (10.1%) neonatologist 10 (3.5%) faculty member 13 (4.5%) work experience (month) 60.66±66. previous ethics education yes 147 (51.4%) no 139 (48.6%) workshop time (hours) 15.01±18.34 according to the caregivers in this study, the most important problems were in the patients’ rights domain. after that, lack of appropriate interaction with parents and sense of duty, and cooperation had similar importance. end of life considerations were the least perceived challenges. the caregivers also believed that one major problem was interest in a specific patient and unfair services to other patients (item no. 14). disagreement between parents in choosing the treatment (item no. 5) was perceived as the next most challenging issue. confidentiality (item no. 1) and problems with patient privacy (item no. 23) were the next most important issues. doctors faced a significantly higher number of challenges than nurses (p < 0.05). the ethical issues from the perspective of the caregivers and the comparison between nurses and physicians are shown in table 4 and figure 1. table 4 the ethical issues in neonatal intensive care units and the comparison between physicians and nurses domain item no. all physicians nurses p value mean sd mean sd mean sd c om m un ic at io n an d c oo pe ra tio n 2 2.80 1.06 2.96 1.06 2.70 1.05 0.05 3 3.21 1.15 3.11 1.21 3.26 1.12 0.27 8 3.29 1.11 3.54 1.09 3.15 1.10 0.004 17 3.01 1.19 3.17 1.22 2.92 1.18 0.08 18 2.81 1.12 2.92 1.17 2.74 1.10 0.19 19 2.83 1.06 2.99 1.12 2.74 1.02 0.06 24 2.39 1.12 2.49 1.20 2.33 1.07 0.27 sum 58.10 14.8 60.53 15.25 56.74 14.55 0.03 j med ethics hist med 8:1 feb, 2015 jmehm.tums.ac.ir maliheh kadivar et al. page 5 of 9 (page number not for citation purposes) pa tie nt s’ r ig ht s 1 3.58 1.06 3.72 1.07 3.51 1.05 0.10 14 3.73 1.13 3.78 1.09 3.71 1.16 0.63 22 2.88 1.12 3.17 1.15 2.72 1.07 0.001 23 3.48 1.20 3.81 1.14 3.30 1.21 0.001 25 3.05 1.14 3.42 1.12 2.85 1.11 0.00 26 3.29 1.12 3.65 1.10 3.09 1.09 0.00 sum 66.74 14.93 71.81 14.08 63.90 14.68 0.00 in te ra ct io n w ith pa re nt s 4 3.15 1.10 3.28 1.07 3.08 1.12 0.13 5 3.64 1.09 3.81 1.09 3.54 1.09 0.05 6 2.78 1.14 2.81 1.21 2.77 1.11 0.77 7 2.16 0.85 2.15 .87 2.17 .85 0.82 16 3.19 1.11 3.28 1.07 3.13 1.13 0.27 20 3.16 1.20 3.37 1.26 3.04 1.17 0.02 21 2.73 1.14 2.88 1.20 2.65 1.11 0.09 sum 59.45 14.36 61.64 14.33 58.22 14.27 0.05 e nd o f l if e c on si de ra tio ns 9 2.50 1.02 2.50 1.00 2.50 1.03 0.95 10 2.66 1.14 3.02 1.12 2.45 1.10 0.00 11 2.27 1.01 2.28 0.98 2.27 1.02 0.91 12 2.10 1.10 2.26 1.16 2.01 1.06 0.05 13 2.02 1.00 2.10 1.05 1.98 0.96 0.35 15 2.87 1.18 3.14 1.20 2.73 1.15 0.005 sum 48.08 12.70 51.00 11.89 46.45 12.87 0.003 sum 58.14 11.74 61.23 11.34 56.41 11.64 0.001 p > 0.05was considered significant. figure 1 perceived issues by physicians and nurses concerning the need for ethics consultation, questions related to ethics committees were allocated the highest priority. in table 5, the most important strategies and a comparison between doctors and nurses are presented. there were significant differences between men and women in perceived issues (p < 0.05). [value] [ 66.74 59 .45 48.08 58.14 0 10 20 30 40 50 60 70 80 accountability and cooperation patient’s rights interaction with parents end of life considerations sum j med ethics hist med 8:1 feb, 2015 jmehm.tums.ac.ir maliheh kadivar et al. page 6 of 9 (page number not for citation purposes) table 5 the main strategies in confronting ethical issues and the comparison between physicians and nurses item no. all physicians nurses p value mean sd mean sd mean sd 27 2.14 1.05 2.26 1.08 2.08 1.03 0.15 28 1.88 0.79 1.91 0.81 1.86 0.78 0.61 29 1.87 0.92 1.90 0.99 1.86 0.89 0.69 30 2.02 1.01 2.22 1.21 1.90 0.85 0.00 31 3.48 1.04 3.47 1.08 3.49 1.01 0.87 32 3.96 1.02 3.96 0.99 3.96 1.04 0.99 33 3.56 1.05 3.49 0.98 3.60 1.08 0.37 34 2.29 1.14 2.30 1.10 2.29 1.17 0.93 35 2.48 1.14 2.51 1.20 2.46 1.12 0.72 36 2.33 1.06 2.58 1.15 2.19 0.99 0.004 (significant if p > 0.05) men reported more challenges in the domains of patients’ rights and interaction with parents. there was a negative relationship between work experience and perceived issues (p = 0.002, r = 0.186). the relationships between age (p = 0.32, r = 0.06), ethics education course duration (p = 0.75, r = 0.03) and perceived issues were not significant. marital status and educational level did not have a significant effect on perceived issues among physicians (p > 0.05). moreover, nurses with a bachelor’s degree had a higher perception of ethical issues (p < 0.05). the relationships between ethical issues and demographic characteristics are presented in table 6. table 6 the relationship between demographic characteristics and perception of ethical issues communication and cooperation patients’ rights interaction with parents end of life considerations ethical issues perception mean sd mean sd mean sd mean sd mean sd g en de r female 57.55 14.62 66.11 14.72 58.49 14.06 47.92 12.86 57.56 11.57 male 62.28 16.72 72.80 16.40 67.77 14.48 49.73 11.46 63.29 12.43 p value t=-1.52, df=282, p=0.12 t=-2.14, df=282, p=0.03 t=-3.14, df=282, p=0.002 t=-0.67, df=282, p=0.50 t=-2.34, df=282, p=0.01 e du ca tio n bachelor 57.85 14.25 65.62 13.81 58.91 14.33 47.12 12.63 57.46 11.25 master of science 48.81 14.43 51.88 15.16 53.41 13.10 41.73 13.81 49.13 11.88 p value t=2.84, df=181, p=0.005 t=4.40, df=181, p=0.00 t=1.73, df=181, p=0.08 t=1.88, df=181, p=0.06 t=3.29, df=181, p=0.001 resident 62.96 14.84 74.24 14.39 60.00 14.64 52.61 10.52 62.38 11.26 pediatrician 61.08 16.24 67.81 12.79 64.82 15.08 48.73 11.31 60.79 10.90 neonatologist 54.57 14.90 72.00 15.88 57.14 10.94 46.33 12.21 57.38 12.38 professor 54.28 13.35 71.02 13.63 64.39 13.02 53.33 16.77 60.65 12.35 p value f=1.71, p=0.16 f=1.31, p=0.27 f=1.19, p=0.31 f=0.57, p=0.63 f=2.08, p=0.10 pr ev io us e th ic s ed uc at io n yes 56.90 13.87 65.71 14.28 57.95 13.48 47.89 12.67 57.14 11.10 no 59.36 15.84 67.84 15.56 61.02 15.11 48.29 12.76 59.21 12.33 p value t=1.39, df=181, p=0.16 t=1.20, df=181, p=0.22 t=1.81, df=181, p=0.07 t=0.27, df=181, p=0.78 t=1. 49, df=181, p=0.13 (significant if p > 0.05) j med ethics hist med 8:1 feb, 2015 jmehm.tums.ac.ir maliheh kadivar et al. page 7 of 9 (page number not for citation purposes) discussion the main objective of the current study was to assess the most perceived ethical issues in neonatal intensive care units. another objective was to determine the caregivers’ opinions about ethics consultation and hospital ethics committees. finally, the perceptions of doctors and nurses were compared. according to the results, issues related to confidentiality and patient privacy were considered the most important. although the pattern of perceived challenges was the same in both groups, physicians reported more ethical challenges than nurses, which may indicate their higher ethical sensitivity. two other studies also indicated differences between these two groups, and a higher sensitivity to ethical issues in physicians (10,11). the first study was conducted in eight western european countries: france, germany, great britain, italy, luxembourg, the netherlands, spain and sweden. one hundred and twenty-two neonatal intensive care units (nicus) were recruited by census. a total of 1235 completed questionnaires from doctors and 3115 from nurses were returned. similar to our study, both doctors and nurses participated, but only the findings related to doctors were reported. the results showed that most physicians reported having been involved at least once in setting limits to intensive care because of a baby’s incurable condition and/or poor neurological prognosis (10). in the second study all internal medicine, oncology and intensive care specialists and associated nurses (n = 532) employed at a university hospital in croatia participated. the most frequent ethical dilemmas involved uncertain or impaired decisionmaking capacity, limitation of treatment at the end of life and disagreements among family members. findings of this study showed that the two groups had similar opinions in their strategies (11). our results revealed some differences between women and men in their perception of ethical issues. the most challenging area for both genders was patients’ rights. in this regard, we found another study on 500 health professionals employed at the mexican institute of social security in mexico city conducted in the form of structured interviews. the results showed that women attributed more importance to mutual respect, patient privacy and confidentiality, while men were more ethical in terms of providing up-to-date information and telling the truth (1). these findings indicate that women and men perceive different forms of ethical challenges. nevertheless, conflicting results have been reported. there was a study on physicians and nurses engaged in geriatric and surgical care at a major hospital in sweden that was conducted to compare differences in moral reasoning between men and women. the results showed no difference between men and women in this respect (12). similarly, research conducted on kuwaiti students did not indicate differences in patterns of moral reasoning between the genders (13). another study on one hundred healthy volunteers recruited from students at the university of milan showed that men tended towards utilitarian views in their moral judgments (14). considering all the conflicting findings mentioned above, it seems that more research is needed in this area. in the present study, participants' attention to ethical issues decreased with increasing age and more experience. in a study of nurses’ perceptions, there was no significant relationship between age and level of participation and satisfaction with ethical decision making (15). we were also able to find two studies that showed no correlation between increasing age and ethical sensitivity. the first study was conducted on 156 accounting undergraduates employed in china, and the results showed no relationship between age and ethical sensitivity (16). the second was a study by hassanpoor et al. in kerman, and did not indicate a significant relationship between age and ethical sensitivity (17). in a study conducted in turkey, physicians who had more work experience showed more sensitivity to ethical issues (18). our results showed that the perceived issues decreased with increasing age. this may be due to non-ethical work atmosphere. it seems that the lack of promotion of moral knowledge and compliance with hospital routines reduces ethical sensitivity. nevertheless, further investigation seems to be necessary to confirm these results. the field study confirmed that although the majority of participants had positive views about ethics committees, they did not have specific information about the dimensions of work, authority, and the role of these committees. schneiderman et al. also showed that the majority of doctors, nurses and patients/guardians (87%) believed that ethics consultation can help resolve ethical conflicts. they concluded that ethics consultation may be helpful in settling conflicts, and is a useful technique to prevent unwanted treatments (19). despite these advantages, studies have shown that clinical staff are often unaware of ethics committees or do not know how to seek their services (3,8,20). it is recommended that neonatal specialists, staff, and parents be aware of the potential role of ethics committees and use their services in cases of moral conflicts (3, 21). our results showed no relationship between previous ethics education and perceived issues. while participation in training programs may foster attention to ethical issues, results of studies have not confirmed this. studies by ersoy in turkey showed that people who had received prior training j med ethics hist med 8:1 feb, 2015 jmehm.tums.ac.ir maliheh kadivar et al. page 8 of 9 (page number not for citation purposes) in ethical issues had more knowledge and ethical sensitivity (18,22). a study in taiwan showed, however, that training alone does not raise awareness of ethical issues among nurses, and ethical sensitivity should be internalized (23). we recommend that the effectiveness of current ethics education be further examined. conclusion based on the current study results, the most important issues in the field of ethics were related to patients’ rights, interaction with parents, communication and cooperation, and end of life considerations respectively. special attention should be paid to this aspect of training programs for residents and nurses. on the other hand, the effectiveness of current ethics training programs needs to be examined. the results also showed that caregivers are not adequately familiar with the concept of ethics consultation and the functions of hospital ethics committees. meetings between different departments, courses on the role of hospital ethics consultation and ethics committees can be helpful in this area. today, complex health systems need staff who pay attention to the ethical aspects of their work, are familiar with ethical principles, and can make proper decisions. failure at any stage can cause non-ethical action. based on the results of the present study, employees need to be more sensitized to the ethical aspects of their work. in conclusion, the decreased attention to ethics resulting from the increase in age and job experience is an important issue that needs to be further investigated. acknowledgements the researchers would like to express their gratitude to the personnel and physicians of the neonatal intensive care units of tehran university of medical sciences, and residents of pediatrics at the teaching hospitals affiliated with tehran university of medical sciences. conflict of interest: none references 1. valdez-martinez e, lavielle p, bedolla m, squires a. ethical behaviours in clinical practice among mexican health care workers. nurs ethics 2008; 15(6): 729-44. 2. numminen oh, leino-kilpi h. nursing students' ethical decision-making: a review of the 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10. cuttini m, casotto v, orzalesi m, euronic study g. ethical issues in neonatal intensive care and physicians' practices: a european perspective. acta paediatr suppl 2006; 95(452): 42-6. 11. sorta-bilajac i, bazdaric k, brozovic b, agich gj. croatian physicians' and nurses' experience with ethical issues in clinical practice. j med ethics 2008; 34(6): 450-5. 12. norberg a, uden g. gender differences in moral reasoning among physicians, registered nurses and enrolled nurses engaged in geriatric and surgical care. nurs ethics 1995; 2(3): 233-42. 13. al-ansari em. effects of gender and education on the moral reasoning of kuwait university students. soc behav personal 2002; 30(1): 75-82. 14. fumagalli m, ferrucci r, mameli f, et al. gender-related differences in moral judgments. cogn process 2010; 11(3): 219-26. 15. philpott dw. neonatal intensive care nurses' perceptions of participation in ethical decision making in the care of imperiled newborns. kirkhof grand valley state university; 2000. 16. chan sys, leung p. the effects of accounting students' ethical reasoning and personal factors on their ethical sensitivity. manage auditing j 2006; 21(4): 436-57. 17. hassanpoor m, hosseini ma, falahikhoshknab m, abbaszadeh a. evaluation of the impact of teaching nursing ethics on nurses decision making in kerman social welfare hospitals in 1389. iran j med ethics hist med 2011; 4(5): 5864.[persian] 18. ersoy n, gundogmus un. a study of the ethical sensitivity of physicians in turkey. nurs ethics 2003; 10(5): 472-84. 19. schneiderman lj, gilmer t, teetzel hd, et al. effect of ethics consultations on nonbeneficial life-sustaining treatments j med ethics hist med 8:1 feb, 2015 jmehm.tums.ac.ir maliheh kadivar et al. page 9 of 9 (page number not for citation purposes) in the intensive care setting: a randomized controlled trial. jama 2003; 290(9): 1166-72. 20. slowther a, johnston c, goodall j, hope t. development of clinical ethics committees. bmj 2004; 328(7445): 950-2. 21. larcher v. ethical considerations in neonatal end-of-life care. semin fetal neonatal medicine 2013; 18(2): 105-10. 22. ersoy n, goz f. the ethical sensitivity of nurses in turkey. nurs ethics 2001; 8(4): 299-312. 23. yang wp, chen ch, chao csc, lai ws. bioethics education for practicing nurses in taiwan: confucian-western clash. nurs ethics 2010; 17(4): 511-21. journal of medical ethics and history of medicine review article is past life regression therapy ethical? gabriel andrade department of ethics and behavioral science, school of medicine, xavier university, aruba, santa helenastraat. corresponding author: gabriel andrade address: santa helenastraat no.23, oranjestad, aruba dutch caribbean, xavier university school of medicine. email: gabrielernesto2000@gmail.com tel: +584265651980 received: 21 may 2017 accepted: 22 november 2017 published: 2 dec 2017 j med ethics hist med, 2017, 10:11 © 2017 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract past life regression therapy is used by some physicians in cases with some mental diseases. anxiety disorders, mood disorders, and gender dysphoria have all been treated using life regression therapy by some doctors on the assumption that they reflect problems in past lives. although it is not supported by psychiatric associations, few medical associations have actually condemned it as unethical. in this article, i argue that past life regression therapy is unethical for two basic reasons. first, it is not evidence-based. past life regression is based on the reincarnation hypothesis, but this hypothesis is not supported by evidence, and in fact, it faces some insurmountable conceptual problems. if patients are not fully informed about these problems, they cannot provide an informed consent, and hence, the principle of autonomy is violated. second, past life regression therapy has the great risk of implanting false memories in patients, and thus, causing significant harm. this is a violation of the principle of non-malfeasance, which is surely the most important principle in medical ethics. keywords: past life regressions, psychiatry, reincarnation, medical ethics mailto:gabrielernesto2000@gmail.com j med ethics hist med 10: 11, december, 2017 jmehm.tums.ac.ir gabriel andrade introduction past life regression is a technique that attempts to use hypnosis in order to recover memories from previous lives. according to past life regression therapists, many mental health issues that patients experience may have their origins in traumatic experiences of past lives. thus, through hypnosis, practitioners take the patients back in time (regression) (1). this regression could be to periods of their infancy, but also to periods of their gestational development, or periods before they were born with their current body, but their soul may have been embodied in another body, i.e., past lives. past life regression therapy, therefore, assumes the reality of reincarnation. based on this assumption, practitioners believe that various mental disorders can be treated by addressing the events that an individual went through before he or she was born in this life. mainstream psychiatry has traditionally rejected this assumption. however, some high profile practitioners in the field have upheld past life regression therapy, and actually incorporate it in their medical practice as a therapeutic technique. perhaps the most prominent promoter of this therapeutic approach is psychiatrist dr. brian weiss. in a series of bestselling books, dr. weiss has recommended hypnosis for patients, in order to overcome phobias. these phobias, dr. weiss believes, go back to experiences from previous lives (2). by going back to those experiences through hypnosis, the patient confronts his/her fears, and ultimately, becomes desensitized to his/her original fears. dr. weiss’s therapeutic approach has gained notoriety, because at first, he did not believe in reincarnation. according to his testimonies, as he encountered patients that allegedly gave precise details of their past lives, dr. weiss came to change his mind. in the public’s view, dr. weiss’s initial skepticism renders him some professional credibility; he came to believe in reincarnation and the efficacy of past life regressions not due to some whacky previous religious beliefs, but rather because evidence from his medical practice led him to it. although the medical establishment does not favor these procedures, there is a high demand for them in the general population. according to some estimates, 25% of the american population believe in reincarnation, and that figure is surely higher in countries with religions (buddhism, hinduism) that give karma and reincarnation a strong relevance in their belief systems (3). for the most part, professional psychiatric associations have refused to offer support to these techniques, but they have not gone further in calling into question the ethics of such procedures. in this article, i shall evaluate the ethics of past life regression, by considering three of the most important principles in medical ethics; autonomy, beneficence, and non-malfeasance. i will address three points: 1) is reincarnation even conceptually possible? 2) does the evidence really support the reincarnation hypothesis?; and 3) is past life regression therapy harmless? is reincarnation even conceptually possible? reincarnation beliefs are quite ancient. in ancient greece, pre-socratic philosophers speculated about the soul travelling from one body upon death to another newly born. these beliefs were not particularly important in western societies, but in the east, they did become quite prominent, first, during the vedic period, and then, with some of the great religious reforms by buddha and mahavira. yet, even from very early times, some philosophers realized that, regardless of the actual evidence, there are some conceptual objections to reincarnation. first, there is the problem of population growth. the human population has increased continuously throughout history. in 8,000 bce, the human population was at about five million; today, it is at about six billion. now, if the doctrine of reincarnation is true, the number of souls is constant. for, when someone dies, her soul does not become extinct, and when someone is born, her soul is not new, as it is travelling from another body. however, if the number of souls is constant, how can we explain the increase in the number of bodies? presumably, in the year 8,000 bce, there were five million soles in the world. today, presumably, there are six billion souls. where did these additional souls come from? in truth, this objection is not formidable. according to the reincarnation doctrine, there is no reason to assume that no new souls can be created. even if the number of souls is constant, some of them could have a disembodied existence while they wait for new bodies to come into existence, as the population increases. furthermore, if, as hinduism teaches, reincarnation need not only take place amongst human beings, then, the remaining souls could also be embodied in animals, while they wait for new human bodies to be born. however, there are some other important conceptual objections. if reincarnation is real, it is nevertheless true that most people do not remember their previous lives. now, without memories from previous lives, how can we allege that someone is the same person (or, as philosophers would phrase it, numerically identical) as the one who lived in a previous life? for the sake of argument, we may admit that the criterion of personal identity (i.e., how do we make sure that a person at a given time is the same person at another time?) is not the body (although, some philosophers do insist that the only possible criterion is the body, for reasons that i shall not delve into). under this assumption, one need not have the same bodily continuity in order to be considered the same page 2 of 8 j med ethics hist med 10: 11, december, 2017 jmehm.tums.ac.ir gabriel andrade person, as long as there is at least some psychological continuity. the philosopher john locke famously argued that if a prince would one day wake up in the body of a cobbler, but would keep his memories as a prince, then, he would still be the prince (4). nevertheless, the problem with reincarnation is that there is precisely no psychological continuity, as most people do not remember their previous lives. by the psychological criterion of identity, then, we cannot be someone of whom we have no memories. defenders of reincarnation claim that we have no memories from our earliest infancy, but that does not mean we are not the same person. furthermore, patients with memory impairment (such as patients with alzheimer’s disease) have few, if any, memories of their life, but again, that does not mean they are not the same person. however, philosophers have usually pointed out an important caveat regarding the psychological identity criterion: if there is a chain of memories from one stage to a later stage, then, identity is preserved. thus, for example, an elderly general may have memories of his time as a young officer, and this officer had memories of his childhood, then, we can say that the elderly general is the same person as the child. yet, in the case of reincarnation, there is no such chain. apart from these conceptual problems specific to reincarnation, there are also conceptual problems regarding the existence of souls. the doctrine of reincarnation assumes that souls exist, as a person’s soul abandons his/her body upon death, and enters another body at the moment of birth. however, if the soul is a mysterious nonmaterial substance, how does it interact with matter? back in the 17th century, philosopher rene descartes was aware of this problem, and he argued that soul and body interact in the pineal gland (5). now we know that this is wrong; the pineal gland has no cognitive function. but even if it did, the problem remains: how does a nonphysical substance make its entry into the physical universe and become a causal agent? is there evidence for reincarnation? as early as the times of plato, some philosophers have tried to offer evidence that seems to support the reincarnation hypothesis. according to a famous argument laid out in plato’s phaedo, we have knowledge that we could not possibly acquire in this lifetime. plato was intrigued by the abilities of some people to do certain things that they never learned to do. in plato’s estimation, learning is actually a form of reminiscence: in education, while we are stimulated by our teachers’ questions, we come to remember things from our previous lives (6). it is no doubt true that we have innate knowledge and innate mental contents. nevertheless, as opposed to what plato believed, that does not imply that it comes from previous lives. actually, our brains may be genetically hardwired for certain mental traits, and some specific innate knowledge. one need not have been bitten by a snake in a previous life in order to innately fear snakes. the fear of snakes was very likely advantageous in the african savannah, and thus, that fear is probably encoded in our genes. defenders of reincarnation also point out déjà vu experiences. they are the strange feeling some people get when they encounter a situation for the first time, but they have the sensation that they have already lived through it. but again, we must not rush and jump to conclusions. it has been proposed that déjà vu experiences are due to a mismatch in the timing of sensorial information processing; it is possible that one of the brain’s hemispheres assimilates information, and a short time later, the other hemisphere assimilates the information. in such a scenario, the person would believe that he/she is reliving incident that, in fact, only occurred a few milliseconds ago. déjà vu experiences may also be explained as instances of cryptomnesia, i.e., when a person stores some sensorial datum in their memory, but it soon disappears from conscious memory. these memories may remain hidden in the person’s mind, and they may again be activated in a similar situation, without the person having a clear understanding of those memories. probably the strongest body of evidence in favor of reincarnation comes from the collection of cases by a prominent american psychiatrist, dr. ian stevenson (7). stevenson was skeptical about past life regressions, but he did believe that the etiology of many mental disorders can be traced back to unsolved conflicts in previous lives. in particular, dr. stevenson was interested in gender identity disorders (the dsm 5 now calls this disorder “gender dysphoria”); in his estimation, many of these cases are due to the fact that, in a previous lifetime, the patient belonged to another gender group. stevenson’s main area of research was the phenomenon of children who allege to remember previous lives. he collected a considerable amount of cases in india, sri lanka, turkey, brazil, lebanon, and the us. in most of those cases, children would not behave as expected. many of these children would speak rudely to their parents, for they believed themselves to be their own grandparents. according to stevenson’s reports, other children developed attitudes and interests not in accordance with their age; stevenson interpreted this as coming from a previous life. some children developed particular phobias, with no particular experience to activate them. again, he speculated that these phobias came from traumatic events in previous lives (8). in the majority of cases investigated by stevenson, page 3 of 8 j med ethics hist med 10: 11, december, 2017 jmehm.tums.ac.ir gabriel andrade children alleged to be the reincarnation of some member of the same family. in other cases, however, children alleged to be the reincarnation of persons with the family of whom the child’s family was not acquainted. some of these children were capable of giving details regarding their previous lives, without any possibility of the child having known these details through other means. in one case, a boy from a village claimed to be the reincarnation of a man who died some decades ago, and lived in a distant village. the child had never abandoned his own village, and therefore, never had the opportunity to know the details about the man’s life. stevenson also paid attention to birthmarks and birth defects in children who remembered past lives (9). in most of these cases, children claimed to be people who died violently, and their birthmarks would correspond to the wounds they had as a result of the injury that caused their death. stevenson claimed to have found a considerable number of this type of cases. stevenson’s studies are quite extensive, and in this brief space, i cannot discuss the details of each case. however, i can point to some methodological flaws that cast a big shadow over his findings. even if he claimed not to have definitive data supporting the reincarnation hypothesis, stevenson seemed to have a preconceived idea, and he just sought the way to confirm it. he may have been guilty of confirmation bias. all stevenson ever did was to look for cases that seemed to confirm his initial preconceived hypothesis, and ignore the massive amount of cases that do not fit his initial expectation. the number of children who did not remember past lives far exceed the number of children who did, but stevenson never took this into account. whenever a case did not fit his preconceived idea, he just moved on to the next one that, apparently, did fit into his mold. the main problem with stevenson’s research, then, is that his hypotheses are not falsifiable. according to philosopher karl popper, this is the definite criterion separating science from pseudoscience (10). no possible counterexample can ever refute pseudoscience, because pseudoscience always has a way of accommodating via ad hoc hypothesis. this was the case with stevenson’s research. every time he was presented with evidence that seemed to refute his hypothesis, he would just move to another case. stevenson was apparently apt at verifying his hypothesis (hence his massive data), but not at confronting evidence contrary to his theories. in his research, unlike true scientific research, there was no possible counterexample that he would be willing to take as a refutation of his claims. the question “what evidence would be enough for you to change your views?” was left unanswered by stevenson. another important criterion in the philosophy of science is predictability. as opposed to pseudoscientific theories, scientific theories can make predictions. science assumes regularity in nature. thus, if science pretends to know the laws of nature, it should have the capacity to elaborate predictions on the basis of its knowledge of nature. stevenson’s theories, however, have no predictive value. for example, if, as stevenson claims, a violent death will lead to a reincarnation in which the child will have birthmarks, then, we should at least expect some predictions about particular birthmarks in future incarnations. yet, stevenson did not provide any clue on future specific birthmarks. it is true that stevenson never claimed that his data is definitive, and it is also true that science requires an open mind to consider possible cases. apart from stevenson’s studies, little research has been done on the possibility of reincarnation, and the jury may still be out. however, stevenson’s data is too weak to even suggest reincarnation, and his collection methods are very questionable. stevenson did not speak the languages of the societies in which he carried out his studies. he relied on local interpreters, and this allowed for various cases of corruption. in many of the countries where stevenson did his research, there is considerable cultural expectation when it comes to cases of reincarnation. the interpreters, consciously or not, could have offered data confirming reincarnation, even though it may not have been the subjects’ original testimonies. stevenson should have been careful to independently validate his interpreters’ translations, but he never did that. his research does not present audio recordings or even transcriptions of interviews in the informants’ original languages. in fact, stevenson had some interpreters who were later found to be fraudulent (11); stevenson himself admitted his interpreter’s dishonesty in some aspects, but he still trusted his translations. that is extremely naïve and scientifically unacceptable. there are other graver problems. in the vast majority of stevenson’s cases, children claimed to remember the lives of people who were either a part of the child’s family or close to them. in addition, stevenson’s questions induced the informants to give the information that he wanted in the first place (12). furthermore, the interviewing time was extremely short, which again, seems to suggest that stevenson was more interested in getting the information that fit his preconceived ideas, and after he got that, he would not investigate further. stevenson also had the habit of not only incorporating the children’s testimonies, but also the adults’ interpretations into his reports. in most cases, adults would favor the reincarnation hypothesis, so their biases were incorporated into the data. in fact, stevenson rarely spoke to the children, in part because the children were too shy to talk to a western researcher. adults spoke for the children, and again, this allowed for the adults’ biases to come through. some parents even knew the relatives of the page 4 of 8 j med ethics hist med 10: 11, december, 2017 jmehm.tums.ac.ir gabriel andrade person whose life the child allegedly remembered; hence, the probability of the child getting information from them was increased. as a matter of fact, only in a small proportion of cases, the child’s family did not know the deceased person’s family. generally, stevenson received the news that in some village, a child claimed to remember past lives, and then, he went to investigate the case. between the time that he received the news and he finally reached the village, a lengthy time (three weeks to two years) passed. during that time, the child’s family could have met the deceased person’s family, and they could have gathered information that ultimately reached the child. by the time stevenson arrived, the child would be able to give some specific details, and of course, they would not come from the child’s alleged memories, but rather, from the information that came as a result of the families’ encounters. furthermore, the fact that the majority of cases investigated by stevenson were violent deaths also raises some suspicions. violent deaths are much more publicized than nonviolent ones. that increases the availability of information, and hence, the probability of the child gaining details on the deceased person’s life. the fact that most of these cases take place in countries where reincarnation is a mainstream religious belief also raises suspicions. the child’s family may already be conditioned to believe that the child does remember a previous life, and they may actually encourage such beliefs in the child. any small gesture coming from a child may be interpreted as a sign of remembering past lives, and this further serves as feedback for the child to elaborate on his claims in fulfilment of the parents’ expectations. in the cases collected by stevenson, there also seemed to be a correlation between the culture’s beliefs and the way the cases develop. for example, in cultures where it is not accepted that someone may reincarnate in the opposite sex, no child would remember a previous life in the opposite sex. in matrilineal cultures, children mostly remembered the lives of matrilineal relatives, whereas in patrilineal cultures, children remembered the lives of patrilineal relatives (13). there is also the issue that many of stevenson’s cases were from india. this raises the suspicion that some children may claim to remember the lives of people from upper castes as a way to scale upwards in the caste system. all these methodological problems come up as a result of a central flaw in stevenson’s research: all he really did was to collect anecdotes. anecdotal evidence may be useful at first, but it is not enough to build a strong case for a hypothesis. furthermore, as carl sagan famously claimed, extraordinary claims require extraordinary evidence. reincarnation is an extraordinary claim, but stevenson’s investigations are not extraordinary evidence. in stevenson’s research, there are no controlled experiments. as for the extraordinary talents developed by children, reincarnation is not the only possible explanation. talents (artistic, academic, and etc.) have various heritability rates, but basically most of them do have a genetic basis. some defenders of reincarnation claim that some children with extraordinary talents come from families without those talents. however, that is not a good enough argument, for it ignores a basic law in mendelian genetics: a given trait may disappear in one generation and reappear in another. the parents may carry the dominant unexpressed variety of a gene for a specific talent. it has been frequently claimed that mozart must have been the reincarnation of a great musician, for, how can someone at such a young age develop those musical skills? again, there is no need to appeal to reincarnation: it is quite possible that mozart may have had an acute auditory cortex, which allowed him to develop his impressive musical talents at an early age (14). stevenson always claimed that the most important cases were the ones in which children had birthmarks supposedly coinciding with the wounds that came as a result of the deceased person’s violent death. but again, all this evidence is just anecdotal. the deceased person’s body had already decomposed, so there did not seem to be a good opportunity to analyze the details of the wounds and compare them to the birthmark. stevenson only relied on testimonies and photographs; both types of evidence are highly susceptible to fraud. moreover, once again, in these cases, stevenson arrived too late. this delay allowed for the possibility of the child’s family, by contemplating the child’s birthmark, investigating who in the village may have died with similar wounds. the families may have established contact, and the child may have been provided with information about the deceased person. by the time stevenson arrived, the child may have elaborated his/her alleged memories feeding on that information. furthermore, if reincarnation is just about the transmigration of souls, how exactly do marks appear on the body? neither stevenson nor any other defender of the reincarnation hypothesis has ever given a satisfactory response to this important question. once again, we face the problem of interaction between material and nonmaterial substances. is past life regression therapy harmless? despite the fact that, as i have argued, the reincarnation hypothesis faces some tough conceptual problems and the empirical evidence in its favor is very weak, some psychiatrists do insist on using past life regression therapy to treat some mental disorders, specially specific phobias (15). the movement to use past life regression as therapy page 5 of 8 j med ethics hist med 10: 11, december, 2017 jmehm.tums.ac.ir gabriel andrade in psychiatry began with a famous case, that of bridey murphy, in the 1950s (16). in 1952, an amateur hypnotist, morey bernstein, hypnotized virginia tighe, a woman from the state of colorado in the us. under hypnosis, tighe assumed the personality of one bridey murphy, allegedly an irish woman from the 19th century. tighe had never travelled to ireland, but in the hypnosis sessions, she spoke with a british accent, and surprisingly, she gave precise details about irish life in the 19th century. bernstein wrote a book about this case (17), and the details provided in the book made some scientists think that, indeed, tighe was the reincarnation of murphy. however, as the case drew the attention of the media, some reporters went to ireland to investigate, and found out that tighe´s details had some flaws. the registry details of the town where murphy had allegedly been born did not match the local records. tighe claimed that in her previous life she lived in a wooden house, but in fact, in her alleged hometown there were no wooden houses. it turned out that one bridie murphy corwell had been a neighbor to tighe during her childhood. it was highly probable that she heard stories about ireland from this neighbor, and this information came out during her hypnosis sessions, although she believed them to be part of a past life. the case of bridey murphy is very illustrative of what really goes on during past life regressions. during these procedures, cryptomnesia is very significant. cryptomnesia, let us recall, is a process during which a subject records some information in his/her mind, but this information remains “hidden” in the unconscious. under special circumstances (such as hypnosis), the subject may think that he/she is once again living a particular experience, when in fact, it is just a hidden memory. for the most part, memory is a selective process; we daily apprehend an enormous amount of sensory data, and we must discriminate on the basis of relevance. we normally choose what we desire to remember. some data is then deleted, but some unwanted data nevertheless is retained. when this information reappears, we believe it to be a new experience, or in cases such as bridey murphy´s, we believe it to be reminiscence of past lives. in the case of hypnosis and past life regression, the fact that the hypnotized subject is in a state of suggestibility increases the probability of the occurrence of cryptomnesia. in hypnosis, the hypnotist easily manipulates the subject´s mental state. thus, in hypnosis, the hypnotist may easily induce the subject to assume the role of some character in a previous life. the hypnotist may even do this unconsciously, by asking leading questions that, under a state of suggestibility, the hypnotized subject follows and complies with the initial request. for example, the hypnotist may state: “go back to your life as a soldier in the american revolution”, and taking cue from the hypnotist, the subject may begin to behave in a manner that she believes appropriate for soldiers during the american revolution on the basis of some memories stored in history class during her schooldays. the hypnotist may be excited by this response, he may ask even more leading questions, and ultimately, the hypnotized subject may provide some apparently vivid details of some battle, again on the basis of some previous educational experience (reading a book, watching a movie, and etc.). past life regression, as with most psychotherapies, can provide some good results. talking about one´s problems will offer some form of relief. thus, even if reincarnation is not real and past life regression is just a role-playing game in which the patient follows the suggestions of the hypnotist, is it not ethically acceptable? if the bottom line is helping patients, why should there be any moral objections to this procedure? let us consider the three important principles of medical ethics (beneficence, autonomy, and nonmalfeasance) in order to answer this question. it is undoubtedly true that past life regressions are performed with the intention of helping patients, and indeed, many patients do find some relief undergoing these therapies. in such a manner, the principle of beneficence (the promotion of the wellbeing of others) is honored. past life regressions are not forced on patients. they are always done with the consent of the patients. therefore, apparently, the principle of autonomy is also honored. yet, there is concern as to how informed patients are when it comes to these procedures. in order for the principle of autonomy to be truly honored, there must be informed consent. when doctors do not explain to patients that there is no scientific evidence for reincarnation (and that reincarnation even faces some difficult conceptual problems), patients are not fully informed. with such a lack of information, there can be no true consent, and hence, the principle of autonomy is compromised. most ethicists agree that the most important principle of medical ethics is actually non-malfeasance (first, do no harm) (18). even if a patient asks for a procedure, if that procedure is likely to cause harm, the physician should abstain from performing it. past life regressions can have good outcomes, but they also carry some significant risks. those risks far outweigh the possible beneficial consequences of this type of therapy. the greatest risk in past life regressions is that the hypnotist may implant false memories in the subject, and due to suggestibility, the subject may come to feel them as quite real. this implantation of false memories need not even be intentional. the therapist may ask a question, such as “were you ever a soldier in the american revolution?”, and the subject, inasmuch as she desires to fulfill the role that the page 6 of 8 j med ethics hist med 10: 11, december, 2017 jmehm.tums.ac.ir gabriel andrade therapist apparently expects of her, elaborates on the details. if the hypnotist asks a leading question that may suggest a traumatic experience to the subject, even if that traumatic experience never actually happened, it may actually become quite real for the hypnotized person. in fact, this danger became especially acute during the satanic ritual abuse moral panic of the 1980s in the us. hundreds of patients underwent hypnosis in order to recover memories of alleged sexual and ritual abuses during their infancies. a thorough fbi investigation was carried out, and no evidence whatsoever was found to support the allegations of sexual and ritual abuse (19). nonetheless, the hypnotists had asked leading questions, and these false memories had come to be perceived as quite real by the subjects. as a result of hypnotic sessions, these subjects had to face the troubling consequences of having false memories of traumatic events that, in fact, had never happened to them. the same risk is present in past life regressions. in these therapies, a traumatic false memory from a previous life may be implanted in the subject, causing significant harm. hence, by the principle of non-malfeasance, past life regressions are not ethical. furthermore, the time and resources wasted on past life regressions could be better allocated to therapies that are far more efficient, especially in the treatment of phobias. cognitive behavioral therapy (cbt) is an evidence-based approach that is quite efficient in treating mood and anxiety disorders (including specific phobias). it is unethical to propose to a patient to go back to a previous life to come to terms with a traumatic event in order to treat a phobia, when in fact, it is much more efficient to do so through some of the techniques in behavioral therapy (such as flooding or systematic desensitization). conflict of interest the author declares that there is no conflict of interest. page 7 of 8 j med ethics hist med 10: 11, december, 2017 jmehm.tums.ac.ir gabriel andrade references 1. wagner mcclain f. practical guide to past life regression,1st. usa: llewellyn publications; 1997. 2. weiss lb. through time into healing: discovering the power of regression therapy to erase trauma and transform mind, body and relationships. usa: touchstone; 2012. p. 116. 3. schmiker m. best evidence: an investigative reporter's three-year quest to uncover the best scientific evidence for esp, psychokinesis, mental healing, ghosts and poltergeists, dowsing, mediums, near death experiences, reincarnation, and other impossible phenomena that refuse to disappear. usa: i universe; 2002. p. 9. 4. strawson g. locke on personal identity: consciousness and concernment. https://press.princeton.edu/titles/9594.html (accessed on 2017). 5. finger s. origins of neuroscience: a history of explorations into brain function. uk: oxford university press; 2001. p. 26. 6. gallop d. phaedo. uk: oxford university press; 2009. 7. stevenson i. twenty cases suggestive of reincarnation. usa: university of virginia press; 1980. 8. stevenson i. children who remember previous lives. a question of reincarnation. usa: macfarland; 2000. 9. stevenson i. where reincarnation and biology intersect. usa: praeger; 1997. 10. gorton wa. karl popper and the social sciences. usa: state university of new york press; 2012. 11. anonymous. the skeptic’s dictionary. http://www.skepdic.com/stevenson.html (accessed on 2017). 12. edwards p. immortality. usa :prometheus books; 1997. p. 14. 13. rockley r. the apparent belief system of ian stevenson. http://skepticreport.com/sr/?p=481 (accessed on 2017). 14. d’souza d. life after death: the evidence. usa: regnery faith; 2015. p. 56. 15. sclotterbeck k. living your past lives: the psychology of past-life regression. usa: i universe; 2003. 16. gardner m. fads and fallacies in the name of science. usa: dover publications; 1957. p. 315. 17. bernstein m. the search for bridey murphy. usa: doubleday; 1989. 18. jackson j. ethics in medicine: virtue, vice and medicine. usa: polity press; 2006. 19. conway am. recovered memories and false memories. uk: oxford university press; 1997. page 8 of 8 journal of medical ethics and history of medicine original article the underlying factors affecting the ethical performance of health service providers when faced with disasters: a qualitative study mahmoud abbasi1, mohsen fadavi2*, shabnam bazmi3 1associate professor, medical ethics and law research center, shahid beheshti university of medical sciences, tehran, iran. 2phd candidate in medical ethics, medical ethics department, school of traditional medicine, shahid beheshti university of medical sciences, tehran, iran. 3associate professor, medical ethics department, school of traditional medicine, shahid beheshti university of medical sciences, tehran, iran. corresponding author: mohsen fadavi address: school of traditional medicine, no 8, shams alley, across from shaid abbaspour st., vali asr ave.,tehran, iran. email: fadavima@yahoo.com tel: :( +98) 21 8877 3521 received: 8 apr 2017 accepted: 27 jun 2017 published: 19 dec 2017 j med ethics hist med, 2017, 10:14 © 2017 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract disasters are sudden catastrophic events leading to decisions in health service provision that are not in compliance with the principles and frameworks used in normal circumstances. it is essential to develop guidelines in order to ensure the ethical performance of health service providers and to prevent and manage the adverse consequences. as the first step in guideline development, the present study investigated the underlying factors affecting the ethical performance of health service providers in disasters. this was a qualitative research based on grounded theory, and was conducted through unstructured in-depth interviews with various health service providers including paramedics, physicians and crisis zone managers who had some experiences in a number of domestic and foreign disasters. the collected data were analyzed using conventional content analysis. the underlying factors extracted from the 24 interviews were divided into structural and mediatory factors. the structural factors covered the nature of the disaster, the type of social interactions, and lack of a unity management; the mediatory factors were connected to the emotional atmosphere governing the field, the behavior of the local people, the locals’ economic status, the locals’ trust in the authorities, and the safety of the crisis zone. we can look into more effective, continuous and dynamic relationships between the components of the process of ethical performance. it is evident, however, that the underlying factors have more effective roles than the other components. according to our findings, the role of the underlying, structural and mediatory factors are more of a threat than an opportunity in disasters. keywords: health service providers, professional ethics, disasters, ethical performance mailto:fadavima@yahoo.com j med ethics hist med 10: 14, december, 2017 jmehm.tums.ac.ir mahmoud abbasi et al. introduction disasters are sudden catastrophic events that affect not only the public health, but also the society’s economic and social development (1). the survey of the epidemiological crisis research center of disaster showed that the death rate in countries with low incomes is three times more than high-income countries. the increase in people's deaths in association with decreasing in the frequency of disasters shows the vulnerability of communities to natural disasters. due to the disproportionate burden of disasters in low-income countries, there is a need to improve and develop measures to reduce harms (2). of the 41 types of natural disasters reported around the world, 31 have occurred in iran, making this country one of the ten most disaster-prone countries in the world (3). war, terrorism, airplane collision and nuclear incidents are conceived as man-made, or a combination of man-made and natural, disasters. as a country of geopolitical and geostrategic importance in the middle east and asia, iran has always been exposed to all of the above-mentioned events. when disasters strike, the decisions related to the provision of health services often do not comply with the principles and frameworks used in normal circumstances. most disaster-prone countries face various ethical issues concerning health service provision, such as respect for autonomy regulation, implementation of useful medical procedures, human dignity of those engaged (including the people in the region and health care workers, etc.), precluding hurt to those involved, allocation of scarce resources, triage of the injured and victims, and information provision. rios et al. believe that the challenging ethical principles which should be hold during these circumstances include fairness and equalitygenerating processes (4) health care workers often face three basic challenges in disaster situations: accountability, decisionmaking restrictions and allocation of inadequate resources (5). throughout crisis, we learn that the guidelines used in normal situations are often unfeasible because of the necessity of immediate decision-making, the emotional ambiance of the field and the shortage of resources. in addition, ambiguities emerge in the responsibilities and the ethical performance of health service providers in disasters (6). previous studies propose that health care workers have an unclear conception of "personal preparedness" in disaster situations. thus, it is essential to determine the major factors empowering people in such circumstances (7). national disaster guidelines need to be developed with an ethical approach for stake holders so that they can supply widespread health services in the face of disaster (8). iran is a vast country that is exposed to a variety of natural and man-made disasters, but is unfortunately lacking disaster guidelines based on professional medical ethics. the development of such guidelines is contingent upon determination of the factors affecting ethical performance and explanation of the exact process. the present article is based on a study conducted to determine the underlying factors affecting the ethical performance of health service providers in disasters in iran. method the present qualitative study was conducted using a method that emphasized the understanding of human experiences as they are and in the context in which they have been lived (9). this study performed based on grounded theory. the study began in spring 2014 and was completed in winter 2016. the research and the interviews took place in different cities in iran and mostly in tehran. the participants were selected through purposeful and theoretical sampling among individuals with two attributes: 1) a theoretical knowledge of disasters, and 2) having the experience of presence in disaster zones. they consisted of relief workers with different roles and responsibilities, including paramedics, physicians, disaster managers, and transportation and evacuation coordinators. during the study, a total of 24 interviews were conducted. the first participant was chosen after careful assessment, and the next participants were selected based on the findings obtained from the previous interviews with the aim of deepening and expanding the findings. all the interviews were conducted by the same person (i.e., the corresponding author of this article). each interview began with the general open-ended question “in your experience, what are the underlying factors affecting the ethical performance of health service providers in disasters?". the interviews were recorded and transcribed and simultaneously analyzed. every interview lasted half an hour to 45 minutes. data were collected through unstructured, in-depth, individual interviews that helped increase the depth of the information gained and the flexibility of the study. after each interview, the meaning units were extracted and the step-one category was defined. then, this category was corresponded with the findings of the previous interviews, and thus the main categories were determined. categories were directly extracted from the data (9), and sampling stopped with data saturation. continuous comparative analysis and conventional content analysis were used to analyze the data obtained from human experiences. the following methods were used to increase the validity and rigor of the data: 1) prolonged engagement, 2) time triangulation, 3) peer check, peer debriefing and external check, and 4) choosing the principal participants (8). page 2 of 9 j med ethics hist med 10: 14, december, 2017 jmehm.tums.ac.ir mahmoud abbasi et al. ethical considerations the participants submitted informed consents and were ensured of their right to withdraw from the study at any stage and to stop the recording of the interviews at their own discretion. they were also ensured of the confidentiality of their data and their anonymity throughout the study. intellectual property rights and the privacy of the subjects were fully observed in the publication of the results. there were no conflicts of interest between the researcher and any legal or natural beneficiaries. the literature listed in the references was reviewed and cited with honesty and integrity. results the participants consisted of 24 disaster relief workers with different roles. four participants were female and the rest were male. their mean age was 51 and their mean duration of involvement in disaster relief was 21 years. some of the participants were volunteers and others were serving their organizational duties. the underlying factors obtained were divided into the structural and mediatory categories, as shown in table1. table 1the categories of underlying factors u nd er ly in g fa ct or s structural exclusivity and uniqueness of disasters lack of organized communication selection of service providers not based on professional competence unorthodox interference of influential people the deficient education system lack of a unity management impaired social interactions mediatory (facilitator/inhibitor) environmental attributes personal attributes demographic attributes managerial attributes public conduct as shown in the table above, these two categories are also divided into sub-categories. “exclusivity and uniqueness of the disaster” was one of the extracted subcategories of structural factors. most participants believed that although they thought they had learned great lessons from the bam earthquake, they did not have a satisfactory ethical performance in later events such as varzaghan. they thought that these earthquakes might have been similar, but each had its own peculiarities. one participant commented: [we should realize that each disaster has its own features and occurs only once] (participant no. 6). “lack of organized communication” was another subcategory of structural factors. the participants attributed this problem to all intraand interorganizational levels. one participant said: [communication is not merely to convey information on the phone or on the transceiver, you should also know if the information is actually practical. and the type, time and means of communication need to be planned ahead] (participant no. 2). the majority of the participants believed that the improper exchange of information disrupts needs assessment and obscures the process of decision-making. this defect facilitates performance outside the principles of professional ethics. “selection of service providers not based on professional competence” was extracted as another subcategory. the participants unanimously believed that workers are recruited according to general conditions and then take classes that mainly focus on their technical performance. some believed that in disasters that require large numbers of relief workers, the majority are volunteers with perhaps no proper training, which means a much higher likelihood of unethical performance. “unorthodox interference of influential people” was another finding of this study that may be due to various motivations such as "the need to be seen". one participant said: [occasionally, a director or an authority attends the zone just to get people’s votes in future elections and pretends to serve the victims by interfering in rescue operations. the presence of these opportunists can even make the relief workers leave the zone and stop providing services] (participant no. 3). some participants believed that the presence of managers and authorities with no disaster management duties often leads to delays in rescue operations and brings the rescue workers' spirits down. “the deficient education system” was obtained as a subcategory of structural factors. most participants believed that they would have had at least some knowledge of ethics if issues related to ethical performance or ethical decision-making in disasters had been included in their training syllabus. they argued that there were no topics on what is nowadays construed as “the science of professional ethics in disasters” in any of their school programs. “lack of a unity management” was among the categories extracted in the study. the majority of the participants believed that although the position and page 3 of 9 j med ethics hist med 10: 14, december, 2017 jmehm.tums.ac.ir mahmoud abbasi et al. activities of every organization are clearly defined in the guidelines, a unity management is nonexistent in practice. rescue workers are thus faced with confusion and ambiguity, and may inadvertently perform actions contrary to professional ethics. one participant said: ["if the workers are not properly managed, they make decisions according to their own knowledge, and disagreement, annoyance, exhaustion and tension may arise, which will make ethical performance unfeasible] (participant no. 4). “impaired social interactions” was obtained as the last subcategory of structural factors. most participants believed that public capacity is not fully taken advantage of in disasters as a result of improper communication with people and the inadequacy of announcements. some participants said that the public should receive training in advance so that they know what services they can provide to themselves and to others in the face of disaster. they admitted that not only had they performed poorly in this respect, but had interacted ineffectively with people in times of actual disaster. the circumstances would then lead to conflict, which greatly affected the ethical performance of service providers and wore them out. the mediatory factors were categorized into smaller categories, as shown in table 2. table 2: the subcategories of mediatory (facilitator and inhibitor) factors m ed ia to ry (f ac ili ta to r/ in hi bi to r) environmental attributes existence of endemic diseases unfavorable biogeographical conditions vulnerable infrastructures personal attributes inability to control one’s emotions low threshold of tolerance desire to be seen inadequate training and experience demographic attributes multiplicity of the population affected by the disaster the large numbers of vulnerable groups such as children and older adults public culture public awareness locals’ economic status and poverty public conduct unorthodox emotional behaviors inappropriate expectations unclear role of people in the rescue process locals’ lack of trust in the authorities and action forces managerial attributes lack of appropriate control over conflicting interests inadequate attention to teamwork ineffectual utilization of resources improper maintenance inappropriate distribution of resources the participants also believed that deficiencies in or absence of public safety, outbreaks of endemic diseases and vulnerable infrastructures have been and still are among "the environmental factors" conducive to a performance contrary to professional ethics in health service providers. some participants believed that in the absence of public safety, health service providers are constantly faced with fear, concern and anxiety. they worry that they might harm themselves or damage the equipment they have been given. most participants believed that the existence of an endemic disease in the region could lead to a fear of illness among the service providers. one participant said: [i later realized why some colleagues skived off work and preferred to work in support or warehouse rather than in the field and with people. they were afraid of catching malaria or leishmaniasis] (participant no. 10). another finding in the category of environmental factors was the vulnerability of the infrastructures. some participants argued that when the staff saw the poor construction or management of the water and electricity supply networks and the buildings and constructions in the disaster zone, they came to the conclusion that the local people and authorities had not been concerned about their own safety and did not bother to resolve the issues, so why should relief workers try so hard and endanger their lives? they concluded that no matter how hard they tried, the result would be no good. “personal attributes of the health service providers” was another factor that was extracted in the study. most participants believed that health service providers currently lack the acceptable level or type of skills for teamwork in disaster situations. one participant said: [sometimes we feel we’re competing against each other, which is why instead of helping one another out as members of a larger group, we cause problems and hinder each other's work] (participant no. 7). the ability to control one's emotions was another personal attribute that was considered significant. one participant commented: [many people come to help, but leave the very first night without notice when they see the conditions in the zone. sometimes page 4 of 9 j med ethics hist med 10: 14, december, 2017 jmehm.tums.ac.ir mahmoud abbasi et al. they don’t leave, but they are unable to work the following day due to worry and anxiety. obviously, these people can’t have a proper ethical performance either] (participant no. 4). another finding pertaining to personal attributes was the health service providers' motivations. the majority of the participants believed that most people who come to help, whether from ngos or official organizations, consider philanthropy to be their motivation; however, some of them come to serve in the disaster zone looking for adventure, or to market themselves, or simply to be seen. the participants believed that this group often lack an ethical performance and seek only their personal goals. “demographic characteristics of the area” comprised another finding of the study. according to the participants, the locals’ economic status, their social culture, the public level of education, the population density and the large number of vulnerable groups directly or indirectly affect the ethical performance of the health service providers. some participants argued that when a large number of people, including children and older adults, need extensive services, the workload and the associated mental pressure substantially increase and make relief workers more prone to unethical performance. most participants believed that in some areas, people have specific behaviors that largely depend on their culture. for instance, they may be overly emotional or have their own particular social customs. if service providers are not aware of such details, their intervention may turn into a big challenge at the sign of the slightest conflict, and the people's cooperation may diminish as a result. sometimes locals may not trust the authorities for different reasons and will not trust relief workers either and resort to lying to receive further services, and this adversely affects ethical performance. another group of the participants pointed out that in the disaster zone, most people who have lived all their life in poverty tend to attempt to make up for part of this poverty when they see the help being sent to their zone, and this tendency makes them behave aggressively and have the wrong expectations; in these circumstances, the health service providers may be forced to act unethically. for example, when they see people raiding the water distribution vehicle when there is plenty of drinking water, they start throwing the boxes of water to the people. one participant explained: [i have seen the other staff having to speak harshly and be aggressive or lie about not having so and so, or even refrain from distributing certain items, because despite understanding the crisis situation, they didn’t consider the people's reaction right] (participant no. 18). “management factors” comprised another finding of this study. some participants argued that improper management in the distribution, maintenance and utilization of resources leads to increased environmental pressure on health service providers and affects their performance. most participants believed that failure to resolve the challenge leads to mental imbalance in everyone and severely affects their performance. in such situations, it is the management that can restore peace to the group and resolve the issue. discussion the present study is a qualitative study that was conducted using content analysis to identify and explain the underlying factors affecting the ethical performance of health service providers in disasters. many experts in qualitative research believe that a number of mediatory (including preventive or inhibitor, and facilitating) and structural factors form the underlying aspects of phenomena. as noted in the results, attempts were made to enhance the validity and rigor of the data and form more comprehensive categories through the careful selection of participants. “exclusivity and uniqueness of disasters” comprised an important finding of the study with subcategories including a) the uniqueness of each disaster, and b) the unfamiliarity of the environment. each type of disaster, including natural and man-made (or technological), have its own distinct characteristics. this attribute creates major challenges in the ethical decision-making and performance of health service providers despite their utilization of all the necessary measures, knowledge, and experience. chaos, disorder, disharmony and the mismatch of supply and demand are part of the nature of disasters and unexpected events. the failure to properly identify and control these components may lead to a performance contrary to professional medical ethics. this uniqueness means that in addition to the general principles of disaster, there is a special and unique situation in each case. communication disintegration was the main subcategory of “lack of organized communication”. this is a factor that paves the way for unethical performance through depletion of resources and exhaustion of rescue workers. a degree of communication failure occurs at all levels in disasters. nevertheless, excessive disruption beyond the norm can affect the performance of any health service provider. disaster zone management should base its plans and interventions on the information received from every point in the zone. disruption in communication, both in terms of content and timing, makes planning incompatible with the needs of the target population, and may lead to unethical performance on the part of health service providers. in addition, the large groups of people looking into the disaster zone from outside also require correct and timely information for providing their support and empathy. this key role is highlighted in attracting people's support and the management of the post-disaster environment. page 5 of 9 j med ethics hist med 10: 14, december, 2017 jmehm.tums.ac.ir mahmoud abbasi et al. it should be noted that in disasters, teamwork among people in a group or among groups is a moral obligation, and the existence of an organized link and the correct movement of information is an important part of this team work (10). it is imperative that information exchange be ongoing, accurate, documented, classified and timely. obviously, in the absence of organized communications, we will witness parallel work and waste of resources, including financial and human resources. the present findings regarding “selection of service providers not based on professional competence” reveal the absence of a methodical system for assessing the professional competence of people as a key indicator of their performance in disasters. this reflects the defects in the present human resource recruitment system and the unorthodox focus of planners on having the maximum number of relief workers in disasters, which often leads to the attendance of poorly trained workers and obviously promotes unethical performance. having the readiness, in addition to providing appropriate assistance to the injured, has other positive outcomes, including a greater willingness to engage in missions, and has a more favorable effect on recovery (11). this care should prevail in both the initial recruitment of the forces and their training and cooperation. “unorthodox interference of influential people” was another finding of the present research that could be either a threat or an opportunity. attendance of officials, directors and nationally or provincially influential people in the disaster zone when they have no predetermined or structural roles in the field can be very constructive if it accords with the disaster management goals and is free of personal, group, junta or faction interests. their unprincipled conduct, however, often disheartens the health service providers and generates unethical performance, and may also lead to the misuse of the limited resources available, which is contrary to the ethical principle of equitable resource distribution. influential people can engage in decisions within the scope of their responsibilities in executive centers outside the disaster zone, but they should realize that in the disaster zone, they have to follow the instructions and decisions of the zone manager. “the deficient education system” was another finding of the study. the results indicated that medical ethics is not sufficiently covered in the curricula designed for disaster relief workers. although the spirit of philanthropy governs the provision of health services in disasters, lack of ethical knowledge is conducive to a performance contrary to professional medical ethics. an article pointed out a public health paradox in disasters as doubts in decision-making arise from lack of knowledge (12). it is obvious that education is considered as a very effective factor in the empowerment and competence of health care providers that facilitates the achievement of predetermined goals at times of disaster (13). in order to make the right decision, it is imperative for the health care workers to have the knowledge, training, information and experience sufficiently (14). health providers are in many cases the first to help victims of disasters, and therefore educating them is very important. the objective should be to train them to evaluate, stabilize and treat patients with minimum specialized equipment. in addition, they must try to maintain their own health under the circumstances. “lack of a unity management” was another important finding of the study that can result from a combination of factors such as the multiplicity of organizations in charge, a claimant management or trusteeship, and performance confusion between the relief workers and the security forces. despite the instructions and guidelines available on the responsibilities of each organization in the event of a disaster, in practice, no authorities or agents are responsible for certain matters, while for some others, multiple organizations and institutions may claim responsibility. this set of circumstances is created through disorder, distrust, parallel efforts and depletion of resources, and paves the way for the unethical performance of any of the forces or even the organized groups. if the supply and use of human resources and equipment are carried out autonomously, regardless of the needs of the region and without coordination with other service providers, the emergence of redevelopment and parallel organizations and the consequential lack of coordination between them will greatly affect the delivery of fair services and the effectiveness of relief and rescue will damage. “impaired social interactions” was another finding that revealed the complexity of interventions in the society at times of disaster. in the absence of proper social interactions, guiding public interventions becomes an inefficient affair; this in turn leads to loss of the high public capacity for helping to search for, retrieve and rescue the wounded and victims and loss of their cooperation through creating feelings of ineffectiveness. they may even feel as if they are merely users of services and not part of the disaster management team, which then exacerbates the emotional atmosphere of mistrust and encourages the unprofessional performance of the health service providers. in fact, people in or nearest to the community of the disaster can generally provide the most valuable contributions. each society has certain positive traits that are related to its identity, which can be used to manage emergency situations. "the mediatory factors” can be considered as the environmental factors that could lead to the unethical page 6 of 9 j med ethics hist med 10: 14, december, 2017 jmehm.tums.ac.ir mahmoud abbasi et al. performance of health service providers. the lack of public safety is especially alarming for health service providers in disasters. harm to themselves and damage to their equipment are valid threats both from the local people (who, due to the emotional crisis, are highly likely to exhibit aggressive and unorthodox behaviors) and from greedy individuals or even criminals who have entered the disaster zone for looting or other evil purposes. this feeling of unsafety affects the emotional status of health service providers and diminishes their ability to focus on their specialty and increases the likelihood of errors. health care workers are aware that communicable and other types of diseases can spread in disaster situations, and it is therefore imperative to ensure their own health. when service providers learn about an endemic disease in the region, they begin to behave differently. for instance, they try to perform activities that put them in the least contact with the diseased or the locals, which will naturally distance them from the people and may even make them avoid providing services to the people in need for fear of getting sick themselves. although they are well informed about their duties, their fear leads to unethical performance. the importance of maintaining safety and avoiding hurting themselves by disaster-based health service providers has been mentioned as a deterrent to prevent these people from acting on their moral obligations. contagious infectious diseases and security threats in the disaster area are among these risk factors (15). regarding the impact of defective and vulnerable infrastructures on ethical performance, the participants believed that the poor infrastructure of an area is indicative of the unsatisfactory performance of the region’s officials and the locals’ lack of demand. by this reasoning, they came to the conclusion that the people in these areas should expect to pay for their own indifference and not demand the sacrifice of the health care workers under the circumstances. this view occasionally leads to unethical performance in health service providers, for instance they make mistakes, do not take responsibility and thus disrupt teamwork. “personal attributes” of health care workers comprised a key finding of this study. people react differently to the various things that happen in a disaster. the participants revealed that some of the workers ran away from the scene, while others remained astounded for a while and then somehow get adapted to the circumstances. it must be accepted that a high level of stress and mental pressure, which can affect the quality and quantity of the services they provided, thereby suggesting a pressing need for providing relief workers with specific aids and further attending to their needs. some participants considered lack of practical training as a reason for the low threshold of tolerance and the personal vulnerability of the forces present in the scene. training does not make everyone equally efficient, and this difference in efficiency stresses the need for empowerment and ongoing learner assessment, so that the training can promote ethical performance and decision-making in crises. experience was another finding of the study that has a key role and can be acquired through frequent involvement in collective events or through learning from other people's experiences (whether domestic or foreign). step-by-step development is required for getting experienced; otherwise, unethical performance becomes more likely both in individuals and the workforce under their command. as for the desire to be seen, it can be argued that people attend the disaster zone with different motivations, including philanthropy. however, those who enter the zone influenced by communal excitement or out of the desire to be seen and for pretense or for marketing purposes quickly wear out and often perform irresponsibly and unethically due to their psychological discontent. the people's behavior, which mainly arises from their culture, can be emotional, demanding or imbued with unorthodox expectations, which are categorized in this study as “demographic attributes”. such behaviors provoke a reaction in health care workers that may appear unethical at first; for instance, they may restrict the distribution of the demanded items or cause the unbecoming allocation of resources as if they were given out of charity, or lead to the workers’ lying or yelling in order to control the collective behavior. one reason for unethical performance may be the multiplicity of the population, which entails enormous demands for services. another reason is the large number of vulnerable groups, which causes physical and mental exhaustion not only because of the aforementioned reason, but also because of these people’s need for special attention. the locals’ poverty can also affect their behavior and lead them to take more than they need from the large amounts of donations brought to the area after the disaster. the reason is obviously their desire to compensate for their long-term suppressions and current disaster-induced suffering. such motivations can lead to unconventionally demanding behaviors that can mar their adaptive interaction with the health service providers and in a way that causes reciprocal and non-interactive reaction on the part of others. donner et al. believe that the multiplicity and density of the population and the locals’ poverty exacerbate vulnerability in disasters (1). fothergill and peek also believe that poverty is fundamental in the perception of risk and the response to it (16). the results obtained in several previous studies emphasize the importance of the society’s degree of understanding, the empowerment of people, and the development of social capital for creating a page 7 of 9 j med ethics hist med 10: 14, december, 2017 jmehm.tums.ac.ir mahmoud abbasi et al. community-oriented approach in disasters and emergency plans (17). preparation and attention to the dominant culture ensures people that, when a crisis occurs, cultural considerations are carefully taken into account in the efforts made in the face of predicament, so that the most effective response can form and lives can be saved and pains alleviated (18). the issues discussed above do not justify the unethical performance of health service providers, but are realities that should be taken into consideration. “public conduct” comprises unorthodox emotional behaviors, inappropriate expectations, the unclear role of people in the rescue process and the locals’ lack of trust in the authorities and action forces. it must be admitted that in severe catastrophic events such as the bam earthquake, people feel tired, and their response may be a desire to receive maximum assistance. the numerous unconventional expectations may force the health care workers to show certain reactions in order to control the situation, which may then lead to conflict between the two parties and create delicate and vulnerable relationships. people do not have access to the necessary information for statistical calculations of the probability of harm, and obviously follow rumors, stories of others, and emotional accounts. an atmosphere of distrust in the authorities caused by recent or previous experiences can lead to harsh and angry behaviors and unorthodox and greedy expectations in people and thus cause the tensions discussed earlier. the absence of plans for determining people’s position in rescue activities as a great local force with a capacity to direct and reform the actions means dismissing an exceptional opportunity for comprehensive disaster management. “managerial attributes” can directly and indirectly lower the rescuers’ threshold of tolerance and make them indifferent through creating a sense of dissatisfaction with service provision, exhaustion, a feeling of discrimination and intentional mismanagement, and all of these adversely affect the ethical performance of health care workers. conclusion according to the results obtained, there are two major groups of factors that can encourage a performance either in line with or contrary to professional medical ethics among health service providers in disasters, especially at the onset of the event. the first group of factors is completely dependent on the nature of the disaster, and a performance contrary to professional medical ethics is still likely in spite of anticipating all the steps of relief work and meeting all the needs arising in the disaster; in the case of these factors, preventive measures can merely reduce the risk. the second group of factors, however, relies on the forces’ preparation and planning, and the main flaw in ethical performance pertains to this group. the present findings discuss the most sensitive and vulnerable points that need to be urgently addressed in order to develop relevant ethical performance guidelines and management plans. at the moment, we face a shortage of ethical knowledge about health in disasters, lack of inclusive plans related to professional ethics, and an absence of all-encompassing health management in disasters. in addition to all these problems, and issues related to the selection of strategies and their consequences, we should accept the operation strategies of the health care workers in disasters and face the challenges in professional ethics. according to our findings, the role of the underlying structural and meditative factors is more of a threat than an opportunity under the circumstances. in the absence of a roadmap and the proper guidelines for ethical performance, the diversity and multiplicity of evaluative tools can lead to personal and group performances contrary to medical professional ethics. until the necessary guidelines are developed, two strategies can be adopted to resolve this constraint: first, the proper and careful selection of people for attending disaster zones, and second, increasing the ethical knowledge of health service providers. acknowledgment this paper derived from a medical ethics phd thesis registered under number 137 in the school of traditional medicine, shahid beheshti university of medical sciences. whereby appreciate those who helped us with this article, especially the participants in the research. conflict of interest there was no conflict of interest at any stage of preparation and development of this article. page 8 of 9 j med ethics hist med 10: 14, december, 2017 jmehm.tums.ac.ir mahmoud abbasi et al. references 1. donner w, rodríguez h. disaster risk and vulnerability: the role and impact of population and society. http://prb.org/publications/articles/disaster-risk.aspx (accessed on 2017). 2. anonymous. the human cost of natural disasters 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disasters and other mass casualty events. otolaryngol head neck surg. 2008; 139(2):181-6. 9. corbin j, strauss a. basics of qualitative research. usa: sage publication; 2008. 10. larkin gl. unwitting partners in death, the ethics of teamwork in disaster management. virtual mentor. 2010; 12(6): 495-501. 11. thompson c. making ethical decisions during disasters. nurs n z. 2006; 12(11): 30. 12. o’laughlin dt, hick j. ethical issues in resource triage. respir care. 2008; 53(2):190-200. 13. montan kl, örtenwall p, lennquist s. assessment of the accuracy of the medical response to major incidents (mrmi) course for interactive training of the response to major incidents and disaster. am j disaster med. 2015; 10(2): 93-107. 14. karadag co, hakan ak. ethical dilemmas in disaster medicine. ircmj. 2012; 14(10): 602-12. 15. chaffee mw. making the decision to report to work in a disaster: nurses may have conflicting obligations. am j nurs. 2006; 106(9): 54-7. 16. fothergill a, peek l. poverty and disasters in the united states: a review of recent sociological findings. natural hazards.2004; 32(1): 89-110. 17. sobelson rk, wigington cj, harp v, bronson bb. a whole community approach to emergency management: strategies and best practices of seven community programs. j emerg manag. 2015; 13(4): 349-57. 18. bergeron wp. considering cultural in evacuation planning and consequence. j emerg manag. 2015; 13(2): 87-92. page 9 of 9 http://www.ncbi.nlm.nih.gov/pubmed/?term=%c3%96rtenwall%20p%5bauthor%5d&cauthor=true&cauthor_uid=26312492 http://www.ncbi.nlm.nih.gov/pubmed/26312492 journal of medical ethics and history of medicine original article establishment of medical education upon internalization of virtue ethics: bridging the gap between theory and practice mansoureh madani 1 , bagher larijani 2 , ensieh madani 3 , nazafarin ghasemzadeh 1 * 1 phd candidate in m edical ethics, m edical ethics and history of m edicine research center, tehran university of m edical sciences, tehran, iran. 2 professor, m edical ethics and history of m edicine research center, endocrinology and m etabolism clinical sciences institute, tehran university of m edical sciences, tehran, iran. 3 lecturer, dep artment of islamic knowledge and humanities, amirkabir university of technology , tehran, iran. corresponding author: nazafarin ghasemzadeh address: no. 23, 16 azar ave, tehran, iran. p.o. box: 1417863181. email: nghasemzadeh@razi.tums.ac.ir tel/fax: + 98 21 66419661 received: 10 jan 2016 accepted: 18 feb 2017 published: 05 april 2017 j med ethics hist med, 2017, 10:3 © 2017 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract during medical training, students obtain enough skills and knowledge. however, medical ethics accomp lishes its goals when, together with training medical courses, it guides students behavior towards morality so that ethics -oriented medical p ractice is internalized. m edical ethics is a branch of ap p lied ethics which tries to introduce ethics into p hy sicians’ p ractice and ethical decisions; thus, it necessitates the behavior to be ethical. therefore, when students are being trained, they need to be sup p lied with those guidelines which turn ethical instructions into p ractice to the extent p ossible. the current text discusses the narrowing of the gap between ethical theory and p ractice, esp ecially in the field of medical education. the current study was comp osed using analy tical review p rocedures. thus, classical ethics p hilosop hy , p sy chology books, and related articles were used to select the relevant p ieces of information about internalizing behavior and medical education. t he aim of the p resent study was to p rop ose a theory by analy zing the related articles and books. the attemp t to fill the gap between medical theory and p ractice using external factors such as law has been faced with a grea t deal of limitations. accordingly , the p resent article tries to investigate how and why medical training must take internalizing ethical instructions into consideration, and indicate the imp ortance of influential internal factors. virtue-centered education, education of moral emotions, changing and strengthening of attitudes through education, and the wise use of administrative regulations can be an effective way of teaching ethical p ractice in medicine. ke ywords: medical education, virtue ethics, moral emotions j med ethics hist med 10: 3, a pril, 2017 jmehm.tums.ac.ir mansoureh madani et al. page 2 of 12 introduction the goal of medical education programs is to train physicians and provide them with the skills and knowledge required to perform their duty in a legal and ethical framework, because a proficient physician who is knowledgeable enough will not achieve his goal, which is improving patients’ health, if he practices medicine in an unethical way. with regard to this issue, teaching medical ethics and the related laws has been emphasized in the form of important curricula and nurturing ethical physicians (1). regardless of the theoretical basis it is founded upon, ethics is closely related to practice. ethical systems try to present a model to modify and correct individuals’ behavior with respect to every taste and style (2). applied ethics is a branch of ethics that involves the application of ethics in the private and public lives of people and tries to solve common tangible problems in a variety of communities and professions. applied ethics does not aim at developing the understanding of ethical concepts, but at making suggestions that have beneficial practical results and assists in ethical decision-making (3). medical ethics is considered to be one of the branches of applied ethics. its orientation is towards tangible medical issues and it intends to explain the principles and basic concepts of this science and introduces ethics into the field of practice and important ethical decisions (4). in this vein, medical ethics focuses on putting ethics into practice in real-life situations. it is very clear that this branch will succeed if it puts the findings of theoretical research into practice and accomplishes its practical aims. this objective raises the issue of the relationship between knowledge and practice. people’s voluntary behavior (that is, the topic of ethics) is shaped on the basis of their willingness and determination. it is evident that voluntary behavior is preceded by a sort of science and cognition, but not every science and theory necessarily leads to practice. we are always dealing with behavior patterns that are in contrast with the beliefs and ideas of their owners (2). many people who have dangerous behavior, like people who smoke or diabetics who do not follow their diets, believe that their behavior is hazardous and inappropriate. furthermore, regarding ethical behavior, it can be stated that many physicians who do not respect patient’s rights confess that their behavior is wrong or at least are aware of their false behavior from the viewpoint of medical ethics. in order to clarify this issue, it is essential to study the factors that lead to or prevent the transformation of knowledge or beliefs into behavior which has previously been studied in various areas. these studies have mainly considered converting an idea into practice as a process and the stages between these two, and have studied the effect of each. these stages are not identical in various fields, but they have many similarities and the intermediation of desire is accepted in almost all of these models, although it has different names such as attitude, intention, and motivation. regardless of any of these theories, it can generally be mentioned that whatever obliges an individual to act can be extrinsic or intrinsic. the extrinsic factor can be law or custom (5). law is one of the tools that are employed to control the individual, and professional and organizational behavior. although it is powerful, it is inefficient to some extent. for instance, it is costly, and unable to enter some individual and social domains, including private relationships, and control some behavior. like law, custom also relies on external enforcement such as people’s humiliating and blaming looks. therefore, focusing on internal factors would lead to more favorable practical outcomes. internalization of behavior starts from childhood and characters are established gradually. when an individual enters the medical training field, he/she starts learning new knowledge and skills and uses this knowledge in his/her behavior. some of these trainings are imposed on the individual by administrative and regulatory requirements, and in the event of a malfunction or failure of the regulatory system, the individual refuses to act accordingly. however, other trainings turn into a personal value system. in this vein, it is considered that the efforts of the medical education system regarding the presentation of high quality education which results in internalization of most of the teachings will end in greater practical success. on the other hand, teaching ethics cannot be separated from medical training and medical students must be trained in a way that they acquire the knowledge of both ethics and medicine. furthermore, medical training curricula are required to provide the necessary skills and to give an assurance for dealing with challenging problems of medical groups (1). in this regard, universities should pay greater attention to the roles of administrative actions, educational settings, and teachers as role models for students. moreover, they should center their educatio n on training more professional-oriented physicians (6), who have greater intrinsic motivation and do not require external control. due to the fact that it is a new subject area, few studies have been conducted to investigate the issue. the aim of the current study was to illustrate that in order to narrow the gap between ethical theory and practice, especially in the field of medicine, it is crucial to consider behaviors determining intrinsic factors and find ways to intervene in these behaviors, and consequently, change them through medical education. j med ethics hist med 10: 3, a pril, 2017 jmehm.tums.ac.ir mansoureh madani et al. page 3 of 12 method the current article was composed using analytical review procedures. first, the terms internalization, medical education, ethical education, and virtue ethics were searched using valid scientific web sites such as inlm, pubmed, and google scholar. a combination of keywords was used in the search strategy. moreover, classical ethics philosophy and psychology books were used to select the relevant pieces of information. other related books were also found and utilized using these keywords and related articles were identified on the basis of the booklist. after the meticulous studying of the books and articles, the issue of virtue ethics internalization and medical education was discussed. results the main effective factors on ethical internalization and some of the important interventional manners by which the gap between ethical theory and practice can be narrowed are summarized in table 1. table 1 effective factors on ethical internalization and interventional manner intervention in medical education effective factors on ethical internalization  nurture of students' moral sentiments  consideration of emotion's cognitive component and its promotion through medical education  creation of sublimation emotions in medical students  teaching empathy to medical students role of emotions in medical decision making  nurture of characteristics such as strong will, self-confidence, self-motivation, and a sense of control over oneself in medical school  instilling of a moral and virtuous character in medical students and creation of moral agent or teaching of virtue thro ugh professionalism education  careful consideration of hidden curriculum and teachers as role models in medical education moral and virtuous character  consideration of the cognitive, affective, and behavioral dimensions of attitude in medical education  creating attitude and changing attitude through medical education  creating and strengthening positive attitudes  use of faith for the desire to act attitude and change of attitude  codification of appropriate disciplinary regulations (neither strict and nor permissive) with stakeholders involvement and based on their moral convictions and physical and spiritual needs  ethical justification of medical regulations or ethical guidelines and creation of a cultural infrastructure in the medical education system  administrative solutions for subordination of regulations (appropriate authority)  education of self-control and self-regulation for medical students appropriate application of law and administrative solutions the main findings of this study will be discussed in detail in subsequent sections. in this regard, medical schools must plan for internalization of ethical instructions in medical education based on appropriate interventions on internal and external factors (figure 1). j med ethics hist med 10: 3, a pril, 2017 jmehm.tums.ac.ir mansoureh madani et al. page 4 of 12 particular importance of internal requirements in modern medicine the definition of “ethics” in modern medicine differs entirely from its classical meaning. traditional medical ethics was deeply rooted in the ideas of great philosophers such as socrates and plato. for them, ethics was the art of living and a method of self-care which they were trying to learn in addition to medicine (7). after the renaissance, religious teachings were criticized and rationalist orientations increased, especially in the west, and accordingly, ethical attitudes were influenced. even in the late 19 th and 20 th century, originality was completely directed toward the human biological identity and physical pleasures with the rise of theories like the theories of freud and darwin (8). in recent years, the scholars of bioethics have greatly criticized the common structure of modern medicine and medical ethics. george engel, who is one of the most prominent critics, believes that the biomedical approach has mostly emphasized the cellular and molecular level of the individual’s characteristics; however, we deal more with patients’ personal dimension rather than their cellular and molecular identity (9). in modern medicine, the biomechanical model is the basis for research, education, and treatment. as a result, physicians unconsciously conceive patients as machines and their illnesses as mechanical defects. in this way of conception, the physician does not have the ability to de al with patients’ underlying life issues, and thus, cannot have an appropriate relationship with them. therefore, in order to introduce ethics into medical contexts, it is essential that this attitude toward human beings is revised (10). von foerster, another critic of modern medical ethics, states that achieving ethics in life cannot be accomplished through ethical orders (11). he believes that, in the context of life, ethics is related to the time when an individual decides to do or not to do, whereas ethical imperative tells us what to do or what not to do (11). another critic is ten have who notes that, after 1960s, medical ethics, which previously was more like internal ethics, has distanced from its traditional deontologist form and has appeared as modern bioethics in the shape of some applied principles and rules (12). in addition to criticizing, he expressed sorrow for this historical trend and the trade -like nature of modern medicine and points that the transformation trend of internal profession al ethics into external applied ethics is a stranger to its clinical reality. in his opinion, an appropriate interaction must be sought between traditional medical ethics and modern bioethics (12). in iran, medicine is also moving towards this modern structure, while in the past, before and after islam, medicine was closely connected to wisdom (hek mat) j med ethics hist med 10: 3, a pril, 2017 jmehm.tums.ac.ir mansoureh madani et al. page 5 of 12 and theology. especially after islam, iranian physicians paid specific attention to medical ethics due to the great islamic emphasis on ethical issues becaus e the promotion of human ethics is the ultimate goal of the prophets’ mission (be’sat). in islam, medical ethics is closely related to fiqh and sharia according to which the ethical nature of an action is not only related to the characteristics of that action itself, but also to the agent’s qualities. therefore, in practical terms it employs consistent principles in clinical decision making, although it underscores piety and moral virtues and is a kind of “virtue-based ethics” (13). importance of intrinsic motivation and requirement in medicine in the field of medicine, there are numerous situations in which a person decides without thinking and only on the basis of his own intuitions and internal requirements. one such situation is when the physician decides immediately and impromptu or when he/she reacts unconsciously which is very important in the field of medicine since a physician is repeatedly faced with such situations that are both sensitive and vital and there is the need for urgent decision making, too. in these situations, the individual unconsciously uses her/his previously internalized patterns that are externally more difficult to monitor. in this stage, ethical reasoning intervenes less (14-16), and the individual’s characteristics, ethical sens itivity, and emotions are more determining; thus, the best ethical results are gained when ethical instructions have been internalized within the individual. internalizing ethical instructions is important in the case of delayed decision makings, especially when the individual experiences emotions and excitements which, in turn, decrease the power of logic and wisdom (14). complex ethical situations are other cases in which the physician makes a decision based on his intuition and internal motives. some ethical problems are so complicated that their solutions inevitably require a moral agent who has an ethical character. therefore, the individual can only make the most moral decisions when he has a high intuitive understanding and an ethical character. moreover, the physician confronts a dilemma in complex situations which direct him toward an uncertainty about his duties and pave the way for his biased interventions and decisions. under such conditions, only his internal requirements can guarantee an ethical decision making. what are these internal requirements, and how can they be created? psychologists believe that an individual’s personal values motivate him/her towards a pattern of behavior. all human actions have the purpose of actualizing human values and value priorities are the most essential factors for guiding attitude and behavior; therefore, behavior can be predicted if these values are known (17). another internal factor is human affection (emotion). the last factor is strongly connected to internal requirements and is known as moral character which is considered as personality and virtuous character in psychology and philosophy, respectively. internalization of ethical instructions for guiding medical students’ ethical intuitions one of the common concerns of all communities is to convey their values to others and future generations in the best way. one of the goals of educational and behavioral sciences is internalization which has a significant and comprehensive effect on modifying behavior. it is not necessarily a one-way process, but it can be interactive and continuous (18). during the internalization process, the individual adopts the ideals, models, beliefs, and attitudes of others (19) and accepts them as his/her own values to the extent that he/she may be unaware of their source (20). as behavior is internalized, the person feels enthusiastic towards it even when there is no extrinsic control and others are absent, and he/she also feels psychologically tense if he/she fails to perform it. there are various psychological explanations which justify the phenomenon of acceptance of external values over one’s own values and criteria. for instance, the theories of cognitive dissonance, selfencouragement and justification, and empathy can be pointed out in this regard (21). moreover, an individual’s tendency to be assimilated into a group is influential on his/her acceptance of that group’s beliefs and attitudes. one of the most accepted justifications is that human beings try to keep a consistency between their behavior and attitudes, as well as between their different attitudes; hence, they convert the values that are necessary for their social life and environmental adaptation into their own values (22). the outcome of internalization is the long-term persistence of beliefs, attitudes, and behavior without an external controlling force (23). nevertheless, the behavior that is created by an extrinsic motive such as punishment, fine, and reward will be eliminated when the external agent is removed (22). ethical internalization is a quality of advanced ethical growth. for example, in kohlberg’s model of ethical development, internalization is the feature of the post-conventional stage in which an individual behaves neither for reward and punishment n or for adherence to social conventions, but acts on the basis of pure internal factors (21). some of the most important factors in the formation of ethical behavior that originate from the individual’s internal inclinations will be briefly discussed below. these factors include individuals’ emotions, moral and virtuous character, and attitude which can also be controllable. moreover, the effect of law on the internalization of behavior will be discussed. j med ethics hist med 10: 3, a pril, 2017 jmehm.tums.ac.ir mansoureh madani et al. page 6 of 12 1. the role of emotions in medical decision mak ing an individual’s emotional tendencies are one of the factors that internally lead him/her to an action. physicians’ ethical decision makings in many ethical dilemmas, particularly in relation to sensitive issues such as abortion and organ transplants, are significantly influenced by emotions (24). in previous investigations, it was observed that the effect of emotions on decisions was greater than the impact of wisdom (25). some emotional conditions will compel physicians to think irrationally (like a child) and endanger their moral decisions (26). therefore, in the presence of an affective factor, physicians’ selected options differ from other instance; this means that many of the precepts of theoretical ethics in the field of practice are inefficient (26). in the past, most moral philosophers considered emotions to be an inappropriate and also destructive basis for ethics (27). in recent centuries, philosophers have gradually assumed a greater role for emotions. for example, david hume, in the18 th century, paid attention to the role of emotions in moral knowledge and took virtue into account as a sensual quality (28). he accepted the existence of a moral common sense in all people and stated that the resources for moral admiration and condemnation were sympathy and humanitarianism (28). until the past few decades, psychologists had similar views and most of them considered emotion to be the reason for prejudice and bias which prevent correct judgment. in the history of psychology, most of the decision making theories emphasized the role of reason and cognition. moreover, in the field of professional ethics, it was often believed that emotions should be omitted from the realm of professional decisions to the extent possible, particularly in professions such as medicine which deals more with people’s feelings. these theories have been greatly changed over the last century (24). today, according to numerous studies that have been carried out in this area, most experts believe that although some emotions can distort understanding and cause selfish and immoral decisions, other emotions called “moral sentiments” are related to the community and welfare of others and less concerned with personal interests, and thus, important in ethical decision making (29). “empathy” is one of the main moral sentiments and is the main factor in the relationship between the physician and the patient. furthermore, it was shown that the presence of empathy in medicine reduces the risk of medical errors and complaint statistics by improving the physician-patient relationship (30). there are even theories that not only stipulate the positive effects of emotions on ethical decisions, but also consider an essential and central role for them. they believe that what in particular makes a tho ught ethical and necessitates its being ethical is an emotional investment. ethical experiences primarily affect emotions, and then, these moral responses lead to ethical thinking and behavior. therefore, decreasing ethical experiences, disregarding emotions, and deficit in moral sentiments in practice can be regarded as the greatest moral hazards. even regarding feelings that have negative moral influences and must be brought under control, we can say that the amount of their control depends on the person’s emotional saturation. today, one of the critical issues of bioethics and one of the greatest problems of health care students’ education is the lack of emotional responses and empathy (26). emotions’ positive effects on ethical behavior have been demonstrated by several neuropsychological studies (31). it has been observed that patients whose feelings are partially inhibited due to treatment with chlorpromazine are more prone to unethical behavior such as deception (32). furthermore, by studying patients with frontal cortex damage, damasio et al. and bechara et al. showed that emotions have a major role in rational reasoning and disturbance of emotions can disrupt moral decisions (33, 34). based on religious teachings, moral emotions that arise from the transcendent aspect of human existence can be a tool for understanding the virtues and vices of moral and ethical decision making. the individual who possesses these emotions evaluates the values and anti-values with his/her own dignity and honor, and his/her heart can be a mirror for the manifestation of moral knowledge, so that the more innocent heart is, the more realistic moral knowledge will appear (35). due to rapid advances in technology, the physical relationship between the physician and the patient, and consequently, their emotional connection is weakened day by day and medical structure moves towards eliminating the feelings of physicians in ethical decisions (12). controlling emotions human’s emotions and feelings seem to be an involuntary and uncontrollable phenomena, but in fact they are not so. emotions are closely related to perception, cognition, and learning, while cognition and learning are influential on emotions’ development. in fact, human emotions grow and evolve parallel to physical, psychological, and social development (36). this means that human emotions are in a raw state in the first years of life, and gradually escalate and change into perfect feelings or sublimation emotions. for example, in a perfect person like ali ibn abi talib (as), there are no diminished feelings, but only complete sublimation emotions. in fact, the emotions and personality of a person pass through the information and characteristic channel and in fluence that person’s psyche which is intertwined with other parts of the spirit. therefore, it can be said that, in choosing the reasonable ways of life, the real determining factor is sublimation emotions (37). the way cognition influences emotions was j med ethics hist med 10: 3, a pril, 2017 jmehm.tums.ac.ir mansoureh madani et al. page 7 of 12 seriously investigated for the first time by schachter (38). he finally came to the conclusion that it is possible to change people’s emotions by influencing cognition. schachter and singer presented their bifactorial theory of emotion that considered the t wo factors of cognition and stimulus that are together responsible for arousal of emotions. thus, we can say that we are able to control emotions by changing their cognitive components to some extent. concurrent with schachter’s discussions, arnold presented a theory according to which the emotional stimuli are evaluated in different parts of the brain before they lead to emotional response. with the adoption of the evaluation structure in this theory, it can be said that our emotions are controlled by different brain areas (38). today, especially in the past three decades, the relationship between emotion and cognition has been widely studied and the possibility of making more ethical decisions by changing and controlling the emotions has been investigated and approved. many of these theories were also approved by neuropsychological examinations (39, 40). empathy is one of the most important moral sentiments and plays an important role in the relationship between patient and physician, and like other emotions, it has two main parts, an affective component and a cognitive component. if the level of the cognitive component is high, we can control it easier and the quality of physicians’ decisions can be improved. it also provides the opportunity for using specific trainings, creates more empathy in physicians, and improves the quality of medical decisions (29). accordingly, today, many scholars try to enhance the feeling of empathy in physicians by focusing on the cognitive component of emotions to find ways to teach and select medical students, and to train physicians (41). for example, it was shown that empathy training caused physicians to show a 51% increase in empathy measurement criteria which was higher than the control group that had not received training in terms of empathy. according to researchers’ findings, if appropriate curricula are developed for increasing physicians’ empathy towards patients, the influence of training will be clearly observed after 6 months (30). researchers have also tried to find new methods in order to achieve greater success in teaching empathy. for example, tillman et al. presented a method that made training empathy to physicians easier and improved their learning (42). 2. moral and virtuous character ethical and virtuous character is the other issue closely related to a person’s internal tendencies. ethical and moral character psychology is an interpretation frequently used in ethics of psychology and the discussions of moral development. moral character primarily focuses on the virtuous character, but they are not necessarily equivalent. in addition to virtues, other characteristics such as strong will, self-confidence, self-motivation, and a sense of control over oneself can also be important in shaping an ethical personality and being regarded as a moral character (43). moral character in ethics of psychology, ethical development theories either place more emphasis on cognitive factors, such as piaget’s and kohlberg’s theories, or focus more on behavior, like social learning theory. however, in some theories like that of james rest, not only is the ethical action mentioned, but also the necessity of forming an ethical character for repeating an ethical action and stabilizing it in adverse conditions is emphasized. character is built by performing a particular behavior model which here includes virtuous behavior patterns. ethical character is having the power and skill to behave in certain ways in every condition, including under pressure. like every other personal trait, ethical character needs training and it may be different depending on each individual. some people have stronger wills and more personal abilities, and are more self-confident. however, ethical agent must overcome opposing factors, resis t pleasures, and cope with fatigue (44). ethical character is created though practice, and changing it into habit facilitates the occurrence of ethical behavior. our ancestors also considered the existence of a disposition and stable character to be important in ethics, and did not think impromptu behavior to be ethical. on the basis of common definition, ethics is those stable characteristics and features in one’s ego that motivate one to act spontaneously and without thinking. in jame-osaadat, naraghi defines character as a sensual disposition that issues actions without the need for thinking and attitude (45). ibnu miskawaih uses the word “state” to mean stable features in his tahzib al ak laq wa tahhir al a`raq (46). virtue ethics and virtuous character medical ethics was previously virtue-centered. the hippocratic oath requires the physician to follow virtue and promotes virtues like modesty, sobriety, patience, punctuality, and piety. this oath implies that an individual’s character is as important as h is behavior (47). at the present time, medical ethics is action-oriented and principle-oriented, and some doubt has recently been cast upon the effectiveness of principle-based methods. some scholars believe that medical ethics’ solutions are abstract and general, and are not responsive to the mental and emotional aspects of health care, and thus, virtue ethics is the suitable alternative solution (48, 49). the concept of virtue points to individuals’ character traits, and practical attitudes which include a type of motivational force for their behavior (50). in other words, virtue means people’s specific internalized practical modes leading them to immediately behave acceptably (51). in fact, virtue is a disposition which j med ethics hist med 10: 3, a pril, 2017 jmehm.tums.ac.ir mansoureh madani et al. page 8 of 12 helps us to behave appropriately regarding our feelings and actions and it occurs when we are psychologically and intellectually in equilibrium (52). virtue ethics is agent-centered and asks “how to be?” and is opposed to other normative ethics that are action-centered and ask “what to do?”. in virtuebased ethics, righteousness is more important than acting appropriately and the goodness and badness of the agent determines the actions’ correctness and wrongness (53). in fact, virtue is a desirable personal property, its purpose is acquiring virtues and a virtuous life, and it focuses on the individual’s motivation and character traits (54). in the framework of virtue ethics, the most important factor is the individual’s motivation and character, and motivation is a crucial factor for the behavior to be ethical. however, virtue ethics is criticized for being pure virtue ethics which is aristotle’s version of virtue ethics and is applicably weak and cannot tell us what we need to do. furthermore, this theory is ambiguous regarding the evaluation and appropriate justification of an ethical behavior (51). in other words, the question is how a model of ethical behavior can be created for the individual by the benevolent intentions of an ethical agent. therefore, virtue ethics needs to refer to other theories and be complemented by them. this means that virtue ethics can include concentration on duty, following ethical principles, and taking the benefit into account. like practice-centered ethics, in this approach, which is complementary and pluralis tic, the rules of ethical behavior are important, but, unlike practice-centered ethics, virtues are not instrumental and do not serve the laws (51). in this vein, duty-based ethics and virtue ethics that are based on the doer’s character can be considered as two complementary dimensions of ethics rather than competitive and opposing dimensions. accordingly, there is a good ethical trait which is the very willingness to act for each principle, and there is a principle which is indicative of the trait and defines the type of practice for each good ethical feature. in frankena’s words, “principles without traits are impotent” and “traits without principles are blind” (55). the next question that can be posed is whether a virtuous person’s behavior pattern is d uty-based or consequentialist. it seems that duty is prioritized over consequences of an action in the field of virtue ethics, while paying attention to outcome is one of the responsibilities of each person. duty -based ethics is a more perfect stage of consequentialism regarding kohlberg’s stages of moral development theory (35). another feature of virtue ethics is particularism which is highly consistent with medical ethics and avoiding the use of predefined principles. bioethics specialists believe that s olving medical problems based on case-specific theories is more harmonious with conventional moral thinking than decisions based on ethical theories, although particularism is highly criticized for relativity and it is not accepted in the field of ethics philosophy. as a result of this, the appropriateness of using general ethics rules to deal with physicians’ ethical problems has been questioned (56) and resulted in an approach named casuistry ethics which is a modified form of particularism (57) and does not completely deny ethical principles (58). there is not a consensus on the extent to which virtue ethics can be regarded as casuistry ethics (59); however, virtue ethics is more consistent with the feature that medical ethics requires to focus on details and specific cases. another group of particularistic ethicists support care ethics and believe that, in the field of medical ethics, it is necessary to follow the approach which is based on care ethics since there is a strong relationship between medicine and caring (60). the theory of care ethics that was presented by carol gilligan for the first time is one of the new versions of virtue ethics (61). it is based on love, connection, and care for judgment and dealing with ethical issues in comparison to the dominant masculine approach in ethics which is rational and based on concepts such as justice, autonomy, and rights (61, 62). teaching virtue and creating ethical character there are various challenges in the field of medicine regarding the issue of teaching virtue ethics and this can result in the viewpoint that the goal of teaching medical ethics cannot be the training of virtuous physicians when it is sufficient to make the physicians skilled enough to solve ethical problems. the ability to solve problems is as necessary as other medical skills, but it would be more appropriate to conduct studies to clarify how and to what extent teaching virtue is possible and how students’ ethical progress can be evaluated (63). the most important criticism on teaching virtue is that it is not related to medicine faculties, and it is the responsibility of the church, school, and family and etc. on the other hand, some scholars believe that the virtue that is intended to be taught to medical student is related to medicine (e.g., appropriate behavior with a particular patient and how a physician must be) and cannot be conducted by other organizations. moreover, teaching virtue is a de facto reality and medicine faculties will teach medical character and personality whether such teaching is intended to be provided or not and whether it is virtuous or vicious. each student will select a teacher as his/her role model, and the best method for learning virtuous behavior is having a model. therefore, it is necessary to find a way for altering the behavior of the medical model towards virtuous behavior (64). another criticism is related to the fact that we do not have a method for evaluating teaching virtue. how can the success of teaching be understood when the goal of teaching is having good intention, changing character, or even doing the right thing when other people are absent? pellegrino and thomasma believe j med ethics hist med 10: 3, a pril, 2017 jmehm.tums.ac.ir mansoureh madani et al. page 9 of 12 that the students will be taught virtues or vices, regardless of whether they are measurable, during their training of basic sciences and clinical medicine. there are other skills that cannot be easily measured. even the measurement of skills that we consider to be measurable cannot be entirely relied upon. therefore, teaching virtue is unavoidable for this reason, and methods must be sought for evaluating and promoting it (64). 3. attitude and change of attitude attitude is one of the internal factors that have been attended to in the process of change of theory into practice. in sum, attitude can be regarded as the individual’s conceptual and emotional positioning towards an issue (65). it has always been considered that accepted information is changed into attitude and eventually leads to practice. this idea has many opponents and it can only be said that attitude, to some extent, plays a part in the development of a behavior (23). in order to be changed into practice, an attitude should be associated with specific features. as an example, stronger attitudes lead to action more frequently. each attitude consists of three cognitive, affective, and behavioral dimensions and, using various methods, can be intervened and changed by these dimensions (66). several studies with various approaches and methods have indicated that physicians’ attitudes can be changed and their behavior can be improved through different trainings in practical situations (67-69). for instance, critical changes in the education of residents and use of student-centered methods of teaching has changed their attitude towards patients infected with aids which, in turn, has led to the improvement of medical services provided for them (70). in summary, by directing instructions towards creating influential changes in a person’s attitude, more behavioral modifications can be witnessed. another factor that is closely related to attitude is faith. faith is accompanied by a sort of fondness, holiness, and transcendence of values and is followed by the desire to act. faith has extraordinary practical influences and its investigation in relation to religious groups is beneficial and even essential (71, 72). 4. appropriate application of law and administrative solutions law is an external factor that forces the individual into ethical behavior, and it can internalize the behavior in some conditions. law is an important supportive factor of behavior and can have an important role in actualization of ethics. it is even said that collective wisdom and sense of human responsibility cannot be trusted with administering justice and some degree of law enforcement will be required, especially for the relationships between two groups (73). moreover, law provides a suitable environment for ethical behavior and increases the cost of unethical behavior, in addition to decreasing the cost of ethical behavior. its other important effect is helping people to abandon their unethical habits and form other habits (50). one of the reasons of unethical behavior is an individual’s inability to control him/herself. disciplinary regulations that foster individuals’ self-control and self-regulation lead to the internalization of ethics through actualization (18). however, the intervention of law in the field of ethics needs more attention and delicacy. first, the exercise of power and use of legal sanctions without providing the necessary cultural b ackgrounds lead to the formation of extrinsic behavior. participation of the stakeholders in regulation of laws is the necessary requirement for individuals to obey them. it is necessary that the individual understands why laws exist and is convinced that the existence of these laws is essential for group life and beneficial to all (74). second, although strict laws control behavior very well, they make the behavior extrinsic. the clarification that psychology suggests is that human beings always try to jus tify and clarify their own behavior. if there is an excessive external force to change the behavior, the individual will relate his/her behavior change to that force and when the external power does not exist, he/she will not follow that behavior anymore. however, if these laws are not too strict, the individual will connect the behavior to his/her own desire, and therefore, when there is no external monitor, he/she will feel required to behave that way again (18). therefore, it is essential to clarify and justify individuals through appropriate training of laws and creating necessary cultural substructures. in this regard, they can even participate in making laws or be counseled, and the laws should not be strict to the extent possible. on the other hand, intrinsic motivation is converted into extrinsic motivation, and as a result, the behavior turns into its former state when the law is omitted or unable to act. during the process of teaching physicians, these points must be taken into consideration while making regulations and suggesting solutions. furthermore, the medical education system is an appropriate platform for creating the cultural infrastructure of medical regulations and its achievement is greatly influential in the internalization of the regulations of medical society. conclusion due to its importance, medicine needs members who follow its professional principles. these requirements are taught to the physicians during medical training courses, but most of them are not put into practice. to bridge this gap, the sense of following these essential principles can be created by both regulative monitoring and internalization within physicians. due to the fact that law cannot replace physicians’ internalized codes, internalizing these instructions must be considered as a part of medical j med ethics hist med 10: 3, a pril, 2017 jmehm.tums.ac.ir mansoureh madani et al. page 10 of 12 education. internalization is a complex issue to discuss and has been debated in psychology, sociology, and philosophy. the current study has tried to explain the factors effective on ethical internalization and suggest solutions for narrowing the gap between ethical theory and practice by pointing to the issue and stating its necessity. these solutions are mainly medical education -centered and are as follows: 1. controlling emotions by education 2. teaching virtue and creating ethical character 3. changing attitude by education 4. modifying legal and administrative solutions medical education authorities’ attention and acceptance of this issue and its application in curriculum design procedures will be a great step towards putting medical ethics into practice. however, given the structure of modern medicine, this task requires extensive efforts. therefore, more investigations are required 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[in persian] jmehm-7-22 journal of medical ethics and history of medicine continuing review of ethics in clinical trials: a surveillance study in iran amin mohamadi1, fariba asghari2*, arash rashidian3 1clinical research center, milad hospital, and students scientific research center, tehran university of medical sciences, tehran, iran; 2associate professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran; 3associate professor, department of health management and economics, school of public health, tehran university of medical sciences, tehran, iran. corresponding author: fariba asghari address: medical ethics and history of medicine research center, #23, shanzdah azar st., tehran, iran. email: fasghari@tums.ac.ir tel: 98 21 66 41 96 61 fax: 98 21 66 41 96 61 received: 29 jun 2014 accepted: 9 dec 2014 published: 28 dec 2014 j med ethics hist med, 2014, 7:22 © 2014 amin mohamadi et al.; licensee tehran univ. med. sci. abstract in recent years, notable measures have been taken to protect the rights of participants in biomedical research in iran. the present study examines possible trends in adherence to ethical codes regarding informed consent after the development of the national code of ethics in biomedical research (ncebr) and establishment of research ethics committees. in this retrospective study, 126 dissertations from tehran university of medical sciences were evaluated for adherence to ethical codes. these dissertations were all in clinical trial design and had been presented in the years 1999 and 2009, that is, precisely before and after the development of the ncebr. a checklist was developed to evaluate the ethical issues associated with informed consent. a single investigator retrieved and evaluated the consent forms from the dissertations. borderline cases were discussed with other investigators to reach a consensus decision. based on the checklist, the standardized ethical score (ses) was calculated for each consent form. the mean ses and the rate of consent form attachment were compared between the two years. in total, 70 dissertations had reported obtaining informed consent from study participants, whereas consent forms were attached in only 22 dissertations (17.50%). the percentage of dissertations with the consent form attached increased over time from 12.2% in 1999 to 20.8% in 2009 (p > 0.05), but the majority still did not include a consent form. moreover, the mean ses of consent forms was significantly higher in 1999 (0.746) than in 2009 (0.428), highlighting the need for more training of researchers and improved surveillance by the ethics committees. a great amount of effort is still needed to make the consent process more ethical, especially for dissertations as a less visible part of academic research. as for students, more systematic training focused on research ethics should be implemented prior to thesis submission. keywords: informed consent, codes of ethics, clinical trial, academic dissertations, iran mailto:fasghari@tums.ac.ir j med ethics hist med 7:22 dec, 2014 jmehm.tums.ac.ir amin mohamadi et al. page 2 of 7 (page number not for citation purposes) introduction medical research involving human subjects has the potential to improve health care and the quality of life for everyone. the study participants, however, may be exposed to a certain degree of risk, and therefore it is the duty of researchers to protect their rights. furthermore, adherence to ethical codes would safeguard the participants’ rights (1-3). one of the most basic rights of study participants is autonomy. since the 1947 nuremberg code of ethics in support of human subjects in medical studies, all published guidelines including the declaration of helsinki and the iranian national code of ethics in biomedical research (ncebr) have highlighted the right of autonomy (1-3). one of the most important safeguards protecting participants’ autonomy in biomedical research is the requirement that all researchers obtain voluntary and informed consent from study subjects. with certain exceptions, investigators should obtain a written consent that is signed by the study participants and/or their proxy. in the declaration of helsinki, there are seven paragraphs on the conditions and requirements for obtaining consent. similarly, in the ncebr, 15 paragraphs are dedicated to the particulars of obtaining research participants’ consent (2, 3). although consent form is required in all human subject experimentations in order to respect participants’ autonomy, obtaining this form without meeting the specific requirements of valid consent gives no assurance of an ethical study. informed consent requires that patients be given the necessary information (4). however, there is indication that consent forms are not comprehensible for many research participants (5-7). in a prospective study, it was observed that only 20% of the research participants who reviewed consent documents on a physician-patient visit could pass the consent form comprehension test (8). dissertations are more appropriate than articles in scientific journals for evaluating how researchers handle research ethics and how accurately they report ethical issues (9). unlike scientific journals that usually have ethical guidelines regarding requirements for approval, there are no concrete rules for ethical comments or considerations in dissertations after obtaining protocol approval from intuitional review boards (irb) (10). in dissertations, researchers have more freedom to report ethical issues comprehensively (11). there is currently not much research regarding ethical issues in dissertations, but existing studies indicate major ethical deficiencies (9, 11-14). a need assessment study in iran revealed that many medical students and general physicians ignored the importance of research ethics in medical ethics topics (15). according to international guidelines for research ethics, all clinical trials should be supervised by a physician adequately experienced in the related field of study (2). similarly, in iran the principle investigator of a clinical trial should be an accredited physician on the subject in order to obtain ethical approval. for academic research, students in clinical undergraduate or postgraduate programs can register a dissertation with a clinical trial design if the study is performed under the supervision of a clinical faculty member in the field of study. along with the recent growth in scientific productivity in iran, some important steps have been taken to protect the rights of participants in biomedical research (3, 16-17). however, no study has examined the content and quality of informed consent forms in iran to the best of our knowledge. in an early study covering research conducted before 1997 and prior to the development of the ncebr, investigators reviewed 51 clinical trial dissertations of the tehran university of medical sciences (tums). based on their findings, only one dissertation had reported obtaining informed consents from the participants (14), and none had included an informed consent form (14). the present study examines possible trends in adherence to ethical codes regarding informed consent after the development of the ncebr and establishment of research ethics committees. the results of this study could show how effective the establishment of research ethics committees in iranian medical schools has been. although national and international ethical guidelines encompass all types of research with human subjects, we chose clinical trials as the most sensitive type of study in terms of ethical issues. method in a retrospective cross-sectional study, we reviewed abstracts of all dissertations approved by three tums schools (medicine, pharmacy, and dentistry) in the years 1999 and 2009 to find studies with a clinical trial design. we chose these two years to assess any possible difference in adherence to ethical issues before and after the development of the ncebr in 2000. we reviewed the materials and methods sections of all the dissertations with a clinical trial design to find any claims of obtaining informed consent, and then examined the attached consent forms and information leaflets for research participants in the dissertations. a single investigator examined the forms using a checklist (table 2). borderline cases j med ethics hist med 7:22 dec, 2014 jmehm.tums.ac.ir amin mohamadi et al. page 3 of 7 (page number not for citation purposes) were discussed with other investigators to reach a consensus decision. we classified the dissertations into undergraduate or postgraduate categories if they were written for a clinical doctorate degree (md, pharm d and dds), or as postgraduate if they pertained to clinical residencies. additionally, the affiliated department of each dissertation was recorded, but no further information that could identify the authors of the dissertations was retained. our study protocol was approved by the tums research ethics committee. survey tool in this study, we consulted the ncebr and two editions of the declaration of helsinki (1996 and 2008) in order to extract 14 objective ethical criteria to assess informed consent forms. four criteria (table 2, indicators 11-14) were only applicable to dissertations written in 2009 since they were not addressed in former editions of the ethical guidelines. these four criteria were derived from the iranian ethical guidelines covering clinical trials in 2005, and the 2008 edition of declaration of helsinki. a checklist was prepared to review the informed consent forms based on these 14 criteria. finally, two experts reviewed the checklist for content validity. analysis we calculated an ethical score for each consent form where +1 score or 0 score was assigned for each indicator based on whether it was addressed in the consent form or not. the ethical score of each consent form was defined as the sum of these scores. for those indicators that were not relevant to all research studies, the missing data were taken into consideration by standardization of the score. the scores were standardized by dividing the ethical score of each form by the maximum possible score for each consent form. student's t-test was applied for comparison of the mean standardized ethical score (ses) between the years of our study as well as categories of the dissertations. we used one-way analysis of variances (anova) to compare the mean sess among the different schools of tums. in order to examine each criterion and the rate of reporting or attaching consent form we used pearson's chisquare test. results in the present study, a total of 126 dissertations were reviewed, of which 49 (38.9%) had been approved in 1999 and the rest in 2009. undergraduate dissertations comprised 54 (42.9%) of the dissertations, and the rest were written for a postgraduate degree (table 1). table 1categories of dissertations, rate of reporting informed consent and its attachment in the years 1999 and 2009 year of approval undergraduate n (%) postgraduate n (%) reported obtaining consent n (%)* attached consent form n (%) 1999 21 (42.9) 28 (57.1) 15 (30.6) 6 (12.2) 2009 33 (42.9) 44 (57.1) 55 (78.6) 16 (20.8) total 54 (42.9) 72 (57.1) 70 (55.5) 22 (17.4) * a statistically significant difference was observed between the two years a total of 70 dissertations had reported obtaining informed consent, while only 22 (17.50%) dissertations included a copy of their consent form. informed consent was reported in 27 (38.6%) undergraduate and 43 (61.4%) postgraduate dissertations (p > 0.05). of the 22 dissertations with attached consent forms, 16 forms (20.8%) were attached to 2009 dissertations and 6 others (12.2%) to 1999 dissertations (p > 0.05). moreover, a total of eight forms (36.4%) were found in the appendix section of undergraduate dissertations. no significant difference was observed in attachment of consent forms across the different categories of dissertations, and none of the reviewed dissertations had included a study information leaflet for their participants. figure 1 shows the distribution of dissertations and rate of reporting or attaching informed consent in the three schools in this study. we observed no significant difference among these schools either in reporting or in attaching informed consent. in 1999, the mean ses (± standard error of mean) of consent forms was 0.746 (± 0.061), which was significantly higher than 0.428 (± 0.043) in 2009 (p = 0.001). the mean ses of consent forms for undergraduate dissertations was 0.459 (± 0.072), which was less than that of postgraduate dissertations at 0.546 (± 0.061) (p > 0.05). there was no significant difference in claims of obtaining participants’ consent in dissertations between the two years. j med ethics hist med 7:22 dec, 2014 jmehm.tums.ac.ir amin mohamadi et al. page 4 of 7 (page number not for citation purposes) figure 1the distribution of dissertations with clinical trial design, reporting consent form or attaching it among three clinical schools of tums none of the reviewed consent forms met all 14 ethical criteria nor did they declare the source of study funding, investigators’ affiliation, or any possible competing interests. table 2 shows that of the ten indicators shared between 1999 and 2009, eight were observed more in 1999. interestingly, although 87% of the 2009 consent forms declared that participant information would be confidential, two dissertations had attached completed and signed consent forms that disclosed participants’ identities. with only one exception, none of the 2009-specific criteria were reported in consent forms. table 2 indicators in the two years of dissertation review indicator year 1999 n (%) year 2009 p value 1 comprehensible terms and avoidance of using technical terms 6 (100) 14 (87.5) > 0.999 2 direct disclosure that participants are enrolled in a research 6 (100) 15 (93.8) > 0.999 3 purpose of study 6 (100) 11 (68.8) 0.222 4 duration of study 5 (83.3) 7 (43.8) 0.162 5 description of study interventions and other options 3 (50) 5 (31.3) 0.624 6 anticipated benefits of study 4 (66.7) 3 (18.8) 0.054 7 potential risks of study 4 (66.7) 4 (25.0) 0.137 8 confidentiality of participants’ information and possible limitations 2 (33.3) 14 (87.5) 0.025 * 9 voluntariness of participation in study and the freedom to refuse it 6 (100) 12 (75) 0.541 10 possibility of allocation to trial or established group (wherever applicable) 2 (40) 5 (55.6) > 0.999 11 introducing a contact person or center in case of questions, problems or adverse events na 3 (18.3) na 12 investigators’ affiliation na 0 na 13 funding sources na 0 na 14 declaration of investigators’ conflicts of interest (or lack thereof) na 0 na * a statistically significant difference was observed between the two years na: not applicable j med ethics hist med 7:22 dec, 2014 jmehm.tums.ac.ir amin mohamadi et al. page 5 of 7 (page number not for citation purposes) discussion respect for the autonomy of medical research participants is one of the basic principles of medical ethics. in order to safeguard this right, all ethical guidelines for biomedical research include directives on obtaining informed consent, conditions that mandate obtaining written consent, and the various features of a consent form. in iran, numerous measures have been taken in recent years to safeguard the rights of medical research participants (18). these measures include the development of the ncebr by the iranian ministry of health and medical education in 2000, establishment of local ethics committees in medical schools, and compilation of specific national ethical guidelines for biomedical research, which also cover the ethical guidelines for clinical trials, in 2005 (3, 20). thus far, only one study has been conducted on the outcome of the above-mentioned measures (21). this study aimed to evaluate the effects of these measures on adherence to ethical guidelines pertaining to consent forms in clinical trial dissertations before and after the development of the ncebr and establishment of the university ethics committees (18). our findings indicate that during these years, obtaining informed consent in dissertations increased while self-reported adherence to ethical guidelines decreased. however, the quality of consent forms in terms of comprehensibility and disclosure did not improve. it seems that although the rate of obtaining informed consent has increased, the quality of the informed consent forms has not changed. this might be due to the fact that more students were aware of the requirement for informed consent after the development of the ncebr, but they were not adequately informed of the ethical guidelines. ideally, the ses score for each consent form should be one. a low ses in consent forms can indicate low quality and raise doubts concerning students’ competence in preparing the forms or even their ability to handle ethical issues as independent researchers. ethics committees failed to address the issue of low ses scores, an oversight that might be due to lack of knowledge among ethics committee members. four ethical criteria derived from the iranian ethical guidelines for clinical trials (2005) and the 2008 edition of the declaration of helsinki pertaining to the year 2009 were addressed at the lowest rate in consent forms. these criteria were developed using the 2008 version of the declaration of helsinki and were not mentioned in the ncebr (18). when the ncebr was prepared in 2000, the earlier versions of the declaration of helsinki did not address such ethical issues, and when the declaration of helsinki was revised in the following years, no amendment was made to the ncebr. nevertheless, the addition of these four criteria cannot account for the lower ses of consent forms in 2009. firstly, this score is a standardized score, and secondly, the declaration of helsinki states that investigators of research studies involving human subjects must consider international ethical, legal, and regulatory norms as well as those of their own country. deficiencies in ethical reporting, documentation, and conduct have been noted in other research focusing on students’ dissertations or theses (9 13). in a study in turkey, only 28% of the nurses’ dissertations, which had been approved before 1998, documented obtaining consent from research participants (13). an incremental trend of improvement is observed in the reporting of informed consent in dissertations during the past two decades. for example, the rate of reporting informed consent in swedish nurses’ dissertations was as low as 0% in 1987 and 30% in 1997, but increased to 85.9% in 2007 (9). a similar trend was also reported in cameron where none of the reviewed dissertations reported obtaining informed consents in the years before 1990 but the reporting rate increased to 48% in 2010 (11). in iran, one study showed that only 2% of the dissertations approved between 1994 and 1997 included consent from research participants (14). in the present study, we also noticed an improvement from 30.6% of the dissertations with clinical trial design in 1999 to 78.6% in 2009. one of the limitations of this study was that only one stage of the process of obtaining informed consent from research participants was evaluated, and we could not examine the other stages such as physician-patient communication (8). it is also possible that the informed consent attached to the dissertations differed from what was obtained from research participants. in a cohort study, it was stated that authors might report their study data differently than what was submitted to the irbs (22). it should be noted, however, that the assessment of clinical trial protocols submitted to the irbs was outside the scope of this study. another limitation of the present study was that it was performed only in one medical school, and therefore the results may not be generalized. on the other hand, the selected university is the largest university in the country and boasts a high rate of scientific productivity (19). we tried to review dissertations from all clinical schools of this university to find all possible clinical trial dissertations. it can be concluded that deficiencies in ethical considerations in the dissertations of this university are a possible red flag for other universities of medical sciences. some of the criteria under investigation were subjective. for instance, an evidence-based judgment is required to evaluate the benefits or hazards of a study. to simplify this judgment, j med ethics hist med 7:22 dec, 2014 jmehm.tums.ac.ir amin mohamadi et al. page 6 of 7 (page number not for citation purposes) however, when the study investigator included at least one relevant hazard and benefit of the study in consent forms, we assumed that the criterion was addressed. this may have resulted in an overestimation of adherence, although a major overestimation is unlikely since few investigators addressed the benefits or hazards of their studies. informed consent forms are legal documents that testify to the consent of biomedical research participants, but it has been established that the presence of such forms does not guarantee respect for participants’ autonomy (23). to prove this point, there is indication that consent forms are not comprehensible for the majority of participants in clinical trials (4 8). unreliable consent forms may be indicative of shortcomings in the process. as a result, we may conclude that much effort is still needed to make the process of obtaining consent more ethical, especially for dissertations as a less visible part of academic research. students should receive more systematic training focused on research ethics prior to thesis submission, and only those who pass a research ethics course should be permitted to submit a research protocol to the irb for their thesis. nevertheless, there is need for further research on the process of obtaining informed consent to offer a more accurate understanding of how this process is addressed in student research and how much attention is being paid by irbs in reviewing dissertation protocols. acknowledgment this article was extracted from the thesis prepared by amin mohamadi to fulfill the requirements for earning a doctor of medicine and master of public health degree. the authors would like to express their appreciation to the department of medical ethics, school of medicine, department of health management and economics, and school of public health of tehran university of medical sciences. this research project was supported by a grant from deputy of research in tehran university of medical sciences. references 1. u.s. department of health & human services. the nuremberg code 2014. http://www.hhs.gov/ohrp/archive/nurcode.html (accessed in 2014) 2. the world medical association. wma declaration of helsinki ethical principles for medical research involving human subjects [internet]. 2014. http://www.wma.net/en/30publications/10policies/b3/ (accessed in 2014) 3. larijani b, zahedi f. contemporary medical ethics: an overview from iran. dev world bioeth 2008; 8(3): 192-6. 4. schmidt t, salo d, hughes j, et al. confronting the ethical challenges to informed consent in emergency medicine research. acad emerg med 2004; 11(10): 1082-9. 5. ménoni v, lucas n, leforestier j, et al. the readability of information and consent forms in clinical research in france. plos one 2010; 5(5): e10576. 6. mader t, playe s. emergency medicine research consent form readability assessment. ann emerg med 1997; 29(4): 534-9. 7. menoni v, lucas n, leforestier jf, et al. readability of the written study information in pediatric research in france. plos one 2011; 6(4): e18484. 8. fitzgerald d, marotte c, verdier r, johnson w, pape j. comprehension during informed 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[in persian] 20. aramesh k. a brief history of biomedical research ethics in iran: conflict of paradigms. dev world bioeth 2014; epub http://www.hhs.gov/ohrp/archive/nurcode.html http://www.wma.net/en/30publications/10policies/b3/ j med ethics hist med 7:22 dec, 2014 jmehm.tums.ac.ir amin mohamadi et al. page 7 of 7 (page number not for citation purposes) 2014/04/12. 21. fakour y, eftekhari mb, haghighi z, mehr nk, hejazi f. situation analysis of local ethical committees in medical sciences in iran. j res med sci 2011; 16(3): 310-5. 22. redmond s, von elm e, blumle a, gengler m, gsponer t, egger m. cohort study of trials submitted to ethics committee identified discrepant reporting of outcomes in publications. j clin epidemiol 2013; 66(12): 1367-75. 23. emanuel ej, wendler d, grady c. what makes clinical research ethical? jama 2000; 283(20): 2701-11. jmehm-7-12 journal of medical ethics and history of medicine the association between work ethics and attitudes towards organizational changes among the administrative, financial and support employees of general teaching hospitals ramin ravangard1, zahra sajjadnia2, abdosaleh jafari3, najme shahsavan4, jamshid bahmaie5, mohammadkarim bahadori6* 1assistant professor, department of health services management, school of management and medical information sciences, shiraz university of medical sciences, shiraz, iran; 2assistant professor, department of statistics, college of sciences, shiraz university, shiraz, iran; 3msc, department of health services management, school of management and medical information sciences, shiraz university of medical sciences, shiraz, iran; 4bsc, department of health services management, school of management and medical information sciences, shiraz university of medical sciences, shiraz, iran; 5msc student in health services management, department of health services management, school of management and medical information sciences, shiraz university of medical sciences, shiraz, iran; 6assistant professor, health management research center, baqiyatallah university of medical sciences, tehran, iran. corresponding author: mohammadkarim bahadori address: health management research center, baqiyatallah university of medical sciences, mollasadra street, tehran, iran. email: bahadorihealth@gmail.com tel: 98.2182482417 fax: 98.2188057022 received: 04 feb 2014 accepted: 20 jul 2014 published: 28 jul 2014 j med ethics hist med, 2014, 7:12 © 2014 ramin ravangard et al.; licensee tehran univ. med. sci. abstract in order to achieve success in today’s competitive world, organizations should adapt to environmental changes. on the other hand, managers should have a set of values and ethical guidelines for their administrative and organizational functions. this study aimed to investigate the association between work ethics and attitudes towards organizational changes among the administrative, financial and support employees of general teaching hospitals affiliated to shiraz university of medical sciences. this was an applied, cross-sectional and descriptive-analytic study conducted in 2013. a sample of 124 employees was selected using stratified sampling proportional to size and simple random sampling methods. data were collected using 2 questionnaires measuring the dimensions of employees' work ethics (four dimensions) and attitudes towards organizational changes (three dimensions). the collected data were analyzed using spss 18.0 and statistical tests, including anova, independent samples t-test, and pearson’s correlation coefficient. a p < 0.05 was considered statistically significant. the maximum and minimum score of work ethic dimensions were related to being cooperative (4.60 ± 0.38) and dependable (4.29 ± 0.39) respectively. on the other hand, the maximum and minimum score of attitudes towards the various dimensions of organizational changes were related to the behavioral (3.83 ± 0.70) and the affective (3.55 ± 0.88) dimensions respectively. furthermore, there was a significant relationship between the work ethics and education levels of the employees in this study (p = 0.003). also, among work s dimensions, only being considerate had a significant association with attitudes towards organizational changes (p = 0.014) and their cognitive dimension (p = 0.005). to improve employees' work ethics and attitudes towards organizational changes, the following suggestions can be offered: training hospitals managers in participative management style and its application, as well as the importance of meeting the employees' needs and expectations based on their characteristics; familiarizing employees with the islamic work ethic; educating employees on the importance of being considerate towards their colleagues and subordinates in the workplace, and reinforcing this desirable quality; and finally, clarifying the need for changes in the organization for all employees. keywords: work ethics, attitudes, organizational changes, general teaching hospitals, financial employees, support employees mailto:bahadorihealth@gmail.com j med ethics hist med 7:12 jul, 2014 jmehm.tums.ac.ir ramin ravangard et al. page 2 of 9 (page number not for citation purposes) introduction organizations work in a highly variable and dynamic environment and are constantly exposed to changes in their internal conditions or external environment. "change" has been interpreted as a response to some of the most important behaviors or opportunities originating from outside the organization (1). many organizations have come to believe that they should adapt themselves to a reality called "change" in order to achieve success in today's competitive world (2). in contrast to factors that strive to maintain the current situation and prevent changes from happening, there are factors that drive them, including dissatisfaction with the current state of affairs, the quest for new opportunities, and so on (3-5). human resources are the core of every organization, which makes human factors crucial to the success of organizational changes (6, 7). therefore, changes can be effective only if the beliefs and attitudes of employees are challenged because employees are the main components of an organization and the study of their psychological characteristics, interactions, motivations and attitudes can be of great importance (8). the results of several studies have shown that some factors facilitating the acceptance and implementation of changes within organizations are as follows: psychological feelings of possession and ownership (9, 10), belief in one’s own abilities as well as openness of top management (11, 12), organizational commitment (13-15), trust in management (16, 17), appropriate rewards and adequate encouragement (18-22), involvement of employees in the planning and implementation of organizational changes (23), application of transformational leadership style (24-26), senior managers' support of changes (2730), employee empowerment (31), and so on. the results of some other studies have also shown that among the reasons for employees' resistance to organizational changes are uncertainty and fear of losing professional and personal power, dissatisfaction with lack of participation in planning the changes, and the decision to implement them in a short period (32, 33). furthermore, some researchers believe that organizational commitment, leadership styles, employees' interpretation of the actual events and their attitudes towards the process can affect their outlook (13, 34, 35). on the other hand, in addition to institutional and legal standards, managers need a set of values and ethical guidelines to perform their administrative and executive functions and facilitate adaptation to organizational changes (36). ethics have an effective role in the prevention of corruption and tyranny in the society and workplace, and can help identify opportunities, threats, strengths and weaknesses (37). ethical climate is one aspect of organizational climate that represents an institution’s character and, by extension, its ethics (38). work ethics are a set of cultural norms that provide the positive foundations for doing a right and good job in the community, and are based on the belief that the work itself has an intrinsic value (39, 40). according to miller et al., work ethics comprise attitudes and beliefs concerning work behavior and are multidimensional, secular, and consists of motivational constructs reflected in behavior; moreover, they are associated with work and workrelated activities, can be learned, and refers to attitudes and beliefs, and not necessarily behavior (41). an organization’s work ethics can be investigated through its employees' perceptions of the organizational climate, their decisions when faced with ethical issues, and the level of their participation in solving those issues (42). social participation, social justice, cultural unity and cohesion in society are correlated with adherence to work ethics in organizations (43). moreover, employees who are optimistic about the organization's values follow work ethics more than those who are not (39). additionally, employees are more likely to have stronger work ethics if they are more hopeful about the future of their country or organization, have more freedom in their work, and are given responsibilities commensurate with their organizational positions; likewise, closer adherence to traditional social values and optimism about the social environment seem to be other factors associated with sturdy work ethics (44). when an organization is ethically weak, it is faced with higher operation costs. furthermore, decisions can only be effective if there is adequate knowledge and understanding of ethics in the organization (18). the results of some studies have indicated that work ethics is also significantly related to various features of organizational administration and management, including job satisfaction, work stress, organizational commitment, organizational justice, and participative leadership style (17, 4550). moreover, some studies have shown that there is a significant relationship between work ethics and attitudes towards organizational changes (5153), so that when employees have stronger work ethics, they will be more committed and make more attempts to develop the institution and contribute to organizational changes rather than resist them (8). considering the importance of adapting to the rapid changes in the present world and the need for studying work ethics, the association between employees' work ethics and their attitudes towards organizational changes has apparently not been adequately researched, especially in the health care j med ethics hist med 7:12 jul, 2014 jmehm.tums.ac.ir ramin ravangard et al. page 3 of 9 (page number not for citation purposes) industry. the present study aimed to investigate this association among the administrative, financial and support employees of general teaching hospitals affiliated to shiraz university of medical sciences in 2013. methods this was an applied, cross-sectional and descriptive-analytic study conducted in 2013. the study population consisted of administrative, financial and support employees of general teaching hospitals affiliated to shiraz university of medical sciences. a sample of 114 employees was considered appropriate based on the findings of the fallahzade abarghooie study (52), assuming α = 0.05, β = 0.2 and r = 0.26. in order to increase the accuracy of this study, however, and in view of the potential loss of data, 124 employees were finally selected. this sample was selected using stratified sampling proportional to size. for this purpose, each of the two hospitals under study was considered a stratum in which the required sample was selected out of the total number of the employees through simple random sampling using a random numbers table. data were collected using 2 questionnaires measuring the dimensions of employees' work ethics and attitudes towards organizational changes. the work ethics questionnaire was developed by hill and petty in 1995 (54) and translated and modified by fallahzade abarghooie in 2009 (52). it contained 46 items to assess the employees' work ethics dimensions, including 13 items on being dependable, that is, reliability and the ability to fulfill the minimum expectations for satisfactory job performance; 12 items on being ambitious, which pertains to initiative; 14 items on being considerate, indicating interpersonal skills and personal characteristics that facilitate good working relationships with colleagues; and 7 items on being cooperative, or the unconditional willingness to work with others to meet the job requirements. fallahzade abarghooie had confirmed the validity and reliability of this questionnaire in her study by consulting the opinions of experts and using cronbach's alpha coefficient (α = 0.83). a fivepoint likert scale was used to assess employees' work ethics, in which 5 referred to “always” and 1 to “never”. the questionnaire on attitudes towards organizational changes was developed by dunham et al (55) and translated and modified by fallahzade abarghooie in 2009 (52). it consisted of 18 items to measure the employees' attitudes towards organizational changes, including 6 items on the cognitive dimension, that is, the employees’ opinions about the advantages, disadvantages, necessity and usefulness of organizational changes; 6 items on the affective dimension, referring to the employees' feelings towards organizational changes; and 6 items on the behavioral dimension, indicating actions which would be taken in the future, or had been taken for or against organizational changes. fallahzade abarghooie had confirmed the validity and reliability of this questionnaire in his study through consulting the opinions of experts and using cronbach's alpha coefficient (α = 0.82). a five-point likert scale was used to measure the employees' attitudes towards organizational changes, in which 5 referred to “strongly agree” and 1 to “strongly disagree”. furthermore, respondents were asked about their demographic characteristics such as sex, age, education level, job experience, and service unit. an approval for conducting this study was obtained from the ethical committee of shiraz university of medical sciences. moreover, informed consent was obtained from all employees participating in this study and all of them were assured of the confidentiality of their responses. spss 18.0 and some statistical tests including anova, independent samples t-test, as well as pearson’s correlation coefficient were used to analyze the collected data. a p < 0.05 was considered statistically significant. results the results showed that most studied employees were male (n = 87, 70.2%), in the 30 40 year old age group (n = 56, 45.2%), had academic degrees (n = 57, 46%), had less than 10 years job experience (n = 68, 52.4%), and were working in the support unit (n = 76, 61.3%) (table 1). the mean score of the employees' work ethics was 4.41 ± 0.34 and the maximum and minimum score of their dimensions were related to being cooperative (4.60 ± 0.38) and being dependable (4.29 ± 0.39) respectively. moreover, the mean score of their attitudes towards organizational changes was 3.72 ± 0.60 and the maximum and minimum score of their dimensions were related to the behavioral dimension (3.83 ± 0.70) and the affective dimension (3.55 ± 0.88) respectively (table 2). the results showed that there was no significant relationship between the employees' work ethics and attitudes towards organizational changes, and sex, age, job experience, and service unit (p > 0.05). however, there was an indirect association between their work ethics and education level (p = 0.003), that is, an increase in the education level resulted in a decrease in work ethics. the pearson’s correlation test results showed that only being considerate had a significant association with attitudes towards organizational changes (p = 0.014) and their cognitive dimension (p = 0.005) (table 3). j med ethics hist med 7:12 jul, 2014 jmehm.tums.ac.ir ramin ravangard et al. page 4 of 9 (page number not for citation purposes) table 1. demographic characteristics of the employees in this study variables frequency (%) sex male 87 (70.2) female 37 (29.8) total 124 (100) age < 30 48 (38.7) 30 – 40 56 (45.2) > 40 20 (16.1) total 124 (100) education level less than high school diploma 21 (16.9) diploma 49 (37.1) academic degrees 57 (46) total 124 (100) job experience < 10 68 (52.4) 10 – 20 45 (38.7) > 20 11 (8.9) total 124 (100) service unit administrative 36 (29) financial 12 (9.7) support 76 (61.3) total 124 (100) table 2. the mean and sd of work ethics, attitudes towards organizational changes and their dimensions in the employees in this study variables dimensions mean ± sd work ethics dependable 4.29 ± 0.39 ambitious 4.32 ± 0.46 considerate 4.51 ± 0.36 cooperative 4.60 ± 0.38 total 4.41 ± 0.34 attitudes towards organizational changes affective 3.55 ± 0.88 cognitive 3.77 ± 0.67 behavioral 3.83 ± 0.70 total 3.72 ± 0.60 table 3. the correlation between work ethics, attitudes towards organizational changes and their dimensions in the employees in this study dimensions of attitudes towards organizational changes dimensions of work ethics affective cognitive behavioral attitudes towards organizational changes (total) dependable r = 0.059 p = 0.516 r = 0.110 p = 0.225 r = 0.058 p = 0.520 r = 0.092 p = 0.307 ambitious r = -0.010 p = 0.910 r = 0.007 p = 0.938 r = -0.100 p = 0.267 r = -0.041 p = 0.647 considerate r = 0.121 p = 0.182 r = 0.253 p = 0.005 r = 0.162 p = 0.079 r = 0.220 p = 0.014 cooperative r = -0.013 p = 0.884 r = 0.102 p = 0.258 r = 0.049 p = 0.588 r = 0.050 p = 0.576 work ethics (total) r = 0.053 p = 0.538 r = 0.139 p = 0.123 r = 0.048 p = 0.597 r = 0.096 p = 0.286 j med ethics hist med 7:12 jul, 2014 jmehm.tums.ac.ir ramin ravangard et al. page 5 of 9 (page number not for citation purposes) discussion the present study aimed to investigate the association between work ethics and attitudes towards organizational changes among the administrative, financial and support employees of general teaching hospitals affiliated to shiraz university of medical sciences in 2013. the maximum and minimum score of work ethics dimensions were related to being cooperative and being dependable respectively. the maximum and minimum score of attitudes towards the various dimensions of organizational changes were related to the behavioral dimension and the affective dimension respectively. there was also a significant relationship between the work ethics and education level of the employees. on the other hand, among work ethics dimensions, only being considerate had a significant association with attitudes towards organizational changes and their cognitive dimension. the results of the present study showed that among the work ethics dimensions, being dependable has the lowest mean score. this may be due to the mismatch between the employees' fields of study and education levels and their occupations and salaries. another reason may be lack of variety and repetitive assignments, lack of employees' proper understanding of the job and not receiving appropriate feedback about their work. all this can result in a decrease in employees’ self-confidence, job satisfaction, involvement, and motivation to perform their tasks well. on the other hand, the maximum score of work ethics dimensions was related to being cooperative. it should be noted that employees gradually become familiar with their jobs and workplaces and get more accustomed to them, and as a result, feel accountable for all issues related to their jobs. they try to make comments and suggestions about problems in their work groups, and also consider their colleagues' suggestions and comments in order to perform their duties well. accomplishing predetermined tasks collaboratively and in partnership with other colleagues can decrease individuals' workloads and responsibilities. nowadays, jobs have become more complex and specialized, and therefore cooperation within organizations is absolutely necessary, as the only way to do things more efficiently is to foster collaboration and participation. the results of moidfar's study showed that the maximum and minimum mean scores among work ethics dimensions are related to being cooperative and being dependable respectively (39), which confirms the current study results. in the study by fallahzade abarghooie, however, the highest mean score among work ethics dimensions was related to being considerate (52), which is inconsistent with the results of the present study. in the present study, the affective dimension of attitudes towards organizational changes had the lowest mean score. this may be due to the fact that when employees get accustomed to their jobs, they will not accept changes easily. in this case, most people feel like they do not have the capacity to deal with new organizational changes and cannot adapt. it is part of human nature to initially oppose new ideas when they are used to doing things in a certain way. lack of security and fear of losing their positions are the main reasons why people dislike change and feel that it will lead to inability and failure to do the job (33, 56). the results of the present study also showed that the behavioral dimension of attitudes towards organizational changes has the maximum mean score. this is probably due to the fact that individuals feel responsible for their work, and they also need to maintain their positions in the organization on account of various economic, social and psychological reasons. therefore, they inevitably adapt to organizational changes and respond to them appropriately. fallahzade abarghooie demonstrated through her study that the cognitive dimension of attitudes towards organizational changes has the maximum mean score (52), which does not confirm the results of the present study. rahmanseresht and moghadam's study showed that the managers' interpretation of actual events and their attitudes towards the process of organizational changes affect their decisions to accept or reject these changes (35). furthermore, the results of the present study showed that there is an indirect relationship between education and work ethics, that is, an increase in the employees’ education level leads to a decrease in the mean of work ethics. the reason for this can be that employees with higher education have more expectations of the job, such as benefits and salaries. when these expectations cannot be met, especially in the public sector, employees feel discouraged, which may result in a decrease in their dependability and ambition. on the other hand, employees with lower education levels usually have fewer job opportunities (57-59), and this can cause them to try hard to perform their tasks with more dependability and ambition in order to maintain their organizational positions. furthermore, higher education and achievement of better positions is usually detrimental to friendships and intimate relationships with colleagues and subordinates. the reduction in employees' relationships and communication can lead to a decrease in offering opinions and suggestions, using others' comments and ideas, and getting involved in work teams. the results of the studies by pieri (48), moidfar (39), ter bogt et al. (60), kavian (61), yousef (45), hill (62), and abboushi (63) confirm the findings of the present study as well. moreover, the present study demonstrated that attitudes towards organizational changes do not j med ethics hist med 7:12 jul, 2014 jmehm.tums.ac.ir ramin ravangard et al. page 6 of 9 (page number not for citation purposes) have any significant association with employees' education level and job experience. the results of sajadikhah's study (64) are also consistent with this finding, although the studies of calhoun et al. (32) and grimm and smith (65) do not confirm these results. the results of the current study showed that the age and job experience of the employees do not have any significant association with work ethics. the results of tavasoli and najar nahavandi's study (40) also confirm this finding. however, the results of the studies of jadari (66), pieri (48), kavian (61), yousef (45), and abboushi's (63) are not consistent with the results of the present study. there was no significant relationship between employees' age and job experience and their attitudes towards organizational changes in the present study. the results of the studies by sajadikhah (64) and karimian et al. (67) are consistent with this finding, although calhoun et al. (32) have achieved different results. in addition, the results of the present study showed that there is no significant association between work ethics and attitudes towards organizational changes. on the contrary, fallahzade abarghooie (52), nazarpouri (68), gharamaleki (69), rashidi (53), and yousef (51) found a significant relationship between these two. in general, the discrepancies between the present study and the other studies mentioned above can be due to the differences in the settings, samples and target populations. furthermore, the results of the current study indicated that there is a significant relationship between attitudes towards organizational changes and their cognitive dimension and being considerate. the reason may be that employees who have good relations with others usually have positive character traits that help them accept others' ideas and suggestions and prefer others' needs and wants over their own, and are overall better at collaboration and cooperation with others, etc. therefore, such employees are more inclined to adapt to the changes in their organization and environment as they do not believe that environmental and organizational changes have destructive and counterproductive effects on their social life, and consequently can maintain a good interaction with others. results of the studies by week et al. (70), schwepker jr. (71), yousef (45), and yousef (51) also confirm the current study results in this regard. the limitations of the present study were the use of a single method (i.e. a questionnaire) for data collection, as well as its cross-sectional design, as it is difficult to determine causal relationships in a cross-sectional study. in conclusion, the current study results revealed that there is a significant relationship between work ethics and employees' education level. on the other hand, attitudes towards organizational changes and their cognitive dimension had a significant association with being considerate. to improve the employees' work ethics (especially their consideration for their colleagues) and attitudes towards organizational changes (their cognition of the necessity and usefulness of organizational changes in particular), the following suggestions can be offered: training hospital managers in participative management style and its application can increase the possibility of employees' involvement in organizational decision-making, whereby the employees' commitment to implement those decisions will be increased and their reaction to the changes will be positive. likewise, orientation and training courses should be provided for employees in order to familiarize them with the islamic work ethics and demonstrate the importance of being considerate towards their colleagues and subordinates in the workplace, and attempts should be made to strengthen this desirable quality in them. furthermore, briefings and training courses can be offered in hospitals to educate employees and familiarize them with the concept of organizational changes and clarify the necessity of these changes for employees. thus, employees’ attitudes towards these changes will be positive and they will show less resistance. other measures that can be suggested to improve work ethics in organizations are raising hospital managers' familiarity with employees' characteristics, needs and expectations, especially those of employees with higher education levels, and providing appropriate rewards based on these features. finally, it is recommended to conduct further research on other types of hospitals and employees, even hospital managers and administrators, and compare the results with the findings of the present study. acknowledgment the researchers would like to thank the participating hospital administrators and employees for their kind cooperation with the researchers in collecting and analyzing data. conflict of interest the authors declare no conflict of interest. j med ethics hist med 7:12 jul, 2014 jmehm.tums.ac.ir ramin ravangard et al. page 7 of 9 (page number not for citation purposes) references 1. gilgeous v. operations and the management of change, first ed. london: pitman publishing; 1997. 2. karp t. unpacking the mysteries of change: mental modeling. j change manag 2005; 5(1): 87-96. 3. posner bz, kouzes jm. development and validation of the leadership practices inventory. educ psychol meas 1988; 48(2): 483-96. 4. waddell d, sohal as. resistance: a constructive tool for change management. manage decis 1998; 36(8): 543-8. 5. santos v, garcia t. the complexity of the organizational renewal decision: the management role. leadersh organ dev j 2007; 28(4): 336-55. 6. van schoor a. learning to overcome resistance to change in higher education: the role of transformational intelligence in the process. http://www.herdsa.org.au/wp-content/uploads/conference/2003/pdf/herdsa16.pdf (accessed in 2013) 7. seeley c. change management: a base for knowledge sharing. knowledge manag rev 2000; 3(4): 249. 8. juechter wm, fisher c, alford rj. five conditions for high-performance cultures. train develop 1998; 52(5): 63-8. 9. dirks kt, cummings ll, pierce jl. psychological ownership in organizations: conditions under which individuals promote and resist change. in: woodman rw, pasmore wa, eds. research in organization change and development. greenwich: jai press; 1996. 10. pierce jl, kostova t, dirks kt. toward a theory of psychological ownership in organizations. acad manage rev 2001; 26(2): 298-310. 11. morrison ew, phelps cc. taking charge at work: extra-role efforts to initiate workplace change. acad manage j 1999; 42(4): 403-19. 12. nilakant v, ramnarayan s. change management: altering mindsets in a global context. india: sage publications inc; 2006. 13. iverson rd. employee acceptance of organizational change: the role of organizational commitment. int j hum res manag 1996; 7(1): 122-49. 14. lau c-m, woodman rw. understanding organizational change: a schematic perspective. acad manag j 1995; 38(2): 537-54. 15. vakola m, nikolaou i. attitudes towards organizational change: what is the role of employees’ stress and commitment? 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[in persian] 70. weeks a, terry l, loe c, kirk w. the effect of the perceived ethical climate on the search for sales forces excellence. j personal sell sales manage 2004; 24(3): 199-214. 71. schwepker jr ch. ethical climate's relationship to job satisfaction, organizational commitment, and turnover intention in the salesforce. j bus res 2001; 54(1): 39-52. http://www.oecd.org/dataoecd/8/26/34846890.pdf http://rhill.coe.uga.edu/workethic/hist.htm j med ethics hist med 7:12 jul, 2014 jmehm.tums.ac.ir ramin ravangard et al. page 9 of 9 (page number not for citation purposes) journal of medical ethics and history of medicine original article sociopolitical development of the nursing profession in iran: a historical review afsaneh raiesifar 1 , mohammadreza firouzkouhi 2 , marjaneh fooladi 3 , soroor parvizy 4* 1 phd candidate in nursing, school of nursing and midwifery, tehran university of medical sciences, tehran, iran; 2 assistant professor, department of medical surgical nursing, faculty of nursing and midwifery, zabol university of medical sciences, zabol, iran; 3 professor, faculty of nursing, university of jordan, amman, jordan; 4 professor, department of paediatric nursing, faculty of nursing and midwifery, tehran university of medical sciences, tehran, iran; centre for educational research in medical sciences (cerms), iran university of medical sciences, tehran, iran. corresponding author: soroor parvizy address: faculty of nursing & midwifery, iran university of medical sciences, tehran, iran. email: s_parvizy@yahoo.com tel/fax: 98 21 88 88 28 86 received: 27 sep 2016 accepted: 16 oct 2016 published: 5 nov 2016 j med ethics hist med, 2016, 9:13 © 2016 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract significant sociopolitical changes in recent decades have not only influenced the nursing profession, but also the entire iranian healthcare system. this study describes the historical evolution of the nursing profession within a sociopolitical context. this historical review of unpublished and published literature endorsed personal accounts of historic events by 14 of the oldest nurses in iran chosen through purposive sampling method, as they shared their nursing experiences. individual recollections were collected through in-depth and semi-structured interviews and later analyzed through oral history analysis method. from the results, the 3 categories of the white revolution, the islamic revolution, and iran-iraq war and 8 subcategories emerged, where participants identified factors that fundamentally changed the iranian nursing profession. the nursing profession continues to develop and help revise policies to improve the healthcare system and quality of care. the findings of this study facilitate the better understanding of the influence of sociopolitical events on the nursing profession and guide the revision or development of new healthcare policies. keywords: historical research, iran-iraq war, islamic revolution, nursing history, white revolution mailto:s_parvizy@yahoo.com j med ethics hist med 9: 13 november, 2016 jmehm.tums.ac.ir afsaneh raiesifar et al. page 2 of 10 introduction historically, the nursing profession has been formed with complex ethical and social issues. nursing discipline established upon its’ known historic patterns, and developed based on new sciences, medical innovations, and social movements (1). over time, nursing has undergone considerable changes affecting the healthcare services and treatment modalities (2), and thus far, it has always been responsive to the ever-changing needs of patients and healthcare systems (3). in fact, nursing has gone through a unique historical process before reaching its current state as a trustworthy profession. new trends in the nursing profession have stemmed from numerous factors, such as wars, economic downturns, scientific progress, and nursing shortage. nevertheless, nurses have continually played an important role in shaping the healthcare system (2). since its inception, the nursing profession has faced various upheavals due to historical, religious, cultural, and economical factors (4). the history of nursing in iran shows utilization of housewives, untrained hospital and clinic personnel, along with few trained nurses providing patient care before the establishment of academic nursing in 1915 (5). similar to china, taiwan, and lebanon, the modern nursing program in iran was modeled after the christian missionaries who promoted religion while providing humanitarian nursing services (5). missionaries provided healthcare services to local residents, and later, trained iranian women as hospital nurses to fulfil their religious responsibilities. nurses who graduated from the missionary nursing schools had to care for a large number of patients in the hospitals, and due to cultural barriers, poor social image, and demanding hours, few iranian families allowed their daughters to enroll in the nursing programs (6). in 1935, and during the social movement of the pahlavi dynasty, american nurse educators were recruited to establish the iranian nursing programs in tehran, tabriz, and mashhad (4, 5). later, in 1952, the iranian ministry of health established a nursing division and gradually recognized nursing as a profession (5). years later and after the islamic revolution of 1979, cultural traditions brought about major changes within the higher education system and nursing profession. at this time, nursing education moved from a hospital-based program to a university-supervised system of medical sciences (4). once iranian nurses found a new identity, they chose to celebrate nurses day on the birthday of hazard-e zainab [the daughter of imam ali (as), the first imam of shias, who took part in karbala with her brother, imam hossein (as), the third imam of shias to provide care for the injured and sick]. another historic event with significant influence on the iranian nursing profession was the iran-iraq war during 1980-1988, which resulted in nursing advances in terms of clinical, educational, and research development (7). historical changes in the iranian nursing profession have presented complex social and ethical issues. according to vaughans, a historic review of events related to the nursing profession can be traced to sociopolitical and cultural issues of the time, worthy of exploration to create ideas, meanings, and interpretations, and critical to the present and future paths in nursing (8). the history of nursing reveals repeated patterns of encountering professional issues over time and in every decade with new strategies to resolve them. hence, examination of past events provides effective solutions to future challenges (9). the historical research method can link past, present, and future events. learning about the history of a profession, the process of its development, and its flourishing trends can lead to increased confidence in those associated with the profession. having historical knowledge of a profession is the cornerstone of professional identity, recognition, and criticism surrounding that profession. hence, attention to the professional background is necessary. however, as time passes, access to essential resources for deeper understanding of professional identity becomes limited or restricted. archiving and restoring historical documents are often neglected in developing countries with irreversible losses of learning opportunities. in this study, researchers sought to study and record the history of the iranian nursing profession and needed access to live witnesses to obtain data from lived experiences and establish records. the present study describes changes and challenges within the iranian nursing profession from a sociopolitical perspective. method considering the study objectives, limited access to historical resources and documents, and past library destructions, obtaining oral history from living witnesses of events in iran provided an opportunity to gain historical reviews and apply the oral history method. the oral history method was first described by allan nevins in 1948, and records important events according to recalled lived experiences of study participants. oral history method refers to the recording of individuals’ verbal statements and is recognized as a scientific and regulated method based on theoretical and practical principles for collecting evidence through verbal documents (10). this method can help produce documents after verification, confirmation, and completion with support of other resources, particularly written documents, and is often used by researchers in the fields of history, sociology, and psychology (11). to obtain verbal/oral history, 14 senior and experienced nurses in clinical, educational, j med ethics hist med 9: 13 november, 2016 jmehm.tums.ac.ir afsaneh raiesifar et al. page 3 of 10 managerial, and policymaking areas, who live in several provinces of iran such as rasht, mashhad, tehran, yazd, tabriz, kermanshah, and urmia, were recruited to serve as the primary data source during september 2013 to november 2014. shared lived experiences of participants began from 1937 to 2014. primary sources were obtained from participants through interviews, personal and professional documents, journals, photographs, and letters. the interviews were tape recorded and the researcher took shorthand notes to document each participant’s account in more detail. secondary sources included newspapers, magazines, relevant articles, books, photographs, governmental documents, and personal archives held at the document conservation centers (the islamic revolution document center, library, museum and document center of iranian parliament, central library of astan quds razavi, and the national library and archives of iran) and medical sciences museums (tehran university of medical sciences and tabriz university of medical sciences, iran) to support and verify the oral history data. the same dramatic stories happened for our documents. some of the documents were lost by fire or were taken abroad by nurses who left the country after the islamic revolution; some other documents were lost or destroyed during pre-islamic period in the throes of revolution. moreover, some historic documents were destroyed in previous wars or disposed by the opposing ruling parties. therefore, we found gaps in the available documents and found it necessary to supplement certain parts of the historical data through interviews and participant recalls. after obtaining the approval of the research deputy of the ethics committee at tehran university of medical sciences, the study objectives and procedures were explained to all participants to retrieve signed written informed consent forms. participant’s interviews lasted 45-90 minutes and took place at a location most convenient to them, which included their homes, offices, or a hotel lobby. the oldest living iranian nurses were selected for participation in this study through purposive sampling. the researchers referred to retirement associations, nursing offices at major universities, and convalescent healthcare facilities to identify suitable participants and interview them. it should be noted that participants were selected to represent a wide variety of past events through maximum variation in age, gender, years of work experience, nursing specialty, professional responsibilities, and place of residence. semi-structured interviews were continued until data saturation was reached. participants were asked open-ended questions to allow for elaborate responses which were followed by probing questions to further expand on the topic. examples of openended questions ‎ used‎in‎this‎studs‎are: “please tell me about your nursing experience before and after graduation from the nursing school.”, and “tell me about sour work experience as a nurse.” follow-up and probing questions used were: “according to sour past nursing experience…, what seems to have changed within the last few decades and how has the nursing profession evolved?” explorators questions and complementary interviews were based on questions such as “whs do sou think so?” and “please explain more.”, to gain a deeper understanding of the participants’ experiences and how they felt about their nursing roles, in order to shed light on the less known aspects of nursing profession in iran. data were collected and simultaneously analyzed to form categories and new participants were selected based on data received from previous participants. in total, 17 interviews were conducted with 14 participants for a total of 1,240 minutes. data analysis after the interviews, the recorded data were analyzed using oral history analysis method according to miller’s four level steps for its applicability to the nursing profession (12, 13). the data analysis method used in this study begins with writing narratives and consists of 4 stages. the first stage involves interviews, that is, collecting oral testimonies related to the study topic. the second stage is the portrait(s) of meaning are presented through biographies for the initial interpretation and reconstruction of interviews in detail according to changes in the social environment as raw data are transcribed verbatim. at this level, similar concepts are grouped and coded to form subcategories and the process of interpreting and validating the historical statements begins, where researcher(s) incorporate secondary data from books, newspapers, and other historical sources to validate their findings. the third stage is the seeds of meaning. telling extracts are used at this level to focus on finding the key concepts by cross-analysis through validation of biography. upon the second review, coded data and subcategories are clustered to develop the main categories. at this stage, researchers will be able to identify any inconsistencies by comparing each expression with the whole data pool for cross validation. rigor of the analysis method is established at the 3 rd stage. the fourth stage is the collective meaning; historiography provides the overall picture through a narrative of the researcher’s interpretation derived from the participants' expressions in an integrated story. at the 4 th stage, secondary data sources (newspapers, books, articles, and others) are commonly used to better reconstruct the stories. in this study, narratives were used to present the results based on each category and subcategories. researchers focused on a deeper understating of the phenomena through data triangulation, long-term involvement, and data immersion. date collection j med ethics hist med 9: 13 november, 2016 jmehm.tums.ac.ir afsaneh raiesifar et al. page 4 of 10 and analysis lasted a year from september 2013 to november 2014. external and internal criticism was applied to increase data credibility, verify data genuineness, authenticity, and accuracy. the researchers initially tried to use resources that could verify data validity and if the research team could not validate a resource, the logical deduction was used to confirm or deny the content. after reviewing data and implementing the preliminary content analysis, findings were returned to the participants for confirmation of data accuracy. moreover, the final versions of narratives retrieved from coded data to develop categories were evaluated by research supervisors and two peer experts in terms of clarity and accuracy. to establish recall related accuracy, individual statements were compared with the whole of the interview and with other interviews, and with the existing historical documents of that time period. these steps activated internal criticism of primary resources. it should be mentioned that participants’ anonymity and confidentiality of the information provided and documents presented were strictly observed throughout the data collection and analysis process. results among the 14 participants, there were 11 women and 3 men, whose ages ranged from 53 to 93 years with the mean age of 67 ± 6 years. among them, 4 had clinical nursing experience, 4 had managerial experience, and the rest were nurse educators from 7 different cities in iran. we found that within the past century, sociopolitical events had a significant influence on the iranian nursing profession and researchers were able to identify the 3 main categories of the white revolution, the islamic revolution, and iran-iraq war. the category of the white revolution consisted of the subcategories of the literacy corps, health corps, and gradual formation of the nursing profession. the category of the islamic revolution consisted of the subcategories of restructuring of higher education, and changing the culture of scientific and administrative systems. in addition, the iran-iraq war category consisted of the subcategories of the rebirth of nursing, facilitation of the admission of men into the nursing profession, and changing of the curriculum in response to needs. the white revolution after the second world war (wwii), and due to the changes in the western forum, the second pahlavi king (shah of iran) proposed another forum to develop a western paradigm in iran and enhance its authoritative model under the pahlavi government. with absolute power, the pahlavi dynasty, in an attempt to modernize iran and replace the traditional way of life with a western, and in particular, an american lifestyle, imposed various political and sociocultural changes on the iranian people and deeply challenged their traditional family values. the second pahlavi king followed his father’s attempts to legitimize power and implement new developments in iran. to achieve his goals of having a modern society, western ideas were introduced and implemented through 5 socioeconomic programs during 1941 to 1977. in 1948, the iranian government made changes to the national policies by adding healthcare as the number one priority in a 3part plan (1948-1967), but no set objectives were presented. the fourth program plan included objectives for preventative health measures such as immunizations and fight against communicable diseases. the fifth program plan focused on the improvement of national health. during 1963, the second pahlavi king proposed the white revolution included several codes. two important components were to develop the literacy corps (sepah-e danesh) and health corps (sepah-e behdasht) both of which had significant roles in nursing development. overall, the white revolution led to the development of hospitals, mass national education to improve health and education, and increased cultural knowledge. literacy corps (sepah-e danesh) the literacy corps, which the second pahlavi king considered as the capstone among the nine principles, was formed to improve the 20% literacy rate by sending high school graduates, after four months of educational training, to remote villages and small cities to educate people as part of their mandatory military service. within four years of implementing the white revolution, university student enrollment rate increased by 18% and the number of hired professors increased by 53% (14). since the literacs crops’ main goal was qualitative and quantitative development of universities and scientific centers, the number of nursing schools and volunteers also increased. as part of the white revolution, there were cultural exchanges between iran and western countries, particularly with the united states, where thousands of americans entered iran and held key positions in order to culturally transition iran into a western country. they made changes in sociocultural policies through student and scholar exchange programs. they engaged artists and media links between iran and the united state. [before the 1960s, most of our physicians came from europe; for example, germany, france, and switzerland. they mostly spoke french and after the white revolution, things changed. in the 70’s we had more americans entering iran…and in those years, nursing programs were integrated from a “license equivalent” (a french term) into a baccalaureate of science (b.sc.) degree by adding more clinical nursing courses to the curriculum. nursing began to gain social status as a profession j med ethics hist med 9: 13 november, 2016 jmehm.tums.ac.ir afsaneh raiesifar et al. page 5 of 10 and iranian nurses compared themselves to their american counterparts and performed well.] (participant number 14, female, 63 years old, nurse manager) health corps (sepah-e behdasht) health corps was one of the three principles added to the white revolution along with the literacy corps, which aimed at meeting the national health and education needs. the ministry of health increased its budget considerably to achieve the established goals and began building and developing hospitals and healthcare centers, and thus, advancing the nursing profession. the health corps recruited a medical team consisting of one physician and two assistants with diploma degrees to treat, educate, and vaccinate people in rural areas (14, 15). following the creation of the literacy and health corps, public health and literacy levels improved and the number of nursing programs increased. [another event at that time was having treatment centers managed by oil money. before that, less than half of a 1000-bed hospital was in operation and after the economic prosperity and increased income from oil money, more treatment centers were built, the 1000-bed hospital was completed and in operation, even in its basement.] (participant number 14, female, 63 years old, nurse manager) nursing profession undergoing modernity modernization after the white revolution included more women entering the nursing profession and families being content with a female dominant job for their daughters. hence, the pahlavi dynasty succeeded in improving the professional image of nursing to satisfy the ever-increasing public need for educated nurses. these vast measures helped open more nursing programs during 1956-1971. thus, the 50’s and 60’s could be considered a prologue for the development of nursing profession in iran. it should be noted that prior to this era, a small number of nursing programs were dispersed in some parts of the country and they had no integrated curricula. after a few years, some of them closed for various reasons. with social changes and the establishment of government-funded national institutions providing nursing training, the 60’s became the era of recognition for nursing as an important profession in healthcare and it was enhanced through public awareness efforts. moreover, the ministry of health increased employment opportunities for nurses, midwives, healthcare technicians (in line with the employment law for nurse, midwife, and technical staff for the ministry of health approved on march 03, 1960), and nursing assistants and recognized them as partners in the medical team. nurses’ and nursing assistants’ salaries increased and the first postgraduate education programs were established at the pahlavi university in 1967 (5). [at that time, my salary as a nurse, working the night shifts, with more difficult tasks, was not any different from that of a school principle. i mean we had a fixed salary without overtime and that was unfair.] (participant number 14, female, 63 years old, nurse manager) the interview results in this study showed an added interest in the nursing profession and subsequent increase in the number of nursing graduates within the next two decades, particularls in the 60’s. advances in nursing profession encountered new challenges such as lack of nursing instructors, difficult access to educational resources, inadequate educational facilities, and shortage of medical equipment. [at that time, educational facilities were quite scarce. there were few or no books on nursing. also, there were no modern medical equipment and most tasks were performed manually.] (participant number 3, female, 62 years old, instructor) the islamic revolution the islamic revolution took place on february, 11, 1979 when the iranian government structure underwent a fundamental and significant ideological, sociopolitical, and cultural remodeling with the arrival of a new government. these changes were followed by scientific developments and the way nursing was taught, practiced, and later, recognized as a profession. the cultural revolution aimed to blend the islamic ideologies with the academic philosophies at universities by changing the structure of higher education, and subsequently, altering the path to nursing practice. restructuring of higher education after the islamic revolution, in 1980, the cultural revolution committee under imam khomeini’s command authorized the review and modification of academic curricula for all academic majors and the development of new objectives for universities and higher education institutions. one of the major changes occurred in medical sciences with merging of colleges of health sciences with the ministry of health (hospitals and healthcare centers). in 1985, medical sciences education was completely removed from the ministry of culture and higher education, and a new ministry by the name of ministry of health and medical education was established. this novel ministry mainly focused on health education and medical research by creating a strong network between universities and healthcare facilities to provide health service, treatment, and education, and engage in research in the field of healthcare. this approach centralized nursing education and practice with other medical sciences. the nursing branch of the cultural revolution committee was established september 1980 with plans to develop nursing education and offer different degrees in order to meet the nation’s needs in various geographic regions to provide and improve the quality of healthcare services. prior to the establishment of the ministry of health and medical education, nursing was mainly a part of j med ethics hist med 9: 13 november, 2016 jmehm.tums.ac.ir afsaneh raiesifar et al. page 6 of 10 medical schools and later separated as an independent profession to promote quality of care in large quantities and meet the iranians’ public healthcare needs. since then, more nursing schools have functioned independently, educated and graduated professional nurses, enhanced the quantity and quality of patient care, and improved the public image of nursing as a profession. [in the past, people did not have a proper perception of nursing. but, as time passed and more male and female nurses graduated from college and were employed, the public took notice and viewpoints began to gradually change.] (participant number 7, female, 71 years old, clinical nurse and instructor) the islamic revolution followed by the cultural revolution, not only changed the educational structure of nursing, but also changed its overall policies including geographical expansion of colleges and their capacities for postgraduate education. [one of the factors leading to fundamental changes in nursing education and profession was the student enrolment demand. there were nursing schools in large and small cities competing for students and it was good. the number of postgraduate programs increased to more than what we had in the past. well educated and experienced nurses helped modify the curriculum with courses in different clinical specialties and changed the culture of nursing education.] (participant number 2, male, 62 years old, faculty member) immediately after the revolution, there was a greater emphasis on the quantity of nursing programs to graduate more nurses. meanwhile, the islamic revolution had added religious sensitivities to the provision of care regarding gender appropriateness through male and female nurses attending to male and female patients, respectively. soon noticeable problems surfaced when fewer nurses remained or entered the workforce. this self-imposed shortage of nurses further influenced the quality of care and modified clinical practice and nursing education. [at the beginning of the revolution, instead of quality being taken into account, religious issues became more important and affected nursing education and practice.] (participant number 1, female, 63 years old, instructor) in addition, the islamic revolution and political tensions between iran and western countries resulted in poor scientific relationships between nursing professionals in iran and other countries. [at the beginning of the revolution, one of my colleagues and i received academic scholarship to pursue our graduate degree aboard with an acceptable toefl score. we applied to 50 colleges and unfortunately none would accept students from iran.] (participant number 8, female, 63 years old, instructor) changing the culture of scientific and administrative systems according to the islamic and cultural revolution criteria, acceptance of suitable university professors or students had to abide by the islamic standards, consisting of appropriate islamic attire for men and women, having strong faith, and prior sociopolitical involvements in favor of the islamic revolution. individuals who met these requirements were hired and accepted for enrollment in higher education institutes, hospitals, and universities. these extraordinary changes led to the resignation of many nurses and faculty members and their departure from iran. immediately after the revolution, healthcare and other systems experienced a great loss of human resources. on the other hand, due to the religious and public acceptance of gender appropriate culture within the universities and healthcare system, the number of female applicants in higher education increased, particularly in the field of nursing. [one of the factors leading to basic changes in nursing was increased enrollment in universities and more women taking an active role in social activities. this caused a forward public trend.] (participant number 2, male, 62 years old, faculty member) iran-iraq war the beginning of the war in 1980 and presence of nurses at the frontlines were a turning point for the iranian nursing profession, which led to many changes in the way nurses were perceived. nursing rebirth with increasing number of nurses serving at the frontline during the iran-iraq war, authorities and society at large began to recognize and appreciate nurses. providing care for injured soldiers in hospitals and caring for the victims of chemical warfare with devastating injuries required extraordinary measures by nurses. [nurses, particularly men, had a considerable role at the frontline. i, myself took part in eight combat operations when i was a nursing student. we were present to the end and on the scene during the last operation ‘mersad’. this considerable sacrifice and ever presence at the frontline had a great impact on the islamic authorities and their viewpoints about the nursing profession.] (participant number 4, male, 53 years old, clinician and nurse manager) [with arrival of injured soldiers we did everything we could to improve their condition and people noticed how nurses helped the injured and performed their duties. from then on, the society’s view toward nursing began to change.] (participant number6, female, 64 years old, clinical nurse) facilitating admission of men into nursing war had a major impact on the iranian nursing profession and facilitated admission of men into the nursing profession. before the revolution, few iranian men were interested in nursing and some of them were educated during their military training. j med ethics hist med 9: 13 november, 2016 jmehm.tums.ac.ir afsaneh raiesifar et al. page 7 of 10 after the islamic revolution, enrolling male applicants into a female dominated nursing program was a challenging prospect. more male nurses were needed, especially during and after the iran-iraq war. male nurses found a special opportunity for progress in the nursing profession and were quickly promoted to higher positions even without sufficient training or work experience. male nursing students were sent to war after completing their basic training and they gained significant first hand clinical experiences at the frontline. hence, war played an important role in the iranian nursing education and practice. [at first, men were not easily accepted in nursing programs and later society recognized the need for having male nurses as an important part of the iranian healthcare system. men’s entry into nursing was difficult until the pressures mounted during the war and injured male soldiers needed nursing care.] (participant number 4, male, 53 years old, clinician and nurse manager) [what helped men find a position in nursing, in my opinion, was that women could not go to the war zones, but men could easily go to the frontline. the iran-iraq war made it possible to enroll more men in nursing and reduced hesitation in all aspects toward having male students in a ‘female’ profession.] (participant number 2, male, 62 years old, faculty member) changing the curriculum in response to needs nursing education authorities made the necessary changes to meet the nation’s needs bs creating a temporary reduction in the number of students pursuing baccalaureate of science (b.sc.) in nursing and adding to the associate degree nursing (adn) program in response to the increasing demands for nursing care at the frontline. [the curriculum focus moved from b.sc. to adn to help increase the number of trained nurses for hospitals at the frontline. they told us to train technicians to be sent to the hospitals at the war zones, and we added more adn prepared nurses accordingly… with the stipulation that these nurses could come back after the war and continue their b.sc.] (participant number 4, male, 53 years old, clinician and nurse manager) discussion this study aimed to review the history of nursing in iran within a sociopolitical context by interviewing senior nurses who lived through the changes. developmental progress in nursing is not independent of social events. in this respect, meleis stated that nursing discipline is a dynamic profession that moves toward novel social changes to meet needs and social demands, albeit, from popular movements, healthcare reforms, or global changes (16). similar to other performance-based human and social sciences, nursing is not separate from conceptual practices of power, and economic, cultural, and political forces shaping science, philosophy, and knowledge development (17). based on the findings of this study, the white revolution in iran was one of the most effective ways to help a struggling nation with literacy and health issues. implementation of literacy corps and health corps was a step toward the integration of nursing profession in iran. governmental supports and the establishment of charitable unions also improved nursing in iran. with these social progresses and governmental efforts, nursing was introduced as a legitimate profession to the iranian society. steppe conducted a similar historical study in germany to examine changes in nursing during the nazi era and found that german nurses made significant changes in their profession to conform to the nazi regime (18). at that time, external forces made improvement in social status, unity, and integrity within professional nursing organizations, developed effective nursing laws, and politicized the profession. moreover, nurses observed ethical and professional principles to provide care without the surrounding social influences. overall, steppe argued that advances in nursing could never occur in a neutral and valueless context and are always affected by dominant social forces (18). in this study, we found that pre-revolution governmental plans, such as the white revolution during the pahlavi dynasty, had a direct influence on nursing education and practice regarding the attraction of girls from higher socioeconomic ranks into the profession. nonetheless, sociocultural beliefs prevented religious and traditional families from allowing their daughters to pursue nursing. another historical and sociopolitical change in iran was the islamic and cultural revolution, during which the ideologies of iran’s leadership brought about structural variations in beliefs and nursing values. kent-wilkinson stated that social movements, media events, technological progress, and change in public policies can affect training and development, and lead forensic nursing toward a new direction (19). in this study, religious and cultural changes showed quantitative and noteworthy improvement in nursing after the islamic revolution. iranian families welcomed the religious and cultural changes after the revolution, and nursing profession succeeded in meeting the nation’s needs for healthcare services. on the other hand, some of the overzealous lowranking government authorities and instructors imposed rigid requirements upon nursing students and nurses by demanding adaptation to their own ideologies; thus, immediately after the revolution, the quality of nursing education and practice suffered. in this regard, tabari and deans stated that one of the main challenges in nursing after the islamic revolution was the integration of religious beliefs into the nursing curriculum to meet the societs’s spiritual needs through gender-appropriate j med ethics hist med 9: 13 november, 2016 jmehm.tums.ac.ir afsaneh raiesifar et al. page 8 of 10 care (4). as fooladi reported, nursing programs were gender segregated and the faculty had to divide the curriculum for teaching male and female students in separate sessions, especially in simulation labs and clinical practice (6). to date, such gender sensitivities continue to be regarded and accepted as the iranian public at large welcome such nursing care provisions through same-gender care; thus, witnessing an increase in male enrolment in nursing (4). since religiosity has always been a part of the iranian culture, the islamic revolution simply added a new dimension with a significant effect on women’s rights for higher education, genderappropriate healthcare and acceptance of men in nursing (6). overall, the nursing profession in iran has been positively and negatively affected due to a cyclical path toward religion and cultural sensitivity (20). with respect to structural changes, transferring of nursing education to universities of medical sciences, gender equality in nursing education, expansion of nursing schools throughout the country, and the development of postgraduate education were among the advances in nursing after the islamic revolution. these changes helped form a better social image for the nursing profession due to academic rigor and satisfy cultural beliefs leading to higher student enrolment in nursing. quantitative development of nursing was one of the considerable changes after the islamic revolution. the results of a study by farsi et al. demonstrated that, in recent decades, increase in the number of male nursing students, development of postgraduate education, and introduction of the nursing profession to families improved the social image of nursing (21). the iran-iraq war had a significant effect on the way iranian nurses performed and later were perceived by the authorities as important healthcare professionals. cuellar disclosed that in spite of difficulties, nurses used the war as an opportunity to change their image (1). improved public view towards nursing as well as the need for more men in nursing attracted more male candidates to iranian nursing programs. during 1985 to 1988, almost 50% of applicants for b.sc. in nursing were men, and after the war, the number dropped to less than 20% (22). being at the frontline was viewed as a religious duty and a personal commitment. others considered going to war as masculine responsibility to defend the country and help the injured soldiers. in previous studies, it has been reported that wars demanded more male nurses and increased male applicants in nursing programs (23). this does not mean female nurses had any less impact on patient care during wars, because female nurses’ contributions in military hospitals and frontlines remain undeniable. in fact, study findings by firouzkouhi et al. indicated that during the iran-iraq war, female nurses exhibited their advanced clinical and managerial skills (24). for the limited medical supplies, female nurses used their critical thinking skills and offered services while gaining military and clinical experiences (24). peyrovi et al. revealed another aspect of war, by referring to the shortage of human resources after the islamic revolution, and social changes exhausting all other resources during the iran-iraq war (23). similarly, we found that the nursing profession responded to national events by changing the curriculum and graduating more adn instead of b.sc. nurses to meet the nation’s healthcare needs. nursing has always been responsive to social changes and had a historical relationship with social development, and been determined by religious eras, legacy of wars, and appointed rules to meet patient satisfaction. in each society, health and healthcare ideologies are reflected through welfare and care. nursing and its developments have been an integral part of any healthcare system. conclusion this historical review aimed to describe the iranian nursing profession and examine the sociopolitical events in iran to find possible influences on nursing. the three major sociopolitical occurrences were the white revolution, the islamic revolution, and the iran-iraq war. these events had significant impacts on the iranian education, healthcare, and nursing profession. nursing profession showed immense response to sociopolitical events due to having a close relationship with society. iranian nurses showed professional and personal growth and evolved with new challenges and opportunities. development in the iranian nursing profession did not occur in isolation, and sociopolitical factors had a major influence through mutual understanding between nursing and society. political decisions and sociocultural movements required changes in healthcare policies to accommodate the new ideological and philosophical structure. healthcare policies at the governmental levels ultimately modified previous missions with new goals within the nursing profession. events such as wars and islamic and cultural revolution changed the healthcare practice and moved it toward a gender-appropriate system. moreover, better planning through modifications in nursing curriculum was required to comply with the new rules. sociopolitical events in iran played a major role in advancing the nursing profession through policy changes in education, practice, research, and future plans. the nursing profession continues to develop and revise policies to improve the healthcare system and quality of patient care. the results of this study can help in the better understanding and consideration of sociopolitical impacts on the nursing profession when developing new healthcare policies. j med ethics hist med 9: 13 november, 2016 jmehm.tums.ac.ir afsaneh raiesifar et al. page 9 of 10 limitation the loss of historical documents and subsequent lack of adequate access to essential resources were the main limitations in this study and were substituted with candid recalls and personal interviews with participants who lived through the previous era and witnessed changes as a professional nurse. acknowledgment this study was funded by tehran university of medical sciences. we would like to thank dr. soosan abdollahi, phd candidate at the tehran university of medical sciences, for proofreading the manuscript. moreover, we would like to express our appreciations to all the nurses who participated in this research. funding this study is part of a phd thesis at tehran university of medical sciences. conflict of interest authors declare no conflict of interest. j med ethics hist med 9: 13 november, 2016 jmehm.tums.ac.ir afsaneh raiesifar et al. page 10 of 10 references 1. cuellar et. care and meaning in war zone nursing. nurs clin north am 2009; 44(4): 483-93. 2. klainberg m, dirschel k. today's nursing leader: managing, succeeding, excelling. massachusetts: jones & bartlett publishers; 2010. 3. committee on the robert wood 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countries’ perspectives. nurs midwifery stud 2013; 2(4): 49-56. 23. peyrovi h, parsa-yekta z, vosoughi mb, fathiyan n, ghadirian f. from margins to center: an oral history of the wartime experience of iranian nurses in iran-iraq war, 1980-1988. contemp nurse 2015; 50(1): 14-25. 24. firouzkouhi m, zargham-boroujeni a, nouraei m, yousefi h, holmes c. the wartime experience of civilian nurses in iran–iraq war, 1980–1988: an historical research. contemp nurse 2013; 44(2): 225-31. journal of medical ethics and history of medicine review article hospital/clinical ethics committees' notion: an overview fatemeh hajibabaee 1 , soodabeh joolaee 2* , mohammad ali cheraghi 3 , pooneh salari 4 , patricia rodney 5 1 phd candidate in nursing, faculty of nursing & midwifery, tehran university of medical sciences, tehran, iran; 2 associate professor, center for nursing care research, iran university of medical sciences; iranian academy of medical sciences, tehran, iran; 3 associate professor, school of nursing & midwifery, tehran university of medical sciences, tehran, iran; 4 associate professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran; 5 associate professor, school of nursing, university of british columbia, vancouver, canada. corresponding author: soodabeh joolaee address: rashid yasemi st., vali-asr ave. tehran, iran. email: joolaee.s@tums.ac.ir tel/fax: 98 2188671613 received: 3 jul 2016 accepted: 26 nov 2016 published: 18 dec 2016 j med ethics hist med, 2016, 9: 17 © 2016 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract hospital ethics committees (hecs) help clinicians deal with the ethical challenges which have been raised during clinical practice. a comprehensive literature review was conducted to provide a historical background of the development of hecs internationally and describe their functions and practical challenges of their day to day work. this is the first part of a comprehensive literature review conducted between february 2014 and august 2016 by searching through scientific databases. the keyword ethics committee, combined with hospital, clinic, and institution, was used without a time limitation. all original and discussion articles, as well as other scientific documents were included. of all the articles and theses found using these keywords, only 56 were consistent with the objectives of the study. based on the review goals, the findings were divided into three main categories; the inception of hecs in the world, the function of hecs, and the challenges of hecs. according to the results, the americas region and european region countries have been the most prominent considering the establishment of hecs. however, the majority of the eastern mediterranean region and south-east asia region countries are only beginning to establish these committees in their hospitals. the results highlight the status and functions of hecs in different countries and may be used as a guide by health policymakers and managers who are at the inception of establishing these committees in their hospitals. keywords: clinical ethics, ethics committee, ethics consultation mailto:sjoolaee@mail.ubc.ca http://www.euro.who.int/ http://www.emro.who.int/ http://www.searo.who.int/ j med ethics hist med 9: 17 december, 2016 jmehm.tums.ac.ir fatemeh hajibabaee et al. page 2 of 9 introduction owing to the new knowledge obtained from medical studies and the diversity of not only lifestyles, but also moral and religious values in modern societies, medical involvement and decision-making processes associated with healthcare are becoming more and more complicated. moreover, noticeable economic pressure is being experienced by healthcare systems throughout the world, as awareness of ethical implications in medicine has been raised through public political and medico-legal discussions about patient independence, euthanasia and assisted dying (1). csikai has noted that as complicated ethical issues have drawn widespread public attention and fulfilled the need to have protected patients' rights in the health care setting, the need for formal ethics committees has been recognized by most institutions (2). much significance has been acquired by ethics committees in the hospital setting due to the developments in medical technology (2) around the late 20 th century. over the past 30 years, having hospital ethics committees (hecs) has been encouraged or assigned to hospitals in many countries (3), whereas such committees have not been extensively present in the healthcare settings of developing countries (4). support has been provided to clinicians by hecs when they have met ethical challenges in their clinical practice (5, 6). these committees have made much progress in regards to doctors, nurses, and other health experts becoming acutely aware of the ethical decisions they have to make (4). a healthcare ethics committee or hospital ethics committee is characterized as a body of persons established by a hospital or health care institution and assigned to consider, debate, study, take action on, or report on ethical issues that arise in patient care (7). over time, hecs have moved toward democratic processes of discussion by which ethical processes are advocated with the consideration of the benefit of patients, their families, and health care team members (6). hecs have made considerable progress in many countries since the 1980s (8) and are now well established in many countries (9, 10). an ethics committee consult is periodically called by nurses, to help patients and to get assistance in solving ethical dilemma. preparation before asking for an ethics consultation is critically taken into account (5). ethical issues must be taken into consideration even more in nursing (11) and nurses should be educated on ethical issues through ongoing education programs, in-service programs, patient care conferences, and academic courses (12). moreover, those who serve on an ethics committee have a personally and professionally rewarding experience due to the service provided for staff, patients, and families (5). the title “hospital ethics committee” can be utilized interchangeably with “patient care advisory committee”, "healthcare ethics committee", "clinical ethics committee", "institutional ethics committee", and "hospital clinical ethics committee" (3, 7). hecs are responsible for providing ethics consultations. they also evaluate the results of consultations when the consultant is an individual ethicist instead of a board of ethicists (13). most published literature has reported policy review, education, and consultation as the leading roles of these committees (14). more and more, organizational ethical issues, such as the allocation of resources, are being addressed by the hecs (6). ethics committees consist of members from many various disciplines in the health care setting. a holistic examination of a patient’s or their family’s situation that might involve a complicated ethical dilemma is possible through an interdisciplinary view of the issue (2). the various perspectives of nurses, chaplains, physicians, social workers, lawyers, and others brings variety to the debate and serves the patient in the best way possible (7). committee members should be diverse in terms of their culture and skills, experiences, and knowledge. variety inspires debates to obtain new information and consider alternative ideas (15), which is regarded as a prerequisite to culturally safe and ethically sound discussions (6). in order to prevent parochialism, a number of health professional members should be recruited from outside the institution (4). the committee members "should be inclined to learn about clinical ethics, receptive to various ideas and viewpoints, able to deal with emotionally charged topics and interpersonal disagreements, and capable of tolerating vagueness” (16). in general, the success of any hec is dependent on the commitment and devotion of its members. as a matter of fact, there is increasing attention to the competencies needed for individuals engaged in ethics committees, especially ethics consultants (17). numerous studies have applied different methods to examine the performance and various dimensions of hecs in different countries in recent years, and have revealed similarities and differences. hecs still do not exist or have not been appropriately established in some developing countries, and few studies have been performed in this regard in these countries. thus, it appears necessary to conduct studies that can provide guidelines for the establishment and operation of hecs through presenting an integrated comprehensive image of the process of development and performance of such committees. the three main goals of this review included to describe the history and development of hecs in the world [countries classified according to world health organization (who) regional offices], explain the function of hecs, and to discuss the challenges of their practice. j med ethics hist med 9: 17 december, 2016 jmehm.tums.ac.ir fatemeh hajibabaee et al. page 3 of 9 method initially, world literature was reviewed, and then, analyzed and compared to formulate an appropriate guideline to establish committees with favorable structure and performance in countries where the establishment of ethics committees in hospitals has been newly planned. consequently, this is the first part of a comprehensive literature review conducted between february 2014 and august 2016 by searching through scientific databases such as pubmed, ovid, scopus, web of science, and google scholar. the keyword ethics committee was used in combination with hospital, clinic, and institution. all original and discussion articles, as well as other scientific documents were included without a time limitation. in the present study, countries with published studies on the history and procedures related to hecs development in english were included. the countries were classified according to who regional offices. this study was derived from the first author’s phd thesis performed in iran where hecs have lately been developed. results among all the articles and theses which were found with these keywords, only 56 were consistent with the objectives of this study. there were 5 theses, 18 quantitative studies, 3 qualitative studies, 21 discussion articles, 5 editorials, 1 commentary, 2 comparative studies, and 1 review study. based on the review goals, the findings were divided into three main categories; the history and development of hecs in the world, the function of hecs, and the challenges of hecs. history and development of hospital ethics committees of the documented literatures published on the history of hecs in different countries, 22 belong to western countries and began around 1985 (5, 7, 9, 13, 14, 18-33). the history and process of the development of hecs in western countries are provided in this section based on the year the committees were established. the united states review committees were formed in the us following requests for the approval of all decisions about abortion in the 1960s (20). due to the limited number of dialysis machines in the 1970s, a number of committees were developed to determine patients’ priority in access to hemodialysis (20, 21). since hecs (also known as heath care ethics committees) were developed in the 1980s in the us, most available data on these committees are obtained from the american literature (5, 22). while only 1% of hospitals in the us had hecs in 1983, this rate increased to over 90% by 2001 (23). in 1984, the development of these committees was endorsed by the american medical association and the american hospital association. their tasks were considered to be encompassing several areas and guiding hospital policy, but the key and most groundbreaking goal was to make recommendations in individual cases (34). there has been dynamic discussion over how valuable these committees truly are (35). today, hecs are the primary mechanisms for managing ethical issues in clinical care in the usa (36, 37). canada limited hecs existed in canada before the 1980s (13, 18). in 1986, the guide to accreditation of health care facilities indicated the need for multidisciplinary ethics committees for the resolution of biomedical issues (38). two national surveys of canadian hecs in 1984 and 1989 reported that, respectively, 18% and 58% of the hospitals in the country had a hec (18, 39). today, however, the exact conditions of hecs in canada are not known (13). moreover, a study in 2010 found that 85% of the surveyed canadian hospitals had hecs (13). european region netherlands in the netherlands, hecs were established in the early 1970s. for almost 20 years, however, they were mostly mixed committees. they started as bottom-up enterprises and have maintained their nature ever since (24). it has also been reported that ethics advice on clinical issues can be provided by hecs in the netherlands (40). france the growth of bioethics and ethics committees in france differs greatly from that in other countries (25). two major movements in france led to the formation of ethics committees in the 1980s. the first was a political movement which resulted in the development of a permanent national ethics committee called “comité consultatif national d’ethique” (ccne). the second, a professional movement, facilitated the formation of local ethics committees. during 1983-93, the ccne focused on three major topics including medically assisted procreation and the embryo, research on human beings, and genetics (25). united kingdom among the european countries, united kingdom was one of the pioneers in this regard. a number of local reasons, including institutional response to particular problematic cases and clinicians’ concern about the ethical aspects of clinical practice, were involved in the development of the first clinical ethics committees in the uk (22). one of the first hecs was created at what is now called barts and the london nhs trust, incorporating the formerly independent st. bartholomew's and the royal london hospitals, the london chest hospital, and the queen elizabeth hospital for children. this hec, which began its work in 1995, is now an integral feature of professional life within the trust and is a sub-committee of the trust's clinical governance committee, working closely with the j med ethics hist med 9: 17 december, 2016 jmehm.tums.ac.ir fatemeh hajibabaee et al. page 4 of 9 medical director. the terms of reference of the hec emphasize two important dimensions (41). first, the committee acts proactively in the development of coherent and practical ethico-legal policies and provision of recommendations for the traditional issues commonly faced in clinical settings and mentioned in the literature related to medical ethics and law. the hecs’ second function is reactive and involves the provision of relevant advices on particular ethico-legal issues discussed by clinical colleagues (42). slovakia in slovakia, in june 1992, the ‘‘guidelines on establishment and work of ethics committees in health care facilities and biomedical research institutions’’ (43) were elaborated by the central ethics committee, and published in the form of the ministry of health's recommendations. the guidelines provided detailed directions regarding the formation and responsibilities of local ethics committees (24). belgium a law passed in 1994 obliged all general and psychiatric hospitals in belgium to develop a local ethics committee to handle the responsibilities of both research ethics committees (recs) and hecs. this seems to be the origin of ethics committees in charge of both research and clinical ethics (26). in 2000, however, the belgian court of arbitration excluded ethics consultation from the hec-related tasks. since the belgian hecs are controlled on a national scale, all hospitals have their own ethics committee responsible for a large number of committee tasks (43). norway in 1996, a group of hospital clinicians, politicians, and health authorities, along with the norwegian medical association launched an initiative in norway which led to the development of the first hecs in the country. as a result, there is at least one ethics committee at any of the 23 hospital trusts providing 4.9 million norwegians with specialized and hospital-based healthcare services (44). germany the establishment of a hec is mandatory in all hospitals registered in the christian association of hospitals in germany (22). according to a new study in germany, the percentage of hospitals with hecs was found to be 86.4% (45). croatia among european countries, croatia achieved the legal requirements for the establishment of ethics committees around 1997. the 1997 "law on the health protection" obliges all healthcare institutions in croatia to create an ethics committee. each committee should have 5 members including 2 individuals who are not involved in the field of medicine (28). in croatia, a top-down approach was adopted for the development of ‘‘mixed’’ ethics committees, i.e., a combination of hecs and recs, in healthcare institutions (24). ethics committees were established in almost half (46%) of all healthcare institutions in the country (except drugstores and homecare provision centers) 6 years after the reinforcement of the law on the health protection in croatia (in 2006). most of these committees (89%) consist of 3 medical professionals and 2 experts in other fields. moreover, while 49% of the committees were mainly involved in the analysis of research protocols, a small percentage of them provided standing orders, professional guidelines, or other related documents (28). lithuania in lithuania, hecs, called medical ethics commissions, are established based on the health care system law of the republic of lithuania and the model guidelines for medical ethics commissions (released by the ministry of health in 1997). the health care system law of the republic of lithuania was passed by the parliament in the early 1990s and obliged all large healthcare institutions to create a specific hec. the lithuanian national bioethics committee was then established in response to the need for an organization to manage and support these hecs. the model guidelines for medical ethics commissions provided details on the mission, functions, establishment, and composition of hecs (24). turkey although ethics committees exist in university hospitals in turkey, so far, these committees have had no advantages over pharmaceutical recs. due to the need for hecs to resolve the ethical issues faced by not only doctors, but also patients, the senate of kocaeli university medical faculty in turkey approved the establishment of a hec on november 13, 2000 (46). demir and buken stated: "in turkey, the introduction of hecs is relatively recent and the number of committees is limited" (10). poland there were no documents of existing hecs in polish hospitals until 2007 (43). we could not find any legal or ethical regulation concerning hecs. medical ethics committees of medical councils or chambers of physicians and dentists, working at national and regional levels, are the only committees in poland which handle issues related to medical ethics and have similar functions (but not exactly) to those of hecs. however, they have limited effects on the development of healthcare policies and clinical decision-making. in 1990, the first general medical assembly, the highest authority of the polish chamber of physicians and dentists (pchpd), recommended the establishment of the medical ethics committee of the supreme medical council (43). nevertheless, not many hospitals in poland currently have hecs and the existing committees usually fail to provide the required structure, services, and workload (29). j med ethics hist med 9: 17 december, 2016 jmehm.tums.ac.ir fatemeh hajibabaee et al. page 5 of 9 western pacific region australia despite their ongoing development in australia, hecs and other ethics support services are generally not accessible by all institutions (47). the committee at john hunter has published their experience (48), but there are not many documents about australian hecs. in new south wales and other parts of australia, public hospitals are supposed to focus on providing clinical ethics support as a priority (49). china chinese medical association (cma) set up the hec as one of its branches in 1988. the regulation of hospital ethical committees in china was issued at the sixth conference of medical ethics in chengdu in 1991, and then, revised by the cma in 1995 (50). in 2007, the ministry of health of china published a review of methods used in biomedical research involving humans. today, all medical institutions and hospitals in the country have an ethics committee whose main function is to ensure respect for principles of autonomy, beneficence, and justice (50). japan in japan, 20 (25.6%) medical organizations developed an ethics committee in 1998, and this rate increased to 29 (50.0%) in 2003 (50). a recent study on 4000 hospitals in japan reported 51.1% of the surveyed hospitals to have an ethics committee. moreover, 16.8% of the hospitals were working on developing their hecs (51). korea when faced with ethical dilemmas in university hospitals, residents and physicians in korea have very limited access to clinical ethicists or active hospital ethics committees to consult with (52). according to a study in korea, only 3.4% of the surveyed residents had discussed their ethical issues with an attending faculty member or a hospital ethics committee. the participating residents tended to resolve their ethical conflicts on their own (15.1%) or by asking for advice from their colleagues or senior residents (44.9%) or the hospital’s ethics committee (0.7%) (52). new zealand a total of 15 health and disability ethics committees have been established in new zealand. these committees are currently working based on the national guidelines (53). these committees are accredited by the health research council ethics committee for the ethical review and approval of research (4). the report of the inquiry into national women’s hospital (1988) concluded that the ethical review of research proposals and other issues should be performed by independent ethics committees consisting of 50% lay people (not involved in health professions) and also chaired by a lay person (53). eastern mediterranean region iran in the previous two decades, there have been remarkable movements in the field of bio-medical ethics in iran, mainly in the educational, research, and policy-making aspects (54). the regulations and guidelines for the hecs were established by the iranian ministry of health and medical sciences in 2000. based on a national study for identifying the priorities of medical ethics in iran, the constitution of hecs was one of 10 priorities (55); however, hecs are not yet working as strong as other hospital committees. the results of a study conducted in one of the major cities in iran indicates that hecs are functioning as combined committees (85.7%) entitled ethics committee and religious principles. these committees are chaired by doctors (42.8%), hospital directors (2.5%), hospital managers (14.28%), and nurses (14.2%) in different educational hospitals (56). in this review, very few documents were found regarding other countries in the middle east region. this might be because of the language limitation, since our search was conducted only in english documents. the review indicated that while hecs in most developed countries are well established and active, in some developing countries, even if they exist, there is a gap in their activating strategies. in some cases they are only a grand name on the list of different hospital committees and do not perform any specific tasks. functions of hospital ethics committees slowther et al. stated: "the healthcare ethics committees were born out of a grass-root process in american hospitals" (57). three domains or functions must be covered by hecs in their ordinary work. first, the hec needs to educate its members, hospital staff, and also patients about ethical issues. the second function of an hec is to cooperate in the development and revision of various hospital policies and guidelines to facilitate service provision by hospital personnel. the third function of a hec is the task of ethical case analysis (58). the committees have a variety of responsibilities including the resolution of clinicians’ ethical issues, provision of ethical training to their members (at least one individual) and individuals from other institutions, and cooperation in the formulation of institutional policies related to clinical ethical issues. although a committee may perform only one of the mentioned tasks, most existing committees are involved in all of them (4). the function and constitution of these committees are different from recs, the purpose of which is considered the ethical review of research on human subjects (4). one or more of the following three functions may ordinarily be performed by the hecs in the united states (59): (1) providing ethical http://www.emro.who.int/ j med ethics hist med 9: 17 december, 2016 jmehm.tums.ac.ir fatemeh hajibabaee et al. page 6 of 9 consultations upon the requests from clinicians or sometimes patients and their families. the main goals of an ethics consultation in hospital ethics committees is presented in table 1; (2) assisting in the formulation of hospital policies and guidelines by presenting the required ethical input; and (3) training the health personnel of the institution (22). in norway, individual patient cases are normally debated in the hec, not with ethics consultant teams or individual consultants, as is often the case in many other countries (27). the procedures for case discussions suggested in the hec manual are defining the ethical problem(s), describing all facts, identifying the values and pertinent laws at risk, identifying and discussing probable solutions of the case, conclusion, and follow-up and evaluation. the manual puts more emphasis on the patient’s situation, values, and interests which are to be given a central place in the committee’s work (30). a study in norway indicated that between 1 and 8 seminars for hospital employees during the last 2 years with, altogether, 4,400 participants had been arranged by 30 of the 31 hecs. to elaborate on the ethical guidelines, 26 of the hecs had become involved. the topics of the guidelines were end-of-life issues (including not attempting resuscitation and caring for the relatives), patient autonomy issues/involuntary treatment, prioritization issues, confidentiality, communication with patients on facebook and cultural issues/language problems (30). in croatia, the implementation of ethical principles of the medical profession, approval of research activities (protocols) within the healthcare institution, supervision of drug and medical device trails, supervision of organ procurement from deceased persons, and resolution of other ethical issues in the health institution are undertaken by the ethics committees (28). table 2 shows the suggested functions for hospital ethics committees. table 1the main goals of ethical consultation in hospital ethics committees (9)  developing relevant interventions to protect patient rights  proposing solutions to real or imagined conflicts  modifying patient care protocols to improve quality  enhancing patient/family satisfaction  providing the staff with ethical education  developing strategies to prevent future ethical issues  satisfying the perceived needs of the staff  providing the staff with moral support  discontinuing undesirable or inefficient treatments  minimizing the risk of legal liability the challenges of hospital ethics committees challenges of hecs can be divided into three main categories based on the reviewed literature. clarifying and maintaining their position inside the institution although hecs may have a multiplicity of goals and functions, one of the challenges that all hecs share is clarifying and maintaining their position inside their respective institution. hecs in europe have to protect the interests of both individuals and the organization while maintaining a critical independence (8). convincing professionals of the necessity of engaging patients and their families in the decision making process persuading health professionals of the significance of engaging patients and their families in medical decision-making is also a challenge. in fact, when a discussion about the hospitals’ "do not resuscitate policy" was started, some committee members and other clinicians involved in the initial development of the policy disagreed with the disclosure of information and the engagement of patients and their families in "do not resuscitate" decisions. finally, the committee agreed on a policy that ensured the patients’ right to be involved in making such decisions, unless exceptional conditions were present. recent media publicity has supported the committee's point of view (31). educational challenges in the educational setting, a major challenge was to convince the staff, especially the junior medical staff, of the equal significance of ethical issues and clinical teaching. in fact, medical students are more focused on acquiring factual clinical knowledge than on discussing the ethical issues they face (31). according to a recent national survey in the us, 81% of the 519 surveyed hospitals and 100% of hospitals with over 400 beds provided ethics consultation services. despite these noticeable rates, there is still ongoing debate about educating bioethicists, the objectives of ethics consultation, methods of evaluating consultation outcomes, and the best approach toward ethics consultation (9). developing more objective methods for the evaluation of effectiveness and providing the required ethical education for the members of such committees can be considered as the future challenges in this field. the relationships between these committees and the national structure and guidelines for ethics committees in some countries, such as new zealand, need further attention. in fact, particular requirements for ethical approval of research projects may not be relevant when individual clinical situations are concerned (4). a multiplicity of concerns has been raised about hecs. hecs can damage the doctor-patient relationship which is a delicate and vital component of health care, decrease doctors’ professional autonomy, and gradually undermine their j med ethics hist med 9: 17 december, 2016 jmehm.tums.ac.ir fatemeh hajibabaee et al. page 7 of 9 responsibility and authority to act in the best interest of their patients (61). table 2suggested functions for hospital ethics committees (60)  holding regular monthly or quarterly educational sessions on relevant ethical issues for not only hec members and hospital staff, but also patients  setting annual goals for the ethics committee and regular evaluation of the steps taken toward their achievement  reviewing the policies proposed by the committee  encouraging each member of the committee to hold meetings with the members of their department about ethical issues related to their scope of activity  providing patients and their families with brochures containing information about the process of treatment decision-making, advance directives, and the role and responsibilities of the hec  holding meetings about ethical issues encountered in different hospital units with nursing managers or head nurses  arranging meetings with other local ethics committees to share experiences and activities and assess the committee’s performance accordingly  reviewing the available literature, selecting and summarizing significant articles about ethics, and providing the staff and physicians with the produced content  designing a protocol to ensure the provision of adequate pain relief for terminally ill patients  assisting other health care institutions in the establishment of their ethics committees  asking nurses, physicians, and social workers to show the committee how they share information about advance directives, terminal care decisions, or bad news with patients  summarizing hospital policies with significant ethical content and distributing the produced summary among physicians and other hospital staff  designing and implementing a bioethics week with specific daily activities for both the day and night shift personnel  providing courses in mediation or other methods of conflict resolution  asking a sociologist to help the committee create its sociogram to clarify the relationships within the committee that influence its performance  identifying health care personnel (including physicians and nurses) who were admitted to the institution as patients and ask them to share their experiences with the committee they may either limit the patients’ freedom of choice or neglect (rather than protect) their interests by attracting attention to various competing interests, e.g., the interests of the hospital and its personnel. by adding an extra layer to the overburdened administrative bureaucracy of hospitals, hecs may decrease the already insufficient time available for clinical care. they may also raise unnecessary moral and even political disputes (32). finally, in an attempt to protect themselves, hecs may act (e.g., perform analyses and provide recommendations) with extreme caution (33). conclusion according to the results, the americas region and european region countries such as united states, canada, and netherlands have been the most prominent considering the establishment of hecs. nevertheless, the majority of eastern mediterranean region countries and south-east asia region countries are only beginning to establish these committees in their hospitals. the major functions of hecs were ethics consultation, education about ethical issues, and policy-making. based on the reviewed literature, challenges of the hecs can be divided into the 3 main categories of elucidating and establishing their position within the institution, persuading professionals of the importance of participating patients and families in decisionmaking, and challenges related to providing education. the authors of this study tried to present an integrated image of the development of hecs and their performance and challenges around the world. since the inception of these committees was in western countries, the findings of this study may be used as a guide by health policymakers and managers who are only beginning to establish these committees in their hospitals. moreover, health service providers in countries, where there is still no report about activities of hecs or these committees do not act efficiently, do not have any information about the performance of such committees. therefore, the results of this study help health service providers become familiar with the status of these committees in different countries and their main functions. there is a need for further research addressing the real gaps and some of the institutional challenges of hecs and evaluating the functions of hecs. j med ethics hist med 9: 17 december, 2016 jmehm.tums.ac.ir fatemeh hajibabaee et al. page 8 of 9 references 1. jansky m, marx g, nauck f, alt-epping b. physicians’ and nurses’ expectations and objections toward a clinical ethics committee. nurs ethics 2013; 20(7): 771-83. 2. csikai el. the social work role on hospital ethics committees [dissertation]. pennsylvania. university of pittsburgh; 1995. 3. gaudine a, 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[in persian]. 55. bagheri a. priority setting in islamic bioethics: top 10 bioethical challenges in islamic countries. asian bioethics review 2014; 6(4): 391-401. 56. meraji m, sadoughi f, ramezan ghorbani n, nezami a. the performance of the ethics committees in teaching hospitals affiliated with mashhad university of medical sciences. iran red crescent med j 2014; 16(4): e12332. 57. slowther a, johnston c, goodall j, hope t. a practical guide for clinical ethics support. http://www.ukcen.net/uploads/docs/education_resources/prac_guide.pdf (accessed in 2016) 58. jiwani b. an introduction to health ethics committees: a professional guide for the development of ethics resources. alberta (canada): provincial health ethics network; 2001. 59. blake dc. the hospital ethics committee. health care's moral conscience or white elephant? hastings cent rep 1992; 22(1): 6-11. 60. ross jw, glaser jw, gregory dr, gibson jm, bayley cb. health care ethics committees: the next generation; 1993. http://si.easp.es/eticaysalud/sites/default/files/health_care_ethics_committees_suggested_activities.pdf (accessed in 2016). 61. siegler m. ethics committees: decisions by bureaucracy. hastings cent rep 1986; 16(3): 22-4. ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ 1 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e really good stuff volume 13 (suppl.) number 25 december 2020 copyright © 2020 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. virtual learning for teaching medical ethics during covid-19 pandemic *corresponding author mina mobasher afzalipour faculty of medicine, kerman university of medical sciences, 22nd bahman blvd., kerman, iran. postal code : 7616914115 tel : (+98) 34 33 25 76 60-4 email : m.mobasher@kmu.ac.ir received: 2 oct 2020 accepted: 20 nov 2020 published: 19 dec 2020 citation to this article: mobasher m. virtual learning for teaching medical ethics during covid19 pandemic. j med ethics hist med. 2020; 13(suppl.): 25. mina mobasher* assistant professor, department of medical ethics and history of medicine, school of traditional medicine, kerman university of medical sciences, kerman, iran. what problem was addressed? covid-19 has been spread in many countries around the world, and its death toll is on the rise. during this covid-19 pandemic, medical students and their professors faced numerous challenges due to restrictions caused by canceling or disrupting clinical education programs (1,2), especially for medical ethics courses. medical students learn medical humanities and professional values from their interactions with patients, as well as with their professors, colleagues, other healthcare providers, and the society (3). although altruism, responsibility, honesty, respect, and justice are better understood by medical students at the time of a world-wide covid-19 catastrophic pandemic (4). teachers should employ suggested methods for training the values and concepts in the formal curriculum of medical ethics. many studies support the use of student-centered approaches for teaching professionalism and concepts related to medical ethics and recommend that students should participate in the learning process to the furthest possible extent (5). critical thinking plays an indispensable role in learning ethics, and is involved in interactive teaching methods (6). when online platforms were adapted for educational purposes, medical ethics teachers did not think that they could use interactive techniques (e.g., group discussions) to analyze clinical cases. accordingly, they did not see the possibility of developing critical thinking competency without face-to-face interaction with students. virtual learning for teaching medical ethics during covid-19 pandemic 2 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 25 december 2020 as e-learning and online platforms are the staples of social-distancing and similar practices during the quarantine period, the primary concern is whether these platforms are suitable to be utilized for teaching the values and concepts of medical ethics and professionalism. what was tried? the author modified the medical ethics curriculum for medical and dental students and created an online course consisting of 16 sessions to teach and then assess reasoning skills. in this modified curriculum, the fundamental concepts of medical ethics taught through a series of self-study materials to analyze cases that were freely available in the learning management system (lms) platform of the university. in each session, a specific theme from the medical ethics curriculum was discussed. the students interacted in the virtual class to contribute to the case analysis and discussion of the introduced issue. each session’s materials included assessment topics which allowed for formative feedback. assessment topics were uploaded in the lms platform based on the specific themes to be taught. these topics consisted of case analysis, storytelling, and review of excerpts from books and articles, and case presentation (figure 1). figure 1. assessment topics and analysis tools in lms platform a qualitative study was conducted using inductive content analysis of the students’ responses in three main phases: open coding, creating categories, and abstraction (7). figure 2 shows an example of the abstraction phase. this study showed that applied concepts in the analysis of individual cases by medical students and the review of books by dental students had meant the same for both students and teachers without faceto-face communication. mobasher m. 3 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 25 december 2020 figure 2. an example of the abstraction phase in this inductive content analysis this finding can demonstrate the efficacy of the tried approach for teaching ethical concepts and promoting critical thinking for real-life problem-solving. the students could access various materials, including guideline for professional practice prepared by the medical council in iran (8), the world medical association (wma) manual1 and the dental ethics manual (9), using ethical analysis tools. the students’ engagement with the lms platform of the university provided them with a good opportunity to access all valuable course resources. additionally, the new generation of students is more interested 1williams jr. medical ethics manual. https://www.wma.net in learning information from the virtual sources at their convenience, and hence they could more precisely analyze the ethical clinical cases. this virtual communication can help students participate in the learning process and enable them to develop cognitive and practical skills based on their capabilities as well as to obtain and incorporate assessment criteria. especially, students’ performance in ethical case analyses can be used to determine their reflection on concepts and values in light of what is being offered in the online class. furthermore, use of on-line sources for the current generation of medical and dental students provides a good opportunity to build their reasoning skills and virtual learning for teaching medical ethics during covid-19 pandemic 4 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 25 december 2020 reinforce their lifelong learning of medical ethics. what lessons were learned? during covid-19 pandemic, to meet the educational standards, a validated curriculum should be prepared for learning ethics. the areas that need to be improved in medical ethics training are critical thinking skills and related competencies. virtual learning initiatives can provide high-quality, engaging, and active learning environments to improve decision-making skills and foster a healthy mindset. students’ interaction with the training approach tested in this study can help build critical thinking and reflection skills as well as result in achieving medical ethics learning. this approach can be a student-centered or student participatory method for teaching medical ethics. acknowledgments the author is grateful to the students of kerman university of medical sciences for participating in this new online medical ethics training program. conflict of interests the author declares no conflict of interests. mobasher m. 5 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 (suppl.) number 25 december 2020 references 1. ahmed h, allaf m, elghazaly h. covid-19 and medical education. lancet infect dis. 2020; 20(7): 777-8. 2. tabatabai s. covid-19 impact and virtual medical education. j adv med educ prof. 2020; 8(3): 140-3. 3. miles sh, lane lw, bickel j, walker rm, cassel ck. medical ethics education: coming of age. acad med. 1989; 64(12): 705-14. 4. rose s. medical student education in the time of covid-19. jama. 2020; 323(21): 2131-2. 5. beigy m, pishgahi g, moghadas f, et al. students’ medical ethics rounds: a combinatorial program for medical ethics education. j med ethics hist med. 2016; 9: 3. 6. cruess sr, cruess rl, steinert y. role modelling-making the most of a powerful teaching strategy. bmj. 2008; 336(7646): 718-21. 7. elo s, kyngas h. the qualitative content analysis process. j adv nurs. 2008; 62(1):107-15. 8. anonumous. [rahnamey akhlagh herfeii shagelin heraf pezashki va vabaste sazeman nezam pezeshki iran]. [cited 2020 december]; available from: https://b2n.ir/841415 [in persian] 9. brands w, naidoo s, porter s, sereny m, van dijk w, welie j. dental ethics manual 2. [cited 2020 december]; available from: https://www.fdiworlddental.org/resources/manuals/dental-ethics-manual-2 ______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ original article copyright © 2021 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. journal of m edical ethics and h istory of m edicine teaching professionalism in cadaver dissection: medical students' perspective *corresponding author mohammad taherahmadi address: school of medicine, tehran university of medical sciences, poursina st., tehran, iran. tel: (+98) 21 64 05 33 65 email: m-taherahmadi@razi.tums.ac.ir received: 28 mar 2020 accepted: 1 jun 2021 published: 22 july 2021 citation to this article: khabaz mafinejad m, taherahmadi m, asghari f, mehran nia k, mehrpour sr, hassanzadeh g, farahani p, hosseini dolama r. teaching professionalism in cadaver dissection: medical students' perspective. j med ethics hist med. 2021; 14:7. mahboobeh khabaz mafinejad1, mohammad taherahmadi2*, fariba asghari3, kobra mehran nia4, saeeid reza mehrpour5, gholamreza hassanzadeh6, parisa farahani2, reza hosseini dolama2 1.assistant professor, department of medical education, education development center, health professions education research center, tehran university of medical sciences, tehran, iran. 2.students' scientific research center (ssrc), tehran university of medical sciences, tehran, iran. 3.associate professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. 4. assistant professor, department of anatomy, tehran university of medical sciences, tehran, iran. 5.associate professor, department of orthopedics and trauma surgery, tehran university of medical sciences, tehran, iran. 6. professor, department of anatomy, tehran university of medical sciences, tehran, iran. abstract this study was designed to facilitate freshman medical students’ adaptation to the dissection room and familiarize them with the related ethical codes. single-group post-test design research was conducted at tehran university of medical sciences in 2018 2019. the program began with a brief explanation of the necessity of the subject, and after a documentary film was shown, the principles of professional and ethical behaviors in the dissection room were discussed by a panel of experts. in the end, a valid and reliable evaluation questionnaire (cronbach's alpha coefficient = 0.89) was distributed among the students. a total of 129 questionnaires were completed and returned. overall, 94.4% of the students believed that the program provided an excellent opportunity to reflect on professional behaviors during practical anatomy sessions. in addition, 92.8% of the students believed that they would use the ethical points mentioned in the program in the future. content analysis of the open questions produced three main categories: "motivating learning", "application of theory in practice" and "changing the attitude toward responsibility". the results indicate that adequate preparation for cadaver dissection sessions and learning about professional behavior codes in the first exposure can help medical students to better understand the principles of professional behaviors. keywords: anatomy; ethical codes; professionalism; cadaver; dissection. teaching professionalism in cadaver dissection: medical students' perspective 2 j med ethics hist med. 2021(jul); 14: 7. journal of m edical ethics and h istory of m edicine introduction in recent years, along with the rapid advancement of technology, several methods have been introduced to teach anatomy, including surface anatomy, simulators, graphics, etc. (1, 2). among the existing methods, studying the human body and dissection still have a special place in teaching anatomy (3). according to mcmenamin and colleagues, the dissection of cadavers is essential not only in terms of understanding body structures and functions, but also for resolving psychosocial issues that hinder the advancement of medical science (4). evidence shows that anatomy education will not be complete without cadaver dissection, even with the new technology that is available in the field of teaching (3). cadaver dissection has long been one of the most common methods of teaching anatomy and provides students with better and more realistic visualization of different parts of the human body (5, 6). from this perspective, the science of dissection is a way of studying and entering the human body for a better understanding of diseases. in addition, many experts believe that attending the dissection room is the first experience of medical students in their professional encounter with the human body; therefore, these sessions are among the first training opportunities to teach professionalism to the students (7). furthermore, the role of cadaver dissection has evolved over time and now encompasses the teaching of professionalism and ethics. the most recent recommendations of the medical council of india were intended to integrate professionalism in undergraduate medical curricula (8). despite the great importance of dissection in learning anatomy, there have always been challenges. today, cadavers are donated by the so-called "whole body donors" (9). the most significant ethical aspect of donation is to fulfill the donors’ wishes (10, 11). respectfulness, maintenance of dignity, accountability, language, compassion, identification/anonymity, etc. are other aspects of respecting the rights of donors and some major concerns of donors’ families (12, 13). this issue is so important that one of the main reasons for refusing to donate is concerns about disrespect to the body (14). furthermore, students' inappropriate perceptions of the cadavers and how they are prepared for the dissection room can exacerbate their anxiety and sometimes lead to neglecting the principles of ethical and professional behaviors in the dissection room. because of these challenges, some experts have stressed the need to prepare students for entering the dissection room so that they can cope effectively (15, 16). several studies have pointed out the importance and necessity of preparing students for exposure to cadavers and the dissection room, emphasizing the need to change the attitude of students (17, 18). evidence shows that the opportunity provided by cadaver learning and exposure may serve as medical students’ first teacher to enhance professional behaviors (14, 19). although studies indicate a growing interest in preparing students for exposure to cadavers professionally, there is a paucity of khabaz mafinejad m., et al. 3 j med ethics hist med. 2021(jul); 14: 7. journal of m edical ethics and h istory of m edicine empirical studies assessing the impact of teaching programs on medical students in establishing codes of conduct for cadaver dissection. this study was aimed at designing, implementing and evaluating an intervention program from students’ perspective to prepare them for entry into the dissection room by familiarizing them with the principles of professional behaviors regarding cadavers. methods setting along with revising the undergraduate medical curriculum at tehran university of medical sciences (tums), the expected competencies of graduates of medicine were developed (20). “professionalism and medical ethics” is considered as one of the expected competencies in which students will be taught and assessed in their studies. furthermore, the practical session of the anatomy course at tehran university of medical sciences consists of dissection, surface anatomy, simulation, and graphics. all medical students are exposed to cadavers for about 94 hours during the basic sciences phase. attending the dissection room and exposure to cadavers are among the first professional experiences of medical students that occur as early as the initial days of their curriculum. participants the study population consisted of first-year undergraduate medical students of tehran university of medical sciences. inclusion criteria for entering the study were being a freshman student at the university and having the experience of attending the dissection room and familiarity with its conditions. the exclusion criterion was the unwillingness to participate in the program. a convenience sample of 193 medical students participated in our study, 49.21% of whom were female, and the average age was 18.32 years. intervention program a quasi-experimental study with single group post-test design was developed at tehran university of medical sciences in 2018 2019. the researcher-made questionnaire including closedand openended questions was used to evaluate students' perspectives after the program. the educational program was held to prepare the medical students for entry into the dissection room by familiarizing them with the principles of professional behaviors regarding cadavers. this program was conducted in the first month of the basic sciences phase in two sessions. during the first 2-hour session, medical students were exposed to cadavers in the dissection room. after a week, the 4-hour educational program was held. this program first began with a brief explanation of the necessity and purpose of the subject. then, a documentary film about the ethical issues surrounding the donation of bodies was shown to all first-year medical students. the showing was held in the amphitheater of the medical school in persian language using a video-projector. in the current study, the whole film was shown over a period of 30 teaching professionalism in cadaver dissection: medical students' perspective 4 j med ethics hist med. 2021(jul); 14: 7. journal of m edical ethics and h istory of m edicine minutes without any interruption, followed by a discussion. after that, a panel with seven experts in the fields of medical ethics (2 professors), anatomy (4 professors) and medical education (1 professor) explained the code of practice and the necessary ethical codes for performance in the dissection room. examples of these codes include: refraining from photography and filming in the dissection room, avoiding joking with other students or acting contrary to student etiquette, treating cadaver characteristics as confidential information, inhibiting damage to the cadavers, equipment and facilities of the dissection room, and so on. the training material for the panel was presented based on the guideline for professional conduct in medical practice in iran (21). furthermore, two applicants intending to donate their bodies to the dissection room took part in the expert panel. they were invited to explain the reasons for their decision to donate their bodies as well as their concerns. in order to provide an opportunity to reflect on the views of students, some experiences and points of view were presented by four students. in the end, the ethical points were summed up, and after reading the commitment letter of the ethical code, the students completed the questionnaires. instrument a researcher-developed questionnaire was used to assess students' attitudes. the questionnaire included 12 closed-ended questions and one open-ended question to evaluate students' perspectives on the program. items were scored on a five-point likert scale ranging from 5 (totally agree) to 1 (totally disagree). to assess the instrument's content validity, the draft was given to eight experts in the field of medical ethics, medical education, and anatomy for appraising the clarity and conciseness of the instrument qualitatively. once their comments and feedbacks were incorporated into the draft, the final version of the instrument was pilot tested on twenty medical students. cronbach's alpha test was used to determine the internal reliability of the questionnaire (cronbach's alpha coefficient = 0.89). the results were analyzed using spss software version 22.0. frequency and percentage were used to analyze the descriptive data, and the mannwhitney test was used to analyze the results by gender. for the open-ended questions, a conventional qualitative content analysis was used to analyze responses (22). responses were read several times by the analyst, who determined a coding scheme inductively. after coding, segments of the text were abstracted and summarized. ethical considerations the study was approved by the ethics committee at tehran university of medical sciences no. ir.tums.vcr.rec.1397.644). participants were offered the opportunity to complete an anonymous, voluntary survey at the end of the program. all participants were assured that their responses were confidential and that their answers would not influence their educational status in the university. result khabaz mafinejad m., et al. 5 j med ethics hist med. 2021(jul); 14: 7. journal of m edical ethics and h istory of m edicine of the 193 students participating in the program, 129 completed and returned the questionnaire (response rate of 66.8%). quantitative results the majority of participants (94.4%) stated that this program provided the opportunity to think and reflect on the principles of professional behavior in dissection classes. also, 88.9% of the students considered the program to be quite informative in terms of the ethical codes of the dissection room, and 89.6% of them acknowledged that this program enhanced their motivation to follow these principles in anatomy sessions. in addition, according to 95.9% of the respondents, this program increased their sense of responsibility to better use the equipment and facilities of the dissection room and learned more efficiently. also, the majority of the students (92%) stated that this program created the basis for understanding the importance of professionalism since the early years of medical education. details of the students' views are presented in figures 1 and 2. figure 1 shows the percentage of students’ agreement about the program's effects on awareness of ethical codes and professionalism in cadaver dissection. figure 2 shows the percentage of students’ satisfaction with the implementation and content of the program. table 1 provides answers to the questions according to gender. there was a significant difference between the viewpoints of male and female students except in the items of “understanding the purpose and necessity of the program” and “increased motivation to follow the principles of professional behavior”. teaching professionalism in cadaver dissection: medical students' perspective 6 j med ethics hist med. 2021(jul); 14: 7. journal of m edical ethics and h istory of m edicine table 1students’ opinions about the effects of the educational program by gender sig totally disagree disagree neither agree nor disagree agree totally agree gender items 0.20 0 (0%) 0 (0%) 1 (1.6%) 13 (21%) 48 (77.4%) female the necessity and purpose of participating in this program were clear to me. 2 (3.1%) 5 (7.8%) 6 (9.4%) 20 (31.3%) 31 (48.4%) male 0.03* 0 (0.0%) 0 (0.0%) 2 (3.2%) 18 (29.0%) 42 (67.7%) female the program provided a good opportunity to think and contemplate the principles of professional behavior in practical anatomy sessions. 0 (0.0%) 2 (3.1%) 3 (4.7%) 27 (42.2%) 32 (50.0%) male ** 0.01 0 (0.0%) 2 (3.2%) 2 (3.2%) 18 (29.0%) 40 (64.5%) female this program informed me about ethical codes that need to be observed in dissection session. 1 (1.6%) 1 (1.6%) 8 (12.5%) 27 (42.2%) 27 (42.2%) male 0.11 0 (0.0%) 0 (0.0%) 3 (4.8%) 14 (22.6%) 45 (72.6%) female this program was effective in increasing my incentive to adhere to the principles of professional behavior during practical anatomy sessions. 0 (0.0%) 3 (4.8%) 7 (11.1%) 14 (22.2%) 39 (61.9%) male ** 0.01 0 (0.0%) 0 (0.0%) 0 (0.0%) 12 (19.7%) 49 (80.3%) female from now on, i will feel more responsible while using the equipment and facilities of the dissection room and school to learn more effectively. 0 (0.0%) 0 (0.0%) 5 (8.1%) 19 (30.6%) 38 (61.3%) male ** <0.01 0 (0.0%) 0 (0.0%) 1 (1.6%) 11 (17.7%) 50 (80.6%) female the film was helpful in encouraging the students to observe the ethical codes in the dissection room. 1 (1.6%) 0 (0.0%) 7 (10.9%) 20 (31.3%) 36 (56.3%) male 0.02* 0 (0.0%) 0 (0.0%) 2 (3.3%) 23 (37.7%) 36 (59.0%) female attendance of professors from different fields in the panel was effective in understanding the importance of the topic. 0 (0.0%) 2 (3.4%) 12(20.7%) 18 (31.0%) 26 (44.8%) male ** <0.01 0 (0.0%) 0 (0.0%) 6 (9.8%) 15 (24.6%) 40 (65.6%) female signing a printout of ethical codes will help the students remember their commitment to preserve these principles during their study. 0 (0.0%) 6 (9.5%) 10(15.9%) 21 (33.3%) 26 (41.3%) male ** 0.01 0 (0.0%) 0 (0.0%) 2 (3.2%) 16 (25.8%) 44 (71.0%) female participation in the program helped me understand the importance of the principles of professional behavior. 0 (0.0%) 2 (3.2%) 6 (9.5%) 23 (36.5%) 32 (50.8%) male 0.03* 0 (0.0%) 0 (0.0%) 5 (8.1%) 12 (19.4%) 45 (72.6%) female i will observe the ethical points i have learned about in this program in the future. 0 (0.0%) 1 (1.6%) 3 (4.8%) 26 (41.3%) 33 (52.4%) male ** 0.01 0 (0.0%) 1 (1.6%) 6 (9.8%) 8 (13.1%) 46 (75.4%) female i think this program is essential for all students taking basic sciences. 2 (3.2%) 3 (4.8%) 9 (14.3%) 15 (23.8%) 34 (54.0%) male ** <0.01 1 (1.6%) 0 (0.0%) 0 (0.0%) 15 (24.2%) 46 (74.2%) female overall, this was a successful program. 0 (0.0%) 3 (4.8%) 5 (7.9%) 25 (39.7%) 30 (47.6%) male khabaz mafinejad m., et al. 7 j med ethics hist med. 2021(jul); 14: 7. journal of m edical ethics and h istory of m edicine qualitative results the conventional content analysis of the responses of forty-one participants who answered the open-ended questions yielded 112 initial codes. after summarizing relevant concepts, 23 codes were extracted. these codes were classified according to their differences and similarities and summarized into three main categories: "motivating learning", "application of theory in practice", and "changing the attitude toward responsibility". motivating learning according to students, the use of documentary films in explaining the dissection room issues increases the program's impact. in this regard, one of the participants said: "the documentary was very influential and showed the importance of the issue." (participant no:40) the attendance of experts from different fields in the panel drew more attention to the principles of professional behavior and their role in dissection; this statement was expressed by another participant: "the presence of professors from different fields makes us realize the importance of the subject more." (participant no. 23) in this regard another student said: "seeing successful professors and role models has increased our motivation to learn." (participant no. 17) application of theory in practice according to the participants, the strong point of the program was reflecting on their previous (and first) experience of attending the dissection room in terms of observing the principles of professional conduct. a quote from one medical student elucidates this point: "the presented subjects have led us to think about observing ethical principles in the future." (participant no. 9) participants believed that increasing their knowledge of the ethical codes of the dissection room would help them follow the teaching professionalism in cadaver dissection: medical students' perspective 8 j med ethics hist med. 2021(jul); 14: 7. journal of m edical ethics and h istory of m edicine principles of professional behavior in practice. “i became aware of the use of materials after participating in the program.” (participant no. 38) changing the attitude toward responsibility this program will prepare students for professional attendance in the dissection room and is an introduction to the observance of professional behaviors in their future profession. according to the students, applying the same principle to other programs with similar goals could internalize professional behaviours. one of the participants said: "i wish such meetings to be repeated, so we will not forget our main duties and sense of responsibility. personally, whenever i attend such meetings, i feel like my first day at the university." (participant no. 11) facilitating the transition to the dissection room and expressing the ethical codes of the dissection room will increase the sense of responsibility in medical students. this issue has been expressed by several contributors as follows: "this program created a sense of responsibility toward learning in the dissection room." (participant no. 31) another participant also described the effect of this program on the students' beliefs and viewpoints: "this program made me feel more serious about medical education." (participant no. 5) discussion professionalism is one of the core competencies of physicians and is believed to be the cornerstone of physicians' communication with society (23). teaching these principles to students is the responsibility of all institutions involved in medical education and is not exclusive to clinical units. in addition, the internalization of these principles requires education and repetition from the first days of the curriculum (24, 25). many experts consider attendance at the dissection room and cadaver encounter as the medical student’s first professional experience, and believe that it provides an excellent opportunity to teach them the principles of professional behavior (7). hence, in this program at the tehran university of medical sciences, school of medicine, codes of professional behavior of the dissection room were presented to freshman students. in a study conducted at dublin university, students' attitudes toward dissection were studied and according to the results, 34% of the students were not ready to attend the dissection room even as late as 9 weeks into the anatomy course; this indicates the importance of offering a training course to prepare students for the dissection room (18). thus, in addition to familiarizing the students with the principles of professional behavior, the present study provides the basis for facilitating their adaptation to attend the dissection room. we developed our program for undergraduate medical students by combining a film display accompanied by khabaz mafinejad m., et al. 9 j med ethics hist med. 2021(jul); 14: 7. journal of m edical ethics and h istory of m edicine holding a panel discussion and a donor interview as a new teaching format. due to differences in students’ learning styles, various teaching methods were used in this program. most of the students considered the program to be successful and recommended the program for other freshman medical students in the future. the results of the study by cahill and ettarh showed that 30.4% of the medical students preferred participating in a group discussion about the dissection room and 32.3% of them preferred to hear statements about body donation, while 50.9% believed that watching a film about dissection would be helpful before attending the dissection room (18). according to the majority of participating students, showing the film played an important role in forming, sharing, and further considering their thoughts and feelings in light of maintaining the dignity of the cadaver. increased emotions and insights in this study corroborate these earlier findings (26). on the other hand, because the dignity of the cadaver is a multifaceted issue, experts in various fields of medical ethics, anatomy, and medical education were invited to explain the different aspects of the code of practice in the dissection room. in this study, the participants stated that the experts of "different fields" helped them understand the various dimensions of the issue and that their divergent comments were beneficial to facilitate the reflecting process. according to study results, creating an opportunity for thinking and reflecting on the principles of professionalism regarding cadavers helps students better understand the importance and necessity of following professional behaviors. on the other hand, familiarity with the principles of professional behavior is related to the promotion of other aspects of professionalism in students (27). in a study conducted at the university of pakistan school of medicine, the majority of students believed that preparation meetings were highly influential in coping with psychosocial issues, and 71.9% of the students believed that these meetings had increased their respect for human life and those who donate their bodies (28). based on the results of this study, the majority of participants acknowledged that after participating in the program, they felt more responsible in using the equipment and facilities of the dissection room. understanding the necessity of the issue and motivating the students to comply were the most important results of the present study period. students cannot be expected to have the motivation to implement the principles of professional behavior without knowing them. another critical issue is the tendency of students to use these ethical points in the future. given that the basis of ethical codes in the dissection room and medical practice is similar, one can consider the observance of codes of professional behavior in the dissection room as a form of practicing professionalism in clinical settings (25), especially when attending the dissection room is considered as medical students’ first professional experience at the beginning of the study period (7). in addition to motivating students to observe teaching professionalism in cadaver dissection: medical students' perspective 10 j med ethics hist med. 2021(jul); 14: 7. journal of m edical ethics and h istory of m edicine the principles of professional behavior, ensuring that they will follow these principles was another objective of the program. for this purpose, a commitment letter to follow the principles of professional behavior was signed by the participants and then hanged in the dissection room as a reminder. according to the positive comments of 82% of the students about the impact of this strategy on maintaining their observance of the principles of professional behavior, it is recommended to follow this practice in future studies. the female students had more positive views than the male students, except in two items: “understanding the purpose and necessity of the program”, and “increased motivation to follow the principles of professional behavior”. one possible explanation can be that female students are more likely than male students to underrate their competencies, including professional commitment in self-assessments (29). however, after participation in this program, they were more eager to follow the principles of professional behavior in the dissection room. in addition, according to studies, female medical students usually experience more anxiety levels in dealing with different medical education situations (30), and are more likely to be emotionally affected by the dissection experience (31); this can be the reason why participating in this program proved to increase female students’ self-confidence. furthermore, several studies have suggested that female students might generally be more inclined to change their professional attitudes due to educational interventions. a study by pearson et al. demonstrated that after frequent exposures to cadavers through a gross anatomy course, female students tend to prioritize altruism more frequently in comparison to male students (32). also, it has been demonstrated that female students are more supportive of commemoration ceremonies for body donors (33), which may, to some extent, account for the differences in responses. another study found that female students are more likely to view the cadaver as a person than a specimen (34). this suggests the importance of paying attention to preparing medical students, especially female students, for entry into the dissection room. one of the limitations of this study may be the lack of examining of the students' attitudes toward the dissection room before and after the program. it would be better if some form of preand post-exposure survey could be developed in the future. another limitation of the study was the timing of completing the questionnaire, which was immediately after the program since the participants’ views could change over a longer time. furthermore, the study is limited to assessing students' attitudes. the results presented here are reasonably limited with some confounding variables, including participants' previous attitudes about donation, students' limited exposure to the dissection room, and the tightness of the program. it is suggested that in future studies, student attitudes toward observing the principles of professional behavior after attending the program be assessed a while after attendance in the dissection room. khabaz mafinejad m., et al. 11 j med ethics hist med. 2021(jul); 14: 7. journal of m edical ethics and h istory of m edicine conclusion this study indicates the need to teach students the principles of professional behavior in dissection classes at the beginning of undergraduate medical education. this type of education will increase freshman students’ respect for human life and those who donated their bodies. providing adequate preparation for cadaver dissection sessions and describing professional behavior codes in medical students’ first encounter helps them to better understand the principles of professional behaviors. acknowledgements the authors wish to thank the efforts of all the students who participated in this study for presenting their views. the authors also thank the personnel of the education development office of tehran university of medical sciences, which co-sponsored the program. the abstract of this paper was presented in amee 2018, basel, switzerland. conflicts of interests none declared. teaching professionalism in cadaver dissection: medical students' perspective 12 j med ethics hist med. 2021(jul); 14: 7. journal of m edical ethics and h istory of m edicine references 1. standring s. gray's anatomy: the anatomical basis of clinical practice, 41thed. elsevier health sciences; 2015. 2. bin p, delbon p, piras m, paternoster m, di lorenzo p, conti a. donation of the body for scientific purposes in italy: ethical and medico-legal considerations. open med (wars). 2016; 11(1): 316-20. 3. granger na. dissection laboratory is vital to medical gross anatomy education. the anatomical record part b: the new anatomist: an official anat rec b new anat. 2004; 281(1): 6-8. 4. mcmenamin p, mclachlan j, wilson a, , et al. do we really need 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349-59. abstract introduction references journal of medical ethics and history of medicine necessity of observing patient’s rights: a survey on the attitudes of patients, nurses and physicians alireza parsapoor 1, kazem mohammad 2, hussein malek afzali 2, farshid ala’eddini 3, bagher larijani 4* 1.medical ethics phd student, medical ethics and history of medicine research center, school of medicine, tehran university of medical sciences, tehran, iran. 2.professor, faculty of public health, tehran university of medical sciences, tehran, iran. 3.phd in biostatistics and epidemiology. 4.professor, endocrinology and metabolism research institute, medical ethics and history of medicine research centre tehran university of medical sciences, tehran, iran. *corresponding author: larijani b. address: no.21,16 azar ave., keshavarz blvd., tehran, iran. tel: (+98) 21 66 41 96 61 email: mehr@tums.ac.ir received: 01 jan 2012 accepted: 04 feb 2012 published: 01 mar 2012 j med ethics hist med. 2012; 5:2. http://journals.tums.ac.ir/abs/20739 © 2012 parsapoor a. et al.; licensee tehran univ. med. sci. abstract keywords: patients’ rights, medical ethics, patients’ rights charter. studying the situation of observance of patients’ rights and interaction of those individuals who provide and/or receive health services are regarded as the most significant and salient parameters of qualitative evaluation of health services. the main aim of this study is to compare the attitudes of patients as recipients of healthcare services with those of physicians and nurses as representatives of healthcare providers regarding the necessity of observance of various aspects of patients’ rights in three hospitals selected as representing the three models of providing medical service (teaching, private and public). this was a cross-sectional descriptive analytical study and the data were gathered using a questionnaire. researchers helped the patients to fill in the questionnaire through interviewing and the physicians and nurses filled in their own questionnaires. the field consisted of three hospitals (a teaching general hospital, a private hospital and a public general one) all located in tehran. the questionnaires included a set of general questions regarding demographic information and 21 questions about the necessity of observance of patients’ rights. they were filled in by the interviewer for 143 patients and, after being sent to other groups, 143 nurses (response rate = 61.3%) and 82 physicians (response rate = 27.5%) filled them in. the criterion for necessity of each right was measured according to the likert scale [from 0 (not necessary) to 10 (absolutely necessary]. the data were analyzed using spss 11.5 software. given the abnormal distribution of the data, non-parametrical tests were used. the results of this study showed that all of the study groups agreed with the necessity of almost all aspects of patients’ rights and the highest level of disagreement between groups was related to patients’ right of access to information and right of choosing provision provider and deciding on treatment plan. however, these disagreements were not significant altogether. according to the results, it seems that healthcare providers, especially physicians, should be better familiarized with patients’ right of access to information and right of choosing and deciding. based on the disagreement between the attitudes of the patients and physicians in this study, it seems that the patients had a higher level of expectations concerning their rights compared to physicians. j med ethics hist med 2012, 5:2 parsapoor a. et al. introduction: a review of the historical course of “patients’ rights” issue reveals its global importance in the arena of health system management. developing the “patient’s rights charter” can be considered as the starting point for moving toward comprehen sive attention to securing patients’ rights and providing an accurate definition of relation between healthcare providers and recipients. however, taking into account the interest groups’ views concerning the necessity of these rights and the impact of different factors such as professional status and environmental differences on evaluation of this necessity will guide policymakers in planning promotional and supervisory programs to improve the observance of patients’ rights. literature review shows that several studies have been carried out about the awareness of various interest groups regarding different aspects of patients’ rights and the impact of demographic, environmental and cultural factors on this aware ness (1-5). other studies have evaluated the attitudes of various groups of beneficiaries toward some aspects of patients’ rights (6-7) and the effects of various underlying factors such as age, race, socioeconomic status and intensity of diseases on these attitudes (6-8). some other studies have compared the attitudes of different groups in different models of providing healthcare service (8). considering various factors influencing the attitudes of interest groups with respect to different aspects of patients’ rights, the purpose of this study was to compare the attitudes of main interest groups including patients, physicians and nurses in sample hospitals from three models of providing healthcare services, namely, teaching, private and public hospitals. the comprehensiveness of this study in evaluating the attitudes of various groups was not found in previous similar studies. methods: this study was a cross-sectional descriptive and analytic one, for which the information was gathered through questionnaires which were filled in by interviewer for patients and physicians; but nurses filled in their own questionnaires. question naire’s content was based on literature review and the questions were modified after consultation with experts for the assessment of validity. to increase the reliability of the questionnaire, the interview was performed by the same inter viewer at all three hospitals. furthermore, the average disparity and differ ences in answering questions in test and retest were studied at two stages, which showed the reliability of the questionnaire. the field of study consisted of three hospitals including a general teaching hospital, a private hospital and finally a public therapeutic one, all located in tehran. the questionnaire comprised of a series of general questions concerning demo graphic information and 21 questions concerning the necessity of observance of the patients’ rights. in this study, patients were selected from inter nal medicine and surgery wards of the hospitals. patients were excluded from the study if: had been hospitalized for less than 24 hours, suffering from moderate and severe cognitive problems, or had moderate to severe pain. the interview was conducted with patients after being informed of the objective of the study. the only inclusion criterion for physicians and nurses was involvement in clinical activities in any of the above-mentioned hospitals. before interview, it had been emphasized that each interviewee should express his/her judgment concerning each question only on the basis of the hospital circumstances. it should be noted that questionnaires were filled out and gathered within a three-month period at large. the information related to the 143 patients was filled out by interview and was also filled out by two other groups including 143 nurses (response rate = 61.3%) and 82 physicians (response rate = 27.5), respectively. the criterion for necessity of each right was measured according to likert scale ranked from 0 (not necessary) to 10 (absolutely necessary). for describing the results of the study, mean, median and standard deviation (sd) were used concerning quantitative variables, while number and percentage points were used in for qualitative variables. non-parametrical tests were used for comparing approaches of groups concerning the degree of necessity of each right in hospitals and other independent variables in the three groups of patients, nurses and physicians. since the variable of necessity of rights had been measured on a graded basis with zero mark (not necessary) up to 10 (absolutely necessary) and had no normal distribution, non-parametrical tests were applied. in the cases where independent variables con sisted of two groups (like puberty), mann-whitney test was used, while kruskal-wallis test was used in the cases where independent variables had more than two groups (such as hospital). in assessing the results of questions posed by the three groups, i.e. patients, nurses and physicians, at three selected hospitals, some cases of meaningful differences were considered both statistically and clinically significant in a way that the average disparity of marks obtained in this regard topped 2. page 2 of 9 (page number not for citation purposes) j med ethics hist med 2012, 5:2 parsapoor a. et al. page 3 of 9 (page number not for citation purposes) ethical considerations: informed consent was obtained of participants. it is noteworthy that patients' information will not be disclosed to a third party without obtaining written authorization. considering the requests of some of the officials in charge of the hospitals cooperating in the study, no mention will be made of the names of these hospitals. results: this study shows different approaches of pa tients, physicians and nurses with regard to necessity of observance of the patients’ rights and also differences of attitudes of each group at three healthcare centers as healthcare providers. in patients’ group, in terms of gender, at the private hospital men were high in number than women (35 out of 50 subjects), while women constituted the highest interviewees at the educa tional hospital (23 out of 41) and the public one (28 out of 50). the age of patients ranged from14 to 80 years (46.57±17.36 and median 46.00 for the all of the patients). the mean age was 51.36 and 41.29 years for men and women respectively, and it showed a statistically significant difference between two groups (p=0.000). one hundred and twenty referrals were married and 21 were single. marriage between two groups of men and wom en had similar distribution. as regards marriage, no statistically significant differences were observed in the mentioned three hospitals. the number of illiterate patients hospitalized at the public hospital and also the number of patients holding high school diploma and bachelor degrees hospitalized at the private hospital were significant ly higher than that of the two other hospitals (p=0.000). the minimum age of physicians was 28 years, while the maximum was 68 (45.33±10.107). distribution of work experience was not statisti cally significant between physicians of the three hospitals. similarly, no statistically significant differences between the two gender groups were observed. the results of this study showed that the study groups had different attitudes toward various aspects of observance of patients’ rights. the highest level of disagreement was related to the right of choosing and deciding by the patients, which was not observed satisfactorily in the teaching hospital. according to the results, it seems that healthcare providers, especially physicians, should be better informed of patients’ right of access to information and right of choosing and deciding. on presenting the results of research, questions can be studied in four categories: the first category: the results shown in table 1 mainly concern respecting patients, their privacy and provision of non-discriminatory treatment. all groups agreed on the definite necessity of ob servance of these rights. although in some of the results there were statistically significant differ ences in the rates of agreement, these differences were not remarkable. the second category: in table 2, the results of the study on the patients’ right to access infor mation regarding their disease are shown. the three study groups, regardless of their place of employment, agreed on the absolute necessity of declaring patients’ access to healthcare and non medical services in hospitals and their rights during hospitalization as well as access to medical information regarding their disease, its prognosis and common complications in a language under standable for them and responsiveness of the healthcare providers to their questions about their disease. however, in the group of patients, there was a statistically significant difference between the patients in the public hospital and those in the other two hospitals regarding the necessity of this issue. furthermore, the nurses in the private and public hospitals had an emphasis on the necessity of this issue, with a statistically significant and remarkable difference between them and the other two groups. in the teaching hospital, this difference was not statistically significant. the necessity of presenting personal characteris tics of the healthcare providing team was less emphasized by all groups in this study. the nurses put the highest emphasis on this issue and the patients put the lowest. in the patients and physi cians groups, there was no statistically significant difference between the three hospitals regarding the necessity of observance of this right. in the nurses group, this difference was statistically significant, with highest emphasis on it in the private hospital and the lowest in the public hospital. regarding the necessity of providing infor mation about less common adverse effects of treatment, less emphasis was put on it by the studied groups (more than two points lower than the more common ones). statistically, the necessity of observance of this right was more emphasized by the nurses than the other two groups. this study showed that none of the studied groups believed in the high necessity of patients’ access to their medical records. the patients suggested a statistically significant, but unremarka j med ethics hist med 2012, 5:2 parsapoor a. et al. page 4 of 9 (page number not for citation purposes) ble, necessity of this issue compared with the other two groups. the third category: table-3 shows the results of the study on the patients’ right for choosing and deciding freely. in this study, the nurses generally put more emphasis on the necessity of observing patients’ right for choosing the healthcare provider (the main physician) for treatment, significantly more than the other two groups. no statistically significant difference was observed between the nurses in the three hospitals. while the patients and physicians in the teaching hospital put less emphasis on the necessity of this right, those in the private hospital put the most emphasis on this issue. on the other hand, male physicians put more emphasis on it compared to their female counterparts in all three hospitals. furthermore, regarding the necessity of seeking the opinion and participation of the qualified patients for deciding about diagnostic and thera peutic measures, all three studied groups empha sized, with no statistically significant difference, on the necessity of this issue. however, comparing the three groups in the teaching hospital revealed that the physicians put the most emphasis on the subject and the patients put the least. in the other two hospitals, there were no statistically significant differences between the attitudes of the three groups regarding the necessity of seeking the opinion and participation of the patients. the patients in the teaching hospital put less emphasis on this issue than their counterparts did in the other two hospitals, while, in the private hospital, this issue was more emphasized by the patients. in this study, the patients with more than 10 days of hospitalization put less emphasis on the necessity of seeking the opinion and participation of patients than those with up to 5 days and 5 to 10 days of hospitalization did. regarding the possibil ity of leaving the hospital with personal consent against the advice of the care providing team, the findings demonstrated that the nurses in the studied centers put significantly less emphasis on the necessity of this issue than the physicians did. this difference was remarkable, especially in the nurses of the teaching hospital. the intra-group comparison showed that the nurses in the teaching hospital put the least emphasis on this issue, while those in the public hospital put the most. however, in the physicians group, there was no statistically significant difference between the three hospitals. surveying this issue among the patients was not possible and this question was not included in the patients’ questionnaire. regarding the possibility of consulting another physician by the patient, the physicians and nurses in the three hospitals acknowledged the necessity of such a right and there was no statistically significant difference between these two groups and, also, between the three groups in the hospitals concerned. the fourth category: the results shown in ta ble-4 concerning the implementation of a patient complaint system and the necessity of disclosing medical errors. all the studied groups in the three hospitals emphasized on the absolute necessity of an active complaint system in hospitals and there was no statistically significant difference between the three groups and the groups in each hospital in this regard. however, the patients of the public hospital put significantly less emphasis on the necessity of this right than those in the other two hospitals. the results of the study on the viewpoints of physicians and nurses regarding the necessity of revealing the compensated medical error to the patient by the responsible person demonstrated that none of the studied groups believed in the absolute necessity of this right. this necessity is significantly, although not remarkably, less in the public hospital than in the other two hospitals. as for the necessity of revealing the uncompen sated medical error, the results indicated that it was considered more necessary by physicians and nurses compared with the previous type. there was no statistically significant difference between the three groups and the groups in the three hospitals agreed in this regard. as for the necessity of revealing the truth about uncorrected medical error for the patient by the responsible person, the least importance was attached to this issue by the physicians in the public hospital and the most by those in the teaching hospital. there was no statistically significant difference between the attitudes of the nurses in the three hospitals in this regard. discussion: a review of the opinions of the three groups (patients, physicians and nurses) in the three types of healthcare service providing centers showed that all of them acknowledged the necessity of most of the rights under question and, in a few cases, there were remarkable differences between the attitudes of the three groups and also the groups in the three hospitals, although these differences are statistical ly significant in several cases. the analysis of the results of the study is presented in four categories: the first category (respecting the patients and their privacy and non-discriminatory treatment): the results of our study demonstrated that there was a general consensus among all of the groups about the absolute necessity of these rights and showed that all of the studied groups attach a j med ethics hist med 2012, 5:2 parsapoor a. et al. page 5 of 9 (page number not for citation purposes) special importance to this right. this finding reveals the necessity of providing the required facilities for observance of the above-mentioned rights. the second category (the right of patients to access information): the results of this study showed that there was consensus with respect to the necessity of inform ing the criteria of patients’ access to healthcare and non-medical services in hospitals and their rights during hospitalization in terms of having access to sufficient information regarding their disease and its treatment as well as common complications. however, regarding the less common complica tions, all of the three groups believed in a lesser degree of necessity of observance of this right. these results were consistent with findings of similar studies found in the literature. in a qualita tive study on the attitude and perception of patients, physicians and nurses regarding patients’ rights in public hospitals of catalonia, the right of patients to access information and respecting their autono my was considered by patients and nurses as the most important right of a patient. of course, in that study, the younger and more educated patients attached more importance to this right, while, in our study, this difference was not remarkable. in addition, the results of the above-mentioned study showed that physicians often believed that their patients were not fully aware of medical issues and had no correct information in this regard; hence they considered the principle of patient autonomy as a potential threat to patients. therefore, the process of obtaining patients’ consent was consid ered a bureaucratic one and the patients’ trust in their physician was regarded as a key issue in the relation between physician and patient. this difference in the attitude of physicians and that of patients and nurses was not observed in our study (6). the fact that none of the groups in this study emphasized on the definite necessity of patients’ right to access their medical records indicates that such a right has not much popularity. this may be a result of concerns about mismanagement of informing the patient if such a right was to be asserted. the third category (patients’ right for choosing and deciding): according to the results, it seems that the less necessity accorded to the right of patients for choosing their physician in the teaching hospital was a result of the teaching context of that hospital. this is an issue that the nurses agreed upon less than the physicians did. it also seems that despite the finding that the patients’ inclination to receive information has no statistically significant differ ence in the teaching hospital compared with the other two hospitals, when they have to make decision, this inclination was significantly less. this is similar to the finding of a study by oliver (6). in our study, similarly, although the patients wished to receive information, this did not indicate their active contribution in decision making in the process of treatment. in other words, receiving information seemed to be more important than autonomy. also, a study by fotaki in four russian cities on the quality of healthcare services showed that the percentage points of patients’ awareness of their right to access information about treatment in the four studied cities were 73.8, 36, 35.1 and 75.4. the figures for the necessity of obtaining consent for therapeutic interventions were 87.1, 68.7, 62.3 and 80.2; and for the right to consult other physi cians were 27.5, 17.4, 28.8 and 24.6 (9). in this study, too, there is a difference between the necessity of the right to access information and that of participation in decision-making. in a comparative study of nurses and patients’ perceptions about patient participation in clinical decision-making by florin et al. conducted on 80 patient-nurse pairs in sweden, it was demonstrated that the nurses, more than the patients themselves, thought that patients wished to be more involved in clinical decision making. in that study, 61% of the patients preferred to have a less active role in clinical decision-making, which was more than the nurses estimation (24%). an active role was sought by 9% of the patients, while the nurses believed that 45% of the patients had such an expectation (7). such a difference in the viewpoints of the patients and the nurses in the teaching hospital are demonstrated in table 4. however, no such difference was seen in the other two hospitals. finding the reason of such a difference in attitudes can be the subject of further research in this regard. several studies showed that patients’ willing ness for participating in clinical decision making may be dependent on their age, race, socioeconom ic status and severity of illness (6-8). in this study, such a difference is seen between the viewpoints of the patients with more than 10 days of hospitaliza tion and those with less hospitalization duration. however, no statistically significant difference was observed between different groups in terms of age, gender and level of education. the possibility of leaving the hospital with personal consent in spite of objection by the care providing team is a well defined and accepted regulation in all healthcare centers as an indispen sable procedure. the physicians and nurses’ perception in this regard may indicate that a group of healthcare providers are reluctant to accept it, given their concerns about potential risks of such a decision to patients. the fourth category (patients’ right to investi gate their complaints and be informed of medical errors): j med ethics hist med 2012, 5:2 parsapoor a. et al. page 6 of 9 (page number not for citation purposes) the results shown in table 5 indicate that all of the studied groups emphasized the definite necessi ty of establishment of an active complaint examining system in hospitals. however, there was a difference in viewpoints about the necessity of revealing medical errors depending on the type of the error. physicians and nurses considered no definite necessity for revealing the corrected medical errors although they believed in a higher necessity of revealing a reparable uncorrected medical error. however, in the public hospital, the physicians did not believe in the necessity of revealing an uncorrected medical error, the reason of which needs to be investigated. in cases of correctable error, given the fact that informing the patient may cause unnecessary worries and even mistrust in the physician, if the correction of the error has not imposed additional costs on the patient, not revealing the error can be justified. nonetheless, in case of uncorrected medical errors, revealing was considered necessary. it seems that revealing an uncorrectable medical error to the patient, although less sensitive than revealing the correctable ones, is necessary because of the responsibility of physicians in terms of patients’ trust. further research on the issue of methods and conditions of revealing medical errors seems to be necessary. the relatively low response rate of the question naires was one of the limitations of this study. however, we tried to minimize this limitation through coordination with the hospitals’ directors and preparing the correspondence bearing their signature concerning the questionnaires to be filled in by the physicians. considering the study’s methodological and practical limitations, it was not possible to study some aspects of patient’s rights. for example, since no research activity was performed in the private hospital, it was not possible to study observation of the related rights and obligations there. asking about medical error was also not possible lest worrying patients. that is why some articles of the patients right charter were not included in the questionnaire. it can be suggested that generaliza tion of these results to various service providing models (private, teaching and public) requires larger samples from several hospitals in each group. conclusion: based on the obtained results, it seems neces sary for healthcare providers, especially medical services, to be better informed of patients’ rights to access information and to choose and decide. accordingly, based on our results, a difference between the attitudes of the patients and those of the physicians indicates higher expectations of the patients regarding these rights than what the physicians considered as required. acknowledgement while appreciating honest cooperation of heads , managers and nurses of the three mentioned hospitals and also each of the participants in the present research, i seize the opportunity to express my sincere thanks to dr. fariba asghari and dr. pooneh salari for their critical review, ms. heidarian for performing interviews, ms. karimi for carrying out typing affairs and pagination and also ms. aqaii for following up necessary measures for realization of objectives of the present research paper. page 7 of 9 (page number not for citation purposes) j med ethics hist med 2012, 5:2 parsapoor a. et al. table 1: necessity of observing patients’ rights to receive respectful and non-discriminatory service hospital model health care providers public general hospital (mean±sd) private hospital (mean±sd) teaching general hospital (mean±sd) p value total (mean±sd) non-discriminatory health service after hospitalization (in terms of age, gender, race, and other related issues) patients 9.95±0.31 10.0±00 10.0±00 0.28 9.99±0.16 physicians 9.45±1.01 8.87±1.64 9.55±1.50 0.03* 9.12±1.49 nurses 8.56±2.22 9.55±1.34 9.70±1.01 0.09* 9.39±1.53 p value 0.00* 0.00* 0.00* 0.00* respect for religious, national, ethnic, cultural patients 9.41±2.24 8.85±3.05 10.0±00 0.01* 9.41±2.23 physicians 9.95±0.21 9.74±0.65 9.70±0.67 0.33 9.80±0.56 nurses 9.48±0.97 9.54±1.76 9.34±2.09 0.25 9.47±1.73 background of the patients p value 0.45 0.10 0.07* --0.33 observance of the patients’ privacy (private examination, confidentiality) patients 8.98±2.45 8.29±3.59 9.94±0.42 0.00* 9.06±2.62 physicians 9.77±0.52 9.61±0.83 9.70±0.48 0.80 9.68±0.70 nurses 9.68±0.67 9.83±0.48 9.61±1.53 0.55 9.73±0.94 p value 0.12 0.00* 0.30 -0.00* * shows a significant p value. all data are presented as mean (±sd). page 8 of 9 (page number not for citation purposes) j med ethics hist med 2012, 5:2 parsapoor a. et al. table 2: necessity of observing patients’ rights to access their own information hospital model health care providers public general hospital (mean±sd) private hospital (mean±sd) teaching general hospital (mean±sd) p value total (mean±sd) informing patients of their rights regarding access to clinical or general services patients 8.8±2.05 8.65±2.40 9.08±1.72 0.78 8.85± 2.07 physicians 9.45±1.18 8.77±1.77 8.36±2.06 0.11 8.90±1.96 nurses 8.56±2.20 9.14±1.86 9.18±2.14 0.16 9.04± 2.01 p value 0.25 0.37 0.46 -0.71 providing sufficient information about the disease and its prognosis in a comprehensible language for patients who could and wished to know patients 9.12±2.04 9.88±0.47 9.20±1.88 0.031 9.43 ± 1.74 physicians 9.23±0.97 8.85±1.31 9.18±1.07 0.50 9.00 ± 1.20 nurses 9.11±1.60 9.34±1.61 9.53±0.90 0.81 9.35 ± 1.43 p value 0.97 0.00* 0.55 0.12 informing the patients about their disease by health care providers patients 9.20±2.35 8.94±2.53 9.48±1 55 0.78 9.20±2.18 physicians 9.36±0.90 9.13±1.07 8.91±1.13 0.51 9.16±1.03 nurses 9.41±0.97 9.41±1.16 9.90±0.37 0.01* 9.55±0.98 p value 0.86 0.32 0.03* -0.10 informing patients of the responsibility of different members of the health care provision team patients 8.63±3.10 8.52±3.13 7.30±3.89 0.01* 8.13 ± 3.44 physicians 8.68±1.32 7.40±2.40 7.20±3.25 0.14 7.73±2.33 nurses 8.85±1.83 9.31±1.46 9.30±1.57 0.16 9.21±1.57 p value 0.93 0.00* 0.00* 0.00* introducing health care provision team to the patients (by name) patients 3.80±4.36 4.83±5.50 4.98±4.02 0.52 4.59±4.30 physicians 8.09±1.60 7.67±2.06 6.36±4.03 0.73 7.60±2.81 nurses 7.68±2.77 8.65±2.35 6.95±3.23 0.00* 7.93±2.81 p value 0.00* 0.00* 0.04* -0.00* providing sufficient information about the therapeutic plan for patients who would understand and were willing to contribute to the decision making process patients 9.29±2.23 8.79±2.80 8.44±3.48 0.46 8.81±2.92 physicians 9.32±0.99 8.85±1.23 8.73±2.10 0.25 8.96±1.32 nurses 9.57±0.74 9.52±1.04 9.53±1.08 0.84 9.53±0.99 p value 0.76 0.04* 0.015* -0.009* explaining common risks and side effects to patients patients 9.88±0.45 9.37±2.19 9.04±2.74 0.38 9.40±2.12 physicians 9.09±1.10 8.94±1.82 8.60±1.50 0.54 8.94±1.60 nurses 9.29±1.18 9.43±1.12 9.25±1.39 0.83 9.35±1.21 p value 0.00* 0.28 0.68 -0.13 provision of information about less common side effects in an understandable patients 7.56±3.93 6.40±4.52 6.80±4.54 0.50 6.87±4.36 physicians 6.82±2.64 6.35±2.42 6.13±3.18 0.71 6.48±2.56 language for a well oriented patient nurses 7.68±2.22 7.84±2.70 7.24±3.05 0.57 7.64±2.71 p value 0.59 0.02* 0.73 -0.05* patients’ access to their medical records and their content patients 8.27±3.40 6.67±4.44 8.04±3.66 0.14 7.61±3.93 physicians 6.29±3.13 7.42±2.77 6.35±3.61 0.31 6.93±3.00 nurses 6.96±2.64 5.85±3.60 7.18±3.09 0.13 6.47±3.31 p value 0.04* 0.11 0.28 -0.02* necessity of informing patients about their rights upon admission to a treatment center patients ----- physicians 8.29±2.43 8.79±1.29 7.22±2.68 0.78 8.43±9.26 nurses 9.36±1.09 9.31±1.31 9.11±1.59 0.97 9.26±1.35 p value 0.04* 0.05* 0.00* -0.00* * shows a significant p value. all data are presented as mean (±sd). page 9 of 9 (page number not for citation purposes) j med ethics hist med 2012, 5:2 parsapoor a. et al. table-3: necessity of observing patients’ right for choosing and deciding freely hospital model health care providers public general hospital (mean±sd) private hospital (mean±sd) teaching general hospital (mean±sd) p value total (mean±sd) ability to choose care-provider (management consultant) by patients patients 5.57±4.47 8.39±3.32 7.64±3.94 0.003* 7.38±4.01 physicians 5.14±3.33 8.67±1.34 7.73±2.24 0.00* 7.61±2.61 nurses 7.79±2.75 8.60±2.41 8.60±1.82 0.16 8.43±2.34 p value 0.03* 0.84 0.33 -0.017* seeking the opinion and involving the qualified patient in diagnostic and treatment measures patients 7.32±3.73 9.15±2.42 8.31±3.27 0.00* 8.33±3.20 physicians 9.09±1.06 8.36±1.64 8.50±2.17 0.19 8.62±1.58 nurses 8.82±2.16 8.54±2.40 8.97±1.89 0.62 8.72±2.21 p value 0.02* 0.20 0.52 0.43 possibility of leaving the hospital with personal consent against the advice of the treatment team patients ------ physicians 9.09±1.10 8.76±1.95 8.44±2.87 0.97 8.82±1.87 nurses 7.15±2.53 7.87±2.89 8.57±2.18 0.03* 7.93±2.65 p value 0.00* 0.07* 0.87 -0.01* possibility of consulting with physicians other than the treating physician by the patient patients ----- physicians 7.91±2.52 7.95±2.54 8.80±1.54 0.64 8.06±2.41 nurses 8.48±2.02 8.61±2.02 8.74±2.11 0.45 8.62±2.03 p value 0.38 0.14 0.93 -0.08* * shows a significant p value. all data are presented as mean (±sd). page 10 of 9 (page number not for citation j med ethics hist med 2012, 5:2 parsapoor a. et al. table-4: necessity of observing patient’s right to follow up their complaints and revealing medical errors hospital model health care providers public general hospital (mean±sd) private hospital (mean±sd) teaching general hospital (mean±sd) p. v. total (mean±sd) the active patients’ complaint-examining patients 9.44±1.71 9.81±1.38 8.63±1.33 0.02* 9.30±2.35 physicians 9.32±0.99 8.98±1.42 8.20±1.81 0.28 8.97±1.39 system in the hospital nurses 9.50±0.83 9.55±1.25 8.23±2.95 0.04* 9.71±1.92 p value 0.89 0.00* 0.81 -0.51 revealing the compensable (corrected) error in treatment to the patient by the responsible physicians nurses 7.14±2.55 6.76±2.25 5.13±3.27 0.24 6.68±2.53 p value 7.64±2.84 7.73±2.94 5.74±3.88 0.03* 7.13±3.32 revealing the corrected error in treatment to the patient by the responsible person physicians 8.43±1.83 8.24±1.7 6.63±3.53 0.38 8.10±1.96 nurses 8.07±2.28 7.89±2.85 6.73±3.50 0.00* 7.59±2.98 p value 0.56 0.50 0.94 -0.22 revealing the corrected error in treatment to the patient by the responsible person physicians 8.85±1.13 7.93±2.64 4.88±3.18 0.01* 7.28±2.61 nurses 8.04±2.36 8.26±2.70 7.25±3.69 0.47 7.93±2.96 p value 0.16 0.58 0.10 -0.80 * shows a significant p value. all data 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program for medical ethics education journal of medical ethics and history of medicine original article students’ medical ethics rounds: a combinatorial program for medical ethics education maani beigy1, ghasem pishgahi1, fateme moghaddas1, nastaran maghbouli1, kamran shirbache2, fariba asghari3, navid abolfat-h zadeh4* 1md-mph student, medical ethics association, students’ scientific research center (ssrc), tehran university of medical sciences, tehran, iran; 2md student, medical ethics association, students’ scientific research center (ssrc), tehran university of medical sciences, tehran, iran; 3associate professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran; 4*resident of ophthalmology, eye research center, rassoul akram hospital, iran university of medical sciences, tehran, iran. corresponding author: navid abolfat-h zadeh address: medical ethics association, students’ scientific research center (ssrc), tehran university of medical sciences, keshavarz blvd., vesal st., no 56, tehran 1417755331, iran. email: navid.ab@gmail.com tel: 98 21 88989161 fax: 98 21 88989161 received: 27 dec 2014 accepted: 1 may 2015 published: 1 may 2016 j med ethics hist med, 2016, 9:3 © 2016 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract it has long been a common goal for both medical educators and ethicists to develop effective methods or programs for medical ethics education. the current lecture-based courses of medical ethics programs in medical schools are demonstrated as insufficient models for training “good doctors’’. in this study, we introduce an innovative program for medical ethics education in an extra-curricular student-based design named students’ medical ethics rounds (smer). in smer, a combination of educational methods, including theater-based case presentation, large group discussion, expert opinions, role playing and role modeling were employed. the pretest-posttest experimental design was used to assess the impact of interventions on the participants’ knowledge and attitude regarding selected ethical topics. a total of 335 students participated in this study and 86.57% of them filled the pretest and posttest forms. we observed significant improvements in the knowledge (p < 0.0500) and attitude (p < 0.0001) of participants. interestingly, 89.8% of participants declared that their confidence regarding how to deal with the ethical problems outlined in the sessions was increased. all of the applied educational methods were reported as helpful. we found that smer might be an effective method of teaching medical ethics. we highly recommend the investigation of the advantages of smer in larger studies and interdisciplinary settings. keywords: medical ethics, medical education, teaching rounds, role playing, large group discussion mailto:navid.ab@gmail.com j med ethics hist med 9:3 may, 2016 introduction medical ethics is an important part of the medical curriculum today (1). presently, all medical schools increasingly require that students be well educated in ethical issues, so as to be equipped with the necessary skills for better management of ethical dilemmas (1-3). it is well recognized that there is no single, best model for medical ethics education; therefore, there was a trend toward developing high quality undergraduate curricula in the past decades (4, 5). the aims of medical ethics education is well portrayed in literature. however, the effective methods of teaching ethics to students have not yet been investigated comprehensively and there is still significant debate on learning and teaching methods (1). it is clear that the current curricular educational methods cannot provide a suitable context for ethical issues to form students’ professional attitudes, because of the different perspectives of medical ethics to the other components of medical knowledge. medical ethics educators believe the current single, separate course of medical ethics presented during the medical curriculum is insufficient to meet the goals of medical ethics education (1, 6, 7). evidence shows medical students and residents have great interest in diverse ethics topics and learning practical skills of preparation for ethical decision making in clinical situations (5, 8, 9). moreover, recent recommendations for medical ethics education support the student-centered education in medical curricula (1, 10). the active involvement of students in the process of medical ethics education is advocated (11). in this regard, small group discussion (12-14), problem-based learning (3, 13, 14), case-based discussion (5, 15, 16), ethics grand ward round, ward rounds with ethicists, simulated patients and retreats (1, 7, 17-19), and some other educational methods have been introduced in literature. however, there is a lack of information regarding the efficacy of combinatorial programs using the diverse proposed medical education methods. thus, we conducted a student-based extra-curricular program of medical ethics teaching, and investigated its impact on the students’ attitude and knowledge regarding medical ethics. methods setting and participants the project of students’ medical ethics rounds (smer) was conducted in the students’ scientific research center (ssrc) of tehran university of medical sciences, iran, from october 2012 to february 2014 as an extra-curricular program of medical ethics education. all students of medical sciences including medicine, dentistry, nursing, pharmacy, and etc. were eligible and allowed to voluntarily participate in round sessions. the program was designed based on a combination of jmehm.tums.ac.ir navid abolfat-h zadeh et al. medical ethics is an important part of the medical curriculum today (1). presently, all medical schools increasingly require that students be well educated in ethical issues, so as to be equipped with the ills for better management of ethical 3). it is well recognized that there is no single, best model for medical ethics education; therefore, there was a trend toward developing high quality undergraduate curricula in the past decades e aims of medical ethics education is well portrayed in literature. however, the effective methods of teaching ethics to students have not yet been investigated comprehensively and there is still significant debate on learning and teaching methods is clear that the current curricular educational methods cannot provide a suitable context for ethical issues to form students’ professional attitudes, because of the different perspectives of medical ethics to the other components of medical dical ethics educators believe the current single, separate course of medical ethics presented during the medical curriculum is insufficient to meet the goals of medical ethics evidence shows medical students and residents have nterest in diverse ethics topics and learning practical skills of preparation for ethical decisionmaking in clinical situations (5, 8, 9). moreover, recent recommendations for medical ethics education centered education in medical icula (1, 10). the active involvement of students in the process of medical ethics education is advocated (11). in this regard, small group based learning (3, 13, based discussion (5, 15, 16), ethics grand ward rounds with ethicists, simulated 19), and some other educational methods have been introduced in however, there is a lack of information regarding the efficacy of combinatorial programs using the diverse oposed medical education methods. thus, we curricular program of medical ethics teaching, and investigated its impact on the students’ attitude and knowledge the project of students’ medical ethics rounds (smer) was conducted in the students’ scientific research center (ssrc) of tehran university of medical sciences, iran, from october 2012 to curricular program of tion. all students of medical sciences including medicine, dentistry, nursing, pharmacy, and etc. were eligible and allowed to voluntarily participate in round sessions. the program was designed based on a combination of educational techniques. for assessm interventions, we used a pretest questionnaire-based design to evaluate knowledge and attitude changes. students were informed about the program via letters sent through the medical ethics association (mea) email list of members, tehran university of medical sciences and ssrc websites, and a few posters in hospitals and departments. a pilot session was held and was followed by 5 other sessions. each session lasted approximately 3 hours. a summary of each smer session activities is displayed in figure 1. figure 1summary of students’ medical ethics round (smer) plan project design we reviewed the existing literature on medical education methods in the field of medical ethics. we investigated the current methods of medical ethics education in iranian medical schools including tehran university of medical sciences, and then, we adopted the most effective and feasible methods. we decided to use the peer large group discussion, multimedia, theater-based case presentation, and role play methods. we chose the topics of the sessions based on previous studies on learners’ needs, especially the research conducted in tehran university of medical sciences (20). the pilot study was focused on confidentiality and honesty. the topics of the next 5 smers included medical team errors, informed consent, medical education ethics, et al. educational techniques. for assessment of interventions, we used a pretest-posttest based design to evaluate knowledge and attitude changes. students were informed about the program via letters sent through the medical ethics association (mea) email list of members, and ssrc websites, and a few posters in hospitals and departments. a pilot session was held and was followed by 5 other sessions. each session lasted approximately 3 hours. a summary of each smer summary of students’ medical ethics we reviewed the existing literature on medical education methods in the field of medical ethics. we methods of medical ethics education in iranian medical schools including tehran university of medical sciences, and then, we adopted the most effective and feasible methods. we decided to use the peer large group discussion, presentation, and role play methods. we chose the topics of the sessions based on previous studies on learners’ needs, especially the research conducted in tehran (20). the pilot study was focused on confidentiality and honesty. the topics of the next 5 smers included medical team errors, informed consent, medical education ethics, j med ethics hist med 9:3 may, 2016 jmehm.tums.ac.ir navid abolfat-h zadeh et al. page 3 of 12 conflicts of interest, and end-of-life issues, respectively. pilot session in order to resolve any unexpected problems, we ran the first session as the pilot session. in the pilot session we reviewed the strength and weaknesses of our methods using participants’ comments. in addition, feedbacks were taken from expert teachers of the round. based on this small survey, we found priorities regarding the ethical topics to be discussed and educational interventions. continuous monitoring after smers, we had a number of meetings for assessment of the rounds. we invited experienced students in the medical ethics and medical education field to the brain-storming session, and discussed the process of the round titled: "how can we improve the effectiveness of smer sessions?" we used this approach to attaining feedback from the audience and experts throughout the whole project, so that we could observe its encouraging outcomes in the quality of sessions. more exactly, several interventions were added to the smers plan based on the aforementioned feedbacks as the rounds were progressing. moreover, we filmed the round sessions and took pictures of the sessions, so that we were able to review the whole process later, which helped us to be better informed of our performance. medical education interventions we used several medical education strategies to perform smers. our rounds were established in the frame of large group discussion in which we used a theatrical play to introduce the ethical dilemma. video presentation, role playing, and role modeling were the other strategies that were utilized. large group discussion was conducted as the major part of smers. in fact we provided a comfortable environment where students could examine and present their pre-existing knowledge and beliefs, and challenge others’ ideas in a safe environment. patients’ story (scenario) and theater the first step of having a theatrical play was writing a scenario to show ethical distress. we chose genuine stories from patients in our hospitals to assure the participants that these events are not limited to ethical books and may also happen to them. of course, we changed the names of characters and places to respect confidentiality. every scenario should have 3 parts; exposition, complication, and resolution. however, our scenarios consisted of 2 parts; exposition, through which we introduced the characters and the event, and complication, in which we brought up the ethical challenge. we terminated the play just after the climax, when the ethical dilemma had occurred. hence, this provided an opportunity for discussing and resolving the dilemma under the supervision of experts in the remainder of the session. it was important for the director to find appropriate actors for the roles given in the scenario. after receiving the script, the first step was to select actors for the play through matching some physical or emotional characteristics of actors and characters of the script. actors were chosen from the 3rd or 4th year medical students who volunteered and were interested in exploring the enjoyments of the theater. our preference was to choose students with previous experience in theater. about 3 to 4 rehearsals (according to the complexity of the scenario) were conducted to prepare actors for the performance. experts’ opinions we tried to use the experts' opinions after the students' discussion. we invited 2 faculty members; a medical ethics professor to instruct the idealism of ethics, and a clinical professor with ethics teaching experiences to explain the realism of ethics in clinical situations. furthermore, some other faculty members voluntarily participated in round sessions and expressed their opinions, and thus, they helped us to have a more effective discussion. after students’ group discussion, the expert panel answered the learners’ questions and explained their own ideas and comments about the session’s topic and parts, such as the play, patients' movies, and etcetera. the other roles of the experts in the smer sessions included summarizing the points of participants’ discussions and explaining specific questions. patients’ films to inform the students of the opinions, feeling, and requests of patients regarding certain ethical issues, we made a number of films of real patients. we approached a few of them and asked them to express their opinions while we were filming. for some smer sessions, we asked health care providers (nurses, students, and etcetera) working in hospitals affiliated to tehran university of medical sciences to express their opinion in front of the camera. informed consents were obtained orally and we reassured participants during the filming that the films would only be used in smer sessions. in addition, the wards and hospitals they were admitted to and their personal and medical information were not revealed. pamphlets and guidelines at the end of the sessions, we distributed pamphlets containing the most important points discussed. it was used to help participants to remember the general concept of the ethical duties in the discussed ethical issue. in some rounds, we designed algorithms or guidelines in which the suitable approaches to those problems were provided. for developing the pamphlets, we used the most relevant articles and textbooks. moreover, we presented them to an expert for further editing and revision. we used the instructions provided in the writing effective pamphlets guideline by newell (21). role playing and role modeling at the end of each smer session, we performed a short modified format of role playing. we presented j med ethics hist med 9:3 may, 2016 jmehm.tums.ac.ir navid abolfat-h zadeh et al. page 4 of 12 a problematic or dilemmatic scenario and asked the participants to imagine that they are the person involved in those situations and act out what they would have done. in this way, they have the opportunity to practice what they have learned. finally, we asked 1 expert (usually the clinician) to act out the same situation as an active role-model for learners. tests and statistical analysis pretest and posttest were designed under the supervision of experts of the main smer topics. the items of the questionnaires were extracted from the best articles and textbooks. the questions were in the form of statements to which the respondents gave their answer through a 5-point likert scale including strongly agree, agree, neither, strongly disagree, or disagree. we evaluated the face validity of the questionnaires by obtaining expert feedback on the questionnaires. the internal consistency reliability of questionnaires was analyzed using cronbach’s alpha. data are expressed as numbers (percentages) for certain responses. for convenience, we transformed the 5-point likert scale to a binomial scale (true or false, bad or perfect, and etcetera) to better describe the participants’ responses in the tables. differences between pretest and posttest responses were analyzed using the wilcoxon signed-rank test. between items, differences were analyzed using the mann-whitney u test. data were analyzed using spss software (version 16, spss inc., chicago, il, usa). the p-value of less than 0.05 was considered statistically significant. results a total of 335 students participated in this study and 85.6% of them (290 students) filled the pretest and posttest forms. the average age (mean ± sd) of participants was 22.22 ± 2.3, the majority of participants were female (207 girls, 71.5%), and 94.5% (274 students) were medical students. in addition, 81% of individuals were in their first 4 years of education; thus, they had not passed the ethical course of the medical curriculum. moreover, students were not obliged to participate in all sessions. participants’ opinions on each subject of smer are summarized in table 1. in the total of rounds, 89.2% of participants reported that the theater group could successfully display the ethical problem. the presenter’s (i.e., lecturer’s) role of facilitation of discussion was described by 96.7% of participants as a perfect performance. large group discussion was reported to be effective by 88.3% of participants. approximately 87% of audiences were satisfied with the professors’ role in answering the participants’ questions and summarizing the important points in each session. nearly 90% of audiences thought the subjects of sessions were practical and necessary. interestingly, 89.8% of participants reported that their confidence regarding how to deal with the ethical problems outlined in the session had increased. role-play was reported as an effective method by 80.9% of students, and 86.3% of participants requested that pamphlets be provided for them. table 1participants’ reflections on the smer plan items* participants’ responses# students’ medical ethics rounds topics difference medical errors (%) informed consent (%) medical education (%) conflict of interest (%) end-of-life issues (%) total of rounds (%) p-value† theater bad 11.8 14.3 14.3 6.8 3.4 10.8 0.249 perfect 88.2 85.7 85.7 93.2 96.6 89.2 presentation bad 0 3.1 2.4 4.5 0.0 3.3 0.013 perfect 100 96.9 97.6 95.5 100.0 96.7 large group discussion bad 2.9 15.6 0 6.8 3.4 11.7 < 0.0001 perfect 97.1 84.4 100 93.2 96.6 88.3 professors bad 0 26.6 14.3 4.5 34.5 12.3 0.010 perfect 100 73.4 85.7 95.5 65.5 87.7 practicality bad 7.9 11.1 19 4.5 0.0 10.2 0.275 perfect 92.1 88.9 81 95.5 100.0 89.8 confidence bad 31.6 25 33.3 25.6 35.7 10.2 0.507 perfect 68.4 75 66.7 74.4 64.3 89.8 pamphlet bad 15.8 not asked 14.3 9.1 6.9 13.7 0.187 perfect 84.2 85.7 90.9 93.1 86.3 role-play bad 7.9 11.1 19 34.9 10.3 19.1 0.090 perfect 92.1 88.9 81 65.1 89.7 80.9 * these items enquire into the participants’ satisfaction regarding the quality of educational methods used in each smer. # the participants’ responses regarding the quality of these items were, first, obtained using a 5-point likert scale, then, transformed to this binomial scale for convenience. †for total (bad/perfect) answers, z-test ( = ( − ) ̅ × + ) was performed, which was consistent with results of the wilcoxon signed-rank test for the 5-point likert scale. j med ethics hist med 9:3 may, 2016 jmehm.tums.ac.ir navid abolfat-h zadeh et al. page 5 of 12 participants’ responses to the knowledge questionnaires are summarized in table 2. only 4 knowledge questions were provided in each session. in the total of the smers, the students’ knowledge was significantly increased (p < 0.05). results of participant’s responses to the attitude questionnaires are summarized in table 3. their responses were transformed from a 5-point likert scale to the positive and the negative attitudes. interestingly, we observed that in the total of smers, the positive attitude of participants had significantly (p < 0.00001) increased. table 2participants’ responses to knowledge pretest and posttest items* participants’ responses# students’ medical ethics rounds topics medical errors (%) informed consent (%) medical education (%) conflict of interest (%) end-of-life issues (%) total of rounds (%) pretest false 45.45 32.2 42.22 58.3 65.56 45.45 true 54.55 67.8 57.78 41.7 34.44 54.55 posttest false 21.05 25.3 32.5 53.98 38.26 21.05 true 78.95 74.7 62.5 46.02 61.74 78.95 difference p-value 0.0017 0.1446 0.3129 0.3358 0.0029 < 0.00001 * these items enquire into the participants’ knowledge regarding the topic of each smer. english translations of them are provided in supplementary material. # the participants’ responses were, first, obtained using a 5-point likert scale, then, transformed to this binomial scale for convenience. in addition, we summed the total responses (true/false) of all knowledge questions. †for total (true/false) answers, z-test ( = ( − ) ̅ × + ) was performed, which was consistent with results of the wilcoxon signed-rank test for the 5-point likert scale. table 3participants’ attitude scores in pretest and posttest items* participants’ attitude# students’ medical ethics rounds topics medical errors (%) informed consent (%) medical education (%) conflict of interest (%) end-of-life issues (%) total of rounds (%) pretest negative 47.2 18.1 56.3 40.3 64.4 42.3 positive 52.8 81.9 43.7 59.7 35.6 57.7 posttest negative 28.1 11 43.6 10.9 47.1 25.4 positive 71.9 89 56.4 89.1 52.9 74.6 difference p-value† < 0.00001 0.08 0.143 < 0.00001 < 0.00001 < 0.00001 * these items enquire into the participants’ attitude regarding the topic of each smer. english translations of them are provided in supplementary material. # the participants’ responses were, first, obtained using a 5-point likert scale, then, transformed to this binomial scale for convenience. in addition, we summed the total responses (true/false) of all knowledge questions. †for total (true/false) answers, z-test ( = ( − ) ̅ × + ) was performed, which was consistent with results of the wilcoxon signed-rank test for the 5-point likert scale. discussion in the traditional model of medical ethics education, medical ethics is taught as a separate course during the clinical years of the undergraduate medical curricula in iranian medical schools. however, incorporating these ethical principles into clinical training still remains challenging (22). furthermore, lecture-based education has been demonstrated to be insufficient in terms of empowering students to employ their knowledge in clinical reasoning (1, 2, 6, 7). there is increasing evidence supporting methods in which students are more involved in the learning process including ethics grand ward rounds, ward rounds with ethicists, and simulated patients and retreats (1, 3, 7, 17-19). moreover, literature supports the advantages of innovative student-based programs in which students watch each other role play and discuss clinical tasks, such as obtaining informed consent, giving bad news, and discussing do not resuscitate orders (3, 7, 23, 24). thus, we designed an innovative extra-curricular program of teaching medical ethics in a student-based project, in which a combination of educational methods were employed. we found that this program could successfully attract medical students of tehran university of medical sciences and could satisfy their expectations of an open environment for discussing ethical dilemmas. fortunately, the results of pretest and posttest showed a significant increase in selfconfidence, knowledge, and attitude scores in the total of rounds. almost all of the educational methods were considered helpful by the participants. there were no extracurricular, student-based, combinatorial programs of medical ethics education in the literature; there were few, if any, extracurricular studies which were confined by single methods. however, here we provide the most j med ethics hist med 9:3 may, 2016 jmehm.tums.ac.ir navid abolfat-h zadeh et al. page 6 of 12 similar experiences of medical ethics education, and try to compare their effectiveness. the study by parker et al. which is the most similar intervention to our study includes student case presentations during a modified teaching ward round model named "clinical ethics ward rounds" (7). interestingly, the cases presented by students in "clinical ethics ward rounds" were very similar to the subjects of smer; as unethical behavior in others, confidentiality, endof-life issues, autonomy, and equity were the most common presented cases (7). the importance of peer discussions in maturation of ethical thinking, which is well elucidated (25, 26), has been tried to be covered both in smer and "clinical ethics ward rounds" (7) through the forums provided by these studies. another similar study was conducted by fryer-edwards et al. employing "ward ethics sessions" (22) including peer discussions supported by mentors and faculty members. both "clinical ethics ward rounds" and "ward ethics sessions" showed that engagement of students in discussions and their confidence in encountering ethical dilemmas were improved, similar to our findings. another recent effort to compare problem-based learning and small group discussion methods by heidari et al. (14) showed mild non-significant higher scores of problem-based learning compared to small group discussion. our results regarding the importance of involvement of students in medical ethics education are also in line with the study by huijer et al. (25). they concluded that we should encourage students to express their opinions and deal with values, responsibilities, and the uncertainty and shortcomings of medical interventions (25). similar to our cases, issues of informed consent, end-of-life decisions, and medical errors were the most common presented cases by students in this study (25). one may inquire into how "ethics rounds" can be effective in medical ethics education. the roundbased method [various names have been used, e.g., ward ethics sessions (22), clinical ethics ward rounds (7), and clinical rounds in medical ethics (18)] for ethics education was employed for the first time several years ago. to the best of our knowledge, clinical rounds in medical ethics were established, for the first time, in 1971 in a large medical center (children's hospital medical center in boston, usa) (18). this method was used to provide a forum for the multidisciplinary discussion of moral dilemmas in health care with the aim of "continuing education" in medical ethics (18). their rounds included case presentations and interpretations provided by interdisciplinary discussions of law, pediatrics, religion, and philosophy professionals (18). thereafter, this format was employed in several hospitals and medical universities with the aims of improving decision-making in medical staff and continuous education of professionals. several years later, after the introduction of more powerful educational methods in literature (e.g., problembased learning), some scholars tried to use "ethics rounds" method for ethics education of undergraduate medical students and interns. fryeredwards et al. tried to incorporate ethics education into the clinical years through employing "ward ethics sessions" at the university of washington (22). through supported peer discussions (supervised by mentors or faculty members) of ethical issues, students were allowed to develop their own moral compass and intuition regarding appropriate training behaviors and practices (22). moreover, their ability to identify issues, develop responses to ethical distresses, recognize their own responsibility, and identify necessary skills for appropriate actions was improved (22). somewhat similar successes were reported by parker et al. (7) regarding the use of the "round method", as mentioned above. the feedbacks we obtained from students and faculty members participating in smers were very similar to the study of fryeredwards et al. (22); that clinical years [it has been referred to as "clinical clerkship and internship" in tehran university of medical sciences (27)] are a fruitful period to shape professionalism and ethics. as it has been previously elucidated regarding hidden curriculum (6, 28), students observe, learn, and imitate the behaviors and interaction styles of doctors with peers, patients, and staff (22, 29, 30). the other important feedback we received was the isolation of students in clinical environment which resulted in them rarely finding the opportunity to discuss many of these ethical distresses with peers. this finding was also similar to that of the study by fryer-edwards et al. (22). it is clear that without exclusive forums for supported peer discussions on ethical dilemmas, medical students undergo "ethical erosion" ["a phenomenon of decreased ability to recognize and respond appropriately to ethically problematic behavior" (22)] that has been previously elucidated in literature (31). in addition, the enthusiasm and participation of students in smer was very encouraging for faculty members, especially ethics professors who always reported insufficient interest of students in lecture classes. it should be noted that professionalism was also considered in the smer program (especially in sessions of medical education, medical errors, and end-of-life issues). there is a growing body of evidence about various teaching methods of professionalism (as well as ethics) (32, 33). the didactic lecture is the most common and efficient method for "summarizing large amounts of information", which can improve knowledge and change attitudes (32), but has its own imperfections as lectures can rarely change behaviors and performances (34). the plan of our rounds (figure 1) included a theatrical play at the beginning to introduce the ethical problem. the theatrical play at the beginning can enhance the realization that patients have of "narrative" lives, and that every j med ethics hist med 9:3 may, 2016 jmehm.tums.ac.ir navid abolfat-h zadeh et al. page 7 of 12 patient represents a singular event situated within a more complex contextual structure (35). after that, through large group discussion, the majority of participants were actively involved in the discussions and the remaining were active listeners. then, professors summarized the most important points of the ethical problem and answered the participants’ questions. furthermore, through the group discussion and using innovative visual material such as theatrical play and patients’ films, we increased participants’ interest in the subject, put the burden of learning on them, and increased learners’ involvement (35). group discussion also provides learners with the opportunity of immediate feedback and is useful for guiding learners toward higher levels of thinking and inquiry (35). the other advantages of this educational strategy include providing valuable clues about learners’ motivation and how to better facilitate learning and help students to identify and build on preexisting knowledge (35). in patients’ videos, we could portray realistic situations and patients’ opinions (36). it is recommended to employ multimedia to enhance teaching and learning (e.g., movies on professional and unprofessional behaviors and requesting audience responses after presentation of ethical scenarios) (32). another large group discussion was performed after the video presentation of patients’ opinions and reflections. after the second large group discussion and the professors’ responses and opinions, modified role playing was performed in which some students were requested to voluntarily play in selected ethical problem situations relevant to the smer topic. role playing actively involves participants, develops problem-solving and communication skills in learners, and enables learners to experience in a safe environment with behaviors which strike them as potentially useful and to identify the useless ones (35). recently, use of role playing for undergraduate teaching of ethics was investigated (37). while it showed similar results to that of the lecture method, it seems the students’ satisfaction with and involvement in the education process is increased by role playing (37). furthermore, role playing provided us immediate feedback about the learner’s understanding and ability to apply concepts. another successful example of using role playing in the literature is the “breaking bad news” course at the london hospital medical college and st bartholomew's (38). they employed group discussion, video presentations, and role play involving actors, to develop students’ skills in “breaking bad news” (38). role modeling (an expert clinician’s role play in front of participants) was the other strategy used in smer to introduce professional practice to learners, which helps students to copy appropriate ethical behaviors (1, 32, 35). role modeling has been demonstrated to be an effective means of teaching professionalism (32). in this program, we encountered some limitations. we only ran a few rounds with heterogeneous participants, so we were not able to evaluate the effect of our program on their behavior and their ethical reasoning. the other limitation was the content validity of the knowledge questionnaire. very few questions were included in the knowledge questionnaire because of the time limitation, so the content validity of this tool might not be ideal. however, the results of questionnaires and feedbacks of participants showed that this program can light the way to a new method of conducting more interesting/effective programs of medical ethics education. conclusion in summary, for the first time, we introduced an innovative combinatorial medical ethics education program, conducted in an extra-curricular studentbased project named students’ medical ethics rounds (smer). we employed theater case presentation, large group discussion, expert opinions, role playing, and role modeling methods in smers. all of the methods were reported by participants to be advantageous. furthermore, pretest and posttest results showed us significant improvement in knowledge and attitudes of students. this study represents a research in a local university, but we believe that the results provide new and effective guidance on structuring medical ethics courses for teachers around the world. it seems necessary for future researches on frameworks similar to smer to consider student involvement in managing or planning actions. acknowledgement we are deeply grateful to dr. parvin pasalar, the head of students’ scientific research center (ssrc) and exceptional talent development center (etdc) of tehran university of medical sciences and dr. pooneh salari, the educational dean of medical ethics department of tehran university of medical sciences for their support of this project. in addition, we would like to thank all the participants and invited professors including dr. hamidreza namazi, dr. kiarash aramesh, dr. ali jafarian the chancellor of tehran university of medical sciences, dr. ali labbaf, dr. azim mirzazadeh the dean of educational development office (edo) of tehran university of medical sciences, dr. mohammmad ali sahraeian, dr. ali aliasghari, dr. farhad shahi, dr. mamak tahmasebi, and dr. alireza parsapour. moreover, the assistance of taha kochakinejad, peiman nedjat, and masoud movahhedi (medical students of tehran university of medical sciences) for filming of round sessions is greatly appreciated. this study was supported by a grant (no: 20193) from tehran university of medical sciences (tums), tehran, 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learners and practicing physicians. rambam maimonides med j 2015; 6(2): e0011. 33. iramaneerat c. moral education in medical schools. j med assoc thai 2006; 89(11): 1987-93. 34. davis d, o'brien ma, freemantle n, wolf fm, mazmanian p, taylor-vaisey a. impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? jama 1999; 282(9): 867-74. 35. wehrli g, nyquist j, editors. creating an educational curriculum for learners at any level. proceedings of the aabb conference retrieved may; 2003. 36. wang p-w, chen r-c, chang s-y. assessment of hospital staff satisfaction and training outcome receiving medical j med ethics hist med 9:3 may, 2016 jmehm.tums.ac.ir navid abolfat-h zadeh et al. page 9 of 12 ethics education on disclosure using multimedia case teaching video. http://www.airitilibrary.com/publication/aldetailedmesh?docid=10282424-201206-201302040021-201302040021-9-15 (accessed in 2015) 37. noone ph, raj sharma s, khan f, raviraj kg, shobhana ss. use of role play in undergraduate teaching of ethics-an experience. j forensic leg med 2013; 20(3): 136-8. 38. cushing a, jones a. evaluation of a breaking bad news course for medical students. med educ 1995; 29(6): 430-5. http://www.airitilibrary.com/publication/aldetailedmesh?docid=10282424-201206-201302040021-201302040021-9-15 j med ethics hist med 9:3 may, 2016 jmehm.tums.ac.ir navid abolfat-h zadeh et al. page 10 of 12 practice points • the current single, separate course of medical ethics during the medical curriculum is insufficient to meet the goals of medical ethics education. • combination of educational methods, like large group discussion, multimedia, theater-based case presentation, and role play, are very effective in teaching medical ethics. • medical students are potential human resources for enhancing effectiveness of educational programs. • there is increasing evidence to support student-based teaching of medical ethics. ethics: ethics is the branch of philosophy that deals with distinctions between right and wrong and with the moral consequences of human actions. examples of ethical issues that arise in medical practice and research include informed consent, confidentiality, respect for human rights, and scientific integrity. j med ethics hist med 9:3 may, 2016 jmehm.tums.ac.ir navid abolfat-h zadeh et al. page 11 of 12 questionnaires please determine your level of agreement to the statements below in terms of strongly agree, agree, neither, disagree, or strongly disagree. a) participants’ reflections on the students’ medical ethics rounds (smer) plan 1. theater group could successfully reflect the ethical problem of this session. 2. the presenter persuaded all participants in the discussion well. 3. the group discussion was not conducted appropriately (i.e., there was no difference between this session and university lectures). 4. professors provided a useful summary and responded well to the participants' questions. 5. the subject of this session was practical and useful to me. 6. my confidence has been improved regarding how to encounter the discussed ethical situation after this session. 7. the provided pamphlet was useful for learning the ethical subjects. 8. role playing helped me to improve my skills for a more ethical performance. b) knowledge and attitude questions 1. when i make a mistake during health care services, i do not disclose it to patients and their relatives, mainly in order to not ruin their beliefs in the medical team. 2. when i witness my colleague's mistake (with possible harms to patients), i directly disclose it to patients. 3. i think disclosing errors to my patient damages the physician-patient relationship. 4. in cases of medical errors with minor damages, patients must not be informed about them. 5. all medical errors should be judged based on the severity of the damage; thus, only important harms must be disclosed. 6. disclosure of medical errors lightens the patient-physician relationship and improves the health care service. 7. once my superiors make medical errors, i know what to do. 8. i am self-confident and skillful enough to disclose my own medical errors to patients. 9. patients prefer not to know health care providers' errors, because it disturbs them. 10. i believe it is unethical not to disclose my own medical errors. 11. i am able to convince my colleagues to disclose their medical errors to their patients when necessary. 12. i am usually reluctant to disclose my errors, in spite of guilty feelings. 13. i know what to do when either me or my colleagues make medical errors. 14. i am worried to be considered as a non-professional when disclosing my colleagues' error to somebody else. 15. disclosing medical errors increases the medical charges. 16. disclosing my own medical errors to my patients disrupts my relationship with them. 17. informed consent is a practical subject of medical ethics, and it is necessary to acquire skills for it. 18. i am confident enough to manage the cases of deciding about preparing written informed consent. 19. it is the patients' right to give their written informed consent before procedures. 20. in emergent and threatening conditions, the obtaining of an informed consent can be neglected. 21. it is not necessary to obtain written informed consent from patients with mental disorders. 22. it is not necessary to obtain written informed consent from patients under the age of 18 years. 23. i know ethical considerations of medical education, acknowledgement of which are necessary during my clinical education courses. 24. i always introduce myself as a medical student to patients. 25. i always do my best to cause minimal harm but provide maximal benefit to patients. 26. if the patient is reluctant to tell me her/his history, i will not try to force her/him by asking the professors. 27. practicing procedures on newly dead patients is correct when professors permit. 28. for involvement of patients in clinical education, informed consent should be obtained. 29. actions during clinical education of students must be advantageous for patients. 30. performing procedures is against the ethical law of nonmaleficence, because of the possibility of damages. 31. patients' satisfaction decreases during clinical education of patients. 32. conflict of interests is a practical subject of medical ethics, and it is necessary to acquire skills for it. 33. i am able to recognize any conflict between my interests (as the physician) and my patients' interests. 34. i know how to decide in cases of conflict of interests. 35. physicians should never accept gifts from pharmacy manufacturers. 36. physicians should not directly accept funds for travelling (or registration) for scientific congress from pharmacy manufacturers. 37. advertising medical instruments or medications by health care providers in their offices is forbidden, j med ethics hist med 9:3 may, 2016 jmehm.tums.ac.ir navid abolfat-h zadeh et al. page 12 of 12 based on local (iranian) regulations. 38. inviting or attracting patients from governmental medical centers to private clinics is forbidden, based on iranian regulations. 39. patients' rights should never been neglected by medical students because of justifications like having exams and etcetera. 40. i have enough knowledge about medical ethics considerations of end-of-life care. 41. i believe the physician is allowed to fulfill the patients' will for terminating his life (euthanasia). 42. communication with terminal patients about their prognosis damages them. 43. due to iranian regulations, cessation of life-maintaining interventions for terminal patients is forbidden even for requesters. 44. the request of patients' relatives regarding life-maintaining interventions for terminal patients does not have a role in physicians’ decision-making. 45. i have enough skills regarding communication with terminal patients about death and end-of-life issues. 46. i believe it is good to perform fake cardiopulmonary resuscitation for terminal patients (less than necessary time of protocols) to satisfy their relatives. hhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh copyright © 2023 tehrn university of medical sciences. this work is licensed under a creative commons attribution-non commercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. keywords: colleague’s error; medical error; ethical framework. introduction medical errors are an important and challenging issues in the health system and should therefore be considered ethically and legally. in this case report, a colleague's error was examined and the ethical and legal dimensions of its disclosure were discussed. this case report presents various aspects of a colleague's error disclosure in a framework using a review of studies as a practical guide. medical errors are among the challenges of the health-care system that usually occur due to human error and the poor design of health-care systems. evidence indicates that since medical errors are common and widespread, many patients experience complications while receiving health-care services (1). patients have the right to know what has gone wrong in their treatment process not only to facilitate the decision whether to continue the treatment and compensate for the damage caused, but also to maintain trust in the health-care system (2). the world health organization estimated in 2018 that preventable medical *corresponding author ehsan shamsi gooshki address: no. 23, 16 azar st., keshavarz blvd., tehran, iran. postal code: 1417863181 tel: (+98) 21 66 41 96 61 email: shamsi@tums.ac.ir received: 4 dec 2022 accepted: 1 may 2023 published: 13 jun 2023 citation to this article: khaleghparast s, maleki m, gholampour dehaki m, homami s, sadooghiasl a, mazloomzadeh s, et al. how to approach a colleague’s error: a journey from moral knowledge to moral action. j med ethics hist med. 2023; 16:2. errors caused harm to 10% of all patients receiving medical care (3). in middle-income nations, the rate of adverse events is 8%, 83% of which can be avoided (3). medical error rates range from 1% to 40% according to various studies. in the united states, such errors are the third leading cause of death how to approach a colleague’s error: a journey from moral knowledge to moral action 1. associate professor, cardiovascular nursing research center, rajaie cardiovascular medical and research center, iran university of medical sciences, tehran, iran; msc student in medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. 2. professor, rajaie cardiovascular medical and research center, iran university of medical sciences, tehran, iran. 3. assistant professor, department of health education and promotion, damghan school of health, semnan university of medical sciences, semnan, iran; msc student in medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. 4. assistant professor, department of nursing, faculty of medical sciences, tarbiat modares university, tehran, iran; msc student in medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. 5. professor, cardiovascular nursing research center, rajaie cardiovascular medical and research center, iran university of medical sciences, tehran, iran. 6. associate professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran; department of medical ethics, school of medicine, tehran university of medical sciences, tehran, iran. shiva khaleghparast1, majid maleki2, maziar gholampour dehaki2, setareh homami3, afsaneh sadooghiasl4, saeideh mazloomzadeh5, ehsan shamsi gooshki6* how to approach a colleague’s error: a journey from moral knowledge to moral action j. med. ethics. hist. med. 2023 (jun); 16:2. 2 the low rate of documented medical errors in iran may reflect the inaccurate reporting system of medical practitioners’ errors and not necessarily a low incidence rate (5). various reasons could be cited for negligence in reporting medical errors, including the belief that reporting errors would erode public trust and confidence in the medical community. despite the increasing awareness of and attention to medical errors, few studies have dealt with the issue from an ethical point of view. facing a medical error causes a person to be exposed to ethical questions concerning error disclosure, such as: who should disclose the error? when and how much should be disclosed? what are the conditions of disclosure? and what are the rights and responsibilities of each stakeholder in the disclosure process? in addition, there are differences between disclosing selferrors and the errors of other health-care providers. in order to answer each of the above questions a decision will need to be made, but various factors (such as the decision-making situation) affect the process and the results (6). for instance, in an ethical situation we use ethical decision making, a process in which people use their moral principles to determine the rightness or wrongness of a specific issue. ethical decision making requires a framework that can be relied on, as well as a model for using these principles to deal with moral issues (7). various models have been introduced for ethical decision making. in this research we will try to analyse the case of an error made by a colleague using a step-by-step approach on how to deal with the issue. the clinical case a 60-year-old man underwent coronary artery bypass graft (cabg) and aortic valve replacement (avr) surgeries. an x-ray on the morning following the surgery showed a piece of surgical gauze left mistakenly inside the patient’s chest. he was retransferred to the operating room where the gauze was successfully removed. while several ethical questions could be raised about this case, we concentrate on a rather important one regarding the disclosure of the error to the patient. in this case we examine the issue of whether the surgeon should inform the patient about the medical error before transferring him to the operating room for the second time. case analysis and discussion our method for analyzing this clinical ethics case is an innovative use of some theoretical approaches in the field of moral development and khaleghparast s., et al. 3 j. med. ethics. hist. med. 2023 (jun); 16: 2. moral psychology. this framework is a journey from theory to practice in analyzing such cases and includes 6 major steps based on the james rest model and lawrence kohlberg's approach and theory for moral development (diagram 1) (8, 9). diagram 1. action-oriented approach to medical ethics the first step in this framework is moral knowledge and continues with moral sensitivity, moral judgment, moral motivation and moral action. forming a moral character could be the final output of the model. the process starts when a health-care provider encounters an ethical question during clinical practice. such questions usually arise when the moral agents have some knowledge of the ethical aspects of their acts. as knowledge about related ethical issues increases, more ethical questions and challenges are simply resolved by present guidelines and therefore there is no need for further moral deliberations. such issues gradually become integrated in the daily practices of health-care workers as they basically use their knowledge to do the right thing. for example, based on the present professional ethics guidelines, health-care providers are required to how to approach a colleague’s error: a journey from moral knowledge to moral action j. med. ethics. hist. med. 2023 (jun); 16:2. 4 obtain informed consent from surgery candidates. this is a guideline that almost every surgeon knows and follows prior to surgery. therefore, if the existing knowledge about clinical ethics is sufficient and there is no major challenge in terms of execution, the first step in approaching clinical ethics cases would be to act based on the available knowledge. step 1 in this approach requires searching the existing ethical knowledge and guidelines about medical errors in order to find a clear answer. we recommend reading the “general guidelines on professional ethics for medical practitioners affiliated with the medical council of the islamic republic of iran”, published in 2018 (10). chapter 9 contains 4 articles regarding medical staff’s awareness of common errors in their field, taking responsibility for one’s error, compensating for the damage caused by the error, and respecting the dignity and professional status of colleagues (10). while the contents of the present guidelines provided by the medical council imply that the medical error should be disclosed to the patients, if the attending physician thinks that the guideline does not provide a clear instruction, he/she can be making is not straightforward and a priori knowledge of ethical standards cannot help the moral agent to decide, another process of moral decision-making will start. this process begins with a kind of emotional conflict called moral distress. feeling such distress indicates moral sensitivity, which is handled in step 2 (8). in this case the attending physician has enough sensitivity to moral issues to realize that disclosing the medical error to the patient is ethical and needs to be deliberated. as a rule, steps 1 and 2 are necessary to determine whether we have the answer to our ethical question or we need to start the process of moral judgment. step 3 is the most complicated and deliberative part in the process toward moral action. it necessitates making moral judgments and comprises the following 10 stages (diagram 2) (8) in stage i the biomedical/anthropological context should be determined. we need to know what type of error has occurred. leaving surgical gauze at the surgery site is a sentinel event demanding immediate action to prevent serious complications such as infection (11). this stage mainly requires being sure about the context and its clarification. some of the questions to be asked in this case are: has an error really occurred? how did the error occur? whose error was is? and what are the harms and burdens of such an error for the khaleghparast s., et al. 5 j. med. ethics. hist. med. 2023 (jun); 16: 2. patient? in the present case, the patient underwent cabg and avr during the same surgery. the length of the surgery required hand-over to a second nursing team halfway through, leading to an error in counting gauze pieces and leaving one of them at the surgical site. diagram 2. moral judgment framework the treatment affair deputyship of the iranian ministry of health and medical education issued the “never events” directive in 2017. leaving any device, including gauze, scissors and forceps, inside the patient’s body is among the 28 medical errors that must never happen in health-care centers. in our case, the significance of noticing and following up on the issue is abundantly clear. in stage ii we need to determine who the moral agent in each case is, that is, who ought to decide how to proceed. different members of a medical team may be involved in one clinical ethics case, and because of their moral sensitivity, they may experience moral distress. it is important to note that not all people who feel moral distress should respond to the situation, and therefore in this stage it is necessary to determine who the main how to approach a colleague’s error: a journey from moral knowledge to moral action j. med. ethics. hist. med. 2023 (jun); 16:2. 6 decision-maker is. although making decisions concerning an ethical issue such as a colleague’s error is best done by a team and after consulting clinical ethics committees or services, it should be clarified who has the main role in delivering the moral action. in our case, although the operation team members such as the circulating personnel and surgery assistants were responsible for counting the gauzes during the surgery, due to the central role of the attending physician as the surgeon, he/she should inform the patient or his family about the event and discuss the situation. in stage iii we are faced with the question of who should receive protection. usually many players and stakeholders are involved in clinical settings, for instance patients and their families, physicians, nurses, other health-care workers, hospital managers, medical students and residents, and even the society as a whole. although we need to consider all affected parties, it is essential to explore which one of the involved players should be prioritized for protection in the decisionmaking process. in the present case, it seems that the patient and the circulating nurse are prioritized players who need to be protected from harm. the justification for special protection for the nurse is that the patient and the family might hold the perpetrator solely responsible if the circulating nurse is named. in stage iv we need to make sure that we have in fact a real moral dilemma. a moral dilemma is a situation where two or more ethical standards, principles, rules, values, etc., compete. in the case of disclosing a medical error it is possible to assume that a moral dilemma exists. while some maintain that not telling the patient and the family the truth constitutes a breach of trust or may impose a psychological harm, others take the opposite view (table 1). table 1. the arguments for and against full disclosure of errors to patients and families proponents of disclosing the error opponents of disclosing the error • the patient's right to be informed of his/her condition • supporting the patients in making decisions related to their treatment process • the possibility of receiving timely and appropriate treatment • improving physician-patient communication • rebuilding trust in the medical community • causing severe emotional distress for the healthcare provider • creating anxiety and worry for the patient and his/her family • reducing the patient's trust in the doctor's ability • the possibility of increasing complaints to the court copyright © 2023 tehrn university of medical sciences. this work is licensed under a creative commons attribution-non commercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. in stage v a list of competing moral standards at stake should be specified and listed. in this case, non-maleficence, veracity, respect for autonomy, patient-physician trust, and public trust in the medical profession should be taken into account as ethical principles. for example, introducing the responsible nurse may put her/him in danger in some social contexts, but refusal to name the perpetrator might hurt the patient’s feelings. therefore, all individuals affected by this decision should be taken into consideration. in stage vi moral obligations should be distinguished from supererogatory choices. it is important to note that like any other field, there is a possibility of error in the medical profession. in stage vii the competing moral standards, rules and principles should be balanced to guide the decision making. for this purpose, we need to weigh the various standards listed in the previous stages. albeit hard, a balance should be struck between respecting patients’ autonomy and right as well as their families’ right to be informed of the error made by one’s colleagues on one hand, and preserving the colleagues’ safety and reputation while maintaining the physician-patient trust on the other. in stage viii we need to test the accuracy of our conclusions through some balancing strategies, mainly introduced by beauchamp and childress (12). the safety and reputation of the circulating nurse could be preserved through a complete explanation of the situation to the patient, including issues such as the inevitability of errors in medical practice, the systemic nature of such errors, and the intention of the medical team and the hospital to offer compensation and do everything possible to repair the harm. at the same time, we can argue that it is not possible to hide the error because another operation will need to be performed to remove the gauze, so hiding the fact may further disrupt the mutual patientphysician trust and also the trust in the profession and the institution. it is clear that in case of hiding the main reason for the second operation, the medical team will be lying to the patient, which is ethically unacceptable. therefore, it is safe to conclude that the right action in this case would be to disclose the medical error before performing the second operation. in stage ix the process of reflection, compensation, recovery and relief should commence. here we need to deliberate on various ways of decreasing the impact of our moral how to approach a colleague’s error: a journey from moral knowledge to moral action j. med. ethics. hist. med. 2023 (jun); 16:2. 8 judgments on different stakeholders. these deliberations would result in plans for compensation, recovery and minimizing the negative consequences of the decision on all involved parties. to illustrate the process, we present the following explanation to the patient and his family: “it’s the system’s fault, not the individual’s. as a legal entity, the hospital accepts that there’s been an error and will have to compensate. the least we can do is apologize and perform the second operation for free.” in addition, the patient and his family should be given a chance for legal action: they can sue the staff or the medical center. the medical center authorities should carry out the necessary legal evaluation and consider disciplinary assessment or resource allocation if needed (8). in stage x we need to make sure that our final judgment is compatible with the existing laws and regulations, and if it is not, we will need to resolve the issue by applying another type of moral judgment. being committed to the law could be a prima facie duty and in most cases we are obligated to follow the legal instructions. however, there are situations in which moral judgment is not accepted by the law and therefore following it could be a supererogatory act. after forming the judgment and determining the right moral action, it is time for step 4 of our framework, which covers moral motivation. we know that in many cases where we know what would be the right thing to do, the main problem is lack of motivation for taking the morally right action. this step requires that we analyze the possible motivations behind doing or not doing the morally right thing. in our case we need to consider the factors that contribute to nondisclosure of the error, including personal and institutional factors. understanding such motivations would pave the way to moral action. the theory of moral development mainly introduced by lawrence kohlberg provides an interesting ground for the understanding and categorization of various motivations that can be considered while analyzing clinical ethics cases. in this case fear of litigation would be one motivation of the medical team for not disclosing the medical error. avoiding similar errors in the future requires the medical personnel to have adequate moral motivation. still, a doctor’s moral motivation to report an error hinges on the hospital’s approach to medical errors. for instance, does the medical center hold the individual responsible, or is there a systemic approach? are errors reported in the khaleghparast s., et al. 9 j. med. ethics. hist. med. 2023 (jun); 16: 2. hospital? do higher authorities react to an error? hospitals’ due attention to such issues morally motivates individuals. step 5 includes delivery of the morally acceptable act. in this step we know what the moral action is, but we are also aware that it could be done in various ways. in this case if we consider informing the patient about a medical error that necessitates anther operation, the “bad news” could be delivered in different ways. dealing with a colleague’s error is best done in the presence of a team. the process should commence by offering the patient and his family an apology, which relies on non-verbal communication skills such as appropriate posture with the purpose of ameliorating the patient’s and his family’s distress and reducing the risk of future complaints. the medical center should offer reassurances not only by showing due diligence in actively working on the problem, but also through providing compensation for the costs and damages. also, caution should be exercised not to hurt the dignity of one’s colleagues while informing the patient and his family about the error. with respect to the present case, we would recommend the following line of communication: “we’ve detected an external object in the x-ray, indicating that you need another surgery. i can’t say for sure, but a piece of surgical gauze might have been left behind at the surgery site. to be sure, we need to open up the site.” non-deterministic sentences are highly recommended in this scenario. nevertheless, once the corrective procedure is performed successfully, the patient and his family should be fully informed about what transpired during the operation. we could envisage the following line of communication with regard to this patient: “three people are responsible for distributing and counting surgery gauze: the surgeon, the circulating nurse, and the scrub nurse. it was a long surgery, and a working shift change brought about this unfortunate error.” and finally, repeated moral actions should instill moral character in the medical staff in step 6 (the last step) (8). conclusion based on this analysis, the doctor must inform the patient and his family of the medical error in this case. although disclosure of the medical error to the patient could compromise the doctor-patient relationship, concealing the truth entails a more significant consequence, that is, the patient and his family may lose trust in the medical community. how to approach a colleague’s error: a journey from moral knowledge to moral action j. med. ethics. hist. med. 2023 (jun); 16:2. 10 such a scenario rings particularly true when the patient or the health-care system discovers the error. what should also be considered in this context is that informing the patient and his family of the error could be a case of breaking bad news, demanding certain communication skills to protect the patient from adverse health consequences (13). it is highly advisable that the medical error be viewed systemically. in our case, the error did not occur solely as a result of negligence on the part of the circulating nurse, but the management system is to blame as well. the circulating nurse evidently needs to be replaced during long surgeries, and therefore a management review of the error should investigate the staff’s working shift and determine error will be adequately addressed as long as they are deemed inconsequential and swept under the proverbial rug. indeed, if disclosing medical errors becomes the norm in health-care centers and the system supports those who do it, care receivers will appreciate that the medical team are as prone to mistakes as other professionals, and the patientdoctor trust will not be breached. furthermore, a record of the medical error should be kept in the patient’s file to prevent reoccurrence. needless to say that the patient should not bear the burden of the financial costs incurred by the error. finally, in the spirit of transparency, a sign could be placed in the operating rooms saying, “it has been .... days since we left behind an instrument in the patient’s body. errors happen, but we try to reduce them.” conflict of interests the authors declare that there is no conflict of interests. ethical considerations this article has been approved by the research ethics board at rajaie cardiovascular, medical and research center (ir.rhc.rec.1401.058). acknowledgements there are no acknowledgements references: 1. smits m, christiaans-dingelhoff i, wagner c, van der wal g, groenewegen pp. the psychometric properties of the'hospital survey on patient safety culture'in dutch hospitals. bmc health services research. 2008; 8(1): 1-9. khaleghparast s., et al. 11 j. med. ethics. hist. med. 2023 (jun); 16: 2. 2. rodziewicz tl, houseman b, hipskind je. medical error reduction and prevention. in: statpearls [internet]. treasure island (fl): statpearls publishing; 2023. 3. vatani a, tavajohi a, piri amirhajiloo f. the necessity of disclosure of medical errors: basics, systems and obstacles. scientific journal of forensic medicine. 2020; 26(2): 121-9. 4. xu m, wang y, yao s, shi r, sun l. one-year prevalence of perceived medical errors or near misses and its association with depressive symptoms among chinese medical professionals: a propensity score matching analysis. international journal of environmental research and public health. 2022; 19(6): 3286. 5. javaheri f. analyzing the issue of clarifying medical errors, analyzing the status of iran's medical institutions. iranian journal of social studies. 2014; 8(1): 22-48. 6. roshanzadeh m, vanaki z, sadooghiasl a. sensitivity in ethical decision-making: the experiences of nurse managers. nursing ethics. 2020; 27(5): 1174-86. 7. cerit b, dinc l. ethical decision-making and professional behaviour among nurses: a correlational study. nursing ethics. 2013; 20(2): 200-12. 8. rest j, narvaez d. moral development in the professions: psychology and applied ethics. uk: psychology press; 1994. 9. kohlberg l. the cognitive-developmental approach to moral education. phi delta kappan. 1975; 56(10): 670-7. 10. mohammadizadeh m, rahimi h, sabri mr, yamani n. compilation and implementation of "a set of instructions and evaluation tools for assistants' adherence to professional principles" in clinical training groups training specialized assistants. iranian journal of medical education. 2017; 17(14): 13742 11. lembitz a, clarke tj. clarifying" never events" and introducing" always events". patient safety in surgery. 2009; 3(1): 26. 12. beauchamp tl, childress jf. principles of biomedical ethics. uk: oxford university press; 2019. 13. babaii a, mohammadi e, sadooghiasl a. the meaning of the empathetic nurse–patient communication: a qualitative study. j patient exp. 2021; 8: 23743735211056432. jmehm-9-8_r1_.docx journal of medical ethics and history of medicine original article human dignity of patients with cardiovascular disease admitted to hospitals of kerman, iran, in 2015 roghayeh mehdipour-rabori1, abbas abbaszadeh2, fariba borhani3* 1assistant professor, department of medical-surgical nursing, razi school of nursing and midwifery, kerman university of medical sciences, kerman, iran; 2professor, department of medical-surgical nursing, school of nursing and midwifery, shahid beheshti university of medical sciences and academy of medical sciences, tehran, iran; 3associate professor, medical ethics and law research center, shahid beheshti university of medical sciences, tehran, iran. corresponding author: fariba borhani address: medical ethics and law research center, no 8, shams alley, tavanir cross, valieasr st., tehran, iran. email: faribaborhani@msn.com tel: 98 21 88202511 fax: 98 21 88202518 received: 2 nov 2015 accepted: 5 jul 2016 published: 16 jul 2016 j med ethics hist med, 2016, 9:8 © 2016 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract the human dignity of patients with cardiovascular disease (cvd) is an important issue, because of patients’ dependence upon caregivers, and because it impacts all aspects of their quality of life (qol). therefore, understanding and improving the status of dignity among these patients is of great importance. this study aimed to determine the status of dignity in patients with cvd admitted to cardiac intensive care units (cicus) in iran. this cross-sectional descriptive study was performed in 2015 on 200 patients admitted to the cicus of hospitals affiliated to kerman university of medical sciences, iran. the participants were selected using random sampling method. patients’ understanding of dignity was assessed through the reliable and valid persian version of the patient dignity inventory (pdi). patients who were able to read and write or speak persian and were conscious were included in the study. data were analyzed using descriptive statistics tests, independent t-test, and one-way anova in spss software. the mean age of the study participants was 59.0 ± 17.0. the mean score of human dignity was 3.60 ± 1.39. the mean scores of the factors of loss of independence, emotional distress and uncertainty, changes in ability and mental image, and the loss of human dignity were 3.94 ± 1.06, 3.63 ± 1.37, 3.57 ± 1.20, and 3.30 ± 2.08, respectively. a significant statistical correlation was observed between human dignity and the demographic characteristics of gender and frequency of hospitalizations in a cicu and a significant difference between those who lived alone and those who lived with family was observed (p < 0.05). patients hospitalized in cicus experience numerous problems associated with human dignity in each of its four dimensions. it is recommended that a study be conducted to investigate the relationship between the human dignity of patients with cvd and their qol, anxiety, and depression. keywords: heart disease, human dignity, patient rights, iran mailto:faribaborhani@msn.com j med ethics hist med 9: 8, july, 2016 jmehm.tums.ac.ir roghayeh mehdipour rabori et al. page 2 of 7 introduction the term dignity is derived from the latin words dignitus, meaning competency, and dignus, meaning derived value (1). although the term ‘human dignity’ has been used in numerous studies, its meaning is not clear (2). a simple definition of human dignity is the intrinsic value of an individual due to being human. a sense of this value is formed in the individual through relationships with others (3). human dignity has always been considered as important in all countries and religions and it is the foundation of human rights (4). illness, disability, need, reduced power and authority, lack of privacy, and being treated and hospitalized can affect human dignity (3). the restriction of human dignity can affect the body, spirit, morality, and spirituality of patients and expose them to stress and discomfort (3). different studies have shown that patients and nurses, depending on the culture of their country and region, have different definitions for and expectations regarding their dignity (5). manookian et al. defined the concept of patient dignity from the perspective of nurses as respect for the dignity of human nature, provision of professional patientcentered care, and respect for the rights of patients’ relatives (6). baillie also referred to patient dignity as consisting of feelings (feeling relaxed, in control, and respected), physical performance, and behavior. the environment, patient behavior, and factors related to healthcare personnel impact patient dignity (7). in a review study, shahriari et al. reported that human dignity is considered a trivial matter and accepted as part of the patient rights (8). different studies have shown that a lack of understanding of the concept of patient dignity may cause the treatment process to become difficult or may prevent patients from returning to treatment centers (9). studies indicate that, in recent years, nurses have become interested in issues such as the dignity of children, rehabilitation, patients in need of long-term care, and end-of-life patients (5, 6, 10). however, a limited number of studies have been conducted on dignity and its importance in patients who have been hospitalized in cardiac intensive care units (cicus). cardiovascular disease (cvd) is a major, universal public health problem. in the united states, cvd is an important cause of death. according to the u.s. national vital statistics report, 315,706 men and 315,930 women died of cvd in 2006, which accounted for about 26% of all deaths (11). it is estimated that in developing countries, because of changes in eating habits and the promotion of a sedentary lifestyle, cvd has become one of the most common causes of death (12). in iran, cvd is the most common cause of death (13). this disease affects patients, families, and society, causes the social isolation of patients, reduces quality of life (qol), and causes dissatisfaction (14). cvd results in patients’ dependence on their caregivers (nurses and family). this situation can affect human dignity and lead to patients’ loss of dignity (4). studies have shown that patients who suffer from chronic diseases like kidney disease, multiple sclerosis (ms), high blood pressure, diabetes, stroke, and psychiatric diseases also suffer from cvd (1517). studies have indicated that respecting patients dignity in cicus increases patient’s satisfaction and certainty of care, reduces length of hospitalization, and increases patient’s mental health (18). valian et al. also indicated that showing respect for patients increases patient satisfaction (19). onal and civaner found that one expectation of patients regarding preservation of their rights was respecting human dignity (20). it has been recognized that patients are not well respected in hospitals. in one study, baillie has indicated that patients in london are subjected to a reduction in dignity (21). in iran, ebrahimi et al. conducted a literature review and declared that patient dignity is not well supported and that medical and nursing staff do not have a correct understanding of patient dignity (22). respect for human dignity is the basis of nursing care, and one of the responsibilities of nurses is providing mental health care for patients. the different aspects of human dignity and the difficulties and discomforts that patients experience in this regard, however, are unknown. little research has been conducted on the dignity of patients in cicus. because of the importance of patient dignity and lack of studies in this field which can indicate the current status and requirements of patients, this study was conducted at the aim of assessing the status of patients dignity in cicus. it is hoped that by identifying the status of patients dignity in cicus, nurses and other healthcare providers may try to resolve problems related to human dignity and promote patients dignity. method this cross-sectional descriptive study was conducted in kerman, iran, in 2015. it investigated the status of human dignity in patients with cardiovascular disease (cvd). the study population consisted of cardiac patients hospitalized in cicus in hospitals affiliated to kerman university of medical sciences, iran. the researchers used a two-part questionnaire to collect data. the first part was a demographic questionnaire consisting of items on gender, marital status, education, occupational statues, and frequency of hospitalization (table 1). the second part was the patient dignity inventory (pdi). this tool was designed in 2008 by chochinov et al. and is used to measure human dignity and various sources j med ethics hist med 9: 8, july, 2016 jmehm.tums.ac.ir roghayeh mehdipour rabori et al. page 3 of 7 of distress and discomfort associated with patient dignity (23). in 2015, the validity of the pdi in iranian patients with cvd was approved by abbaszadeh et al. (24). this questionnaire includes 4 dimensions; loss of human dignity (11 items), emotional distress and uncertainty (8 items), changes in ability and mental image (4 items), and loss of independence (2 items) (24). table 1 provides more details about each dimension. each item on this questionnaire is scored between 1 and 5 in terms of the patient’s response, with a score of 1 indicating lack of any problems and 5 indicating presence of severe problems. the higher the score is, the greater is the problem associated with patient dignity. therefore, a score of 3 or higher indicates a serious problem. this standard 25-item tool has been previously investigated on a large number of patients. its internal correlation coefficient was 0.93, and its reliability in retest was 0.85 (25). in order to determine the face validity of the questionnaire, it was given to 20 patients with cvd with different educational levels. as a result, a face validity of 0.95 was obtained. cronbach’s alpha was used to determine the reliability of pdi (α= 0.87). to collect data, the persian version of the questionnaire was distributed among patients with cvd hospitalized in cicus. those patients who were able to read and write completed the questionnaires themselves, and patients who were illiterate completed the questionnaires through an interview with someone tending the patient. conscious patients whose health condition did not allow them to answer the questionnaire completed it when stabilized. to determine the sample size, the researchers first conducted a pilot study in which 20 randomlyselected patients hospitalized in a cicu completed the pdi. after calculating mean and standard deviations and taking into account a 95% confidence interval, an accuracy of 0.05, and s2 of 1296, sample size was estimated as 200 individuals. thus, 200 patients hospitalized in the cicus of educational hospitals of kerman were selected using random sampling method in 6 to 7 months. patients who were hospitalized in cicu, conscious, able to read and write or speak persian, and able and willing to participate in the study were included. patients who were hospitalized for the first time in the intensive care unit (icu) were excluded from the study. the permission to conduct the study was obtained from the ethics committee of the medical sciences research center (ethical code: k93.317). the researchers explained the study to the patients and signed informed consent forms were obtained from all patients participating in the study before the completion of questionnaires. they were assured that their information would be kept confidential. participation or non-participation in the study had no effect on the process of care. the collected data were analyzed using spss software (version 13, spss inc., chicago, il, usa). descriptive analysis tests (mean, sd, and frequency) and the independent t-test were used to compare human dignity in terms of gender, marital status, number of hospitalizations, and lifestyle. one-way anova was used to compare human dignity in terms of education level and occupation. all p values of less than 0.05 were considered significant. results data analysis indicated that of the 200 patients, 117 patients were men and 83 were women. the average age of the participants was 59.0 ± 17.0. other demographic data are presented in table 1. the mean score of human dignity was 3.60±1.39, and data analysis indicated that patients mentioned problems in all four dimensions. the mean scores of categories of loss of independence, emotional distress and uncertainty, changes in ability and mental image, and loss of human dignity were 3.94 ± 1.06, 3.63 ± 1.37, 3.57 ± 1.20, and 3.30 ± 2.08, respectively. the items of uncertainty about the disease and treatment process (4.83 ± 0.17), the feeling of being a burden to others (4.62 ± 0.38), having physically distressing symptoms (4.59 ± 0.41), the feeling that sickness and care have caused an invasion of privacy (4.52 ± 0.46), anxiety (4.36 ± 0.64), the feeling of emotional inability to cope with the challenges of the disease (4.16 ± 0.84), feeling one has changed in appearance (4.04 ± 0.17), and inability to perform daily living tasks (4.01 ± 0.99) had, respectively, the highest to lowest average scores. only two items had average scores of less than 2; the feeling that one is not the same person as before (1.89 ± 3.11) and the feeling that one has not made a meaningful contribution (1.38 ± 3.62) (table 1). table 1the mean scores of patient dignity dimensions and items mean ± sd loss of human dignity not feeling worthwhile or valued 3.27 ± 2.93 not able to carry out important roles 3.16 ± 2.44 feeling life no longer has meaning or purpose 3.14 ± 1.16 feeling that one has not made meaningful contributions 1.38 ± 3.62 feeling one has unfinished business 2.84 ± 2.16 concerns regarding spiritual life 3.16 ± 2.84 not feeling in control 3.91 ± 1.09 reduced privacy 4.52 ± 0.46 not feeling supported by friends 2.12 ± 2.88 not feeling supported by healthcare providers 2.83 ± 2.17 not being treated with respect 3.89 ± 1.11 emotional distress and uncertainty feeling depressed 2.90 ± 2.10 feeling anxious 4.36 ± 0.64 feeling uncertain 4.83 ± 0.17 worried about future 3.62 ± 1.38 j med ethics hist med 9: 8, july, 2016 jmehm.tums.ac.ir roghayeh mehdipour rabori et al. page 4 of 7 not being able to think clearly 2.04 ± 2.96 feeling that one is a burden to others 4.63 ± 0.38 not being able to overcome the challenges of the illness 4.16 ± 0.84 not being able to accept the way things are 2.50 ± 2.49 changes in ability and mental image physically distressing symptoms 4.59 ± 1.41 feeling one has changed in appearance 4.04 ± 0.17 not being able to continue usual routines 3.76 ± 0.13 feeling one is not the same person as before 1.89 ± 3.11 loss of independence not able to perform daily living tasks 4.01 ± 0.99 not able to attend to bodily functions 3.87 ± 1.13 table 2 compares mean human dignity scores in terms of the demographic characteristics of patients in the current study. as can be seen, there is a positive statistical relationship between the mean score of human dignity and the demographic characteristics of gender, frequency of hospitalizations in the cicu, and lifestyle. mean human dignity score was higher in women than men (p = 0.001). the mean score of human dignity was also higher in those who had been hospitalized more than 3 times than in those who had been hospitalized less than 3 times (p = 0.010). moreover, the mean score of human dignity was higher in patients who lived alone than in those who lived with their family (p = 0.001). table 2demographic data and human dignity scores of the participants demographic variables total sample = 200 n (%) mean score of patient dignity p gender men 117 (58.5) 2.80 ± 0.95 0.001** women 83 (41.5) 4.41 ± 1.84 marital status yes 135 (67.5) 3.39 ± 1.37 0.200** no 65 (32.5) 3.81 ± 1.41 education none or primary education 135 (67.5) 3.68 ± 1.32 0.100* high school 41 (20.5) 3.52 ± 1.13 college 19 (9.5) 3.73 ± 1.46 postgraduate 5 (2.5) 3.47 ± 1.65 occupational status employed 61 (30.5) 3.44 ± 2.49 0.500* unemployed 42 (21) 3.40 ± 1.01 retired 24 (12) 3.75 ± 1.31 housewife 73 (36.5) 3.81 ± 0.75 frequency of hospitalizations less than 3 times 137 (67.5) 3.10 ± 1.50 0.010** more than 3 times 63 (31.5) 4.11 ± 1.29 lifestyle live alone 20 (10) 4.47 ± 2.40 0.001** live with family 180 (90) 2.73 ± 0.38 note: *anova, **t-test discussion the present study indicated that the level of human dignity felt by patients hospitalized in cicus is low. this finding is similar to the findings of other researches, including studies by hall et al. and vehling and mehnert (26, 27). however, only a few studies had been conducted on the dignity of patients with cvd. patients with cvd feel that their human dignity is threatened because of their dependence on family, the chronic nature of their disease, and repeated hospitalizations (28). thus, one of the problems of patients during hospitalization is the loss of dignity (29). the present study indicates that patients with cvd have problems in all 4 dimensions of human dignity. regarding changes in ability and mental image, the results of earlier studies have indicated that when a disease is severe, the problems associated with patient dignity, ability, and mental image are also severe. this is due to their dependence upon families and caregivers. physical pain also causes problems for them, and patients with cvd are not excluded from this trend (30, 31). patients in the current study reported experiencing problems related to human dignity in the dimension of emotional distress and uncertainty. in a study conducted by biragh et al., 72% of patients with cvd reported symptoms of depression and 90% of the patients reported anxiety symptoms (31). denollet et al. indicated that a decrease in anxiety and psychological distress improves patients with cvd (32). this finding suggests that patients with cvd experience mental health problems due to their disease. the nature of cvd is such that it affects j med ethics hist med 9: 8, july, 2016 jmehm.tums.ac.ir roghayeh mehdipour rabori et al. page 5 of 7 various aspects of an individual’s life, such as comfort, lifestyle, income, and occupation. nurses should consider this and attempt to rehabilitate patients with cvd in a way that promotes human dignity. patients experienced problems related to human dignity after loss of independence. patients, who are able to make reasonable and rational choices, are competent in having authority, and are able to consciously make decisions based on their knowledge and the information provided them and participate in the mutual cooperation related to their healthcare (33). most patients with cvd are capable of making rational and informed decisions. if they have a problem related to dignity after losing authority, it is significant. nurses should pay sufficient attention to this matter and should involve these patients in their treatment process by providing them with information. the findings of this study indicate that there is a significant relationship between gender and emotional problems related to human dignity; women feel more problems associated with human dignity than men. also vehling and mehnert, in their study, concluded that women experience more problems associated with human dignity than men (27). in a study conducted by hall et al., however, no relationship was found between gender and problems associated with human dignity (26). this difference may be due to cultural differences between iran and england. gender differences between men and women in the iranian family and men’s stronger support system are perhaps the causative factors of this difference. the current study also indicated that there is a significant relationship between the number of hospitalizations and problems related to patient dignity. number of hospitalizations is affected by the severity and duration of the disease. studies have shown that there is a relationship between type of illness and dignity, and this is why the longer the duration of the disease, the more patient dignity is affected and reduced (34,35). this study indicated that there is a statistically significant correlation between living alone and problems associated with human dignity (36). those living alone reported more problems related to human dignity than those living with family. this, too, could be affected by the culture of a country where one tends to have a strong family support system during illness. human dignity is affected by distress; living alone is a cause of distress and is stressful for iranian individuals. a subcategory of dignity is social dignity, which is formed through relationships with others (37). the lower the rate of social interactions, the more social dignity is reduced. in the study conducted by sautier et al. in germany on the dignity of patients with cancer, no significant difference was found between demographic characteristics and the dignity of patients (25). this difference in findings is probably due to differences of the participants studied by sautier et al. with those in the present study. all patients studied by sautier et al. had an advanced-stage cancer and numerous experiences of hospitalization. the difference in the disease of the participants also created differences between the results of that and the current study. all items of the questionnaire used in the current study are valuable and important in patient dignity. a score of lower than 3 does not mean the item is less significant; each item is of great importance, because each one alone has a profound impact on dignity. considering that nurses spend most of their time with patients in hospitals and that patients with cvd are dependent upon their caregivers, nurses can take steps to respect patient dignity and educate patients’ families to preserve and promote patient dignity. through identifying the problems associated with patient dignity, attempts can be made to overcome these problems and steps can be taken to raise the level of human dignity in patients with cvd hospitalized in cicus. conclusion the present study showed that patients with cvd have difficulties in maintaining their dignity. hence, nurses and other health providers should provide assistance to these patients. this study had some limitations. one limitation was that only conscious patients were enrolled. moreover, the study was conducted in teaching hospitals (public), and differences may exist between patients in cicus of teaching hospitals (public) and those of non-teaching hospitals (private). it is recommended that future studies compare levels of human dignity between patients hospitalized in public and private hospitals. acknowledgments the researchers appreciate and sincerely thank all study participants and the staff of the cardiac care units. j med ethics hist med 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admitted to hospitals of tehran. j med ethics hist med 2014; 7: 20. 36. borhani f, hosseini sh. abbaszdaeh a. commitment to care: a qualitative study of intensive care nurses' perspective of end-of-life care in an islamic context. int nurs rev 2014; 61(1): 140-7. 37. chochinov hm, kristjanson lj, hack tf, hassard t, mcclement s, harlos m. burden to others and the terminally ill. j pain symptom manage 2007; 34(5): 463-71. ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ original article copyright © 2021 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. journal of m edical ethics and h istory of m edicine challenges for ethics committees in biomedical research governance: illustrations from china and australia *corresponding author ian olver address: university of adelaide, room 721a hughes building, north terrace, adelaide, sa 5005. tel: (+61) 40 92 20 026 email: ian.olver@adelaide.edu.au received: 16 sep 2021 accepted: 1 nov 2021 published: 10 dec 2021 citation to this article: huanhuan c, li m, wang m, roder d, olver i. challenges for ethics committees in biomedical research governance: illustrations from china and australia. j med ethics hist med. 2021; 14: 25. cao huanhuan1, ming li2, mingxu wang3, david roder4, ian olver5* 1.editor, chinese medical ethics magazine, xi'an shaanxi, china. 2.senior research fellow, cancer research institute, university of south australia, adelaide, australia. 3.chair professor, division of biomedical ethics, xian jiaotong university, xi'an shaanxi, china. 4.beat cancer research chair and professor, cancer epidemiology and population health, university of south australia, adelaide, australia. 5.professorial research fellow, school of psychology, faculty of health and medical sciences university of adelaide, adelaide, australia. abstract in this paper, the evolution of the ethics committees for health research, their history, membership, and function in china and australia is described. investigators in each country compared the history and governance of their ethical systems based on the published evidence rather than personal opinions. similarly, examples of challenges were selected from the literature. in both countries, the aim was to maximize the social benefits of research and minimize the risk imposed on the participants. common challenges include maintaining independence, funding and delivering timely ethical reviews of the research projects. these challenges can be difficult where research ethics committees rely on voluntary contributions and lack a strong resource base. they must adapt to the increasingly rapid pace of research as well as the technological sophistication. population health research can challenge the conventional views of consent and privacy. the principles of the sound ethical review are common in both countries; governance arrangements and operational procedures, however, can differ, reflecting the cultural values and norms of their host countries and in respect of legal environments. by studying the evolution and function of ethics committees in the two countries, we established the differences in the governance and health systems, while similar ethical objectives helped sustain collaborative research. keywords: australia; china; ethics committees; history. challenges for ethics committees in biomedical research governance: illustrations …. 2 j med ethics hist med. 2021(december); 14:25. journal of m edical ethics and h istory of m edicine introduction ethics committees play a vitally crucial role in the governance of the ethical conduct of biomedical research by minimising any potential risk to the research participants. consequently, the anticipated research benefits for society justify any risks. the committee structures, composition, and procedures have similarities worldwide; some differences, however, exist due to the customs, norms, and legislative environments of their host countries. with increasing international collaborative research, it is important to analyse the differences in the ethics review in different countries. this ensures the social benefits of research while minimizing the risk imposed on the participants. the collaboration between the researchers from australia and china in the cancer epidemiological research revealed the historical development of the ethical review process and the approach to the challenges they faced to differ in these two countries. china and australia have vastly different cultures and political structures. this has provided a unique opportunity to compare the history, use, and contemporary challenges of ethics committees in two very different countries, aiming to illustrate their commonalities, differences in the approaches, and challenges. methods the researchers from both countries reviewed the literature on the development, structure, and role of the research ethics committees in their respective countries so that the comparisons would be made based on the published evidence rather than personal opinions. the researchers were familiar with the challenges faced by their ethics committees and selected published examples on the solutions, in order to be helpful for the other countries. international history of the ethics committees the recognition of the necessity for having independent ethics committees for human research arose after world war ii with the 1947 nuremberg trials of the nazi doctors. they were found guilty of subjecting prisoners to research procedures, causing torture and death in their valueless experiments. the subsequent nuremberg code established the principles for human experimentation, including the requirement for voluntary informed consent (1,2). other examples of unethical research included the tuskegee study by the u.s. public health service which left black american males untreated to observe the natural course of syphilis (3). they were given poor and even misleading information about the nature and duration of the study. in 1964, the world medical association adopted a set of ethical principles for medical research by adopting the declaration of helsinki. this declaration was written by the doctors planning selfregulation (4). however, following the declaration, reports revealed unethical research practices in both the united states of america and great britain. henry beecher published a paper in the new england journal of medicine citing 22 examples of unethical research in 1966 (5). huanhuan c., et al. 3 j med ethics hist med. 2021(december); 14: 25. journal of m edical ethics and h istory of m edicine in 1967 maurice pappworth, a british clinician, published a book outlining examples of unethical research (6). such cases provided the impetus for the formation of research ethics committees (7). a major change in the 1975 revision of the declaration of helsinki was the requirement for a research protocol describing the experiment to be presented to a research ethics committee before the experiment could proceed. historical development of ethics committees in australia and china china in china, medical ethics committees were introduced in the 1980s. it was in response to the emerging ethical challenges in medical treatment, research, and the recognition of more formalized ethics review processes required to protect the legal rights of patients and research participants. the ethical challenges of the new developments in medical practice and research in china are similar to those encountered in many other countries. examples include questions around the withdrawal of life support for terminal patients, priorities in the allocation of rare human organs for transplantation, and the extent of treatment provided to newborn babies with major birth defects. additionally, research into the new medical technologies, whether on animal or human participants, are often ethically sensitive, and formalized reviews of the research activity is required to protect the rights of the participants (8). medical ethics committees developed in various stages. in stage 1 (1987-1996), an ethics subcommittee of the chinese medical association was initially proposed by a group of academics with a special interest in biomedical ethics. its purpose was to promote good ethics by monitoring ethical issues in clinical practice, research, and discussing the findings with the government and professional leaders. stage 2 (1997-2006) was developmental and characterized by increasing international collaborations and the emergence of national biomedical-related regulations and codes (9). the number of ethics committees increased markedly during this stage throughout china. nearly 400 hospitals established ethics committees, responsible for ethical review of specific studies, education, training, and broader policy research. the key developments included the establishment of the “biomedical research review committee of the ministry of health” and the “health ministry biomedical ethics committee of experts” in 1998 and 2000, retrospectively (10). since 2001, four key sets of regulations were introduced, relating respectively to “human assisted reproductive technology management”, “human sperm bank management”, “prenatal diagnosis technology management”, and “human organ transplant regulation”. these along with other initiatives provided an essential framework for regulating biomedical ethics applications. subsequent developments included the establishment of a specialized challenges for ethics committees in biomedical research governance: illustrations …. 4 j med ethics hist med. 2021(december); 14:25. journal of m edical ethics and h istory of m edicine drug clinical trial committee, a new biomedical technology committee, a productive medicine committee, and a human organ transplantation committee. these committees were attached to the relevant biomedical institutes. in stage 3 (from 2007), the medical ethics committees benefited from the implementation of the biomedical regulations in china. in some respects, these were stronger than the international standards. they were supported by the publication of two national landmark documents, namely: the “biomedical research ethics regulations” which were released by the ministry of health and revised in 2007 and 2016, retrospectively. the “guidelines for ethical review of drug clinical trials” were released by the national drug administration in 2010 (11). in addition to these national foundation regulations and guidelines, complementary regional regulations such as the shanghai ethics regulations were established (12) and published by the beijing municipal health bureau in 2015 and 2018, retrospectively (8). these regional regulations gave specific direction to the development of detailed functions, procedures, and the composition of the local medical ethics committees. australia the australian medical research focused on bacteriology and parasitology in the 19th century (13, 14). the first medical school was established at the university of melbourne in 1862. in 1936, the national health and medical research council (nhmrc) was established to support discovery research by focusing on the translation of the findings for the community benefits (15). the current ethical guidance document, the national statement on ethical conduct in human research 2007, was developed by the nhmrc, australian research council (arc), and the australian universities and revised in 2018. it was a successor to the first code of ethical conduct issued in 1966 (16,17). the first guideline for the use of animals in the research was also published in 1966 and was updated in 2013 (18). these followed guidelines of the nhmrc statement on the scientific practice (1990), the australian vice-chancellor’s committee’s guidelines for the responsible practice in research, and the problems of research misconduct (1990) (19). there is also a rolling review of the national statement conducted by a subcommittee of the australian health ethics committee of the nhmrc. although in the australian federated structure, the institutional research ethics committees are the states’ responsibility, the nhmrc sets out the certification standards. the nhmrc published a handbook for the national certification scheme of institutional review processes related to the ethical review of multi-centre research in 2012 (20). several states have created committees for this purpose to improve the efficiency and the costeffectiveness of the review of the multicentre trials without compromising the quality or paralleling the international experience (21). huanhuan c., et al. 5 j med ethics hist med. 2021(december); 14: 25. journal of m edical ethics and h istory of m edicine in australia, the national health and medical research council act 1992 (nhmrc act) established the nhmrc as a statutory body that requires human research guidelines to be developed by the australian health ethics committee (ahec), one of the principal committees of the nhmrc. ethics committees throughout australia are required to provide an annual report on their activities to this committee before they can be re-certified. a private australian health research ethics company (bellberry) that complemented the state-run ethics committees, was formed in 2004. bellberry limited is a national, notfor-profit company designed to provide an ethical review for the research conducted in the private sector, although its services are extended to include several public sector institutions. it encompasses new clinical drug studies, social sciences, and observational studies (22). bellberry hrecs provide a turn-around time of 20 working days by using an online e-protocol system and multiple committee meetings weekly. the paid reviewers are expected to deliver timely reviews. bellberry’s committees are also nhmrc certified, like all the other institutional ethics committees in australia. membership of ethics committees china the composition of the ethics committees, based on the publication of updated ethics regulations, evolved between 2001 and 2016. the changes included the national ethical codes for human-assisted reproductive technology, human stem-cell research, human organ transplantation, drug trials, and biomedical research on humans (23). these regulations specified the composition of the corresponding medical ethics committees and indicated standard eligibility criteria, selection processes, and tenure. for example, the human stem-cell research ethical regulation describes in the 9th code that the ethics committee must include researchers and managers in the fields of biology, medicine, law, or sociology. an ethics committee for human organ transplantation research must comprise experts in medicine, law, and medical ethics as stated in the 11th code. an ethics committee for the pharmaceutical trials must be a multidisciplinary team consisting of at least five members with gender balance from pharmacology and non-pharmacology departments, lawyers, and an independent individual. an ethics committee for the biomedical research on humans should have at least seven members, selected in the areas of biomedical sciences, ethics, law, and sociology, and the membership of a noninstitutional community. an ethics committee in the areas with minority ethnicities should include members from the respective ethnic communities. committee members are selected for a five-year term with the possibility of an extension. the committee is managed by a committee director and several vice directors selected by the committee (8). challenges for ethics committees in biomedical research governance: illustrations …. 6 j med ethics hist med. 2021(december); 14:25. journal of m edical ethics and h istory of m edicine the ethics committee structure is a branch of the government with vertical management from the national, provincial, and municipal levels. it is obliged to follow the chinese ethics review regulations, as well as the international ethical guidelines for the biomedical research involving human subjects, and the helsinki declaration. a national ethics expert committee is responsible for guiding or monitoring the provincial ethics review procedures and reviewing the performance of leading national biomedical researchers. the provincial ethics expert committee facilitates the standardized implementation of the regulations and provides training and consultative input into ethics review. at present, the major hospital centres for diseases control, blood centres, and medical research institutions in the main cities of china have established such ethics committees. australia the national statement sets out a minimum membership of a health research ethics committee (16). it specifies that there should be an equal number of men and women in the committee along with a suitably experienced chairperson. however, it was found that the australian ethics committees do not play an active role in monitoring gender equity in the research (24). at least a third of the members should come from outside of the institution for which the hrec is reviewing the research. there should be two laypeople, a man, and a woman, on the team. lay in this context means not engaged in medical scientific, legal, or academic work, nonetheless, these people should be interested in the research ethics. one member should understand professional care or counselling (e.g., a nurse or allied health professional). another one should perform pastoral care in the community, such as a minister of religion, and one should have legal expertise. two members should be researchers in a field of relevance to the submitted research proposals. if specific expertise for a proposal does not exist within the committee, it should be accessed from outside the committee. at least one of the ethics committee members should have ethics expertise. appointments should be made based on a transparent process, reflecting individual expertise not because individuals are representatives of any group or organization with ethics expertise. (table 1) understanding the impact of research practices on vulnerable populations and specific ethnic groups is a global challenge for the ethics committees. in australia, this is exemplified by research involving the aboriginal and torres strait islanders. they often cite inadequate community consultation and lack of demonstrable community benefits among issues reflecting exploitation born in colonialism and indicating an entrenched “western” approach to research (25). ethnically diverse populations in most countries raise the challenge of providing patient information in a diversity of languages and ensuring culturally appropriate decisions. it can be problematic when the ethics committees do not reflect multiculturalism. this, however, can be addressed in larger groups. huanhuan c., et al. 7 j med ethics hist med. 2021(december); 14: 25. journal of m edical ethics and h istory of m edicine nowadays, there are separate aboriginal ethics committees for studies involving aboriginal communities in australia. existing since birth, may develop and change under the influence of environmental factors (e.g., family, society, culture, and religion) and during the process of personal growth. table 1: comparison of ethics frameworks in china and australia china australia membership differs by research field minimum membership categories set by nhmrc gender equity equity governance vertical from national to provincial government state-based with national guidelines role review research protocols using standard operating procedures with code of conduct review research protocols guided by national statement of nhmrc alternate committees no private ethics committees private fee for service ethics committees certification of committees mandated using third parties nhmrc certified challenges finance of committees finance of committees workload workload in china, they have accommodated international ethics review practice in clinical research and traditional chinese medicine ethical review practice (26). in 2014, the first chinese accreditation program of ethics review system for cm research (cap) was established conjointly by the state administration of traditional chinese medicine and the ethics committee of the world federation of chinese medicine societies. both countries have urbanised and sparsely populated rural areas (27, 28). it is important to ensure that all population sectors are adequately represented in the population health and health services research. although, this can raise significant costs and logistical challenges. modern telecommunication and information technologies are increasingly being used to reach remote populations so that the population health research results would be relevant to their needs (29). roles of the ethics committees china the major role of the chinese ethics committees is to review and evaluate the rigor and broader scientific merit of medical research proposals, and their ethical conduct challenges for ethics committees in biomedical research governance: illustrations …. 8 j med ethics hist med. 2021(december); 14:25. journal of m edical ethics and h istory of m edicine with the protection of privacy, dignity, and safety of study participants (30). this includes checking the proposed research complementary to clear objectives of the past research and employing a rigorous methodology including well-defined processes for subject recruitment, informed consent, and privacy. proposals are expected to avoid harm and promote maximum benefits. as proposed therapeutic agents could extend the survival of cancer patients, due consideration is given comparing likely benefits to adverse impacts on patients’ quality of life, research costs, and costeffectiveness. the committees required the research to provide satisfactory responses to the questions about the proposals. approved researches undergo ongoing monitoring for compliance with approved protocols, research conduct, and adverse events as well as for risk/benefit (10,30,). the committees follow the standard operation procedures (sops) to ensure independence and transparency for reviewing ethics applications for biomedical research. sops cover comprehensive codes of conduct in the daily administration and workflow of the review process (31). these codes include mode of the review (e.g., meeting reviews, emergency meeting reviews, rapid reviews, etc.), review of the procedures (initial screening, follow-up reviews, conclusive reviews, etc.), time frames, outcome options for the review decisions (e.g., approval, approval after modification, rejection, and termination of research), protocols for on-site visits, application inquiries, and documentation (23). for example, the codes for an ethical review of the drug trials clearly explain regulations and governing processes for maintaining confidentiality, declaration and management of conflict of interest, training of new reviewers, the selection of independent external reviewers, and procedures for storage and distribution of applications. regulations for the human biomedical ethics committees state that an application should be approved by more than half of the relevant members of the ethics committee at regularly scheduled review meetings. australia likewise, in australia, most of the institutional research ethics committees guide researchers through the nature of the ethics approval process. they also aim for timely assessment of the research protocols. they enter into dialogues with researchers to ensure the risks or benefits to the research participants are minimised as they are fully informed. they monitor the progress of the research by considering amendments, possible ethical issues, or protocol violations that may have occurred (32). research ethics committees meet in fixed intervals, often monthly, and set forms for submitting research protocols. in australia, several committees submit protocols through the nhmrc online human research ethics application (hrea) form collecting detailed information about the proposed research study (33). generally, each committee appoints a spokesperson to present a summary of the proposal to the committee in order to make a collective decision on the study. committees can huanhuan c., et al. 9 j med ethics hist med. 2021(december); 14: 25. journal of m edical ethics and h istory of m edicine approve the study, return the study for amendment, re-review, or reject the study. a key performance indicator for a committee is the timeliness of the review. increasingly, mutual recognition of the decisions made by other ethics committees is encouraged to avoid duplicated efforts and possible delay by having to be reviewerd by multiple ethics committees. major differences in the decisions made between similarly constituted ethics committees are unlikely. for the very-low risk studies (e.g., student surveys), several committees have altered the mechanisms of the review to the chair or a subgroup with later ratification by the full committee. the best committees are willing to engage with the researchers who may have queries before the submission or who wish to discuss amendments prior to resubmission. frequently, the scientific aspects of the study are scrutinized by a separate committee or experts who inform the committee in specialised research areas. research governance issues are usually and separately considered by the administering health unit. committees also have active processes for following the approved studies. many committees require the investigators to submit at least annual reports. a further aspect of the ongoing review is to assess adverse event reports and therefore the ethical viability of the project. challenges for ethics committees research ethics committees across the world face similar challenges independence and funding a challenge for the health research ethics committees is to maintain independence irrespective of whether they are governmentsponsored or depend on an institutional structure for their finances or governance. regularly, the key members come from the management ranks of the institutions in china (34). there may be limited financial support outside of the levies for the review of applications. a survey of 14 fujian ethics committees did not find any stable financial support (30). in australia, there is an ever-increasing workload for the research ethics committees and with limited financial support it makes sense to have a single committee review multicenter trials and the other committees accept that decision. the nhmrc allows mutual recognition of decisions of ethics committees but with australia's federated political structure this has only occurred to date within state borders and not nationally. high workload pressure in china makes it difficult for the committees to maintain standards (30, 34). some ethics committees lack sufficient professional ethics membership, forcing the limited ethical experts to hold membership in 5 to 6 committees at the same time. it is not compulsory to have academics in ethical or legal sciences on the committee, although the required composition of a human-based biomedical ethics committee is clearly stated (31). china has established local ethics committees to improve the overall performance. major municipal cities (beijing and shanghai) and provinces challenges for ethics committees in biomedical research governance: illustrations …. 10 j med ethics hist med. 2021(december); 14:25. journal of m edical ethics and h istory of m edicine (shandong, sichuan, and guangdong) have set up their regional committees, following a government announcement in 2017. more developmental efforts are required to reinforce the regional committees, their composition, and sops (30). in china, the ethics review process is being reinforced by the legislation based on the international codes such as 2001/20/ec, 2005/2b/ec, british “human drug (clinical trials) codes” and the us federal laws (35). however, the legislation needs flexibility as research evolves over time. in australia, in the case of research on mitochondrial replacement therapy, current laws stating that the embryos must be produced from two sources of dna have to be revisited (36). as previously indicated, one of the nhmrc functions is to approve the third-party certification of the ethics committees introduced under the chinese law, the recommendations of the strategic initiative for developing capacity in ethical review (sidcer), and the association for the accreditation of human research protection program (aahrpp) for the existing international 3rd party practice (37,38). this is expected to improve the procedural standardization of ethics committees and their independence of practice. providing education for the researchers and potential ethics committee members would have been an important role for ethics committees as most of them are not resourced to do so. in australia, the nhmrc has no resources for educating ethics committees beyond providing written guidelines on the ethical conduct of research through the national statement and special guidelines for emerging research areas such as assisted reproductive technology and organ and tissue transplantation (39). ethics committees can aid researchers in reducing the number of required amendments by publishing acceptable wording for the standard sections of the patient information and the consent form if they were poorly worded. timeliness of the review process a common challenge for the ethics committees is the review process timeliness. most research ethics committees rely on the member contributions freely given without any charge. this was successful at the beginning; it, however, became more difficult with the increasing demand over time. when the committee secretariat is poorly resourced, additional pressure and lengthened turnaround times hinder timely and productive research. increasingly, the committees have performance standards on the processing time to address this issue. solutions include creating single ethics committees for multicentre trials to reduce the duplication of efforts, and private committees where timely reviews are part of the contractual obligation of the reviews (21, 22). however, a more difficult issue is the timeliness of the parallel governance process where individual institutions want to work on their own due diligence and being reluctant to allow a centralised process to review and yet have not set timelines in parallel with those of the ethics review committees. the performance indicators for the governance reviews of the protocols are required. huanhuan c., et al. 11 j med ethics hist med. 2021(december); 14: 25. journal of m edical ethics and h istory of m edicine the ethical challenges of evolving research capabilities new research capabilities challenge traditional ethical ideals as the digital world and social media have created new problems. large databases and registries can be linked, and special issues are faced in balancing the privacy of information against the importance to the community and policymakers. ethical reflection on big data and the application of artificial intelligence and machine learning, regardless of it being a genomic dataset, biobank, or epidemiological research data, will determine if additional ethical considerations are needed to be considered over the use of older data for research (40). an issue with social media is the easy dissemination of information to the public. ethics committees ensure the balance and accuracy of the information provided to potential trial participants in the consent forms while not applying sponsored online information. social media has also spawned the participant-led research of the virtual communities, raising the need for new methods to assess the ethical standards of consent, privacy, and way of sharing intellectual property (41). issues of consent consent has always been an issue with minors or incompetent patients who require substituted consent (42). with genetic testing, the results may reveal information about the health of the relatives. one question always remains regarding the incidental finding of abnormalities in the genes other than the ones being tested (43). in the field of xenotransplantation research, the greatest concern is the transplanted organ that triggers a human epidemic due to harbouring a zoonotic infection. if the research receives the required permission, the subjects should be monitored and close relatives or contacts need to be informed of the risk. this would challenge two of the traditional statements in the consent form such as the participant being able to withdraw at any time and their confidential participation (44). when dealing with a large population of patients whose data will be analysed anonymously, this is considered low-risk research, and it would not be practical or appropriate to ask for everyone’s consent. in between a waiver of the consent and individual consent can be so-called opt-out consent (45). the group of potential participants is informed of the study and given a mechanism to opt-out if they wish. the ethics committees assess the research that uses registries and other large datasets. such datasets which need to have as complete a sample as possible to be confident of the accuracy of the outcomes may prefer an opt-out option of obtaining consent rather than a waiver of consent where no information is given to potential participants. alternativly, quality assurance activities are often granted the waivers of consent. conclusion by comparing the evolution and the function of ethics committees in two countries with challenges for ethics committees in biomedical research governance: illustrations …. 12 j med ethics hist med. 2021(december); 14:25. journal of m edical ethics and h istory of m edicine distinctly different government and health systems, we have established the similarity of the objectives of the research ethics review processes. these goals include maximizing the social benefits of research while minimizing potential harm to the research participants and so collaborative research was sustainable. both countries face similar challenges; they, however, have often addressed them in different ways, reflecting the cultural values, norms, and legal environments of the countries. this unique comparison has produced insights into a range of solutions available for the challenges faced by research ethics committees. acknowledgements the authors wish to thank all the participants and those who made this study possible. references conflicts of interests the authors have no financial or other conflicts of interest to declare. abbreviation national health and medical research council (nhmrc) australian research council (arc) national health and medical research council act 1992 (nhmrc act) australian health ethics committee (ahec) chinese accreditation program of ethics review system for cm research (cap) standard operation procedures (sops) human research ethics application (hrea) strategic initiative for developing capacity in ethical review (sidcer) association for the accreditation of human research protection program (aahrpp) 1. the nuremberg code (1947). british medical journal. 1996; 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[cited dec 2021]; available from: https://clinregs.niaid.nih.gov/country/united-kingdom 36. newson aj, de lacey s, dowling dk, et al. public attitudes towards novel reproductive technologies: a citizens’ jury on mitochondrial donation. hum reprod. 2019; 34(4): 751-57. 37. anonymous. association for the accreditation of human research protection programs inc. [cited dec 2021]; available from: https://www.aahrpp.org 38. anonymous. strategic initiative for developing capacity in ethical review. [cited dec 2021]; available from: https://www.who.int/sidcer/en/ 39. anonymous. national health and medical research council. ethical guidelines on the use of assisted reproductive technology in clinical practice and research. [cited dec 2021]; available from: https://www.nhmrc.gov.au/about-us/publications/ethical-guidelines-use-assistedreproductive-technology 40. lipworth w, mason ph, kerridge i. ethics and epistemology of big data. j bioeth inq. 2017; 14(4): 489-500. 41. ienca m, ferretti a, hurst s, puhan m, lovis c, vayena e. considerations for ethics review of big data health research: a scoping review. plos one. 2018; 13(10): e0204937. 42. courtwright a, rubin e. who should decide for the unrepresented? bioethics. 2016; 30(3): 17380. 43. broadman f, hale r. responsibility, identity, and genomic sequencing: a comparison of published recommendations and patient perspectives on accepting or declining incidental findings. mol genet genomic med. 2018; 6(6):1079-1096. 44. olver in. ethical issues with xenotransplantation clinical trials. med j aust. 2016; 204(6): 212. 45. olver in. opting in for opt-out consent. med j aust. 2014; 200(4): 201-2. http://trust-project.eu/wp-content/uploads/2016/03/chinese-ethics-review-system.pdf http://trust-project.eu/wp-content/uploads/2016/03/chinese-ethics-review-system.pdf https://clinregs.niaid.nih.gov/country/united-kingdom https://www.aahrpp.org/ https://www.nhmrc.gov.au/about-us/publications/ethical-guidelines-use-assisted-reproductive-technology https://www.nhmrc.gov.au/about-us/publications/ethical-guidelines-use-assisted-reproductive-technology abstract introduction hhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh copyright © 2022 tehran university of medical sciences. this work is licensed under a creative commons attribution-non commercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. abstract: using genetic tests on deceased patients’ samples for diagnostic purposes affects the family members' health and lives but raises some ethical issues in today’s practice of medicine and research. in this paper, we address a common ethical dilemma of clinicians regarding whether to perform genetic tests on a deceased patient’s sample upon a request from first-degree relatives against the patient's wishes in the last days of life. in this paper, a real case scenario is presented that echoes the abovementioned ethical challenge. reviewing the genetic basis of the case, the ethical arguments for and against the reuse of genetic material in a clinical context are discussed. an ethico-legal analysis of the case is proposed based on islamic medical ethics resources. as reusing stored samples of expired patients without their consent also challenges the researchers in the field of genetics, a debate is included on the post-mortem use of genetic data and samples for research. *corresponding author mina forouzandeh address: shahid hemmat highway, school of medicine, iran university of medical sciences, tehran, iran. postal code: 1449614535 tel: (+98) 21 86 70 33 46 email: foruzandeh.m@iums.ac.ir received: 11 aug 2022 accepted: 24 oct 2022 published: 28 dec 2022 citation to this article: noroozi m, bahmani f, mousavizadeh k, saeedi tehran s, hashemi a, forouzandeh m. to use or not to use? an ethical analysis of access to data and samples of a deceased patient for genetic diagnostic and research purposes. j med ethics hist med. 2022; 15: 13. finally, defining the special features of the presented case and positive benefit-risk ratio, it is concluded that reusing the patient's sample may be justified if the first-degree family members insist on genetic testing and are comprehensively informed about the benefits and harms. keywords: genetic information; postmortem disclosure; ethics; family members; confidentiality; consent. to use or not to use? an ethical analysis of access to data and samples of a deceased patient for genetic diagnostic and research purposes 1. assistant professor, medical ethics department, school of medicine, iran university of medical sciences, tehran, iran. 2. professor, department of pharmacology, school of medicine, iran university of medical sciences, tehran, iran. mahshad noroozi1, fatemeh bahmani1, kazem mousavizadeh2, saeedeh saeedi tehrani1, akram hashemi1, mina forouzandeh1* to use or not to use? an ethical analysis of access to data and samples of a …… j. med. ethics. hist. med. 2022 (dec); 15: 13. 2 introduction genetic technologies help improve health and prevent diseases. monogenic diseases can be identified by genetic testing, and genomic testing detects illness risk factors, including several genes (1). therefore, these technologies can discover traits in a patient's dna that may affect her/his health, aiding doctors in preventing or delaying the onset of ensuing illnesses, estimating disease risk for family members, and avoiding transmitting these hazards to descendants (1). the development of diagnostic genetic technologies has been associated with novel ethical issues (2,3). genetic technologies involve the handling of highly personal information that could have far-reaching consequences for patients and family members (1). using a genetic test in an asymptomatic person to predict the future disease risk has significant effects on the family members' health and lives but can lead to inevitable family conflicts (2,3); hence, it is essential that it be practiced with due regard for ethical, legal, and societal factors (1). communicating about a familial genetic risk outside of the context of a patient-doctor relationship is a contentious ethical and legal problem that has been debated for years (4). biotechnological applications also challenge western individualism (2,3). implementing the principle of respect for autonomy can create ethical difficulties and controversies that convey a foucauldian doubt about the indisputable truth of autonomy (2). although new genetic technologies are more affordable and faster, the simple act of reviewing family information still forms a significant part of the daily routine of genetic evaluation. genetic testing of a relative is sometimes necessary for accurate genetic testing on the person seeking advice (5). in some cases, patients requesting genetic counselling should have access to information about their relatives' conditions and genetic traits. if a family member is dead and has not specified how his/her medical records can be used posthumously, obtaining his/her consent is not feasible (5). hence, it is reasonable to expect at-risk family members to be interested in receiving the genetic results of deceased relatives, which may impact their health (6). nevertheless, whether to disclose the genetic information of a deceased patient to family members is a controversial issue needing ethical analysis (6). there is an agreement that genetic noroozi m. et al. 3 j. med. ethics. hist. med. 2022 ( dec); 15: 13. data, such as clinically significant and actionable genetic abnormalities, should be shared with patients. however, there are fewer agreements on how best to share hereditary risk information with family members from a genetic perspective (6). a similar approach has been adopted in the iranian medical context. article 89 of the iranian code of ethics for medical professionals conveys that reusing a patient’s genetic information and samples is permitted only by the patient’s consent or for anonymous use (7). in what instances, if any, do physicians have an ethical obligation to share this genetic risk knowledge with relevant family members, or can they re-use the patients' samples for family members' genetic tests? it is one of the most important unresolved questions (4). following a patient's death, when consent cannot be legally obtained, the issue of whether or not to disclose genetic information to family members becomes very prominent (6). in cancer cases, the patients' relatives may benefit from risk assessment and more precise treatments through genetic and genomic testing, and ethical issues are more significant (8). whether using and sharing identifiable research data after death is ethically permissible is questionable. therefore, in this article, access to data and samples of a deceased patient for genetic diagnostic and research purposes is ethically analyzed. to achieve this goal, a real scenario is presented and the arguments for and against using genetic data against the patient's consent are put forward in an effort to answer two pivotal questions: is it ethical to use the deceased patient's data samples for diagnostic purposes for relatives? is it ethical to use the deceased patient's data and samples for research purposes? real scenario a 59-year-old man with primary myelofibrosis (pmf) was treated with hydroxyurea for five years. he was referred to the hematology department for fever, pneumonia, and pancytopenia. bone marrow biopsy showed hyperplasia and fibrosis. the patient reported a positive family history of cancer in first-degree relatives (his father had laryngeal cancer and his sister had a brain tumor) and seconddegree relatives (his cousin had a brain tumor). he was a candidate for bone marrow transplantation. an eligible donor was not found, and chemotherapy was ineffective. unfortunately, he died a few months after confirmation of the blast phase. tumor genetic tests were performed to find targeted therapies for the patient based on the detected mutations. because of technical issues, the results of genetic tests were prepared a few months to use or not to use? an ethical analysis of access to data and samples of a …… j. med. ethics. hist. med. 2022 (dec); 15: 13. 4 after the patient passed away. the family genetic consulting was performed to propose additional genetic tests to the first-degree family members that included only two members: the patient's sister and daughter; however, targeted genes for this disease have no x-linked inheritance. although the patient had verbally refused to re-use his blood sample for relatives’ genetic tests in the last days of his life, the family members insisted on further genetic evaluation of the patient’s sample. however, the patient's refusal was not obtained through a valid written informed process, and he also did not mention his decision regarding reusing the sample after his death. discussion genetic basis of primary myelofibrosis primary myelofibrosis (pmf) as a myeloproliferative neoplasm is defined by widespread fibrous tissue in the bone marrow and an increased number of myeloid cells. it is accompanied by extramedullary hematopoiesis, organomegaly, pancytopenia, and an altered cytokine expression profile (9). one-third of the patients (30%) have no symptoms and are detected inadvertently, usually due to an abnormal blood count or splenomegaly (10). in the asymptomatic phase, it is difficult to identify and diagnose most pmf cases. the patients may remain symptom-free for many years (9, 11). severe anemia, marked hepatosplenomegaly, fatigue, night sweats, fever, cachexia, bone pain, splenic infarction, pruritus, thrombosis, and bleeding are the clinical manifestations of pmf (12). the cause of death associated is frequently attributed to heart failure, infection, hemorrhage, or acute leukemia (approximately 20% of pmf patients) (9). in asymptomatic patients, clinicians may consider delaying treatment until symptoms appear. this approach is known as "watch and wait" (11). in symptomatic patients, a number of new medications are under ongoing trials. however, allogeneic stem cell transplantation is the only established treatment for pmf in very highrisk patients based on mutations and karyotype. it is a highly experimental procedure; therefore, it is difficult to achieve a cure (9,12). a critical issue is the patient's survival, which is 3.5 to 5.5 years from diagnosis of the disease. in familial cases, the 10-year survival rate is only 30% (9). compared to more distant relatives, the firstdegree relatives of the patients have a 5-7 times elevated risk (9). a dynamic model of the international prognostic scoring system (ipss) (dipss) was used to estimate a patient's survival noroozi m. et al. 5 j. med. ethics. hist. med. 2022 ( dec); 15: 13. (13). recently, gipss (genetically-inspired prognostic scoring system) and mipss70+version2.0 (mipssv2; mutation and karyotype enhanced international prognostic scoring system) have been presented for survival assessment (12). previous studies showed a worse survival in pmf associated with nullizygosity for the special haplotypes of jak2 and in patients with a low jak2 allele burden (13). therefore, the identification of jak2 somatic mutation is valuable in estimating the survival. the presence of mutations in jak2, calr, or mpl is anticipated in approximately 90% of the patients. these mutations are also prevalent in other myeloproliferative neoplasms, including polycythemia vera (pv) and essential thrombocythemia (et). in the presence of a positive family history, these mutations support the probability of pmf (12). in new prognostic models, the mutations and karyotypes are pivotal in assessing the patient’s survival. the bioinformatic analysis of this patient's exome sequencing data revealed several genetic variants in important cancer genes, including jak2, idh1, and chek2. the somatic variants in the jak2 and idh1 may be important for targeted cancer therapy to overcome resistance in this patient. the variant in chek2, known as the germline cancer predisposition variant, may be related to familial cancer in the patient's pedigree (pmid:19401704). therefore, genetic testing in asymptomatic family members may help to detect high-risk individuals. ethical arguments for disclosure and re-use of genetic material beneficence principle: a dynamic approach to medical intervention based on genomic risk information is accessible. blood relatives can learn about their genetic risk through family genetic testing and act proactively (8). it is predictable that conditions that are unpreventable or untreatable at present may become manageable in the future (14). it is argued that disclosure is beneficial, mainly if the hereditary condition is treatable or preventable (6). for specified mutations like brca1/2, relatives might consider prophylactic surgery to prevent advanced cancer if they are aware of a specific mutation. furthermore, a genetic test result can be psychologically beneficial, especially if it helps to better understand the cause of a familial disease. (6). genetic information may benefit relatives, assist in reproductive decisions, and influence their future lives. furthermore, knowledge of the genetic makeup could provide them with meaning. to use or not to use? an ethical analysis of access to data and samples of a …… j. med. ethics. hist. med. 2022 (dec); 15: 13. 6 sharing information with family members enriches well-being by enabling them to take control over their lives to some extent (6,15). the relatives' genetic right to know is fundamentally based on autonomy and control (15). whether physicians have a duty to improve the family members' autonomy remains controversial. physicians are not obligated to improve the welfare of the patients' families at all times since it may interfere with their primary duties. is it reasonable for a physician to support the autonomy of a family member without a physician-patient relationship? (6,15) in recent decades, the emphasis on the self-determination and well-being of patients has formed the concept of autonomy. however, there has been uncertainty about the family’s involvement in a competent patient’s medical decision-making, which is supported by the recently proposed notion of “relational autonomy” (16). relational autonomy, originally a feminist concept, regards “individuals’ identities, interests, ends, and beliefs as fundamentally dynamic, continually constructed and reconstructed in dialogic processes with other people” (17). relational autonomy is a meaningful substitute for autonomy in clinical genetics, as it addresses genetic information that is, by its nature, shared and related to the patient's family members (18). conceptually, pursuing informed consent based on individualistic autonomy increases the inherent complexity of real genetic cases. treating the patient’s consent as a person's decision hinders shared decision making in the family members from whose wellbeing and self-determination are affected by the individual patient’s choices (18). concept of shared possession of genome: despite the dna commonalities in humans, each person has a unique genome arrangement. it is not uncommon for first-degree relatives to receive a significant percentage of this package (6). genetics was developed by family linkage studies illustrating an individual’s genetic risk. moreover, according to some scientists, genetics is a form of family inheritance (2). additionally, a specific medical diagnosis can profoundly impact close relatives' health, and test results could even cause harm to relatives (6). gordon et al. found that participants believed genetic information was shared property. they believed that genetic information should be shared rather than controlled and that the concept of autonomy on personal information was not applicable (15). accordingly, regarding the idea of shared possession of dna with biological relatives, there is an argument that biological relatives should have access to the patient's genetic information to noroozi m. et al. 7 j. med. ethics. hist. med. 2022 ( dec); 15: 13. determine their risk of genetic diseases (6). there are some arguments in medical sociology and anthropology about the concept of kinship and new forms of responsibility to offspring and next-of-kin based on genetic material (19). the degree of relatedness and the concept of next of kin is an essential issue in this idea, and these terms should be recognized in countries' legal systems (5,6). some commentators have suggested the necessity of kinship ethics, which derives from conflicts of interest caused by sharing genetic material and data between relatives (20,21). regarding kinship ethics, moral creatures should avoid interfering with other creatures' survival efforts (22). however, by considering dna as shared property, people may be restricted in their autonomy. therefore, the shared property concept is debatable (6), and the individualist perspective of ethical issues raised by genomic data could be controversial (2). duty to warn relatives and right to know: there is an argument that physicians should inform a patient's relatives about the gene-transmitted disease when certain conditions apply. the information should be informed to relatives if it includes a condition that may result in severe, impendent, or undeniable harm, and there is treatment or prevention. early diagnosis is often associated with the early treatment of certain conditions, while late detection often results in an incurable condition (6). physicians generally encourage patients to tell their relatives about genetic risks during their lifetime. it is no longer possible after their death, making a clinician's duty to care more critical, especially if genomic data become available only after their death. however, because of the patients' confidentiality and privacy issues, the duty of physicians to notify family members is not unlimited. (6). gordon et al. found that contrary to presumed values of the patients' privacy, the participants (patients and their relatives) agreed to share information even after death (15). in the case of abc v st george’s healthcare nhs trust, an english man with huntington's disease was unwilling to disclose the diagnosis to his pregnant daughter because of concerns about her decisions about abortion (4). the court of appeal concluded that, depending on a particular case, a clinician's obligation to warn a patient's relatives of increased genetic risk could be fair and reasonable (4). the court also suggested that if relatives would gain nothing with information disclosure (because of no available preclinical diagnostic tests, approved treatment, or after childbearing age), physicians have no duty to warn and care for them to use or not to use? an ethical analysis of access to data and samples of a …… j. med. ethics. hist. med. 2022 (dec); 15: 13. 8 (4). hence, genetic health policy should focus on culture and reproductive choice in decision-making about the disclosure of genetic data (22). another issue is that a legal duty to warn should be extended to whom as a genetically at-risk relative (14). it is necessary to define the term “family members” (to whom genetic data should be disclosed). this definition must be under the laws of each country; for instance, in the united states, "family member" means anyone from the first to the fourth-degree relative as defined by the genetic information nondiscrimination act of 1988 (14). due to direct-to-consumer technology, healthcare providers are no longer involved in the initial steps of genomic sequencing. nevertheless, they have an essential role in counseling patients and at-risk relatives. moreover, a pivotal matter is that the warning should be delivered appropriately understandably regardless of the person that provides it (a patient or a healthcare provider) (14). however, the patient should be warned that if more genetic information is available, it is linked to a wide range of other data, and new clinical implications are continually being discovered (14). ethical arguments against disclosure and re-use of genetic material nonmaleficence principle: physicians have an obligation not to harm patients. the same can be asserted about their moral duty to inform family members about genetic information. family members may suffer emotional and socioeconomic damage if such information disclosed. the harmful effects of this approach have been suggested numerous times, but the empirical evidence that supports them is minimal. on the contrary, some believe that if the disclosure is denied, the right to know could be violated because it could be paternalistic. (6). genetic information and counseling processes also play an essential role in determining psychological harm. keeping the information secret can also have adverse effects if the results are relevant for preventing or treating relatives. additionally, unconsented disclosure of confidential information may cause harm to the deceased patient and may have possible implications for the family (6). the right to privacy: privacy is the individual's right to limit access to his/her personal information. although four categories of informational, physical, decisional, and proprietary are proposed for the concept of privacy, it is associated with some ambiguities, especially in the field of genetics (23). within the physician-patient relationship, confidentiality, which is rooted in informational privacy, prohibits the disclosure of medical information to third parties. despite being a noroozi m. et al. 9 j. med. ethics. hist. med. 2022 ( dec); 15: 13. fundamental part of current and ancient doctors’ medical oaths, it can be disregarded in certain circumstances, such as the safety and health of third parties (23). most ethical frameworks, including the world medical association and the general medical council, extend confidentiality beyond death to protect patient privacy (5). however, the notion of genetic privacy is controversial. genetic data are a unique identifier for owners, but it can have significant implications for family members and relatives’ health (23). people assume that genetic information is more private than other personal information and believe that such data is specific to them. this perception is called genetic exceptionalism (23). contrary to the dominant perspective, breitkopf et al. found (8) that fewer than 10% of the participants in a pancreatic cancer biobank based at mayo clinic in rochester agreed with the non-disclosure of information with relatives if it would be of medical benefit. the concern for privacy within the family after death was even lower (8). the gmc considers some conditions regarding requests for deceased patients' information, including the probability of causing distress or benefit to the patient’s partner or family, the possibility of anonymity, and the purpose of the disclosure. when balancing the considerations, the deceased patient's wishes should be considered (5). the right not to know: some studies revealed that some people are not interested in their genetic status. according to one study, 50–75% of the family members of patients with brca mutations were willing to participate in a mutation screening program (6). another study found that blood relatives of pancreatic cancer patients agreed with sharing the patients' genetic information with them. this is in contrast with the common belief that information sharing causes feelings of stigmatization and vulnerability in relatives (8). this information may be shared against the preference of the relatives not to be informed, which compromises their autonomy. the unrequested disclosure of genetic information may violate family members' autonomy even if they are unaware that genetic information is available and will diminish autonomous decision-making. although unrequested disclosure of genetic information could breach the right to privacy, depending on other concerns, including whether disclosure may benefit a relative, a balance should be considered between their interest in not knowing and their desire to know (6,8,4). deceased person’s wishes (respect for autonomy): to use or not to use? an ethical analysis of access to data and samples of a …… j. med. ethics. hist. med. 2022 (dec); 15: 13. 10 autonomy conveys an independent agent's selfgovernance and making decisions between alternative choices (24). family members are morally expected to fulfil the wishes of the deceased, so the explicitly declared unwillingness of a dead patient to disclose his/her certain information should be taken into account (5). the general medical council has emphasized that disclosure or non-disclosure of information after a patient's death depends on the patient's explicit desire. therefore, healthcare professionals should comply if the deceased patient has requested that their data be kept private (25). as a patient's autonomy depends on capacity and competence, it is problematic to consider his/her autonomy after death. according to some researchers, the deceased's patient autonomy should be respected by a physician because if those wishes are not honored after death, then the physician violates the patient's autonomy, and the concept of autonomy is diminished. moreover, it could affect public trust in healthcare professionals (6). on the contrary, it may conflict with the relatives' interests. the health-related interests of the family members could be considered in the risk-benefit of breaching the deceased patient's wishes. furthermore, it is complicated to find out what the deceased patient's true wishes were in many cases (6). breitkopf et al. found that most participants believed that if the information benefited relatives, the family benefit should be preferred over individual wishes (8). an islamic ethico-legal approach the islamic legal and ethical maxim pertinent to this case is the principle “no harm, no harassment.” the principle is derived from the prophet hadith “la darar wa la dirar,” which refutes acts of deliberately harming oneself and others (26). this principle has its source in both revelation and reason and is famous among sunni and shi ‘a scholars (27). darar is translated into “harm” and means “detriment, loss,” the opposite of “benefit,” and conveys any detriment or loss suffered by a person to himself, his property, dignity, or personal interest. the second term is dirar that was translated as “harassment” by sachedina and means “harming, injuring, or hurting in return.” both harm and harassment are determined by custom(al-‘urf) (27). islamic ethics methodology includes a careful analysis of harm and benefits while demanding that obligations of preventing harm be prioritized over promoting good (27). hence, we must prevent harm to the patients and their family members. depriving family members of genetic testing causes them essential physical and psychological health issues. noroozi m. et al. 11 j. med. ethics. hist. med. 2022 ( dec); 15: 13. re-using the deceased patient’s blood sample against his/her preferences violates the patient's right to "izn". the islamic legal maxim translated into permission and conveying the meaning of the english word of consent. nevertheless, the question is whether the patient's right to permission (izn) remains after death according to islamic law? to answer this question, one can argue that in islamic jurisprudence, one of the pillars of the validity of permission (izn) is the capacity of the person who gives permission (28). article 956 of the civil code of iran, based on islamic jurisprudence, states that the capacity to possess rights ends with death. therefore, it can be concluded that the patient's right to give permission ends with death (29). a similar approach is taken in islamic countries regarding the individual's permission for organ donation after brain death. the iranian supreme legislative body has approved organ donation from brain-dead patients if they gave permission for donation when they were alive. this permission is acceptable in both forms of written or verbal will (30). however, verbal will (wasiyat) requires special conditions, such as consent of the legal guardians, lack of explicit refusal of the deceased patient, and the intention of preventing harm to individuals in need of organs (31). in the present case, it can be analogously concluded that the patient's blood sample can be used for genetic testing with the consent of the firstdegree family members to prevent harm to them. post-mortem use of genetic data and samples for research obtaining informed consent is still pivotal for protecting participants’ rights in a research project. few ethical guidelines regarding genetic research have explicitly determined the researcher's duty after the death of a participant (32). tasse et al. showed that only 4 out of 24 documents related to biobanking research indirectly addressed the re-use of samples in case of a participant's death (32). on the contrary, a review of the literature published on the post-mortem use of genetic data for research by bak et al. showed that reusing previously collected data for research was highly accepted among family members (3). in 2003, the european society of human genetics (eshg) declared that reusing stored samples for research purposes required re-consent. therefore, if the donor has died, only the ethics committee is authorized to permit the reuse of samples for research purposes based on the notion of minimum risk for the donor. if the donor has not explicitly illustrated his wishes (through a written informed consent), the ethics committee should permit the use of deceased donor’s sample since the risk for to use or not to use? an ethical analysis of access to data and samples of a …… j. med. ethics. hist. med. 2022 (dec); 15: 13. 12 the subject is no more an issue. therefore, the eshg recommendations state that when individuals have restricted the use of their sample when they are still alive, these restrictions also apply after their death (33). the helsinki declaration (2008 and 2013 versions) states that the research sample must be reused with informed consent. if obtaining consent is impossible (donor’s death can be considered as an impossible situation), the secondary use of samples is possible only by an ethics committee's approval (34). although some studies emphasize altruistic aspects of consent for reusing samples for research purposes, the ethical guidelines and policies on research have to explicitly express their position about the secondary use of samples in research after death. donors must decide about it when they are giving consent (3). conclusion the controversy among experts about the concept of consent regarding the disclosure of genetic information and the reuse of genetic samples requires a definite solution. it also imposes significant ethical challenges in medical practice. 1 for more details about the concept of will in islam, please read: tripathi ak. the concept of ‘will’ under clinicians are generally recommended to discuss the importance of genetic information of the other members of the family with their patients requesting diagnostic or predictive genetic services. however, the matter is unclear in case of deceased patients and the prior refusal to share genetic information. the public should be informed about the shared ownership of genetic information and the notion of genetic consent. finally, making decisions on a case-by-case basis is recommended in ethical conflicts. the present case, we believe, has unique features. first, the patient's consent was obtained in an endstage situation in the last days of his life. second, the informed consent capacity assessment was not done, so the validity of the patient's consent is questioned. third, re-use of the patient's sample leads to an earlier detection of the disease, better self-care, and greater attention to potential clinical manifestations for first-degree relatives. moreover, from an islamic perspective, the validity of the patient's refusal is doubted after his death, as it cannot be considered a will1 . therefore, to prevent harm to the patient's family members, the patient's blood sample can be used for genetic muslim law: a study. http://ijlljs.in/the-concept-ofwill-under-muslim-law-a-study/ noroozi m. et al. 13 j. med. ethics. hist. med. 2022 ( dec); 15: 13. testing with the consent of the first-degree family members. the risk-benefit assessment is the essential component of decision-making in both introduced approaches. according to beneficence and nonmaleficence, the relatives' right to know, and kinship ethics, disclosing information to the firstdegree relatives and re-use of the patient's sample are justifiable. in fact, it is not possible to consider explicit preventive and curative benefits for relatives, but reducing their psychological stress can be regarded as a benefit if they are entirely informed about the cost of genetic tests and the applicability of genetic test data. the present scenario demonstrated a positive benefit-risk balance in which the benefits outweigh the risks. therefore, it can be concluded that re-use of the patient's sample may be ethically justified in the presented case if the first-degree family members insist on genetic testing and are comprehensively informed about the benefits and harms. funding there are no funding. acknowledgements there are no acknowledgements conflicts of interests there are no conflicts of interests. reference: 1. ascencio-carbajal t, saruwatari-zavala g, navarro-garcia f, frixione e. genetic/genomic testing: defining the parameters for ethical, legal and social implications (elsi). bmc med ethics. 2021; 22(1): 156. doi: 10.1186/s12910-021-00720-5. 2. gordon d.r, koenig b.a. “if relatives inherited the gene, they should inherit the data.” bringing the family into the room where bioethics happens. new genetics and society. 2022; 41(1): 23-46. doi: 10.1080/14636778.2021.2007065. 3. bak mar, ploem mc, ateşyürek h, et al. stakeholders’ perspectives on the post-mortem use of genetic and health-related data for research: a systematic review. eur j hum genet. 2020; 28: 403– 16. doi: 10.1038/s41431-019-0503-5. to use or not to use? 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(accessed on 2022) patient advocacy from the clinical nurses' viewpoint: a qualitative study journal of medical ethics and history of medicine original article patient advocacy from the clinical nurses' viewpoint: a qualitative study shirmohammad davoodvand1, abbas abbaszadeh2*, fazlollah ahmadi3 1phd candidate in nursing, razi nursing and midwifery college, kerman university of medical sciences, kerman, iran; 2professor, faculty of nursing and midwifery, shahid beheshti university of medical sciences, tehran, iran; 3professor, nursing department, faculty of medical sciences, tarbiat modares university, tehran, iran. corresponding author: abbas abbaszadeh address: nursing and midwifery college, shahid beheshti university of medical sciences, valiasr street, tehran, iran. p.o. box: 1996835119 email: aabaszadeh@sbmu.ac.ir tel: 98 21 88202520 fax: 98 21 88202521 received: 17 nov 2015 accepted: 28 may 2016 published: 11 jun 2016 j med ethics hist med, 2016, 9:5 © 2016 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract one of the advanced nursing care procedures emphasized by nursing organizations around the world is patient or nursing advocacy. in addition to illustrating the professional power of nursing, it helps to provide effective nursing care. the aim of the present study was to explain the concept of patient advocacy from the perspective of iranian clinical nurses. this was a qualitative study that examined the viewpoint and experiences of 15 clinical nurses regarding patient advocacy in nursing. the nurses worked in intensive care units (icus), coronary care units (ccus), and emergency units. the study participants were selected via purposeful sampling. the data was collected through semi-structured interviews and analyzed using content analysis. data analysis showed that patient advocacy consisted of the two themes of empathy with the patient (including understanding, being sympathetic with, and feeling close to the patient) and protecting the patients (including patient care, prioritization of patients’ health, commitment to the completion of the care process, and protection of patients' rights). the results of this study suggest that nurses must be empathetic toward and protective of their patients. the results of the present study can be used in health care delivery, nursing education, and nursing management and planning systems to help nurses accomplish their important role as patient advocates. it is necessary to further study the connections between patient advocacy and empathy. keywords: clinical nurse, patient advocacy, iran, qualitative research mailto:aabaszadeh@sbmu.ac.ir j med ethics hist med 9:5 june jmehm.tums.ac.ir abbas abbaszadeh et al. page 2 of 8 introduction patient advocacy in nursing is a relatively modern idea (1), but its first movements originated in florence nightingale’s era (2). it is of such importance that it has entered the moral codes of nursing institutions (1, 3). the need for justice is among the basic human needs (4) and nurses, more than anyone else, are in contact with patients and their problems (5); therefore, they can provide justice for the patients better than anyone else (6). nurses are the first advocates of patients (7), and are the link between the patient and the health care system (8).patient advocacy is one of the extremely important roles of the nurses (9-12). the patient or client is vulnerable and has experienced varying degrees of damage (13). therefore, many opportunities arise in nursing for the enforcement of patient advocacy, which has turned the nursing profession into the most reliable profession regarding patient advocacy. through the appropriate performance of this role, the trust and respect of the community toward the nurses will increase (7). nevertheless, even when they have effectively performed their role, complications such as fear, anger, frustration, hopelessness, and a sense of separation from their peers are experienced (1, 9). however, effective advocacy improves the quality of patient care and enriches the nursing profession. thus, the failure to play this role effectively may detract from the richness of this profession (14) and result in nurses leaving their profession (15). advocacy is generally described as defending the rights and property of others (3). in nursing, it has been defined as being a patient representative, defending the patient’s rights and universal rights, protecting the interests of the patient, contributing to decision-making and supporting the patient’s decisions (3, 11, 16), ethical-centered skills for the ‘professional self’(17), and ‘being a voice for the vulnerable (3, 18). negarandeh et al. defined the dimensions of patient advocacy in iranian nurses as informing and educating, valuing and respecting, and physical, emotional, and financial support, protecting and representing the patient, and continuity of care (13). however, providing a single definition for the term is difficult (8, 11). today, patient advocacy has taken a wider range of dimensions. for example, ware et al. stated that protecting patients against unethical and illegal acts was only a part of patient advocacy (12). mahlin stated that although supporting the patient is a major goal, the broader problems of patient advocacy cannot be resolved through this method, and the patient’s advocate should address the systematic problems of care and administrative institutions (19). in support of this claim, maryland and gonzalez stated that nurses, in addition to within hospitals, should support patients and their families in other social environments including economic, educational and research, healthcare delivery, and legislative environments, regarding their access to health care, cost control, and health care quality (8). protection of clients in clinical trials (20), supporting of organ donation volunteers, and protection of the fundamental rights and welfare of patients are also added to this category (16). patient advocacy is an ideal in the nursing practice (21). it is reliant upon many factors, including social relationships, human interactions (22), and moral distress and its side effects. however, many aspects of this concept have not been identified (23). many studies have referred to the failure to define and explain the concept of nursing advocacy and their results were not in agreement (8, 10). these ambiguous interpretations of patient advocacy impose a number of problems on the nursing practice (21). considering nurses’ lack of knowledge on patient advocacy in nursing and its irreparable consequences, it is necessary to train nurses on patient advocacy (9, 11). in addition, few iranian studies have addressed this issue. jafari manesh et al. in their descriptivecomparative study found that this perception was higher in the patents than the nurses and higher in the nurses than the physicians, but they did not address the topic of patient advocacy itself (24). negarandeh et al., through the grounded theory, explored the dimensions of patient advocacy in iranian nurses (13). so the present study is part of a greater qualitative study and its results differed in some ways from the results of previous studies especially in terms of empathy. thus, this topic requires further qualitative exploration. the aim of this study was to better clarify nursing advocacy among iranian nurses through a qualitative study. method the present text is a part of a larger qualitative study and this portion of data was analyzed using a conventional content analysis approach to explore clinical nurses’ experiences and perspectives of patient advocacy. qualitative research is suitable for studies on relatively new areas of knowledge (25). in qualitative researches, content analysis is largely applied today to the interpretation of textual data (26) that tend to review less well-known phenomena in their natural environment based on individuals’ views and experiences (27). patient advocacy is a very complex topic in the health care system (9). patient advocacy, like other ethical issues, is related to the socio-cultural context. therefore, the conventional content analysis approach was used in the present article to study patient advocacy in nursing. participants 15 nurses selected through purposeful sampling to participate in the study. j med ethics hist med 9:5 june jmehm.tums.ac.ir abbas abbaszadeh et al. page 3 of 8 data collection and analysis a total of 18 semi-structured face-to-face interviews were conducted from june 2012 until june 2013 to collect the data; 3 interviews were repeated. the duration of the interviews was 25 to 75 minutes with an average of 53.3 minutes. the location and the duration of the interviews were selected by the participants. the primary research questions included: “can you please explain your relationship with the patient as a nurse?” or “what are your responsibilities toward the patient as a nurse?” exploratory questions were also asked during the interviews to obtain the participants' experiences and opinions and to clarify their responses. data collection and analysis were carried out simultaneously. the interviews were recorded and, in order to obtain a general understanding, were studied at least 3 times. the recordings were transcribed verbatim. the obtained data were analyzed according to the following steps (28). 1. in order to gain a general understanding of them, the interviews were studied several times, and then, they were transcribed verbatim. 2. the interview texts were divided into compact semantic units. 3. the compact semantic units were converted into abstract terms and assigned a specific code. 4. the emerged codes were categorized based on their differences and similarities into subclasses and classes. 5. the themes were extracted from the interviews. the research team found no new information of relevance to their study in the data in the 15th interview. this is interpreted as data saturation in qualitative research, and thus, no more interviews were needed (29). trustworthiness to assess the study’s trustworthiness, lincoln and guba’s evaluative criteria and authenticity were used (30). lincoln and guba’s evaluative criteria consist of 4 criteria including: a-credibility: it shows that the identification and introduction of research participants are accurate. b-dependability: it shows that data remain stable over time and under different conditions. c-conformability: it shows objectivity, that is, the potential for congruence between different independent individuals on the accuracy, relevance, or meaning of the data. d-transferability: it shows the potential to generalize the findings of the study (29). authenticity is an additional criterion that shows the extent to which researchers indicate a range of realities fairly and faithfully (31). due to the prolonged and continuous engagement of the researcher with the data, the participants, and member checking, the credibility of the study increased. for this purpose, the researcher gave a typed summery of the interviews to the participants, so they could confirm his interpretations. in order to meet the confirmability of the data, peer check was used. the researcher first coded and classified each interview, and then, presented these classifications and codes to other members of the research team for evaluation. the codes which were not agreed upon were discussed until achieving clarification and consensus. to control the dependability of the data, the researcher retained the preliminary data, codes, categories, and themes. to achieve transferability or stability of the results, sampling was carried out with great variety to contribute to the credibility of data. ethical considerations this study and its ethical considerations were approved by and the necessary permits were obtained from the research deputy of kerman university of medical sciences, kerman, iran. all the participants were informed of the nature, purpose, and method of the study, the researchers’ tasks, their rights, and possible risks (this was a safe study) by the first author. the confidentiality of the participants’ statements, and their right to choose to continue or leave the study was emphasized by the research team. all participants consented to the recording of the interviews, and after receiving the necessary information, they signed an informed consent form. results in the present study, 15clinical nurses with an average work experience of 8 years and 3 months and mean age of 32.25 years were selected from selected wards suitable to the larger study (table 1). the participants were selected from educational and non-educational hospitals in different provinces of iran to gain an adequate variation in experiences and perspectives of nurses regarding patient advocacy in nursing. table 1. characteristics of the study participants characteristics number gender male 3 female 12 marital status married 7 single 8 education level bachelor 14 master 1 working unit coronary care unit (ccu) 7 intensive care unit (icu) 5 emergency unit 3 position nurse 8 head nurse 3 supervisor 3 nursing manager 1 interesting results were obtained from content analysis. according to the participants’ statements, patient advocacy included the two themes of j med ethics hist med 9:5 june jmehm.tums.ac.ir abbas abbaszadeh et al. page 4 of 8 empathy with the patient and protecting the patient (table 2). table 2. results of themes and categories theme categories empathy with the patient understanding the patient's condition showing compassion feeling close to the patient protecting the patient taking care of the patient being a patron to the patient commitment to completing the care period protecting patient rights 1. empathy with patients 1-1understanding patients’ conditions: understanding is a psychological relationship between the individual who knows and what they know. it is a process to gain knowledge on an abstract or physical object that in our study is the patient and his/her condition. nurses’ understanding of the conditions and expectations of patients can improve the nurse-patient relationship. this relationship presented itself as patient advocacy in the present study. the nurses in this study tried to defend their patients, because one day they might become a patient and require care themselves. participant number 10 stated: [when a patient walks into the hospital, he/she must have a problem. his/her problem is understandable for me. i know that if he/she did not have a problem then he/she would not have come to the hospital. i put myself in his/her shoes and try to help him/her in any way that i can. i do not have any problems with the patients.] participant number 4 stated: [each patient has his/her own expectations when he/she comes to the hospital. in the same circumstances, we, ourselves, would want a favorable healthcare service. we would expect an accurate diagnosis from the physician. we would want good healthcare services and would expect to see results.] 1-2 showing compassion: compassion, as an outstanding human characteristic, is a response to the suffering of others and the cause of helping them. in fact, compassion is synonymous with co-suffering. humans cannot simply overlook the problems of others. they are affected by the suffering and pain of one another, seek solutions to alleviate the pain, and become patrons to others. as an example, participant number 3 said: [i feel sorry when i see that the patient does not have anybody to look after her/him. i cannot stand seeing patients suffer. they feel vulnerable. i try my best to help them.] 1-3 feeling close to the patient: this theme is defined as the sense of unity with others. this sense does not depend on the conditions of others. it exists in pain or pleasure, but is more common in pain. humans feel close to their fellow men and perceive their problems as their own. they try to share their sad and happy moments. nevertheless, this feeling is stronger toward children and their immediate family members, and is heightened during illnesses. nurses who have this feeling of closeness tend to defend their patients as they would defend themselves. participant number 15 stated: [i feel closer to some of the patients, for example, in the thalassemia unit, especially children who refer to receive blood. i become friends with some of their families. the thalassemia unit is the second home of these children.] participant number 1 declared: [when i see a patient, i imagine him/her as being my relative. i help him/her in any way that i would help my own family. i do not withhold anything from the patients.] 2. protecting the patient 2-1 taking care of patients: this phrase means caring for the patient in general. it is caution toward others with the aim to prevent individuals from being harmed. one of the main tasks of nurses is to protect patients against injuries and possible risks. these risks may be physical, mental, deliberate, inadvertent, or due to insufficient treatment or incorrect care. given that disease reduces individuals’ defensive strength, patients need someone to protect them against these threats. most nurses have experienced this responsibility as a patient advocate. participant number 2 described this issue more objectively: [we should be careful that the patient does not fall from the bed, protect him/her against any injuries in the ward or against anyone coming to the hospital to hurt him/her, and to control the medication to avoid any further harm.] participant number 7 in confirming the above statements said: [we must monitor the patient for any side effects of the medication that is being used. the patient is here to get better not to get worse. sometimes the patient shows reactions to the blood he/she is taking, and we must intervene immediately to prevent any damage to his/her kidneys, and breathing.] 2-2 prioritizing patients’ health: while working at hospitals, different problems may occur for the nurses. these problems may include family or career issues, interactions with co-workers, or any other problem, and cause the nurses to prioritize their duties. in this case, most of the nurses participating in this study have pronounced the health of their patients as their first priority. participant number 5 described this skill as: [when i find that something is not in the best interest of the patient (for example, the behavior of a colleague, or the treatment method or the care being provided by my colleague), i do not think whether my colleague will get upset with me. my colleague’s feelings are my second priority. my patient’s health is the most important matter for me in my working environment. as hard as it may be, i try to only focus on my j med ethics hist med 9:5 june jmehm.tums.ac.ir abbas abbaszadeh et al. page 5 of 8 patient before entering the unit.] 2-3 commitment to the completion of the care period: by selecting this label for the category, we purposed to address the topic of follow-up in nursing. patient follow-up is a part of nursing care, and without it, nursing care remains incomplete. nurses plan to improve their patients’ health and expect to follow this plan until it is finished. according to the participants, the completion of an appropriate plan brings peace of mind to nurses. actions that interrupt the process cause stress for nurses. this mindset prevents any harm coming to the patients. participant number 14 stated: [the nurse should provide care as soon as the patient is admitted. we are nurses and we should perform our duties and follow our plans under any circumstances. even if the patient is in his/her final days of life, it is our duty to take care of him/her. we should provide our services until the patient is discharged or has died.] 2-4 defending patients’ rights: rights are fundamental normative rules that determine what is permitted and what is not. this is a part of the protection of patients from any harm. every human being has a right. nurses care for individuals who are unable to defend their rights, or do not know their rights and need help in this regard. nurses also help the patients by defending and informing them of their rights. in regards to her colleagues’ violation of patient’s rights, participant number 6 stated: [the head nurse follows up with a patient if she feels the patient is not provided with proper care. for example, a patient was being transferred to the emergency unit, but the crowded environment of that unit was harmful to him. the head nurse insisted on transferring the patient to a calmer and more disciplined unit. i would do the same if the welfare of the patient is in danger.] participant number 15 expressed a more subtle point: [sometimes the medication of a patient is used for another patient. it is very important for me to replace whatever has been taken from a patient, even if it is a tablet.] discussion the aim of patient advocacy, as a fundamental aspect of nursing care, is to provide high quality health care and protect the rights of the clients (32). nevertheless, some factors, such as the lack of competency and recourses (10), burn out, professional suffering, and lack of dedication to nursing (11) hinder achievement of these goals. on the other hands, these factors place the clients at risk, which increases the importance of patient advocacy. considering these barriers, in the present study, patient advocacy in nursing consisted of two themes of empathy with the patient and protecting the patient. these findings have some similarities and differences to other studies that have been conducted in this field. patients experience different degrees of vulnerability (10). moreover, young stated that “all elements of the patient advocacy are consistent with protecting the patient from the harm” (26). therefore, protection is a key element of patient advocacy. regarding children, this protection includes protection against child abuse (33, 34). the nurses participating in this study also suggested that protection forms the predominant part of patient advocacy in nursing. in nursing, however, many internal and external risks threaten a patient's health care environment. the origin of these risks is the disease and the patients’ inability, lack of sufficient defensive power, and lack of sufficient knowledge about the disease, care, and treatment of the disease, and the treatment environment. there are also dangers which threaten the patients’ rights at different levels. the participants of this study had committed themselves to protecting the patients. patients’ rights and health status, and the nature of the nursing profession were the most important factors that nurses stated as reason for protecting the patient. negarandeh et al. have stated that protecting the patient is one of the key factors of patient advocacy, and nurses, as the patient advocate, are responsible for protecting the patient against inadequate health care provided by other healthcare team members (13). their study was a great study that supports the present study results in patient protection. patients often complain about the lack of appropriate verbal communication with the nurses. they choose nurses who establish a close relationship with them as their advocates (35). empathy is the ability to define the unique situation of others (36), and also an inseparable part of the nurse-patient relationship (37). bikker et al. found that empathic patientcentered care is a high quality outcome in the health care system and patients constantly measure and score nurses’ empathy and humanistic behavior (38). by responding with empathy to the patient and his/her family, the nurse can help them adapt to their problem, this outcome is in line with patient protection (39). ferri et al. in an analytical crosssectional study reported that empathy toward patients has a negative relation with nursing burnout and diminishes the course of the disease (40). considering these results, which support our findings, it can be stated that empathy is an implicit component of patient advocacy. empathy is a personal matter which takes on a more professional aspect in nursing. patient advocacy is a developed and distinct form of communication between nurses and patients which has been illustrated in the comments of the study participants. from the perspective of the participants, patients require by their side individuals with whom they can share their problems, individuals who understand them and help them. nurses, like other individuals in these situations, want to gain closeness to others and j med ethics hist med 9:5 june jmehm.tums.ac.ir abbas abbaszadeh et al. page 6 of 8 collaborate with them. since nurses have been trained for these situations, they try to approach patients in different situations in order to defend their rights with more power and a better understanding of the patient. a common concern is then formed among patients and nurses. it stimulates nurses’ sense of compassion when faced with the suffering and helplessness of their counter parts and increases their willingness to help the patients. a feeling of empathy is formed between nurses and patients as part of patient advocacy. previous studies have not provided any support regarding empathy and its relationship with patient advocacy, but the common elements of empathy, communication, and advocacy cannot be denied. for example, a study in 2015 reported that individuals with higher capacity for empathy can more easily understand and accept the perspectives of others (37). tomaschewski barlem et al. stated that patient advocacy provided by nurses is based on their personal values and professional skills (9). the study by jafari manesh et al. (24) differs from our study methodologically and cannot be used to support or contradict our findings. the findings of negarandeh et al. (13) do not support our findings on empathy. in the iranian culture, almost everything, including ethics and values, is influenced by religion. thus, personal value in this culture refers to religious beliefs. protection of the vulnerable and doing all that is in your power for others is ordered in islam. however, the data presented in the current text did not indicate this subject explicitly. it seems that empathy in patient advocacy in nursing is a relatively new issue that is largely dependent on the social context of the iranian society, including religious background, and perhaps more specific studies can confirm or repudiate this matter. conclusion patient advocacy is a social issue which can be evaluated from personal and professional aspects. in this study, patient advocacy in nursing included the two themes of empathy with patients and protecting patients. protection of patients in previous studies has been repeatedly defined as an important component of patient advocacy. nevertheless, empathy with the patient is a relatively new idea and it seems that a more thorough study on this topic can help the better understanding of this relationship. the results of this study can be used in the development of nursing students and novice nurses, retraining of employed nurses, and sensitizing of nursing managers and planners and other related occupations to the improvement of nurses’ performance, reduction of the adverse effects of patient advocacy, and promotion of the health of the society. it is suggested that further studies be conducted on the relationship between empathy and patient advocacy. future studies may be performed on the effect of religion on patient advocacy, especially in religious societies. acknowledgment this study was registered by the kerman university of medical sciences with ethical code: k/92/242 and is the intellectual property of this university. our sincere appreciation goes to all the nurses who participated in this study. conflict of interest statement no conflict of interest has been declared by the author(s). j med ethics hist med 9:5 june jmehm.tums.ac.ir abbas abbaszadeh et al. page 7 of 8 references 1. hanks rg. the lived experience of nursing advocacy. nurs ethics 2008; 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14: 27. neda yavari1, fariba asghari2, zahra shahvari3, saharnaz nedjat4, bagher larijani5* 1.assistant professor, department of medical ethics, school of medicine, isfahan university of medical sciences, isfahan, iran. 2.professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. 3.assistant professor, department of nursing and midwifery, gachsaran branch, islamic azad university, gachsaran, iran. 4.professor, department of epidemiology and biostatistics, school of public health, tehran university of medical sciences, tehran, iran; knowledge utilization research center, tehran university of medical sciences, tehran, iran. 5.professor, endocrinology and metabolism research center, endocrinology and metabolism clinical sciences institute, tehran university of medical sciences, tehran, iran. abstract it appears that up until now, no comprehensive tool has been developed to assess medical students’ attitudes toward the different dimensions of professionalism. the present study aimed to develop a comprehensive quantitative tool to evaluate medical students’ attitudes toward professionalism. this study consisted of two phases: the first phase was item generation and questionnaire design based on literature review and a qualitative survey. the qualitative data were extracted from 49 semi-structured individual interviews and one focus group discussion. in the second phase, the questionnaire was developed and its face, content, and structure validity and reliability were evaluated. to measure the construct validity of the questionnaire, a cross-sectional study was conducted on 354 medical students at different academic levels at isfahan university of medical sciences. the final questionnaire was loaded on five factors. the factors accounted for 43.5% of the total variance. moreover, cronbach's alpha was 0.84 for the total scale, and the interclass correlation coefficient was 0.77 for the test-retest reliability. the 17-item questionnaire measuring medical students’ professional attitude had acceptable validity and reliability and can be adopted in other studies on physicians’ and medical students’ professional attitudes. keywords: professionalism; professional attitude; tool development; medical students. developing a comprehensive tool to assess professional attitude among physicians and … 2 j med ethics hist med. 2021(december); 14:27. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e introduction medical students’ professional behaviors have a great impact on promoting public trust in healthcare providers and thereby accelerating the achievement of desired treatment outcomes. therefore, teaching medical students to behave professionally and monitoring and evaluating their performance is of paramount significance in any society. on the other hand, individuals’ behaviors in different situations are rooted in their values and attitudes. that is, medical students’ professional behaviors are outward manifestations of the values and attitudes governing their minds. accordingly, observing and promoting the professional attitudes of medical students as a source of professional behaviors may play a critical role in nurturing the public trust in healthcare providers. furthermore, positive and deeply-rooted attitudes toward professionalism would lead to the emergence of professional behaviors such as tolerance, sensitivity to patients’ physical and emotional needs, and avoiding discrimination and favoritism (1). in general, it is easier to evaluate students’ professional behaviors rather than their professional attitudes due to the former’s objectivity and measurability. moreover, the objectivity and measurability of behaviors facilitate the provision of an accurate explanation for errors, and it thus seems more feasible to propose a suitable solution to modify professional behaviors. another advantage of assessing students' professional behaviors (rather than their values and attitudes) is that evaluating behaviors and pointing out behavioral errors are less likely to undermine their personality (1). despite the aforementioned advantages of evaluating professional behaviors compared to professional attitudes, the assessment of professional behaviors as an external manifestation of professionalism in medical students may cause us to commit some errors. first, attributing accountability or non-accountability to students based on their professional or non-professional behaviors indicates ignorance of the fact that each nonprofessional behavior represents a conflict between two or more moral values at the same level. the factors affecting a student’s response to such a value conflict are as significant as the behavior itself. the response depends on several factors, including the student’s perception of conflicting values and environmental conditions effective in resolving the conflict. as a logical consequence of the dependence of students' professional behaviors on different factors such as the ones mentioned above, professional behavior cannot be considered as an appropriate benchmark to assess their professionalism. relevant studies on medical students and residents have revealed a periodically significant rising and falling in their abilities to interact with patients (1). medical students’ professional attitude can be considered as their feeling or mental attitude toward the professional principles in medicine. the professional attitude is also defined as "a feeling, talent, or mindset that yavari n., et al. 3 j med ethics hist med. 2021(december); 14: 27. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e supports the ideals of a profession and is the basis for professional behavior" (2). accordingly, evaluation of medical students’ professionalism by measuring their professional values and attitudes has an advantage over evaluation of their professional behaviors. this is because of two main reasons: a) stability of professional attitude and its independence from environmental factors, and b) the fact that professional attitude is the origin of professional behavior, and that its evaluation, reinforcement, or modification can spontaneously provide the grounds for acceptable professional behaviors. it should, however, be noted that an appropriate attitude does not necessarily lead to appropriate moral behaviors, and individuals may exhibit unacceptable performance despite their appropriate moral beliefs. according to an in-depth review of the literature, the tools adopted in previous studies to evaluate medical students’ professional attitudes have only addressed the students' stance on one of the issues raised in professionalism. due to the absence of a comprehensive instrument to assess professional attitude, the present study was conducted to develop a tool for systematic evaluation of physicians’ and medical students' attitudes toward the various dimensions of professionalism. methods the following procedure was adopted to design and validate the questionnaire: a: developing the questionnaire items this phase of the study aimed to detect and gather appropriate attitudinal concepts to prepare the questionnaire items for the assessment of the medical students’ professional attitudes. this phase was performed in two stages including a literature review and a qualitative study in the form of interviews with medical students, followed by a focus group discussion (fgd) session with medical ethics experts. in fgd a small group of participants come together to discuss a specific topic and provide relevant information. a distinctive feature of focus group discussion is the interaction between the moderator and the participants, and among the participants. this technique enables the researcher to understand the participants' views on a specific topic (3). in the library phase, available texts and instruments related to the components of medical professionalism were reviewed. the statistical population of this phase encompassed all english-language articles introducing the components of medical professionalism. no time frame was set for searching the included articles. the search strategy for library study is demonstrated in table 1 below. the keywords “medical professionalism” and “professional attitude” were searched in the title/abstract section of pubmed and web of science databases to select the articles. then, the search continued in the advanced search section of the two databases using combinations of the mentioned keywords with other words and phrases, including developing a comprehensive tool to assess professional attitude among physicians and … 4 j med ethics hist med. 2021(december); 14:27. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e “assessment”, “evaluation”, “measurement”, “medical students”, “medical trainees” and “physicians”. finally, a set of professional attitudinal components were extracted (table 1). table 1search strategy for library study professional attitude or medical professionalism and evaluation or assessment or estimation and medical students or medical trainees or physicians at the end of the library study, a set of professional attitudinal components were extracted from studies on professionalism. this review encompassed studying different definitions of professionalism and extracting the attitudinal dimensions of each proposed component. in this regard, studies specifically examining one of the various professionalism dimensions were also investigated, and their attitudinal components were extracted. the collected professional attitudinal components were then used in compiling the items of a comprehensive questionnaire measuring professional attitude. the next phase of the study encompassed a semi-structured interview followed by content analysis. first, there were some individual and semi-structured interviews with a number of medical students in isfahan university of medical sciences, who were studying at the basic sciences, stagery, and internship levels. the participants were asked to express their opinions about the characteristics of a professional physician and appropriate indicators in assessing physicians’ professional attitudes. the interviewees were selected purposefully, considering maximum diversity in terms of gender and educational level (namely basic sciences, stagery, and internship) from isfahan university of medical sciences. data saturation was considered to determine the number of students interviewed in each grade. there was no time limit for the interviews, and each interview lasted as long as the interviewee was willing to talk (about 15 20 minutes on average). the interviews were digitally recorded and then transcribed verbatim and handwritten. the conventional content analysis method was used to analyze qualitative data. accordingly, the informative units (words, phrases, or concepts) were detected in response to each question. then the units were classified and coded into different categories in a clear, understandable, and orderly manner in terms of their content and theoretical significance. when studying the manuscripts containing the same units of analysis, the researcher tried to achieve their general sense to spare efforts. the meaning units were then extracted as sentences or paragraphs from the interview statements and transcriptions, and the units were coded. the extracted codes were managed using maxqda software version 10. repeated reviews of extracted codes contributed to yavari n., et al. 5 j med ethics hist med. 2021(december); 14: 27. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e detecting their similarities and differences and classifying and organizing them. finally, as the process of analysis progressed, the relationships between specific categories and themes hidden in the interview transcriptions were noticed. finally, the extracted codes were repeatedly compared with those obtained from the first phase of the study, and each unit was thus placed in its respective category based on similarities and differences. in the next stage, the questionnaire items were developed using the attitudinal concepts extracted from the text reviews and qualitative interviews with medical students. the extracted codes were converted into items, and a pool of professional attitude assessment items was formed. finally, the designed items were evaluated by 8 experts in the field of medical ethics in a focus group discussion session, which continued until data saturation. as a result, some items were modified and some overlapping items were removed. the output of this phase was a 20-item questionnaire that could enter the stage of psychometric evaluations. b: questionnaire validation in the second section of the study, the validity and reliability of the primary questionnaire were examined. 1) content validity experts’ opinions were used to assess the content validity of the questionnaire (cvr and cvi). twenty experts including 5 in the field of medical ethics and 15 instructors of medical professionalism were asked to rate the necessity of each item on a 3-point scale (necessary, useful but unnecessary, and unnecessary). they were also asked to score the relevance rate of each item using a 4point scale (completely relevant, relevant, partially relevant, and irrelevant). in addition, the experts were asked to write down their comments for each item in the section designed for this purpose if further modifications of the item seemed necessary. in the next step, cvr and cvi were calculated for each item. the minimum acceptable cvr value was set according to lawshe (2014) and with regard to the number of expert panels (4). the cvi score or the percentage of experts reaching an agreement on the relevance of the items was also calculated for each item by dividing the number of experts who chose option 4 (completely relevant) or 3 (relevant) by the total number of experts. based on hyrkas et al.’s recommendation, scores ≥ 0.79 were set as the criterion to accept the items (5). 2) face validity the face validity of the questionnaire was evaluated by conducting interviews with 10 medical students. to this end, they were asked to express their views about any ambiguity or need for transparency in the items, as well as the items' significance and relevance. 3) reliability assessment internal consistency and stability tests were used to confirm the reliability of the developing a comprehensive tool to assess professional attitude among physicians and … 6 j med ethics hist med. 2021(december); 14:27. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e questionnaire. the stability assessment was performed using test-retest. according to statistical standards, the number of participants in the test-retest stages should range from 30 to 50 (6). in this study, 31 students were willing to cooperate, and they were each assigned a code to ensure anonymity and free and honest collaboration in answering the questions. the same code was used for each student in both the test and retest stages, completed with a twoweek interval in between. the responses were scored using a five-point likert scale (namely, strongly agree, agree, no opinion, disagree, and strongly disagree). cronbach's alpha and icc were first calculated for all items, and cronbach's alpha was recalculated after deleting each item. 4) construct validity exploratory factor analysis was used in the present study to determine the construct validity of the developed questionnaire. the kaiser-meyer-olkin (kmo) test and bartlett’s test of sphericity, principal component analysis, scree plot, eigenvalue, and equamax rotation were then carried out. the turning point of 0.3 was set as the minimum factor load required to maintain each item under the factors extracted from factor analysis. after extracting the factors and the related items, the compatibility of the factors with the concept and the main dimensions of the professional attitude were examined. research setting: the construct validity was assessed at isfahan university of medical sciences or its affiliated teaching hospitals. the convenient sequential sampling method was adopted in this study. to this end, after coordination with the department of medical ethics at isfahan university of medical sciences, the researcher participated in medical ethics classes or conferences where the research sample gathered and distributed anonymous selfreport questionnaires. regarding the internship students who were mostly present in teaching hospitals, the questionnaires were submitted in coordination with the department of medical ethics at the end of scientific conferences such as morning reports. before distributing the questionnaires, the students were informed of the objectives and the procedures of the study, and the anonymity of the questionnaires was emphasized. inclusion criteria were studying medicine at isfahan university of medical sciences at the basic sciences, stagery, or internship levels, and willingness to fill out the questionnaires. the exclusion criterion was the failure to complete at least 80% of the questionnaire items. the sample size in the quantitative part of the study was 100 for each of the three educational levels (namely basic sciences, stagery, and internship). to assess construct validity, medical students at isfahan university of medical sciences were asked to complete the questionnaire. the collected data were then analyzed using spss software version 19. ethical considerations to observe ethical considerations, the necessary ethical approval was achieved from the ethics committee of tehran university of medical sciences (no. yavari n., et al. 7 j med ethics hist med. 2021(december); 14: 27. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e 13951917). in order to conduct the study at isfahan university of medical sciences, the necessary coordination was made with the vice chancellor for research and the department of medical ethics of this university. afterward, the research objectives were explained to the participants, and their informed consent was obtained. they were then ensured of the confidentiality of their information throughout the publication process. the participants agreed on the time and place of the interviews and were also informed of audio-recording and the purpose of doing so. they were also advised that they could request some parts of their interviews not to be audio-recorded if they wished. the interviewees were also reassured that they could terminate their cooperation in the study at any time. result a: item generation library studies: in this phase, a set of attitudinal components were extracted which were used in the next phases to compile the items of the questionnaire. among these attitudinal components, the following can be mentioned: a sense of commitment to scientific advancement; striving for selflearning; the significance of proper communication; the appropriate use of all available resources for scientific advancement; exploiting personal experiences as a resource for scientific advancement; enhancing holistic attitudes and consideration of human dimensions in making decisions; the significance of learning clinical reasoning principles; the significance of simultaneous improvement of scientific and practical skills; facing conditions of doubt and uncertainty; the skill of using abstract knowledge commensurate with the environment; feeling accountable for the patient and the society; promoting the spirit of care instead of mere treatment (7); considering patients' human dignity; commitment to quality improvement and access to health services; role of physicians in establishing distributive justice (8); considering the significance of physical and mental health; the importance of independence in learning; problem-solving and decision-making; the key role of teamwork; considering the role of critical and creative thinking in treatment decisions (9); commitment to environmental factors affecting treatment; honesty and efforts to reach excellence; fairness; self-enrichment (10); reasoning preparation for dealing with unforeseen situations correctly; strengthening the skills of identifying the root and source of unforeseen events to make the best decisions (11); accepting scientific and skill shortcomings and trying to eliminate them; ability to maintain proper performance in complex and uncertain situations (12); self-awareness and reflection (13); reflection on criticisms and commitment to medical error disclosure (14). qualitative study: after interviewing medical students at different educational levels of basic sciences, stagery, and internship and reaching data saturation in each phase, new attitudinal components developing a comprehensive tool to assess professional attitude among physicians and … 8 j med ethics hist med. 2021(december); 14:27. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e were extracted and coded to develop the questionnaire items. using content analysis approach, they were then categorized into three categories (scientific skills, practical skills, and personality traits) and seven subcategories (efforts for scientific promotion, communication with patients and their companions, teaching students, having a research spirit, communication with other members of the medical team, attitudes toward oneself and others, and attitudes toward the medical profession) (table 2). table 2content analysis based on interviews with medical students codes subcategories categories constant attention to improving one’s scientific level, updating scientific information, promptness in emergency decision-making, ability to use scientific knowledge in decision-making, skills in obtaining a comprehensive and purposeful history of the patient, skills in differential diagnosis efforts for scientific promotion scientific skills spending time with the patient, prioritizing the patient's interests over personal interests, listening to the patient, paying attention to the patient's fears and concerns, respecting the patient's rights, telling the truth, respecting the patient’s companions, paying attention to the patient's wishes, skills of gaining patients' trust, skills of transferring experiences and knowledge to students, following the patient's condition until the full result is achieved, communicating properly with nurses, providing the patient with sufficient information, refraining from administering unnecessary treatments, directing the course of treatment while respecting the patient's autonomy communication with patients and their companions teaching students having a research spirit communication with other members of the medical team practical skills not feeling superior to others, paying attention to social norms and red lines of the society, having clear and predetermined moral frameworks to display the right behavior, referring the patient to a more capable doctor if needed, being conscientious, caring about the patient's fate, being honest with the patient and avoiding deception, accepting one’s errors, having a good temper, having a comprehensive view of the patient (physical, mental and psychological), maintaining the dignity of the medical profession while respecting the patient, paying attention to the reputation of colleagues and the medical profession, avoiding discrimination, conscientiousness and a sense of commitment to patients, courage to admit insufficient scientific knowledge or practical skills when necessary, not abusing social status to achieve public advantages, not being indifferent to the sufferings of the patient and his/her companions, avoiding making decisions for the patient based on emotions, paying attention to proper resource allocation, having mental strength when the patient suffers or shows irrational reactions, having self-confidence in medicine. attitudes toward oneself and others attitudes toward the medical profession personality traits in the fgd session, which was held in the presence of medical ethics professors at yavari n., et al. 9 j med ethics hist med. 2021(december); 14: 27. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e tehran university of medical sciences, the participants commented on the significance, relevance, and classification of the items proposed for developing the questionnaire. they suggested some professionalism dimensions in addition to those derived from previous studies. finally, the research team members selected the most appropriate items and combined the overlapping concepts. thus, 53 items were developed to assess students' professional attitudes and were then tabulated using a five-point likert scale. the selected items reflected the physicians’ and medical students’ attitudes toward different aspects of professionalism. b : questionnaire validation a) face validity the results of the interviews with medical students were gathered and summarized in a table, according to which 13 vague or nonsignificant items detected by the interviewees were excluded and some items were modified. the pool of the questionnaire items encompassed 40 items. b) content validity in the next step, cvi and cvr were estimated for each of the 40 items, according to which 20 items had acceptable cvi and cvr scores and were approved as the selected items of the professional attitude assessment questionnaire. further modifications were made based on the professors’ comments to clarify some items in the questionnaire. c) construct validity the prepared questionnaire was evaluated for construct validity. for this aim, 130 students of basic sciences, 110 students of stagery, and 128 students of the internship were invited to complete the questionnaire, of whom 127, 107, and 120 students answered the questionnaire items, respectively. given that 354 out of 368 students completed the questionnaire, the total response rate was 96%. the responses to all the items but one had normal distribution, so that item was removed from the questionnaire in this phase. kmo was reported to be 0.778. the values of kmo and bartlett’s test of sphericity indicated the sufficiency of the sample size. eigenvalue > 1 was accepted, and cumulative prediction revealed the acceptable value of 43.5%. at this stage, varimax rotation was performed, which showed the items were loaded on seven factors, but the results of the component transformation matrix table indicated the relevance of the items, suggesting the employment of non-orthogonal rotations. the items were loaded again on seven factors after running the oblimin rotation, but more acceptable results were obtained numerically. regarding the number of items in each factor and the factor load of each item, the best results were finally obtained by selecting five factors. each factor had at least two items with a factor loading > 0.3. in this phase, two other items were also removed since they were not powerful enough (table 3). developing a comprehensive tool to assess professional attitude among physicians and … 10 j med ethics hist med. 2021(december); 14:27. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e table 3factors extracted in factor analysis using oblimin rotation and the factor loads of items items factors 1 2 3 4 5 considering patients' concerns or fears makes them demanding. 0.711 the physician is not required to ask a hospitalized patient for permission to perform an abdominal examination. 0.633 to preserve the dignity of the medical profession, a physician should not answer the patient’s questions about a colleague’s errors. 0.583 0.318 a physician making the right diagnosis for a patient is a good one, even if he/she does not treat the patient empathetically. 0.558 the physician knows best how to improve the patient’s health status; hence, he/she can make some treatment decisions without informing the patient. 0.516 hospitalization in a teaching hospital implies that the patient should agree to any measure contributing to teaching students. 0.503 0.321 in order not to arouse the patient’s anger, one can hide the errors harming the patient. 0.408 respectful treatment of a patient who behaves disrespectfully goes beyond the professional duty of a physician. 0.371 prioritizing the patient’s health over personal interests represents the physician’s altruism. -0.788 if a physician feels that receiving expensive gifts from different companies has no effect on his/her prescriptions, he /she can accept them. -0.520 0.327 the physician should report his/her colleague’s drug abuse even if it causes no harm to patients -0.731 in cases of rare organ transplant, criminals and non-criminals have equal rights to receive an organ. 0.638 in case of a disaster, it is the physician’s duty to provide overtime services if needed. 0.673 to promote patients’ satisfaction, the physician may accept some of their requests for unscientific measures (e.g., unnecessary imaging). -0.580 accountability is inherent and cannot be promoted. 0.427 the physician is responsible to provide feedback on his/her own, or a colleague’s minor misconduct, even if it has not seriously harmed the patient. 0.797 reporting colleagues’ fraud represents professionalism. 0.629 yavari n., et al. 11 j med ethics hist med. 2021(december); 14: 27. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e with regard to the content covered by the items, the factors were labeled as follows: "patient-centered care", "prioritization of patients’ interests", "honesty", "accountability", and "dealing with misconducts”. after extracting the factors and the related items, the compatibility of the factors with the concept and the main dimensions of professional attitude were reexamined, reducing the number of items to 17 (table 4,). table 4factors, items and factor loads factors items factor loads patientcentered care the physician is not required to ask a hospitalized patient for permission to perform an abdominal examination. considering patients' concerns or fears makes them demanding. to preserve the dignity of the medical profession, a physician should not answer the patient’s questions about a colleague’s errors. respectful treatment of a patient who behaves disrespectfully goes beyond the professional duty of a physician. in order not to arouse the patient’s anger, one can hide the errors harming the patient. a physician making the right diagnosis for a patient is a good one, even if he/she does not treat the patient empathetically. the physician knows best how to improve the patient’s health status; hence, he/she can make some treatment decisions without informing the patient. 0.633 0.711 0.583 0.371 0.408 0.558 0.516 prioritization of patients’ interests hospitalization in a teaching hospital implies that the patient should agree to any measure contributing to teaching students. prioritizing the patient’s health over personal interests represents the physician’s altruism. if a physician feels that receiving expensive gifts from different companies has no effect on his/her prescriptions, he/she can accept them. -0.312 -0.788 -0.520 honesty in cases of rare organ transplant, criminals and non-criminals have equal rights to receive an organ. the physician should report his/her colleague’s drug abuse even if it causes no harm to patients 0.638 -0.731 accountability accountability is inherent and cannot be promoted. in case of a disaster, it is the physician’s duty to provide overtime services if needed. to promote patients’ satisfaction, the physician may accept some of their requests for unscientific measures (e.g., unnecessary imaging). -0.427 0.673 -0.580 dealing with misconducts reporting colleagues’ fraud represents professionalism. -the physician is responsible to provide feedback on his/her own, or a colleague’s minor misconduct, even if it has not seriously harmed the patient. 0.629 0.797 the final questionnaire encompassed 17 items (table 5). developing a comprehensive tool to assess professional attitude among physicians and … 12 j med ethics hist med. 2021(december); 14:27. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e table 5the final questionnaire for the assessment of medical trainees’ professional attitude questionnaire items 1 the physician is not required to ask a hospitalized patient for permission to perform an abdominal examination. 2 considering patients' concerns or fears makes them demanding. 3 to preserve the dignity of the medical profession, a physician should not answer the patient’s questions about a colleague’s errors. 4 respectful treatment of a patient who behaves disrespectfully goes beyond the professional duty of a physician. 5 in order not to arouse the patient’s anger, one can hide the errors harming the patient. 6 a physician making the right diagnosis for a patient is a good one, even if he/she does not treat the patient empathetically. 7 the physician knows best how to improve the patient’s health status; hence, he/she can make some treatment decisions without informing the patient. 8 hospitalization in a teaching hospital implies that the patient should agree to any measure contributing to teaching students. 9 prioritizing the patient’s health over personal interests represents the physician’s altruism. 10 if a physician feels that receiving expensive gifts from different companies has no effect on his/her prescriptions, he /she can accept them. 11 in cases of rare organ transplant, criminals and non-criminals have equal rights to receive an organ. 12 the physician should report his/her colleague’s drug abuse even if it causes no harm to patients. 13 accountability is inherent and cannot be promoted. 14 in case of a disaster, it is the physician’s duty to provide overtime services if needed. 15 to promote patients’ satisfaction, the physician may accept some of their requests for unscientific measures (e.g., unnecessary imaging). 16 reporting colleagues’ fraud represents professionalism. 17 the physician is responsible to provide feedback on his/her own, or a colleague’s minor misconduct, even if it has not seriously harmed the patient. d) reliability the total cronbach's alpha coefficient and the total icc were reported to be 0.84 and 0.77 respectively for the developed questionnaire. the values were calculated to assess the reliability of each item as well. accordingly, not only the questionnaire but also each item had acceptable reliability. discussion in this study, a 17-item scale was developed to assess physicians’ and medical students’ professional attitudes toward five professionalism domains whose face validity, content validity, construct validity, internal consistency, and stability were confirmed. the feature that distinguishes this tool from others that assess physicians’ and medical students’ professional attitudes is its comprehensiveness in evaluating various professionalism aspects. for example, the jefferson scale has been used in several studies in korea, brazil, bangladesh, iraq, turkey, greece, and the us to evaluate medical students’ attitudes, but only focuses on the students' attitudes toward empathy with patients (15 24). other scales have dealt with topics such as social and emotional communication between physicians and patients in new zealand (25), cheating in examinations in the united states (26), communication skills in germany and the netherlands (27, 28), skills yavari n., et al. 13 j med ethics hist med. 2021(december); 14: 27. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e required for communication with colleagues in the us (29), provision of services to the lower classes of the society in the us (30 31), attention to patients’ health and safety in the uk (32), and many other topics in other countries. as noted, the developed tool could evaluate medical students’ professional attitude toward at least five professional domains, including patientcentered care, prioritization of patients’ interests, honesty, accountability, and dealing with misconduct. another distinguishing feature of this questionnaire is that the items include no specialized medical term; therefore, medical students at different levels of education and with any level of medical knowledge can respond to it. furthermore, the ethical issues considered in the items are ones toward which individuals are expected to have an acceptable attitude when they enter the university. in other words, no specific knowledge is required to complete this questionnaire. another feature considered in developing this instrument is that the items include no specific cultural or social considerations or aspects, thereby making it suitable for use in any community or culture. in general, the developed questionnaire is relatively easy to use for assessing physicians’ and medical students’ professional attitudes. also, it can be adopted in various settings such as universities, hospitals and clinics, health centers, and private centers for research purposes. on average, the respondents completed the questionnaire in 10 minutes. the face validity and content validity of the questionnaire confirm the simplicity and clarity of the items. moreover, the questionnaire can easily be completed by medical students at different education levels in various societies. the reliability of the developed questionnaire was well confirmed, and it had acceptable content validity, internal consistency, and cumulative prediction. a significant point in analyzing the results of both library and qualitative studies regarding the characteristics of a committed and professional physician was that the attitudinal components were mainly common in both studies. however, due to their constant involvement with the ethical challenges of working in clinical settings and their accurate and critical views on different issues, the participants in the qualitative study referred to a few points not revealed or regarded in the quantitative part. for example, features such as "physicians’ competence in gaining patients' trust", "prioritization of patients’ interests" and "consideration of social norms or red lines in clinical activities" were of paramount significance from the perspective of the students and were repeatedly emphasized by the interviewees. although these points have been considered by thinkers and authors in other countries, the medical students’ attention and emphasis on the points indicate their concern about the development of some unprofessional behaviors in medical settings. the focus on the need for physicians’ competence in gaining patients' trust might developing a comprehensive tool to assess professional attitude among physicians and … 14 j med ethics hist med. 2021(december); 14:27. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e be due to concerns about patients’ gradual loss of trust in physicians in iran, which has unfortunately been growing rapidly in recent years. on the other hand, the students' emphasis on the ethical consideration that physicians should prioritize patients’ interests also reveals concerns about unprofessional performance in this regard. the need to respect social norms and red lines may also be a critique of disregarded norms, even if rare, in the medical community, which undermines the dignity of the medical community as well as the trust between physicians and patients in iran. on the other hand, the interviewees mentioned some issues regarding the characteristics of a professional physician, which had been addressed less frequently in the studied papers. some examples are "not abusing social position to gain different benefits" and "not believing in one's superiority over other individuals in the society." the points seem to be highlighted by the interviewed students as the characteristics of professional physicians due to the existence of the following ethical problems in the medical community: unjustified enjoyment of social benefits by some physicians because of their scientific and social position, paternalistic view of patients, and the indoctrination of a sense of superiority due to the long history of paternalism in the doctor-patient relationship in our country. the aforementioned points would help health managers and policymakers to better detect ethical deficiencies in the healthcare system and plan to compensate for such shortcomings. one limitation of the developed questionnaire is that it is a self-report instrument and thus entails all shortcomings and limitations of self-administered questionnaires. conclusion the library study method as well as qualitative and quantitative research were adopted in the present study to develop a standard and comprehensive 17-item questionnaire to assess medical students’ various professional attitudinal dimensions. the questionnaire validity and reliability were also evaluated and approved. the distinguishing feature of the tool designed in this study in comparison with other tools for measuring professional attitude is its comprehensiveness. based on our extensive search, previously designed tools for assessment of the professional attitude of medical students were able to assess just one dimension of professionalism, for instance, empathy, communication skills, etc. the questionnaire designed in the present study can be used to assess the attitude of medical trainees toward various dimensions of professionalism including altruism, honesty and integrity, respect for patients, respect for colleagues, accountability, and justice. it can also be used for evaluation of the impact of educational programs on students' attitudes. the findings would provide a guide for policymakers of educational programs at universities to explore the positive and negative points, eliminate the shortcomings, and enhance the strengths in medical students’ professional attitudes. yavari n., et al. 15 j med ethics hist med. 2021(december); 14: 27. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e acknowledgements the present study was extracted from a phd dissertation approved by tehran university of medical sciences. researchers would like to express their gratitude to the medical ethics professors at tehran university of medical sciences for their invaluable guidance and comments, as well as the cooperation of relevant authorities in isfahan university of medical sciences and all medical students who took part in this project. references 1. kirk lm. professionalism in medicine: definitions and considerations for teaching. proc (bayl univ med cent). 2007; 20(1): 13–16. 2. hammer pd. professional attitudes and behaviors: the “a's and b's” of professionalism. 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https://www.ncbi.nlm.nih.gov/pubmed/?term=carruthers%20s%5bauthor%5d&cauthor=true&cauthor_uid=19811201 https://www.ncbi.nlm.nih.gov/pubmed/?term=lawton%20r%5bauthor%5d&cauthor=true&cauthor_uid=19811201 https://www.ncbi.nlm.nih.gov/pubmed/?term=sandars%20j%5bauthor%5d&cauthor=true&cauthor_uid=19811201 https://www.ncbi.nlm.nih.gov/pubmed/19811201 ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ journal of m edical ethics and h istory of m edicine review article copyright © 2021 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. practicing patients’ rights in iran: a review of evidence *corresponding author ebrahim jaafaripooyan address: department of health management and economics, school of public health, tehran university of medical sciences, poursina ave., ghods st., enghelab st., tehran, iran. tel: (+98) 21 42 93 30 58 email: jaafaripooyan@tums.ac.ir received: 12 sep 2021 accepted: 15 nov 2021 published: 25 dec 2021 citation to this article: sharifi t, shamsi gooshki e, mosadeghrad am, jaafaripooyan e. practicing patients’ rights in iran: a review of evidence. j med ethics hist med. 2021; 14: 28. tahere sharifi1, ehsan shamsi gooshki2, ali mohammad mosadeghrad3, ebrahim jaafaripooyan4* 1.phd candidate, department of health management and economics, school of public health, tehran university of medical sciences, tehran, iran; researcher, the national center for health insurance research, iran health insurance organization, tehran, iran. 2.associate professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. 3.professor, department of health management and economics, school of public health, tehran university of medical sciences, tehran, iran. 4.associate professor, department of health management and economics, school of public health, tehran university of medical sciences, tehran, iran. abstract protection of patients' rights is critical in improving healthcare quality, and hence this study aimed at reviewing patient rights’ practices in healthcare organizations of iran. using systematic search, this review was conducted based on preferred reporting items for systematic review and metaanalysis protocols (prisma-p). several keywords, including "patient rights", "patient bills of rights" and "patients rights’ charter" were searched bilingually in the databases of sid, magiran, pubmed, scopus, and web of science from 2010 to 2021, and then, following a three-tier screening using the critical appraisal skills program (casp) checklists, 76 articles were extracted. the degree of compliance with the patients' rights charter (prc) in healthcare organizations was 60.88% on average. as to the observance of the prc dimensions, respectively, the highest and lowest scores were related to the "right to privacy and confidentiality" (70.16%) and "right to access an efficient complaining system" (53.01 %). respect for patients' rights in organizations was assessed at a moderate level, and some aspects of patients' rights should be attended to immediately. therefore, discrepancies in the dimensions of patients' rights and their implementation by organizations should be on the agenda of healthcare managers and policymakers. keywords: patient rights; iran; biomedical ethics; ethics. practicing patients’ rights in iran: a review of evidence 2 j med ethics hist med. 2021(december); 14: 28. journal of m edical ethics and h istory of m edicine introduction all individuals need and use healthcare services throughout their lives, and hence the provision of health care services must be reasonably non-discriminatory and respectful of human rights and dignity (1). patients’ rights (prs) are a set of norms derived from the bases and principles of medical ethics and human dignity, and professional commitments to patients are founded on these rights (2, 3). patients' rights charter (prc) could improve the quality of healthcare, and protection of prs might reduce irreparable physical, mental and social damages (4, 5). accordingly, most countries have adopted prs-relevant laws that healthcare providers must follow. the prc aims to ensure that human dignity is respected by protecting patient health, especially in medical emergencies without discrimination of race, age, sex, or financial status, and with the provision of respectful and quality care (1). although prc is the first step in the realization of prs, the development and proclamation of prc alone cannot guarantee the implementation of prs, and hence, to evaluate the degree of compliance with prc, the execution and application of prs should be persistently monitored. in iran, the first prc (11 items) was launched in 2002, which was rudimentary and incomprehensible in expressing all the basic prs. therefore, a more thorough version was prepared via the participation of various stakeholders and announced in november 2009 by the ministry of health (moh). the charter encompassed 37 articles and five dimensions including; "right to receive appropriate services", "right to access to desired and sufficient information", "right to choose and decide freely about receiving healthcare", "right of privacy and confidentiality", and finally, "right to access an efficient complaining system" (6). several studies were conducted on compliance with prs in iran and some other countries. for example, studies in sudan and india reported that the degree of compliance with prc was favorable and more than 70% on average (7, 8). in iran, conversely, the results showed a relatively unfavorable situation on prs protection in the hospitals of five provinces: 45% in ilam (9), 18.5% in kermanshah (10), 8% in kerman (11), 63.2% in yazd (5), and 14.59% in mazandaran (12). in 2014, a reform was mandated, due to prs challenges, in monitoring, supervision, and evaluation systems, expressed in article 2.6 of the general health policies announced by the supreme leader to legally strengthen prs protection (13). the current status analysis is assumed to be a prerequisite for initiating any improvement in healthcare practices. therefore, several recent studies assessed the degree of prs practice by healthcare organizations (hcos) in iran (14-21). each of these studies presented the situation in a specific region of the country and failed to fulfill policymakers' and managers’ requirements. consequently, other researches aimed at providing a more comprehensive situation of prs in the whole country by combining results via review studies in both persian and sharifi t., et al. 3 j med ethics hist med. 2021(december); 14: 28. journal of m edical ethics and h istory of m edicine english languages (14, 22-24). however, these studies had limitations in terms of target groups (providers or patients), search keywords, and stand-alone places of study such as hospitals. most of these studies were conducted five years ago; some also disregarded various prc dimensions, did not provide a complete depiction of prs protection in iran and did not cover emerging studies after 2016. therefore, scrutinizing current literature, this study aimed at reviewing the protection and observance of prs and prc dimensions in the iranian hcos at all three levels, i.e. prevention, curative and rehabilitation services from 2010 to 2021, delivered at health centers and hospitals. methods this systematic review study was conducted based on preferred reporting items for systematic review and metaanalysis protocols (prisma-p), a designed guide to develop and improve review reports and meta-analysis (25). due to the heterogeneity of studies extracted and their use of different questionnaires, a metaanalysis was not feasible for the present work. keywords included various combinations of "patient rights", "patient bills of rights", "patient rights’ charter", "iran", which were searched bilingually using medical subject headings (mesh) in pubmed. the search was performed in english and persian databases such as pubmed, scopus, and web of science as well as sid1, magiran2, and ensani3. moreover, the reference and citations lists were included (backward and forward tracing). the databases were searched using the following search strings: ("patient's rights" or "patient bill of rights" or "patients' bills of rights" or "patient bills of rights" or "patient right" or "patients' right" or "patient rights" or "patient bill of right" or "patient bills of right") and ("islamic republic of iran" or iran). as shown in the flow diagram 1, 12083 articles were identified after the search (28 in pubmed, 7 in web of science, 47 in scopus, 76 in sid, in 853 magiran, and in 20 ensani). inclusion criteria entailed the articles published between 2010 and 2021 that reported prs practice in iran according to the viewpoints of both patients and providers. the present study also covered review studies conducted in 2010, including the studies before 2010. qualitative studies and articles on prs in other countries were excluded. patient/population, intervention, comparison, outcomes (pico) strategy was used for article selection, an evidence-based search strategy for indexing and retrieving scientific evidence (26). all articles were entered into the endnote software. after duplicates checking and reviewing the titles and abstracts, 200 articles were selected and saved for full-text review. eventually, 1. scientific information database in iran: www.sid.ir 2. specialized and general journals and newspapers database in iran: www.magiran.com 3. the comprehensive humanities portal in iran: www.ensani.ir practicing patients’ rights in iran: a review of evidence 4 j med ethics hist med. 2021(december); 14: 28. journal of m edical ethics and h istory of m edicine following a three-tier screening and using the critical appraisal skills program (casp) checklists, 76 articles were extracted (flow diagram 1). casp is the most commonly used tool for quality assessment in combining quality-related health evidence (27). two authors independently searched for articles (ts and ejp), which were consistent in most cases, and minor discrepancies were resolved during joint meetings with other members of the research team (esg and amm). result seventy-six articles (56 in persian and 20 in english) were relevant to the prs protection in iranian hcos from january 2010 to june 2021. the highest number of studies were conducted in 2015 (21%) and 2012 (14%) and the lowest number in 2020 (1.3%) and 2011(4%). approximately 92% of the studies were observational (eight descriptive and 62 analytical), two interventional, and four review studies. the tools to measure the variables were questionnaires, mainly developed based on prc dimensions. only one study was related to prevention services and one to rehabilitation services, and the rest (74 articles) were addressing curative services. out of the latter, eight articles were on outpatient services sharifi t., et al. 5 j med ethics hist med. 2021(december); 14: 28. journal of m edical ethics and h istory of m edicine (including clinics and minor surgery centers) and 50 articles on inpatient services. as such, 10 articles examined the practice of prs in the private sector, and 70 in the public hcos, while some covered both groups. fifty-six and 31 studies examined prs practice from the perspective of services recipients, and providers, respectively. the research population mainly included patients, plus nurses, physicians, midwives, other staff, and medical students. the studies were conducted in 26 provinces, out of which 30.26% were undertaken in the capital, tehran (28-44). the provinces of khuzestan (45, 46), khorasan razavi (16, 47-49), kerman (11, 19, 50, 51), and mazandaran (12, 52, 53) stood next. the prs practice in service areas the degree of prs practice in three levels of prevention, curative and rehabilitation services, was on average 77%, 58.3%, and 48.5%, respectively. overall, the compliance with prs in iranian hcos was 60.8%, more for the outpatient (65.67%) and less for inpatient (56.37%). prs protection: service providers and recipients’ perspective the providers and recipients believed that prs observance levels by hcos were 70% and 58%, respectively. according to the review studies (final four), prs were moderately observed (14, 22, 23). the last review study, conducted in 2016, showed that the prs compliance by the hospitals was not favorable (24). chronologically, prs protection has increased from 50.75% in 2010 to 69.6% in 2020 (figure 1). figure 1prs practice in iran from 2010 to 2021 as such, geographical dispersion of prs practice was displayed in figure 2. practicing patients’ rights in iran: a review of evidence 6 j med ethics hist med. 2021(december); 14: 28. journal of m edical ethics and h istory of m edicine figure 2provincial practice of prs in iran from 2010 to 2021 compliance with prc dimensions the highest compliance among the hcos was related to the dimension of "the right of privacy and confidentiality" (70.16%) followed subsequently by those of "right to receiving appropriate services" (66.94%), "right to access desired and sufficient information" (59.42%),"right to choose and decide freely on receiving healthcare" (57.33%), and finally "right to access an efficient complaining system" (53.01 %) (figure 3). figure 3the observance of prc dimensions in iran from 2010 to 2021 prs protection and related factors according to 42.4% of the studies, prs practice was significantly related to public awareness of prs. around 27% of studies reported that the level of patients’ education was significantly related to their viewpoint 0 20 40 60 80 right to receiving appropriate services right to access desired and sufficient… right to choose and decide freely on receiving healthcare right of privacy and confidentiality right to access an efficient complaining system 0 10 20 30 40 50 60 70 80 90 sharifi t., et al. 7 j med ethics hist med. 2021(december); 14: 28. journal of m edical ethics and h istory of m edicine on the observance of prs. a statistically significant association was observed between prs practice and patients’ age, gender, marital status, insurance type, experience and expectations, type of inpatient ward, length of hospital stay, living place, hospital type, and providers occupational group (p <0.05). discussion prc was moderately observed among iranian hcos and regarding prc dimensions, the highest and lowest scores were related to the "right of privacy and confidentiality" and "right to access an efficient complaining system", respectively. the prs protection in hcos was evidently perceived higher from the perspective of service providers than that of the service recipients, as the former, i.e. the staff, are part of the organizations and might be biased towards their organization. the same results were reported in egypt (54). this gap could be further adjusted by individuals’ jobs, communication systems, expectations, and preferences (mental paradigms) (6). if the healthcare system aims to attend successfully to prs, in conjunction with root cause analysis, organizational understanding should be improved about how an individual feels as a patient. from 2010 to 2021, on average, the degree of compliance with prs in the iranian hcos was around 61%, with fluctuations, and gradually improved during this period; this percentage is not considered within a high range (14, 23, 24). in some studies, in other countries, such as egypt and uganda, similar results were reported. for instance, in an egyptian university hospital, only 0.5% of physicians and nurses abided by the prs desirably, and 42% had moderate performance (55). in another ugandan national reference hospital, limited observance of prs was reported, in that 80% of the staff just protected a maximum of two-thirds of prc (56). a report in 2016 demonstrated poor prs compliance as a major challenge for six european countries: croatia, cyprus, greece, poland, romania, and slovenia (57). only 51.2% of students in poland and 38.5% of students in slovakia believed that prs were well-protected in their country (58). nevertheless, according to the indian studies, 74% of nurses performed well about compliance with prc (59), and in saudi arabia, the mean score of patients' satisfaction with nurses in terms of respecting their rights was 90.67% (60). such a high level of prs observance, rarely was reported in other studies, could be due to the low level of expectations and economic status of patients, and could not necessarily be linked with the high quality of health services (7, 31). therefore, prs practice should be checked in conjunction with the treatment consequences, such as the patient's health status at discharge and the recurrence rate. chronological order of prs practice the majority of studies were conducted in 2015 (20%) and 2012 (15.4%), which could be attributed to the implementation of the health transformation plan (htp) in 2014 and to the formal initiation of iranian mandatory hospital accreditation in 2012. practicing patients’ rights in iran: a review of evidence 8 j med ethics hist med. 2021(december); 14: 28. journal of m edical ethics and h istory of m edicine protecting patients' dignity and their companions is a key aspect of the country's national accreditation and htp (61, 62). although prs practice has gradually improved in iran since 2010, it has not grown as desired and does not have a promising prognosis. accordingly, for the appropriate practice of prs in hcos, announcement, and communication of the instructions are not enough; in addition, training regarding prc is required and prc implementation should be strictly monitored. for instance, related training programs for healthcare providers on prs, enacting laws and regulations to endorse prs, implementing regulatory guidelines, tracking patients’ rights violations (63), considering prs observance in the employee appraisal, attending to the social and economic rights of staff, especially nurses, reducing staff’s workload, creating a culture for prs in the society and hcos, and strong emphasis on the patient preferences could assist to promote prs practice in hcos (64, 65). geographical dispersion of prs practice the lowest score of compliance with prc was related to qazvin and sistan baluchestan (sb) provinces. this finding resulted from the studies conducted in 26 provinces of the country over different years, but to adjust these results, the average of the findings of several studies in each province was used. recent studies also showed that healthcare development in all provinces was not the same (66-68), which might influence prs practice. sb is considered, in terms of health indicators, among underdeveloped provinces (66-68). imbalanced access to healthcare resources could be crucial for improving prs practice (69). protection of prc dimensions the highest score was for the "right of privacy and confidentiality", which might be attributable to the importance of this issue in the religious teachings as well as to the implementation of the "plan for compliance of medical affairs with religious standards" in hcos (70, 71). the lowest score was for "right to access an efficient complaining system”, which could be due to the poor healthcare system’s responsiveness and weak demanding skills in the country's cultural structure (72-74). in similar studies in saudi and ugandan hospitals, the lowest score was reported on the “right to compensation” (56, 75). in finland, despite the authorization of the right to complain in law, and the presence of a patient ombudsman, the complaint process is difficult for patients, as the general public are practically lacking this right (76). the results were also presented in egypt where in the hospitals under study, patients did not receive any information about the right to complain about physicians' abuse and malpractice or compensation, and they also did not know how to complain in case of dissatisfaction with the services (55). these results could be because physicians and nurses in these studies were afraid of the legal responsibility, and believed that disclosure of these rights to patients might lead to serious consequences (e.g., lawsuits and loss of their jobs). a study in france confirmed that the increase in the number of complaints related to medical issues between 1998 and 2004 was due to an increase in the sharifi t., et al. 9 j med ethics hist med. 2021(december); 14: 28. journal of m edical ethics and h istory of m edicine public awareness of medical errors after the enactment of the prs act (77). the second-lowest score was related to the "right to choose and decide freely on receiving healthcare". similarly, jozi et al. clarified that the "right to refuse" and "right not to participate in clinical trials" were the least important from the nurses’ perspective (9). ghanem et al. (55) also confirmed the necessity of reconsidering physicians' and nurses’ viewpoints in "right to choice and decision-making". in the uk, expectations regarding the choice of hospital and physician were not met (78). in belgium, physicians rarely complied with procedures such as informed consent (16.4%), and little demand of patients for their rights was observed (79). in iran, the non-observance of prs related to the choice presented as a general challenge for the healthcare system; the large difference between the private and public sectors tariffs could be an underlying reason (80, 81), as well as factors such as the increase in the number of hospitalizations, workload and staff shortage in hospitals leading to less time spent by hospital medical staff communicating with patients (82, 83). prs protection: influential factors the present study showed that the observance rate of prs had a significant relationship with patients’ awareness of prc. for example, the highest level of awareness was related to the first dimension of prc ("right to receiving appropriate services"), and the lowest was related to the third dimension ("right to choose and decide freely on receiving healthcare"), but the situation was inverse regarding satisfaction (32, 84). therefore, the dimension with more awareness is more demanded and thus more practiced. moreover, the type of hospital had a statistically significant relationship with prs practice, and this rate in teaching hospitals was lower than both public and private hospitals (1, 31, 85, 86). in egypt, the performance of the university hospital was reported to be better than that of the general hospital (55). in iran, however, in teaching and public hospitals, as opposed to other hospitals, attitudes towards prs were notably inappropriate due to the high referral burden of patients, nursing work overload, insufficient knowledge of medical staff about prs, the existence of different educational groups and students, and their lack of knowledge. as a limitation in this study, access to the full-text of several relevant articles was restricted, which was solved through direct contact with their authors. moreover, judgment on the prs practice in the country was based on the existing studies and primary data was not sought. conclusion patient satisfaction can largely indicate the high quality of services and adequate response to medical needs and the realization of prs. hence prc as a formal package of patient protection principles intended to serve this quality and responsiveness. according to the present study’s findings, hcos in iran are practicing patients’ rights in iran: a review of evidence 10 j med ethics hist med. 2021(december); 14: 28. journal of m edical ethics and h istory of m edicine moderately respected prs; hence, in conjunction with the efforts of authorities, the society and service providers should be fully informed, empowered, demanded, and monitored on the observance of all prc dimensions. the "right to access an efficient complaining system" might be a basic requirement for the existing organizations and should be considered and targeted, because it has not previously been adequately addressed. the present study’s findings, if receive sufficient attention from the authorities, can strengthen prs protection at macro-level decisions by providing an overview of prs practice status in the country and uncovering neglected dimensions of prc. to promote prs, the following strategies can be adopted: (i) developing a process for providing sufficient information on prs, (ii) considering the prs indicators in medical and healthcare staff’s evaluation, (iii) paying attention to the social and economic rights of the staff, especially nurses, (iv) reducing staff’s workload, (v) creating a culture for realizing prs in the society and hcos, and (vi) patient activation and engagement via more emphasis on patients’ preferences. in iran, adopting a multi-level, multi-channel, and patient-centered approach in the development and implementation of laws to combine social services to realize prs is lacking or non-existent. similar studies in other provinces of the country, mainly qualitative, to investigate the causes of poor access to the desired level of prs is recommended for future studies. acknowledgments this manuscript is part of the ph.d dissertation (ir.tums.sph.rec.1398.190) in the department of health management and economics, school of public health, tehran university of medical sciences, iran. the authors are grateful to the reviewers of the manuscript for their useful comments in improving the study. funding this research has not received any specific funding. ethics approval and consent to participate the approval of this study was granted by the ethics committee of tehran university of medical sciences [the code of ethics: ir.tums.sph.rec.1398.190]. competing interests the authors declare that they have no competing interests. sharifi t., et al. 11 j med ethics hist med. 2021(december); 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bioethics, clinical center, national institutes of health, usa. corresponding author: kiarash aramesh address: iran 23# medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. email: kiarasharamesh@tums.ac.ir tel: 98 21 66419661 fax: 98 21 66419661 received: 29 mar 2014 accepted: 17 jun 2014 published: 20 jun 2014 j med ethics hist med, 2014, 7:10 © 2014 kiarash aramesh et al.; licensee tehran univ. med. sci. abstract monetary compensation for human eggs used in research is a controversial issue and raises major concerns about women’s health and rights, including the potential of exploitation and undue inducement. human eggs are needed for various types of studies and without payment, it would be impossible to procure sufficient eggs for vital research. therefore, a solution seems necessary to prevent exploitation and resolve other ethical concerns while ensuring sufficient supplies of human eggs for research. a brief review of legislation in different countries shows the existing diversity and controversy over compensating human egg donation for research purposes. while in more economically developed countries procreative liberty and consumer orientation seem to be defensible, in some developing countries, where concerns about exploitation exist, adopting a more regulated approach to assisted reproduction is more prudent and wise. egg sharing is a program that has been proposed to solve both the ethical problems of purchasing eggs and the shortage of human egg supply for research. in developing countries, however, regardless of whether the egg sharing or the monetary compensation model is adopted, some steps should be taken to guarantee the ethical nature of this practice. these steps include ensuring the existence of independent institutional review boards (irbs), confirming the validity of all steps in the process of obtaining informed consent, and ensuring the existence and viability of independent supervising and auditing bodies. keywords: egg donation, research ethics, purchasing human eggs, compensated egg donation mailto:kiarasharamesh@tums.ac.ir j med ethics hist med 7:10 jun, 2014 jmehm.tums.ac.ir kiarash aramesh page 2 of 6 (page number not for citation purposes) introduction monetary compensation for human body parts used in treatment or research remains fiercely debated throughout the world. the commercialization of obtaining several body parts raises serious concerns, for instance kidneys for transplantation, blood for transfusion, or even human embryos or fetuses for treating infertility or for use in research. similarly, paying women who donate eggs for research is among the most controversial issues of modern medicine (1-6). when it comes to egg donation, in addition to the previously mentioned concerns about commercialization of human body parts, other issues about women’s health and rights must also be taken into consideration. potential exploitation of women as research subjects has frequently raised major ethical and legal concerns. egg donation is a classic example of such a potential (7). the wide array of different and contradicting guidelines, regulations and opinions, which originate from different cultural, religious and theoretical backgrounds, has created a maelstrom around the issue of egg compensation. during the past decades, almost all the contributors to this debate throughout the world have tried to suggest global solutions for the aforementioned ethical and legal concerns; it seems, however, that different cultural and socio-economic contexts and backgrounds necessitate different approaches to the same issue. this article argues that in more developed and prosperous countries highlighting procreative liberty seems to be defensible, but in some developing countries, where concerns about exploitation exist, adopting a more regulated approach to assisted reproduction is more prudent and wise. where the eggs are needed in general, donated human eggs are used for assisted reproduction, but there are also various types of research in which eggs are needed. the most prominent types of such research are embryonic stem cell (esc) research and somatic cell nuclear transfer (scnt). embryonic stem cell research (esc) research has mostly occurred using surplus embryos remaining from infertility treatment (8), whereas obtaining escs with sufficient genetic diversity to study a broad range of diseases will require that new lines be created. moreover, in order to avoid immune reactions in future therapeutic applications, researchers will need embryos that are produced by scnt (4). other types of research that use human eggs are physiological studies and studies on early human development. medical risks of egg donation after a workshop held in 2006 by the institute of medicine and the national research council of the national academy of sciences (nas), the committee on assessing the medical risks of human oocyte donation for stem cell research published a report according to which the medical risks of human egg donation can be divided into three groups (9): the risks of ovarian hyperstimulation: the process of egg donation begins with the egg donor taking doses of hormones aimed to increase the number of eggs that can be retrieved. this ovarian stimulation may cause a number of health problems, the most important of which is ovarian hyperstimulation syndrome (ohss), a condition characterized by signs and symptoms such as abdominal discomfort and mood swings in the mild form; increased ovarian size, ascite (accumulation of fluid in the abdominal cavity), abdominal distension and pain, nausea, vomiting, and diarrhea in the moderate form; and more severe signs and symptoms such as accumulation of protein-rich exudates in the peritoneum and pericardial spaces, breathing difficulties, increased concentration of red blood cells, kidney and liver problems, and, in the most severe cases, formation of blood clots or kidney failure, and finally death (10). about 0.1 to 0.2 percent of women taking ovarian stimulation drugs experience severe ohss and a smaller percent of them experience life-threatening complications. for example, about 1.4 out of every 100,000 women undergoing an in vitro fertilization (ivf) cycle experience kidney failure. in addition, since a large percentage of the serious complications of ohss seen in ivf patients are related to hormonal changes caused by pregnancy, it is predictable that the ohss risks are lower for egg donors than for women involved in ivf. there is also concern that the use of ovarian stimulation drugs may lead to an increased risk of hormonedependent cancers, particularly, breast, ovarian, and uterine cancers. the data to date do not support a significant relationship between such drugs and an increased prevalence of these cancers, although the possibility has not yet been excluded. concern has also been raised about the potential effects of ovarian stimulation on the donors’ long-term fertility, but at present there is no evidence that this is true. the risks of egg retrieval surgery: complications associated with anesthesia, or other surgical complications like infection and ovarian torsion, are extremely rare and even more so among egg donors compared to women undergoing ivf. the psychological risks of egg donation: the potential psychological problems include the side effects of ovarian stimulation drugs, which fade away after the procedure is complete, and the psychological (and even spiritual) issues related to j med ethics hist med 7:10 jun, 2014 jmehm.tums.ac.ir kiarash aramesh page 3 of 6 (page number not for citation purposes) the nature of this procedure. moreover, there are concerns about the long-term effects of egg donation on the donor’s well-being and fertility. the committee mentioned that the health outcomes of egg donation are still unclear and there is a need to continue to gather information on the donors after the procedure and to observe them for potential long-term results (9). some unproven concerns about long-term adverse effects of egg donation have been raised by other authors. among these, cases of colon cancer in young women who had previously donated their eggs are noteworthy (11, 12). the above-mentioned evidence and facts show that there are some rare but undeniable health complications that can be attributed to egg donation. also, it should be noted that imposing burdens on egg procurement for research should be considered with more prudence compared with (infertility) treatment. there has been some criticism concerning the clarity of informed consent obtained in these cases, (13) but if proper informed consent has been given, research egg donation and egg harvesting cannot be considered unethical on account of the possible complications. in summary, one can conclude that egg donation is a reasonably safe procedure, and the potential adverse medical consequences do not validate its exclusion from the list of acceptable research interventions, given that it is likely to yield important benefits to others. the term purchase versus compensation theoretically speaking, there are ethical differences between “purchasing human eggs” and “compensating egg donation”. in practice, however, there seems to be major overlaps. regardless of what the procedure is called, in this article we examine a regulated system of payment to egg donors, or providing them with other services such as free or reduced rate infertility treatment, which leads them to agree to egg donation they otherwise would not accept. it would seem that this compensation is significantly more than the direct costs imposed on the donor, as is the case in other research settings. it should be mentioned that this is true only in developed countries and when surplus eggs remaining from infertility treatment are involved. given the unacceptability of trading human body parts, and the regulated nature of the payments we consider as ethical, we prefer to use the term compensation rather than purchase when discussing the procedure with potential donors or in public media. the term “purchase” has been used in some parts of this article in order to clarify the exact meaning and differentiate it from reimbursement of direct costs. conversely, no significant distinction has been drawn between the terms “donor” and “provider” as suggested by baylis and mcleod (2). arguments against purchasing human eggs for research the main arguments that have been put forth by opponents of purchasing human eggs are as follows: commodification of the human body: one of the main objections against purchasing human eggs is that this practice leads to the commodification of human body parts, which is a violation of the very principle of human dignity (14). this is a real concern in an unregulated setting where the price is determined by brokers and poor women are coerced to donate their eggs. moreover, payment should not be so high as to turn donation into a source of income or give it a commercial nature. egg donation should still preserve its altruistic and honorable spirit, which seems to be possible if the stepwise approach (see below) is adopted. undue inducement: another major concern in economically disadvantaged societies is undue inducement, and the absence of research ethics institutions and regulatory and observatory bodies in such communities can lead to human tragedies (15). however, in well-regulated settings, with providers who are protected by law and ethical institutions and know their rights, a “limited and regulated” payment will not lead to undue inducement. it has also been argued by klitzman (1) that imposing constraints on egg donation out of concerns about undue influence may indicate a degree of paternalism (1). exploitation: considering the aforementioned medical and psychological risks and burdens imposed on egg donors, it has been argued that purchasing human eggs for either treatment or research can lead to exploitation of underprivileged women. as a matter of fact, reported experiences of poor women in some countries, especially developing ones, support this argument. in some cases, frequent donations with the intention of earning more money leads to major health problems. in addition, the money does not usually go to the donor, but to the husband or another dominant member of the family who takes advantage, sometimes to solve the financial problems of the whole family. it should be noted, however, that this form of exploitation cannot be attributed entirely to the monetary compensation of egg donation. the absence or inadequacy of safeguards such as informed and voluntary consent, supportive rules, regulations and regulatory bodies lead to various forms of exploitation. therefore, existence of these safeguards can minimize exploitation of vulnerable women, although it should be mentioned that the root causes of exploitation in such societies are poverty and power imbalance in families. arguments in support of purchasing human eggs for research as a rule, participation in research is compensated; for example, it is customary for healthy j med ethics hist med 7:10 jun, 2014 jmehm.tums.ac.ir kiarash aramesh page 4 of 6 (page number not for citation purposes) subjects in phase 1 clinical trials to get paid. in many cases, the compensation is enough to attract people to an unlikely competitive market of being a human research subject. rationales for such compensation include boosting recruitment by offering an incentive to participate in the research, minimizing financial sacrifice on the part of subjects, eliminating feelings of inertia and distrust, and reimbursing subjects for their time and inconvenience (16). it is acceptable and perfectly legal to compensate healthy human subjects (even children and other susceptible individuals, with added safeguards naturally) for participation in medical research. consequently, some argue that there is no reason to exclude a certain kind of participation from the established reimbursement norm (1, 17). in cases of modest compensation, which usually is the case in research settings, no undue inducement takes place because a fairly small amount of money is unlikely to remove the potential donors’ free will (17). in the clinical setting, egg donors are usually paid. therefore, it seems rather unfair if research subjects receive a smaller sum compared to others undergoing the same procedure in private clinical practice (1). crockin (17) further argues that if compensation for egg donation in research settings is regarded as coercion, the autonomy and free will of all egg donors and healthy human research subjects will be in doubt (17). as a matter of fact, a major limitation to research is women’s reluctance to donate their eggs without compensation. it has been reported that even after costly advertisement, prestigious academic centers, have not succeeded in convincing women to donate their eggs altruistically, but centers that paid donors were able to recruit a sufficient number of donors (1, 5). lack of donors causes delays in the progress of certain research aimed to find vital cures. this delay possibly deprives many patients from treatments they need, which raises some concerns about social justice. therefore, as the proponents of compensated egg donation claim, it serves the common good to allow such payments (1). rules, regulations and guidelines to demonstrate the diversity of opinion on this topic throughout the world, a brief overview of the related rules, regulations and guidelines in three countries with different cultural backgrounds and legal systems is presented here: united states of america, united kingdom, and iran. it should be mentioned that all these countries boast noteworthy research programs and achievements, as well as ethical and legal controversies on the very issues of hesc and scnt in the usa, professional and legal positions towards egg donation compensation are divided. on one hand, there are strong objections, for instance in 2004, california’s stem cell law prohibited payment for research egg donors (17). subsequently, in massachusetts, new legislation was ratified in 2005 which forbids monetary compensation or “valuable consideration” in the case of research donors and requires that any woman undergoing egg retrieval should receive the following documents: 1) an all-inclusive “informational pamphlet” on the potential health risks associated with the egg retrieval process, and 2) an obligatory “informed consent form” (17). in the same year, the national academy of sciences (nas) guidelines for human embryonic stem cell research took the position that no payments should be provided to egg donors other than reimbursement of direct expenses. in 2007-2008, however, the nas changed its stance in this regard to some extent, permitting some out-of-pocket reimbursement to egg donors (1, 17, 18). in 2008, michigan law concerning hesc research only permitted use of surplus ivf embryos in cases of approved research (17). similarly, in 2009, the national institutes of health (nih) guidelines on human stem cell research stated that the ivf embryos created for research purposes are not eligible for nih funding (18). on the other hand, in 2009, new york approved compensation for research donors in that state(19). the american society for reproductive medicine (asrm) also supports compensation for research donors (20); nonetheless, in an attempt to avoid “undue inducement,” payments of more than $10,000 are considered inappropriate. in the united kingdom, the human fertilization and embryology authority (hfea) does not allow payment to egg donors, unless they participate in the so-called ‘egg-sharing’ program, which means that women undergoing ivf treatment donate their spare eggs to be used for reproduction or research purposes and are compensated by free or reduced rate treatment (21, 22). in iran, according to the national ethical guidelines for biomedical research, only surplus embryos remaining from infertility treatment should be used in research, and it is forbidden to produce human embryos solely for research purposes (23, 24). the existence of this guideline does not eliminate all the concerns about this practice in iran. according to the author’s experience and conversations with physicians and lawyers working in major infertility clinics in tehran, these guidelines are not recognized and observed as solid national policies and mandates. instead, such clinics prefer to operate under legal advice of their consultants which are based on two main sources: first, the formal legislations, which appear to be insufficient and incomplete, and second, the religious decrees issued by religious authorities that help practitioners to solve their ethical and legal problems. there are, however, j med ethics hist med 7:10 jun, 2014 jmehm.tums.ac.ir kiarash aramesh page 5 of 6 (page number not for citation purposes) some ethical issues and concerns in different aspects of clinical practice in such institutions. as a matter of fact, the current system of recruiting donors and retrieving eggs for infertility treatments may raise some concerns about the possibility of emerging egg donors undergoing repetitive and frequent periods of egg retrieval. under the circumstances, the validity of the informed consent for both treatment and research purposes also needs improvement. furthermore, researchers’ knowledge and their attitude toward the above-mentioned guidelines have not been assessed and are subject to reasonable doubt. it seems that in iran, as in some other developing countries, the main ethical issues regarding human egg donation, both for infertility treatment and for research, are the insufficiencies in the process of obtaining informed consent and ethical and legal supervisions and audits. it should be added that although research ethics committees have been established in almost all major research institutes in iran, their independency and efficacy are not always verifiable. this brief review of the legislations in different countries demonstrates the existing diversity and controversy over purchase (or compensation) of human eggs for research purposes. it also shows that concerns of possible exploitation and undue inducement are more serious and noteworthy in developing countries than in more economically developed countries. suggested solutions egg sharing: as described above, egg sharing is a program that has been proposed to solve both the ethical problems of purchasing eggs and the shortage of human egg supply for research. critics have pointed out that in egg sharing, the ability to obtain informed consent is jeopardized because women who seek infertility treatment are sometimes in a desperate mindset to have a child; therefore, they might accept such donations without fully considering all the implications and consequences (25). although the egg sharing system seems to provide an ethically approved model for obtaining human eggs, precautionary measures should be taken to prevent exploitation and coercion, especially in developing countries. a stepwise approach: as mentioned above, the proponents of purchasing human eggs (or compensating egg donation) argue that a modest compensation would not influence the potential donors’ free will. nevertheless, this is not true in lowor even many middle-income societies, considering the urge of poverty and lack of gender equality, which may result in a coercive effect on females in the family to obtain money by selling their eggs. additionally, the egg sharing model cannot eliminate exploitation and coercion in such communities. hence, compensation or egg sharing seem to be justified and ethically acceptable only after all of the following steps are taken: 1. ensuring the existence of independent institutional review boards (irbs) that follow international standards in evaluating all research proposals, their scientific design and the associated risk-benefit ratio from the ethical standpoint. 2. confirming the validity of all the steps in the process of obtaining informed consent, including disclosure (by supplying comprehensive and well-designed pamphlets), understanding (especially of illiterate donors and ethnic minorities), and voluntariness (through appointing a trained and independent committee to assess each case). 3. establishing clarified and defined legal and regulatory limits on all sensitive aspects of the process, including restrictions on payment and the frequency of donation for each donor. 4. ensuring the existence and viability of independent supervising and auditing bodies. restrictions on compensation: payment should not be so high as to turn egg donation into a source of income or give it a commercial nature, and the act should preserve its altruistic and honorable spirit. in the united states, the payment proposed to research egg donors is a fraction of the amount offered to reproductive egg donors ($1000-1500 for research versus $5000-10000 for reproduction) (16, 19). this amount cannot be the same in different countries, given the differences in income and cost of living. accordingly, it seems to be reasonable that an independent committee determines the limits of such payments in each country. disclaimer the opinions expressed here are the author’s and do not reflect the policies and positions of the national institutes of health, the u.s. public health service, or the u.s. department of health and human services. acknowledgement this study was supported in part by the intramural research program of the nih and medical ethics and history of medicine research center of tehran university of medical sciences. the author wishes to express many thanks to christine grady and alan wertheimer, nih department of bioethics, for their helpful comments, and cindy clark, nih library writing center, for her assistance with manuscript editing. j med ethics hist med 7:10 jun, 2014 jmehm.tums.ac.ir kiarash aramesh page 6 of 6 (page number not for citation purposes) references 1. klitzman r. payment of egg donors in stem cell research in the usa. reprod bio med online 2009; 18(5): 603-8. 2. baylis f, mcleod c. the stem cell debate continues: the buying and selling of eggs for research. j med ethics 2007; 33(12): 726-31. 3. steinbrook r. egg donation and human embryonic stem-cell research. n engl j med 2006; 354(4): 324-6. 4. robertson ja. compensation and egg donation for research. fertil steril 2006; 86(9): 1573-5. 5. egli d, chen ac, saphier g, et al. impracticality of egg donor recruitment in the absence of compensation. cell stem cell 2011; 9: 293-4. 6. dickenson d. commodification of human tissue: implications for feminist and development ethics. dev world bioeth 2002; 2(1): 55-63. 7. grady c, denny c. research involving women. in: emanuel ej, grady c, crouch ra, lie rk, miller fg, wendler d, eds. the oxford textbook of clinical research ethics. new york: oxford university press; 2008: 407-22. 8. green rm. research with fetuses, embryos, and stem cells. in: emanuel e j., grady c, crouch ra., lie rk, miller fg, wendler d, eds. the oxford textbook of clinical research ethics. new york: oxford university press; 2008: 488-99. 9. committee on assessing the medical risks of human oocyte donation for stem cell research, giudice l, santa e, and pool r, eds. assessing the medical risks of human oocyte donation for stem cell research: workshop report. washington, dc: the national academies press; 2007. 10. ellison b, meliker j. assessing the risk of ovarian hyperstimulation syndrome in egg donation: implications for human embryonic stem cell research. am j bioeth 2011; 11(9): 22–30. 11. schneider j. fatal colon cancer in a young egg donor: a physician mother’s call for follow-up and research on the longterm risks of ovarian 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embryonic stem cell research advisory committee; national research council. final report of the national academies' human embryonic stem cell research advisory committee and 2010 amendments to the national academies' guidelines for human embryonic stem cell research. washington, dc: national academies press; 2010. 20. anonymous. the ethics committee of the american society of reproductive medicine. financial compensation of oocyte donors. fertil steril 2007; 88(2): 305-9. 21. ahuja kk, simons, eg, fiamanya w, et al. egg-sharing in assisted conception: ethical and practical considerations. hum reprod 1996; 11(5): 1126-31. 22. blyth e, golding b. egg sharing: a practical and ethical option in ivf? expert rev obstet gynecol 2008; 3(4): 465-73. 23. larijani b, zahedi f. ethical and religious aspects of gamete and embryo donation and legislation in iran. j relig health 2007; 46: 399-408. 24. aramesh k, dabbagh s. an islamic view to stem cell research and cloning: iran’s experience. am j bioeth 2007; 7(2): 62-75. 25. levens ed, decherney ah. human oocyte research: the ethics of donation and donor protection. jama 2008; 300(18): 2174-6. http://stemcells.nih.gov/policy/pages/2009guidelines.aspx ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ 1 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e original article volume 13 number 15 september 2020 copyright © 2020 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. rate and causes of discharge against medical advice from a university hospital emergency department in iran: an ethical perspective *corresponding author ehsan shamsi gooshki no.23, 3rd floor, 16azar st., keshavarz blvd., tehran, iran. tel: (+98) 21 66 41 96 61 email: shamsi@tums.ac.ir received: 27 jan 2020 accepted: 22 sep 2020 published: 28 sep 2020 citation to this article: rouhbakhsh halvaei s, sheikh motahar vahedi h, ahmadi a, mousavi ms, parsapoor a, sima ar, shojaee aa, shamsi-gooshki e. rate and causes of discharge against medical advice from a university hospital emergency department in iran: an ethical perspective. j med ethics hist med. 2020; 13: 15. sanaz rouhbakhsh halvaei1, hojat sheikh motahar vahedi 2, ayat ahmadi 3, maryam sadat mousavi4, alireza parsapoor5, ali reza sima6, amir ahmad shojaei5, ehsan shamsi-gooshki5* 1.medical student, school of medicine, tehran university of medical sciences, tehran, iran. 2.associate professor, shariati hospital, school of medicine, tehran university of medical sciences, tehran, iran. 3.assistant professor, knowledge utilization research center, tehran university of medical sciences, tehran, iran. 4.medical ethics supervisor, medical ethics and professionalism office, shariati hospital, tehran university of medical sciences, tehran, iran. 5.assistant professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran; department of medical ethics, school of medicine, tehran university of medical sciences, tehran, iran. 6.assistant professor, digestive diseases research center, digestive diseases research institute, tehran university of medical sciences, tehran, iran. abstract discharge against medical advice (dama) is a common problem in the health-care system. it imposes risks to both patients and medical staff and could be the subject of ethical deliberation. this cross-sectional study was conducted in 2017 on 400 patients who were discharged against medical advice from the emergency ward of shariati hospital, tehran, iran. patients’ information was collected using clinical records and telephone calls. the collected data were analyzed using stata software. dama rate was 12% in the emergency department of shariati hospital. male gender was found to be a risk factor for dama (or: 1.90; ci (95%): 1.44 2.52; p < 0.0001). in addition, younger patients were more likely to leave hospital against medical advice (p-value: 0.04). the more common reasons for dama were feeling better, long delay in diagnostic and therapeutic procedures and the hectic ambience of the emergency ward. patients’ self-discharge is a multi-dimensional phenomenon that is affected by patients’ characteristics, medical conditions and hospital circumstances. it raises some ethical concerns, mainly due to a conflict between patients’ autonomy and beneficence. it is helpful for the medical staff to create an effective relationship with patients who are at higher risk of dama, in order to increase their compliance and prevent the consequences of leaving hospital against medical advice. keywords: discharge against medical advice (dama); emergency department; iran; medical ethics. rate and causes of discharge against medical advice … 2 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 15 september 2020 introduction discharge against medical advice (dama) or self-discharge occurs when a patient chooses to leave hospital before the treating physician recommends discharge. according to the policies of shariati hospital, a request for leaving hospital against medical advice is considered only if a related form has been filled and signed by the patient or his/her legal representative. dama reflects a patient’s non-compliance with the physician’s advice for continued inpatient care. the high number of patients leaving hospital against medical advice can be a sign of their discontent or a problem of considerable importance. discharge against medical advice is a distressing problem for physicians and other health professionals throughout the world as it disrupts the doctor-patient relationship. patients discharged against medical advice are less likely to form an established relationship with their physician and may have unsatisfactory medical outcomes. investigating the causes and predictor variables can be useful in planning to reduce the dama rate and to increase patients’ satisfaction (1). these patients may be susceptible to serious health consequences as a result of inadequate treatment. previous studies have shown that morbidity and mortality rates are higher among patients who were discharged against medical advice in comparison with regularly-discharged patients (2). in addition, dama patients are an at-risk group for readmission and they may require more invasive and complicated therapeutic procedures after being readmitted. therefore, they increase healthcare costs (1). patients who leave hospital against medical advice have to confront an additional source of distress, which is the reason why they decided to self-discharge in the first place. discharge against medical advice can pose an ethical dilemma for medical staff. the conflict between the principle of beneficence and patients' autonomy is the most prominent ethical dilemma in dama. the importance of beneficence or doing good to patients has been emphasized throughout the history of medicine, for example in the hippocratic oath and the declaration of geneva (3). this principle has been one of the most crucial factors in developing the physicianpatient relationship, and anything that disrupts it may threaten a favorable outcome for patients. (4) the principle of patient autonomy is based on the right of every individual to make informed decisions about their personal issues and patients’ responsibility in managing their own health. it is the absolute right of the patient to have a free choice and make decisions about receiving health-care services, and to choose when, where and how to be treated (5). presently, there is a shift from the previously accepted paternalistic approach in medical practice toward shared decision-making or even a completely patient-centered model due to the increasing health literacy level and social awareness of health issues. when a patient decides to leave hospital against medical advice, the main ethical conflict for health-care providers is between the principles of autonomy and beneficence, that is, protecting patients from harm. the question is, which of them should take precedence? it is obvious that there is no rouhbakhsh halvaei s., et al. 3 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 15 september 2020 clear-cut answer and that each case has to be examined individually (4), but overall, physicians’ obligations are to improve their patients’ health and well-being. physicians should make every effort to promote informed decision-making by discussing the likely harms and benefits of leaving hospital or choosing alternatives for inpatient treatment. an informed decision is one that is made with a full understanding of risks, benefits and alternative plans. to that end, it is critical for the physician to talk to the patient directly and negotiate to make the patient’s hospital stay more tolerable. determining the cause of the patient’s dissatisfaction is a suitable starting point. broadly speaking, clinicians faced with these cases should first evaluate the patients’ decision-making capacity and then assess the external factors that have influenced their decision, and finally encourage and facilitate after-care (6). informed consent is one of the most critical steps that must be taken in caring for patients who opt for dama. obtaining informed consent also involves an evaluation of patients’ decisionmaking capacity (2). it should be mentioned that legal issues may arise in the context of dama. according to a study conducted by devitt et al., although most health-care professionals believe that documenting a discharge against medical advice may protect them from the consequences of legal actions, they may be sued for medical malpractice. the treating physician should first perform a thorough and well-documented physical examination including an assessment of the severity of illness and the risk of a premature discharge. the physician should confirm that the patient’s decision to leave hospital is informed and not forced by risks, benefits, and alternative plans. overall, good medical practice and thorough documentation are the best legal protection (7). finally, it is the physician’s responsibility to minimize the probability of harms that dama patients may be susceptible to through effective education and follow-up schedule. this study aims to evaluate and discuss the ethical aspects of main causes and also the rate of dama in one of the referral university hospital in tehran. method this is a cross-sectional study that has been conducted in 2017. the research was carried out in the emergency ward of shariati hospital, which is a tertiary, referral, university teaching hospital in tehran. dama contributing factors were identified through comprehensive literature review, and a question list was created using the results of previous theses and articles on similar subjects. the question list contained demographic characteristics (sex, age, literacy, economic status, etc.), reasons for dama (which were categorized into three sections: individual factors, factors related to medical staff, and factors related to the physical and structural features of the hospital) and post-discharge care. furthermore, three questions were designed to estimate how medical staff deals with dama cases. finally, patients’ postdischarge plans and actions were recorded. the content validity of the question list was rate and causes of discharge against medical advice … 4 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 15 september 2020 confirmed through an expert panel including medical ethicists, head of the emergency department, and head nurse of the emergency ward. utilizing a hospital inpatient database, all patients who had been discharged against medical advice from the emergency ward of shariati hospital in 2017 were identified. assuming a 3% prevalence of dama based on previous studies, a precision of 0.04% and an α level of 0.05, the sample size was calculated to be 400 for this cross-sectional study. a population of 400 patients was chosen as a sample group via stratified random sampling, while the wards were considered as strata. demographic and clinical information for 400 selected patients were extracted from clinical records. next, a telephone interview was conducted with all the 400 patients in the sample group in order to find out the reason why they had decided to leave hospital against medical advice. interviewees were allowed to choose one reason in each category. all the interviewees were assured of the confidentiality of their information and they participated in the research program willingly. patients under 18 or those whose decision-making capacity was affected by mental or psychological disorders were excluded. in addition, patients who had been unwilling to cooperate were excluded and replaced by dama cases. demographic variables such as age and sex of an equal number of patients who were discharged according to their physician’s advice was compared with the study group. the research methodology was fully approved by the tums research ethics committee (ir.tums.vcr.rec.1397.095). statistical analyses were performed via stata 12.1 statistical software using descriptive statistics (frequencies and percentages). statistical significance was defined as a p-value smaller than 0.05. results during the 12-month study period, 16767 patients were admitted to the emergency department of shariati hospital, 12% of whom were discharged against medical advice (a total of 2053 patients). the rate of dama varied between 12 14% per month during the first half of the year, but this rate dramatically soared to 20% in september and dropped to 5 6% at the end of the year. the response rate of the telephone interview was 88.1% (n = 400 out of 454). fifty-four people (11.8%) were eliminated and replaced by another person because of their unwillingness to cooperate, and 26 patients (5.7%) stated that they were unwilling to participate because of their patient’s death. those discharged against medical advice were more likely to be male compared with those who did not (or = 1.90; ci (95%): 1.44-2.52; p-value < 0.0001). in addition, younger patients (under 35 years old) were more likely to leave hospital against medical advice (p-value = 0.04). the mean age and standard deviation of the sample group were 54.15 and 19.8 respectively, while the mean age and standard deviation were 58.22 and 21.39 in the control group. rouhbakhsh halvaei s., et al. 5 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 15 september 2020 table 1the characteristics of dama cases variables groups sample group n percent gender male 236 59% female 164 41% age 18 35 93 23.25% 36 60 145 36.25% above 60 162 40.5% marital status married 290 72.5% not married (single, divorced, widow) 110 27.5% economic status low 80 20% medium 225 63.75% high 65 16.25% education level illiterate 29 7.25% primary 111 27.75% high school diploma 201 50.25% secondary education 59 14.75% payer status self-pay 52 13% medicaid pending 348 87% domicile tehran 352 88% other 48 12% smoking smoker 127 31.75% non-smoker 273 68.25% drug abuse yes 34 8.5% no 366 91.5% consumption of psychiatric medication yes 26 6.5% no 374 93.5% history of previous hospital admission yes 246 61.5% no 154 38.5% history of previous admission in shariati hospital yes 82 20.25% no 318 79.5% admission time day shift 193 48.25% night shift 207 51.75% discharge time day shift 192 48% night shift 208 52% responsible medical service inside hospital emergency department emergency service 222 55.5% internal medicine service 110 27.5% neurology service 27 6.75% surgery/orthopedics/urology 41 10.25% our findings showed that 63.96% (n = 142) of the patients who had received emergency services were discharged against medical advice during night shift. however, dama was more common during day shift among those receiving other types of services (n = 112, 62.9%). table 2 depicts the chief complaints of patients discharged against medical advice. pain (abdominal pain, chest pain, etc.) had been the most common complaint among those patients. rate and causes of discharge against medical advice … 6 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 15 september 2020 table 2the chief complaints of patients discharged against medical advice n percent abdominal pain 80 20% chest pain 37 9.25% pain * 48 12% nausea/vomiting/diarrhea/constipation 22 5.5% fever 21 5.25% trauma (multiple/single/blunt/penetration) 51 12.75% bleeding** 26 6.5% high blood pressure/tachycardia 20 5% dyspnea 20 5% loss of consciousness/lethargy/seizure 33 8.25% plegia / paresis 26 6.5% skin lesions 16 4% * includes any kind of pain except abdominal and chest pain ** includes gi bleeding, hematuria, hemoptysis, active bleeding of wounds or mucosa chart 1patient-reported reasons for leaving hospital against medical advice all the patients admitted in the emergency ward had been visited by a doctor within 30 minutes. the mean waiting time in the sample group was 14.78 minutes. the mean hospitalization time in the emergency ward was 13.8 hours in dama cases. reasons for dama as stated by dama cases are illustrated in chart 1. as mentioned earlier, these reasons are categorized into 3 main groups: individual rouhbakhsh halvaei s., et al. 7 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 15 september 2020 factors (shown in yellow), factors related to the medical staff (shown in blue), and factors related to the structural and physical features of the hospital (shown in green). according to chart 1, the more common reasons why patients decided to leave hospital against medical advice had been feeling better, long delay in diagnosis, therapeutic procedures and hectic environment of the emergency ward. about 25 % (n = 100) of the patients mentioned lack of appropriate inpatient room as the reason why they opted for dama, and 73 % (n = 292) pointed to delay in delivery of health services as well. interviewees were allowed to choose one reason in one, two or all categories. fortyeight percent (48%) of the patients mentioned a reason in each of the three categories (a total of 3 reasons), and 37.5% of them chose a reason in two categories, while only 14.5% of the patients stated just one reason for their dama. there was no patient who had decided to leave hospital against medical advice just because of “dissatisfaction with non-clinical services” or “inappropriate hygiene”. in other words, these factors had always been accompanied by other reasons in dama cases. roughly half of the patients who mentioned no “noticeable improvement” as a reason for self-discharge, also did not trust in their caring physician (52.17%). almost all the patients who mentioned “long stay in the emergency ward” as a reason for self-discharge were also dissatisfied on account of delay in delivery of health-care services. only 3 (0.75%) dama cases claimed that they were only dissatisfied with the structural and physical features and had no complaint about the medical staff and no individual reasons. the mean age of the patients who mentioned structural and physical features as a reason for dama was lower than those who did not mention this factor (mean difference = 15.82 years). according to the data analysis, 39.19% of the patients who had received care service from emergency specialists did not mention any factors related to medical staff as their reason for dama; conversely, this percentage was 11.82% and 12.02% for internal and surgical service, respectively. roughly a third of those whose caring physicians were emergency specialists were dissatisfied due to delay in delivery of health-care services, while this percentage was 65.45% and 78.05% in internal and surgical wards, respectively. about three quarters of the patients admitted because of dyspnea mentioned one reason in all categories. however, this percentage was lower among patients with other chief complaints. patients answered three questions about their physicians’ approach to their dama request. the first question was whether the caring physician had made an effort to discourage them from dama, to which 70.5% (n = 282) gave a positive response. the second question was whether the physicians discussed the alarming signs of rate and causes of discharge against medical advice … 8 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 15 september 2020 their illness and educated the patients on how to deal with them. according to the patients’ responses, only 39.5% (n = 158) of the patients had received the appropriate education before leaving hospital against medical advice. ultimately, responses to the final question indicated that only 38.25% (n = 153) of the physicians asked their patients about their post-discharge decisions and plans for continuing their treatment. as can be seen in chart 2, 47.75% (n = 191) of the patients were re-admitted in either a private or a public hospital. in addition, 4% (n = 16) of the patients went back to shariati hospital after discharge against medical advice. however, 25% (n = 100) of the patients were cured without undergoing any treatment, and 18.5% (n = 74) of the dama cases continued their treatment through outpatient care. chart 2patients' decision after dama during the interview, it was revealed that 4.75% (n = 19) of the patients had passed away; among these, there were 2 who had been motivated by the medical staff to leave hospital and receive palliative care at home instead of being hospitalized. among the dama cases who had passed away, 42% had left hospital because they were tired of being hospitalized. furthermore, it is noteworthy that 90% of the patients with terminal illnesses who died after dama had been dissatisfied with the structural and physical features of the hospital. sixty-four percent of the patients who had opted for dama because they started to feel 100 16 28 163 74 19 cured without any further treatment re-admission in shariati hospital hospitalized in private hospital hospitalized in another public hospital out-patient treatment death 0 20 40 60 80 100 120 140 160 180 rouhbakhsh halvaei s., et al. 9 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 15 september 2020 better were cured without any further treatment. moreover, 25.66% of them continued their treatment through outpatient care. in other words, 89.66% of the patients who decided to be discharged against medical advice because of feeling better did not experience adverse complications or readmission. discussion discharge against medical advice generates challenges to emergency department physicians, who should make a balance between respect for patients’ autonomy and the necessity for complete evaluation. in this study we examined the characteristics of patients and their reasons for dama from an emergency department. more than a tenth of the patients admitted in the emergency ward of shariati hospital were discharged against medical advice. this rate is high compared to previous iranian studies, which reported a prevalence ranging from 3.24% to 10.3% (8, 9). one research on dama rates in different wards of a hospital found that the emergency department is one of the hospital units with the highest prevalence of dama (9, 10). thus, the higher dama prevalence in this study can be due to the fact that it was conducted exclusively in the emergency department. the rate of dama in a similar study conducted by shirani et al. in an iranian emergency department was 20% (11). there are many contributing factors to the higher dama rate at emergency departments. incompatibility of the perceived necessity for emergency admission between patients, and the emergency medical service and personnel of the emergency ward may be one factor contributing to the higher dama rate in emergency departments. furthermore, according to the ems protocols in iran, patients who demand urgent medical care may not be referred to the hospital of their choice; therefore, they prefer to be transferred to other hospitals after relative improvement. for instance, they may wish to continue treatment with their trusted doctor or be admitted in a hospital in their neighborhood. another significant finding is the considerable higher rate of dama in september. this is the time of the year when new residents begin their training and senior residents graduate. previous research has shown the potential effect of this large changeover on patient care, so that in the uk they call it the “killing season”; in north america it is called the “july effect”. although there is no previous study that compares the relationship between the rate of dama and the “july effect”, young et al. showed that mortality increases and efficiency decreases in hospitals because of the “july effect” (12). as a result, higher dama rates during september in our study may be attributable to residents’ changeover in this month. as mentioned before, there is a statistically significant correlation between male gender and dama. in other words, male gender can be considered as a risk factor for selfdischarge. the results of many studies conducted in iran and other countries (1, 2, 9) as well as the results of a review of the existing studies (9) have confirmed that male patients are more likely to leave hospital rate and causes of discharge against medical advice … 10 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 15 september 2020 against medical advice. this finding may be attributable to the social and financial responsibilities of men in the family as well as their risk-taking attitudes (10). it should be mentioned that the lower dama rate among women can also be attributable to the iranian culture. although the written consent of the father or spouse is not essential for dama, they have considerable influence in the decision-making of female patients. according to the results, dama is more prevalent among younger patients. this finding is correlated with those of previous studies (1, 3, 13-16). also, a review article that studied 61 previous articles (9) showed that young age is a predictor factor for dama. this can be attributable to young patients’ risk-taking tendency for refusing complete treatment. according to the results, the mean age of the patients who mentioned the structural and physical features of the hospital as their self-discharge reason was lower; in other words, younger patients have higher expectations regarding the physical features of the hospital. this finding can also provide another explanation for the higher prevalence of dama among young patients. according to the statistical analysis, there is a significant correlation between older age and previous hospitalization (p-value: 0.0001), that is, elder patients are more acquainted with hospital routines and environment. this finding can also explain why younger patients are more likely to opt for dama. patients’ reasons for dama were not correlated with age, sex, marital status, socioeconomic status, domicile, history of smoking, addiction and identified psychological disorders. in contrast, a study conducted by manouchehri et al. indicates that men leave hospital against medical advice mostly due to personal and familial reasons, while the reason for women’s dama is often dissatisfaction with hospital facilities (17). the number of dama cases who mentioned financial problems as the reason why they left hospital was lower in comparison with a similar study conducted in 2013(8). in iran the health transformation plan (htp) became effective in 2014 to provide access to universal health coverage. this transformation plan protects people financially against health expenses and provides equity in access to the benefits of health services. the ultimate goal of this plan is delivering health-care services according to patients' needs and not their ability to pay (18). it can be concluded that the lower number of patients who mentioned financial problems for dama in this study can be attributed to the decrease in medical costs (19). in this study, there was no significant difference between the rate of dama during day shift and night shift. however, in a study conducted by vahdat et al., 76% of the patients decided to leave hospital against medical advice during night shift (14). the similar dama rates during day and night shift in this study may be related to the 24hour presence of emergency medicine faculty specialists, who can better manage challenges compared to junior physicians. most patients decided to leave hospital against medical advice as a result of multiple factors. this finding shows that trying to rouhbakhsh halvaei s., et al. 11 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 15 september 2020 eliminate only one factor may reduce the dama rate significantly in this setting. the percentage of patients who were satisfied with factors related to the medical staff was higher among those whose caring physicians were emergency specialists. furthermore, these patients were less dissatisfied with delay in delivery of healthcare services. these results may be due to the greater availability of emergency specialists in the emergency ward, which results in more effective doctor-patient communication and relationship. the crucial impact of communication on provision of quality health care, especially in high stress contexts such as emergency departments, is being increasingly recognized. conversely, ineffective communication not only causes patients’ dissatisfaction and anxiety, but also is a major cause of critical medical incidents (20). a study conducted by slade et al. has argued that positive interpersonal relationship between patients and their physician including rapport and empathy results in more favorable clinical outcomes, such as mutually agreed treatment plans and better patient adherence (21). in our study, roughly 13% of the dama cases indicated either dissatisfaction with staff’s behavior or not receiving adequate information as a major cause for their decision. in the highstress, time limited context of the emergency department, communication is complex, interrupted, rushed, and error prone. in addition, the interdisciplinary nature of health care in emergency departments and the number of different clinicians may cause confusion and anxiety for patients. sometimes, doctors and nurses wrongly presume that a medical condition, test or treatment has been explained to the patients by the other party or previous shift’s doctors, while it has not; therefore, they do not inform the patient about the treatment schedule and patients remain in a state of confusion (21). thus, communication skills are particularly important for emergency departments staff due to their complicated situation and they should make an effort to improve their communication skills with both patients and other clinicians in the emergency department. furthermore, empathy and rapport increase clinicians’ efficiency in communicating with patients, which results in enhancement of patient satisfaction and overall health outcomes. another 9% of the dama cases claimed distrust in medical staff as a reason for their decision. audiey et al. have explained that patients’ trust in their physician is related to having a longer relationship with them and trust in the health-care organization (22). both of these elements seem unachievable in emergency settings; however, suitable doctor-patient relationship can be created even in short stays through effective communication. approximately 30% of the patients cited feeling well as the reason for leaving hospital, which is more than the rate reported by studies conducted in other countries (23, 24). this indicates the failure of the caring physician in convincing patients that they need to continue their treatment. this percentage was 28.4% in a similar study conducted by pour karimi et al. in iran (25). almost 90% of the patients who decided to dama because of feeling rate and causes of discharge against medical advice … 12 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 15 september 2020 well did not experience adverse complications, re-admission or mortality. however, the results of previous studies indicated that patients who opt for dama have increased 7-day and 28-day readmission rates, and that dama is associated with both increased short-term and long-term mortality (26-28). it can be concluded that iranian physicians have adopted a defensive approach in order to reduce or prevent complaints or criticism. however, according to the “general guideline of professional ethics for members of the islamic republic of iran medical council”, it is forbidden to encourage patients to use unnecessary services in order to defend oneself against possible legal action (29). as mentioned before, 4.75% of the studied patients passed away after dama, all of whom were suffering from poor prognostic diseases, and almost all of them had been dissatisfied with the structural and physical features of the hospital. this indicates that the environment of the emergency ward is not suitable for end-stage patients. in addition, 83% of the patients who had been discharged against medical advice in our study were dissatisfied with environmental factors including non-clinical facilities, room, and also the hectic ambience of the emergency ward. several studies have emphasized the importance of environment to patients’ health outcome (30). discordance of admission capacity with the number of admitted patients and inadequate allocation of space to each patient arise discomfort and dissatisfaction among patients. moreover, unavailability of appropriate rooms for patients may invade their privacy during admission. hence, providing a solution to address capacity may improve clinical outcomes. in our study, 3 patients claimed that they left hospital because their managing physician had suggested that they do so. motivating patients to leave hospital against medical advice deems contrary to professional decency. a closer look at these dama cases in our study showed that 2 of them suffered from incurable diseases and were at end stage, and were advised to seek palliative care as they would not benefit from being admitted in the hospital. in most developing countries including iran, home care and hospices are not adequately established, and therefore physicians are not able to refer these patients to palliative and home care services. considering the importance of discharge against medical advice and its consequences for patients and health systems, it is necessary to minimize its incidence by adopting practical approaches. one of the most effective solutions is to improve the communication skills of the medical staff, which will result in improvement of the doctor-patient relationship (2, 31, 32). another important approach is to expand the capacity of backup wards in order to increase patient flow and early evacuation of patients from the emergency department to final wards, and promote practical protocols to accelerate diagnostic and therapeutic measures. these interventions can decrease overcrowding of the emergency ward, which will result in providing a better environment for patients in this ward. rouhbakhsh halvaei s., et al. 13 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 15 september 2020 another crucial subject in discharge against medical advice is how to accurately manage a dama case in a way that it would be as safe as possible. the first substantial step is to obtain an informed consent. in practice, obtaining informed consent consists of some essential steps including an evaluation of the patients’ decision-making capacity and providing them with necessary information about their diseases, tests, treatment plans and the consequences of cessation of treatment in hospital (2). in our study, approximately 70% of the patients stated that they had not been informed by their managing physician about alarming signs and emergency situations in which they should rush to the hospital. they also claimed that they did not receive any information about alternative treatments available for them. this finding indicates that clinicians of emergency departments do not perform appropriately in obtaining informed consent and managing dama cases safely. the main limitation of this study was lack of a control group to compare dama patients’ socioeconomic and medical variables with those who were discharged regularly. furthermore, interviewing with a control group would be beneficial to discovering and comparing the problems and dissatisfactions of patients who were discharged regularly with dama cases. it is crucial for future research to investigate dama risk factors. we have only investigated risk factors in terms of age and gender, while several other contributing factors may be important predictors of dama at the emergency department. conclusion this study’s findings indicated that commitment to patient, commitment to self, and commitment to profession are integral components of occupational therapists' clinical competence. professional commitment and ethical conduct are closely related to sense of responsibility. hence, accommodating one of the commonest, most serious problems in the health-care system that involves both patients and physicians is discharge against medical advice. dama can also be considered as a potentially high-risk event leading to malpractice litigation. physicians must be cautious in such cases since dama does not ethically or legally absolve their responsibilities as health-care providers. therefore, a systemic approach should be adopted in order to reach a realistic compromise between maintaining patient autonomy and upholding beneficence. we hope that the findings of this study will raise awareness of the present status of dama, as well as the predictors and causes among policymakers and hospital managers. as a result, we are expecting these authorities to provide the necessary interventions and thus increase patient satisfaction. prevention of dama is clearly desirable, but certainly not easy. if the medical staff is capable of detecting patients who are high risk for dama, they will adopt the necessary measures to prevent it. in addition, identifying and ameliorating dama factors rate and causes of discharge against medical advice … 14 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 15 september 2020 that are related to the medical staff or hospital environment can significantly decrease the dama rate. a comprehensive explanation of the outcomes of dama to a patient who has decided to leave hospital and competent management of the situation may avert some self-discharges. finally, providing clear instructions during a dama case is of paramount importance. if a patient insists on leaving hospital against medical advice in spite of his/her physician’s disapproval, it is the duty of the physician to make the discharge as safe and risk-free as possible. this is achievable through giving patients adequate information about their illness as well as helping them seek followup treatment after discharge. authors’ contribution all authors reviewed the final manuscript. conflict of interests there is no conflict of interests to be declared. rouhbakhsh halvaei s., et al. 15 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 15 september 2020 references 1. aliyu zy. discharge against medical advice socio demography: clinical and financial perspective. int j cli pract. 2002; 56(15): 325-7. 2. alfandre dj. i’m going home: 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[cited 2020 september]; available from: http://research.gmu.ac.ir/rdsm_project.php?slc_lang=fa&sid=1&mod=project_profile&proj ect_id=751&rds_id= https://irimc.org/%d8%b3%d8%a7%d8%b2%d9%85%d8%a7%d9%86-%d9%86%d8%b8%d8%a7%d9%85-%d9%be%d8%b2%d8%b4%da%a9%db%8c-%d8%a7%d9%86%d8%aa%d8%b4%d8%a7%d8%b1%d8%a7%d8%aa/agenttype/view/propertyid/147 https://irimc.org/%d8%b3%d8%a7%d8%b2%d9%85%d8%a7%d9%86-%d9%86%d8%b8%d8%a7%d9%85-%d9%be%d8%b2%d8%b4%da%a9%db%8c-%d8%a7%d9%86%d8%aa%d8%b4%d8%a7%d8%b1%d8%a7%d8%aa/agenttype/view/propertyid/147 https://irimc.org/%d8%b3%d8%a7%d8%b2%d9%85%d8%a7%d9%86-%d9%86%d8%b8%d8%a7%d9%85-%d9%be%d8%b2%d8%b4%da%a9%db%8c-%d8%a7%d9%86%d8%aa%d8%b4%d8%a7%d8%b1%d8%a7%d8%aa/agenttype/view/propertyid/147 https://irimc.org/%d8%b3%d8%a7%d8%b2%d9%85%d8%a7%d9%86-%d9%86%d8%b8%d8%a7%d9%85-%d9%be%d8%b2%d8%b4%da%a9%db%8c-%d8%a7%d9%86%d8%aa%d8%b4%d8%a7%d8%b1%d8%a7%d8%aa/agenttype/view/propertyid/147 http://research.gmu.ac.ir/rdsm_project.php?slc_lang=fa&sid=1&mod=project_profile&project_id=751&rds_id= http://research.gmu.ac.ir/rdsm_project.php?slc_lang=fa&sid=1&mod=project_profile&project_id=751&rds_id= cancer -137mahmood tabatabaee (1) journal of medical ethics and history of medicine diagnosis and treatment of cancer in medical textbooks of ancient iran seyed mahmoud tabatabaei1*, seyed mohammad ali tabatabaei2 1professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran; 2postgraduate student, department of periodontics, faculty of dentistry, babol university of medical sciences, babol, iran. corresponding author: seyed mahmoud tabatabaei address: #23, shanzdah azar st, medical ethics and history of medicine research center, tehran, iran. email: smtabataba_md@yahoo.com tel: 98 21 66 41 96 61 fax: 98 21 66 41 96 61 received: 27 apr 2014 accepted: 26 jul 2014 published: 01 oct 2014 j med ethics hist med, 2014, 7:16 © 2014 seyed mahmoud tabatabaei et al.; licensee tehran univ. med. sci. abstract research shows that ancient iranians were among the pioneers of medical science, and are therefore admired and praised by non-iranian scholars for their efforts and accomplishments in this field. investigations of medical and historical texts indicate that between the 10th and the 18th century a.d., ancient iran experienced a golden age of medicine. great physicians such as rhazes, al-ahwazi, avicenna and others reviewed the medical textbooks of civilizations such as greece and india, theories were scientifically criticized, superstitious beliefs were discarded, valuable innovations were added to pre-existing knowledge and the ultimate achievements were compiled as precious textbooks. alhawi by rhazes, cannon by avicenna, and kamil al-sina'ah by al-ahwazi are among the works that were treasured by domestic and foreign scientists alike, as well as future generations who continued to appreciate them for centuries. the above-mentioned textbooks discuss diseases and conditions related to neurosurgery, ophthalmology, ear, nose and throat, gastroenterology, urology, skeletomuscular system and other specialties, as well as cancer and similar subjects. one of the richest texts on the description, diagnosis, differential diagnosis, and prognosis of cancer and therapeutic approaches is alhawi by mohammad ibn zakarya al razi (rhazes). this article presents a brief summary of rhazes’ views about the definition of cancer, types, signs and symptoms, prevalence, complications, medical care, treatment and even surgical indications and contraindications. moreover, his opinions are compared against the views of other physicians and theories of modern medicine. it is also recommended to review the medical heritage of iran and evaluate the proposed treatments based on modern methodologies and scientific approaches. keywords: cancer, iranian ancient medicine, rhazes mailto:smtabataba_md@yahoo.com j med ethics hist med 7:16 oct, 2014 jmehm.tums.ac.ir seyyed mahmoud tabatabaei page 2 of 6 (page number not for citation purposes) introduction although medicine and medical practice is considered to be as old as the human history, most physicians and researchers believe that detailed knowledge of cancer may be no older than some decades or a century at the most. it is amazing that prominent iranian physicians have mentioned the term “cancer” in their textbooks since about twelve centuries ago, and have associated certain conditions with it. among these are headaches, ailments of the ear, eyes, pharynx, larynx, nervous system, musculoskeletal system, gastrointestinal tract, and urologic diseases. they have also provided descriptions of some types of cancer, methods of diagnosis and treatment, prognosis, and other interesting issues. one of the most significant works on the description, diagnosis, differential diagnosis, prognosis and therapeutic approaches towards cancer is alhawi by rhazes (figures 1 and 2), which was written prior to avicenna's cannon and al-ahwazi's kamil al-sina'ah. figure 1. the front cover of al-hawi, arabic manuscript, vol.12 j med ethics hist med 7:16 oct, 2014 jmehm.tums.ac.ir seyyed mahmoud tabatabaei page 3 of 6 (page number not for citation purposes) figure 2. the back cover of al-hawi, arabic manuscript, vol.12 in this article, first a brief summary of rhazes’ views on cancer is presented, and subsequently it is recommended to review the medical heritage of iran and evaluate the proposed treatments in order to help resolve complicated and problematic cases. definitions and general information about cancer in medical textbooks of ancient iran according to ancient iranian textbooks, cancer is a hard lump with a dark color, abnormal appearance and uneven margins with peripheral outgrowths that give it the appearance of a crab, and hence it is called “cancer” (1, 2). cancer may occur in the skin, external or internal organs, especially in intestines or the uterus (1, 3). it can also occur in some major organs of the body, such as the brain and heart, which will make surgery impossible (1). if cancer spreads to internal organs and surgery is not an option, it must not be manipulated because any form of stimulation may lead to side effects such as severe and intolerable pain (1, 4). some causes of cancer 1. liver dysfunction and production of abnormal or harmful chemicals by this organ (1, 5). 2. spleen dysfunction and inability of this organ to remove abnormal or harmful substances from the blood (1, 5). 3. eating food that can cause cancer (1, 6, 7). prevalence as mentioned in medical textbooks of ancient iran and confirmed by modern studies, the prevalence of cancer is higher in women than men (1, 8, 9), with uterine and breast cancer being the most common. breast cancer is the most prevalent type of cancer among women. cancer is more common in soft tissues than in hard tissues (1, 6) and also in organs with more blood vessels. it also occurs more frequently in organs closer to the neck area and those organs with abundant blood vessels and nerve fibers (1). j med ethics hist med 7:16 oct, 2014 jmehm.tums.ac.ir seyyed mahmoud tabatabaei page 4 of 6 (page number not for citation purposes) diagnosis of cancer according to rhazes and avicenna it is difficult to diagnose cancer at its onset stage and most physicians cannot successfully detect it at first. if diagnosed early on, however, medication may be administered, although definitive treatment is rarely achieved (1, 4). at the onset stage, a cancer mass or tumor is the size of a fava bean, lacks adhesion and moves when touched, but after growth it becomes adhesive and immovable. the outer tissue turns red and becomes very painful, and the patient may feel a burning and agonizing sensation (figure 3). after the tumor grows, there are sometimes unclean and foul smelling secretions, and in some cases the vessels surrounding the cancer afflicted organ become congested, warm and dark (1). symptoms of some types of cancer rhazes, avicenna, ali ibn abbas al-ahwazi and other physicians have written about cancer of the eye, nose, pharynx and larynx, breast, uterus, gastrointestinal tract and other organs in their textbooks; they have described diagnostic signs and symptoms, differential diagnosis, treatment and prevention, and have discussed other interesting details that can be subject of research and study. in the following section we will investigate some instances of their works. 1. eye cancer if cancer occurs in any of the eye layers, they become red and varicose-like protuberances develop in ophthalmic vessels. the patient will feel a severe pain from cornea to the temporal bone, and the pain will be more severe while walking or moving around (figure 4). other symptoms are headaches, diluted and burning secretions and loss of appetite. potent drugs are not effective and may even intensify the patient’s pain (3, 5, 6, 10-15). uterine and breast cancer one symptom of uterine cancer is a prolonged, diluted bloody discharge (1). ali ibn abbas alahwazi wrote that a hard and thick mass detected between the navel and pubic area in a woman may indicate uterine cancer (7). according to rhazes, there is a correlation between breast cancer and the quality and quantity of menstrual bleeding, that is, the more regular and normal the menstrual bleeding is, the less the possibility of breast cancer will be (1, 3, 16). there is also a correlation between breast cancer and liver and spleen dysfunction (1, 5). 2. intestinal cancer ali ibn abbas al-ahwazi believed that continued, bloody stools, diarrhea, and painful, frequent and foul smelling defecation may be symptoms of figure 3. rhazes on the appearance of cancer figure 4. rhazes on eye cancer j med ethics hist med 7:16 oct, 2014 jmehm.tums.ac.ir seyyed mahmoud tabatabaei page 5 of 6 (page number not for citation purposes) advanced intestinal cancer, which usually leads to the patient's death (3). differential diagnosis in the differential diagnosis of cancer, detection is of great importance as some non-cancerous cases may be very similar to cancer in the examination and evaluation stage. for example, if the areas around the neck or axillary lymph nodes are suspected to be cancerous, the physician will examine those areas carefully, and if they are warm to the touch, he may conclude that they are afflicted by cancer. on the other hand, some tumors like scrofula are colder than body temperature or have the same temperature as the body (1, 6). metastasis in some cases of breast cancer, despite mastectomy of the cancerous breast, the cancer will spread to the other breast due to the causative factor (1, 4) (figure 5). figure 5. rhazes on the metastasis of cancer disease transmission ali ibn abbas al-ahwazi argued that some malignant diseases may affect the male semen and thus be transmitted to the next generation. it is interesting that he differentiated between this kind of transmission and the transmission of diseases such as smallpox (3), as the hereditary transmission of cancer is an ongoing topic of discussion in modern medical texts (17). general principles in cancer treatment 1. if cancer is detected at the onset stage, in some rare cases it can be treated definitively. 2. if cancer is advanced, the physician must try to prevent its progress by medication or surgery. in surgery, all cancerous cells must be removed and the whole afflicted organ may need to be extracted. 3. if cancer is confirmed to be resistant and permanent, its progress must be prevented in order to prolong the patients' life. in such cases, however, inappropriate attempts may cause side effects that can lead to the patients' death. sometimes the patient may live longer and suffer less without undue intervention. 4. in cases where surgery is impossible, the cancerous mass must not be incised or pierced, and if ulcerated, prevention from infection must be provided and the ulcerated area must be treated carefully. 5. the important side effects of surgical therapy such as damage to the nerve fibers, vessels and/or muscles should not be overlooked (1). generally speaking, ancient physicians would have three objectives in treating patients with cancer: 1. preventing progress of the disease 2. preventing the cancer mass from being incised or pierced in order to avoid complications 3. reducing the side effects and trying to calm the patient and treat secondary infections (18). prognosis the majority of great ancient iranian physicians have categorized cancer and leprosy among major malignant diseases (3), and have pointed out that pessimism, continuous anxiety and depression can cause malignant diseases. in modern literatures on psycho-oncology, it is stressed that cancer patients are afflicted by depression and anxiety and similar disorders are important factors in the prognosis of the disease (16, 19). ancient iranian physicians believed that cancer is a malignant disease which is particularly challenging for the physician, and that the physician must not expect a definitive treatment as there is not much hope for one (2, 7, 20). they also thought that the darker and more concentrated the patient's blood is, the more malignant the disease j med ethics hist med 7:16 oct, 2014 jmehm.tums.ac.ir seyyed mahmoud tabatabaei page 6 of 6 (page number not for citation purposes) will be. this may be true of certain types of cancer that are associated with abnormal changes in the blood (8). they also believed that in cancers of the throat, palate and female genital organs, surgery might result in the patient's death (20). discussion ancient iran experienced a golden age of medicine between the 10th and the 18th centuries a.d., when great physicians such as rhazes, al-ahwazi, avicenna and others lived and practiced. these physicians revised the medical textbooks written in the centuries before christ that were adopted and translated from civilizations such as greece and india, and attempted to advance this very important and vital science. each of these prominent physicians revised and criticized the opinions of others before themselves, eliminated incorrect ideas such as superstitious beliefs, added their innovations to the pre-existing knowledge and passed their achievements to the next generations. it can be claimed that iranians made great contributions to the medical science during these years and provided the grounds for the development of modern medical knowledge, a fact that most people nowadays are hardly aware of. among the abovementioned contributions are valuable textbooks such as alhawi by rhazes, cannon by avicenna and kamil al-sina'ah by al-ahwazi, all of which contain a wealth of medical knowledge. this article presents a brief, selective investigation of the phenomenon of cancer as discussed in these works. it is clear that despite their limited resources and lack of advanced equipment, ancient iranian physicians had succeeded in gaining valuable information that may even be beneficial to modern science. the details in these works on the diagnostic symptoms, differential diagnosis, predisposing factors, treatment, and prognosis of cancer are strong evidence for this claim. we hope that contemporary researchers will review and study the above-mentioned textbooks to help solve some of the medical problems in our age. references 1. rhazes m. [alhawi alkabir fi al teb], 1st ed. heydarabad, india: daerat al maaref al osmanyah; 1962, vol.13, p. 335. [in arabic] 2. kermani n. [sharh alasbab val alamat]. qom, iran: islamic organization of islamic medical studies; 2003, vol. 2, p. 434.[in arabic] 3. alahwazi a. [kamil al senaah al tebyah]. qom, iran: islamic organization of islamic medical studies; 2003, vol. 2, p. 284, 290,378, 449, 528.[in arabic] 4. avicenna h. cannon of medicine. tehran, iran: traditional publishing; 1876, vol. 4, p. 70-71. 5. avicenna h. cannon of medicine. tehran, iran: traditional publishing; 1876, vol. 3, p. 63, 179-197, 210-212. 6. tabatabaee sm. [abstract of alhawi], 1st ed. mashhad, iran: mashad university of medical science; 2010, vol.1, p. 51-94, 184-188. [in persian] 7. alahwazi a. [kamil al senaah al tebyah]. qom, iran: islamic organization of islamic medical studies; 2003, vol. 1, p. 115, 126, 502. .[in arabic] 8. mendelsohn j, hunt kk, robb gl, strom ea, ueno nt. breast cancer, 2nd ed. new york: springer science & business media; 2007, p. 1-18. 9. rhazes m. [alhawi alkabir fi al teb], 1st ed. heydarabad, india: daerat al maaref al osmanyah; 1961, vol.10, p. 120. [in arabic] 10. tabari a. [ferdos al hekmah fi al teb]. beirut, lebanon: dar alkotob alelmyah; 2002, p. 227.[in arabic] 11. tabatabaee sm, kalantar aj. [motaleeh tatbighi sardard as ketab alhawi va osoule novin pezeshki]. majaleh pajuhesh dar pezeshki 1389; 33(1): 1-4. [in persian] 12. tabatabaee sm, kalantar aj, sedaghat mr. [cheshm pezeshki az ketab alhawi razi va moghayeseh an ba danesh novin pezeshki]. majaleh pajuhesh dar pezeshki 1389; 33(2): 59-63. [in persian] 13. rhazes m. [alhawi alkabir fi al teb], 2nd ed. beirut, lebanon: dar ehia altorath alarabi; 2002, vol. 3, p. 386-407. [in arabic] 14. rhazes m. [alhawi alkabir fi al teb], 2nd ed. beirut, lebanon: dar ehia altorath alarabi; 2002, vol. 6, p. 133. [in arabic] 15. rhazes m. [alhawi alkabir fi al teb], 2nd ed. beirut, lebanon: dar ehia altorath alarabi; 2002, vol. 2, p. 221-226. [in arabic] 16. sadock bj, sadock va, ruiz p, eds. kaplan and sadock's comprehensive textbook of psychiatry. baltimore: lippincott williams and wilkins; 2009, p. 2315-32. 17. boyle p, levin b, eds. world cancer report, 2008. lyon, france: international agency for research on cancer; 2008. 18. avicenna. encyclopædia britannica. http://www.britannica.com/ebchecked/topic/45755/avicenna (accessed in 2010) 19. schmoll hj, veer lv, vermorken j, schrijvers d, eds. european society for medical oncology handbook of cancer diagnosis and treatment evaluation. ny, usa: informa healthcare; 2009, p. 65-73. 20. rhazes m. [alhawi alkabir fi al teb], 1st ed. heydarabad, india: daerat al maaref al osmanyah; 1962, vol.12, p. 5, 6, 8. [in arabic] http://www.britannica.com/ebchecked/topic/45755/avicenna ______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ original article copyright © 2021 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. journal of m edical ethics and h istory of m edicine value-rich exposures in medical education: phenomenology of practice according to the lived experiences of medical students in iran *corresponding author leila afshar address: department of medical ethics, shahid beheshti university of medical sciences, shams alley, valiasr ave., tehran, iran. postal code: 1967846911 tel: (+98) 21 88 77 35 21 email: leilaafshar@sbmu.ac.ir received: 16 apr 2021 accepted: 1 jun 2021 published: 13 jul 2021 citation to this article: sabeghi h, yazdani s, foroutan sa, hosseini sm, afshar l. value-rich exposures in medical education: phenomenology of practice according to the lived experiences of medical students in iran. j med ethics hist med. 2021; 14: 9. hakimeh sabeghi1, shahram yazdani2, seyed abbas foroutan3, seyed masoud hosseini4, leila afshar5* 1.phd candidate in medical education, virtual school of medical education and management, shahid beheshti university of medical sciences, tehran, iran. 2.professor, virtual school of medical education and management, shahid beheshti university of medical sciences, tehran, iran. 3.associate professor, permanent member, academy of medical sciences of iran, tehran, iran. 4.department of medical education, faculty of medicine, mashhad university of medical sciences, mashhad, iran. 5.associate professor, department of medical ethics, shahid beheshti university of medical sciences, tehran, iran. abstract values predispose people to make the right and especially ethical decisions, and are important for good performance in medical sciences. students’ lived experiences and the valuerich exposures during their education are some effective means of achieving professional values that help them build their own value frameworks. in this phenomenology of practice study, we aimed to explore and describe the lived experiences of a sample of medical students in shahid beheshti university of medical sciences regarding their value-rich exposures. in-depth interviews, students’ written stories, recorded video interviews related to past trips and photographs were used to collect data. the data was analyzed based on van manen’s thematic analysis method. five themes emerged from the data: “in the shadow of a supportive mentor”, “a well-orchestrated, value-rich program”, “human interactions in a value system”, “acquiring values in a real-life environment”, “and seeking values in oneself”. our study identified different dimensions of value-rich exposure based on the lived experiences of medical students and pointed out some issues that medical education planners can consider to improve the quality of value-based education for medical students. keywords: medical students; medical ethics; medical education; value-rich exposure; phenomenology of practice. value-rich exposures in medical education: phenomenology of practice according to… 2 j med ethics hist med. 2021(jul); 14: 9. journal of m edical ethics and h istory of m edicine introduction working in the medical profession is a kind of moral enterprise due to its effects on human lives (1). ethics should therefore be taught as a part of the core identity of the profession, and medical ethics education must prioritize the transmission of professional values. teleologically, values in medical professionalism are derived from the concept of the unitary good of the patient, which is the aim of all medical sciences (2). values are defined as normative guidelines that help us resolve conflicts and challenges and choose the right course of action, and they are effective in the clinical decisionmaking and judgment process (3, 4). integrity, compassion, altruistic beneficence, equality, justice, security, truth, and working in partnership with members of the wider healthcare team are examples of values that should be conveyed through medical education (2, 5). neglecting values creates barriers to the physician-patient relationship, which disrupts the overall process of ethical decision-making. therefore, it is essential for physicians and medical students to learn about values, their roles and meanings (4, 6). thus, medical students should be empowered via medical ethics education programs to balance their individual values with the values of patients and the society. teaching of values must be at the forefront of medical education (5). it is noteworthy that value education is beyond the osmotic transfer of ethical considerations and principles from teachers to students in the traditional education model (7). the methods of teaching values should aim at the internalization of professional values in students. therefore, such teaching reflects humanistic and value-conscious medical practice (2). recent research in the field of medical ethics education suggests that it is imperative to integrate the values into the medical education curriculum (1, 8). students’ lived experiences during their education are effective resources for achieving professional values that help them build their own value framework (4). in fact, real situations and exposure to value-rich experiences in the course of one’s education are unique opportunities that can have a tremendous impact on transfer of values. students' first experiences of caring for a sick or dying person, their visits to an elderly care center, their first attendance in an operating room or intensive care unit, and many other experiences can be considered as value-rich exposures (9). value-rich exposure programs a self-reflective program is an effective way to deliver ethics education as it helps students perceive themselves better and make decisions based on their own beliefs and values (10). in this regard we had a unique experience in shahid beheshti university of medical sciences in iran. we designed a value-rich exposure program as an elective, extracurricular activity for medical students. this type of project has been implemented sabeghi h., et al. 3 j med ethics hist med. 2021(jul); 14: 9. journal of m edical ethics and h istory of m edicine for over a decade and students participating in these programs are involved in various activities during their academic period frequently. the students learned scientific contents along with value-based concepts in workshops, training sessions tailored to different topics in different environments, and field trips to various cultural sites. in addition, an average of two journeys were designed annually to provide students with the opportunity to experience more valueladen environments along with the experience of group life. case study discussion, interaction with people in the community, site visits, critical analysis and self-reflective journals were the predominant educational methods used in this program. such programs expose medical students to many value-based concepts that are essential for a physician, such as sincerity, team morale, empathy, creativity, critical thinking, kindness, commitment, accountability, justice, freedom and security. these programs are entitled "mohajer1" and are a unique example of using value-rich exposure to transfer values. they were approved as a selected educational process in shahid motahhari’s educational festival (2012), which is held by the ministry of health and medical education of iran annually. this study examined the experiences of students who were members of the “mohajer group” to achieve the concept of value-rich 1 in its abstract sense in persian literature, the word refers to someone who sets out on a journey to reach a better condition externally and especially internally. exposure in medical education. since qualitative methods are suitable for obtaining complex details of emotions, behaviors, lived experiences, and in general for perceiving what people think and do (11), this study used a phenomenological approach. methods our study was a phenomenology of practice, which was conducted from june 2019 to july 2020 using the hermeneutic phenomenological approach. according to van manen, phenomenology is fundamentally practical, and its ultimate goal is “to nurture a measure of thoughtfulness and tact in the practice of our professions and in everyday life” (12 14). he called this pragmatic concern "phenomenology of practice" (13). we tried to reveal the nature of the phenomenon of value-rich exposure in the form of a deep and rich phenomenological text by implementing van manen’s six-step approach (15, 16) and using pathic methods and deep reflection on students' lived experiences. participants & setting participants were students who were members of the mohajer group and had the most involvement in its programs from 2010 to 2020. data collection the present study employed the following methods to collect data: in-depth interviews: semi-structured value-rich exposures in medical education: phenomenology of practice according to… 4 j med ethics hist med. 2021(jul); 14: 9. journal of m edical ethics and h istory of m edicine interviews were used that began with openended questions, so that the participants could easily express their experiences. examples of these questions include: “would you please tell us about the experiences you had in the mohajer group?”, “what was your mohajer experience like?”, “what values did your exposures transfer to you?”. then, follow-up questions were asked to clarify the concept under consideration. in addition, the interviewer probed participant responses by using questions or statements like “please explain more”, “what did you think then?” or “can you give an example, so that i can better understand the meaning of this?”. seven interviews were conducted with six participants, and each interview lasted between 50 and 75 minutes. the recorded interviews were transcribed verbatim within 24 hours. students’ written stories: four writings that contained rich information from students’ memoirs were selected for review. recorded videos of mohajer students immediately after the trips: 285 minutes of recorded interviews related to the trips in 2010 2014 and 2018 were analyzed. mohajer photographs: according to van manen, one of the sources of data collection in phenomenological studies is artistic sources such as photographs (16). in this study, nine images with deep concepts of value-rich exposure were included. sampling continued until data saturation. data analysis the data analyses were conducted based on van manen’s thematic analysis method in the following steps: isolating thematic statements, composing linguistic transformations, and gleaning thematic descriptions (16). we used a combination of holistic, selective and detailed approaches to isolate thematic statements. in-depth interviews, recorded interviews and students’ writings were analyzed using holistic and detailed approaches, and photographs were analyzed by selective approach. in the next step, the extracted thematic statements were changed to phenomenological language, and finally five main themes were extracted. according to van manen’s view on participatory analysis of the themes (15, 16), several meetings were held with members of the research group until a final agreement was reached over the extracted themes. as the last step, the themes were expressed in the form of meaningful and artistic statements that described the specific aspects of the phenomenon in question in a pathic way. maxqda software was used to facilitate data management and analysis. trustworthiness the criteria presented by guba and lincoln (17) were considered to maintain the validity of the study. to enhance the credibility, the researchers used an interview guide based on previous studies and the experiences of the research team. attempts were also made to select students with different experiences who had participated in various programs of the mohajer group. in addition, students’ written stories, photographs and recorded video interviews were used. to maintain sabeghi h., et al. 5 j med ethics hist med. 2021(jul); 14: 9. journal of m edical ethics and h istory of m edicine dependability, the researchers explained in detail all the steps of data analysis and the emergence of themes. to observe confirmability, two researchers analyzed the interviews independently, then compared the results of the analyses and reached a final agreement. furthermore, peer and member checking were used. for transferability, the conditions and characteristics of the context and participants were described in full detail to allow their comparisons and applications in other conditions. result the final analysis yielded 5 themes and 17 subthemes (table 1) table 1frequency distribution of the demographic characteristics of the participants themes subthemes in the shadow of a supportive mentor companionship of mentor and students life mentor determined wise instructor a well-orchestrated, value-rich program dynamic, value-based curriculum unique learning methods confluence of science and value outside of traditional classrooms program’s desiderata value preloading human interactions in a value system collective exploration team learning communication with people committed to values acquiring values in a real-life environment real exposures as a launching pad to achieve values the magic of real experiences in a value-laden environment gradual exposures to achieve a deep perception of values seeking values in oneself migration from oneself in pursuit of values practice of moral values covenant guarding in the shadow of a supportive mentor mentoring students to achieve the expected outcomes in confrontation with different value-laden situations is very important. based on the experiences of mohajer students, their movement toward acquiring values was supported by their mentor and his/her wisdom. participants described their mentor as a partner whose particular views, trust in students and empathy facilitated extraction of value-based concepts from students’ experiences. note a comment as below: "the teacher cared about each of the students and assigned everyone a task based on the knowledge he had about them. he was always and everywhere beside us, and encouraged the students at all times". [ participant no. 3] teachers were real role models for mohajer students in different situations and their concern over students’ learning from every experience made them mentors for all aspects of life. as indicated by a participant: value-rich exposures in medical education: phenomenology of practice according to… 6 j med ethics hist med. 2021(jul); 14: 9. journal of m edical ethics and h istory of m edicine "one of the reasons i became a member of the mohajer group was dr. f., because students’ education was very important for him. he taught me things that are not found in any book. i want to be like him." [ participant no. 1] a student also wrote: "dr. f. has a distinct aim; everything is in the direction of reaching that specified goal, from fundamental ideas to the arrangement of the journey process. familiarity with such thinking is valuable for me. [student’s written story no. 2] a well-orchestrated, value-rich program as participants reviewed their experiences, they mentioned points that were actually various sections of a systematic and purposeful curriculum and each served as a value-laden movement 2 of a larger symphony. the dynamism and purposefulness of the designed program and its impact on inducing values, types of exposure and teaching methods have led to deep learning. as declared by one of the students: "we had a lot of different programs, from mystical to completely scientific ones that were carefully planned". [participant no. 6] the appeal of using different learning methods was clearly expressed in the different parts of the participants' statements. "the students in the corner of the vaccination room (our classroom!) typed and recorded details of each injection and uploaded them on the mohajer website. how 2 a movement is a self-contained part of a musical composition or musical form. different is this from memorization of book pages!” [student’s written story no. 1]. statements, photographs and written stories of mohajer students showed that attending non-traditional academic classrooms full of desiderata that encourage learning caused better involvement in activities and a deeper perception of the topics under consideration. the students were also able to perceive many value-rich concepts by attending such climates outside the university campus. note the participants’ quote below: "when we travelled to the desert, we went out at night. dr. f. asked a teacher to tell us about the milky way. the stars were closer to us in the desert. a lot of medical students don’t have such experiences, but i did, and it was miles away from the curriculum of medical education. i could feel the power and greatness of god." [participant no. 1] “we had a theme for each of our programs. ‘in search of self’ was the theme for a journey to the south. at first, we did not quite understand it, but little by little, we thought more about it during our exposures. for example, the philosophical discussions we had with ms. a., or the book of shahid motahhari or the stories of rumi that we read together were like pieces of a puzzle that were put together. we could find some other pieces while visiting cultural and national museums, or in interactions with local families. then we started to discuss what was really meant by “in search of self”, and in the group we put the pieces of the puzzle together and came to an understanding.” [from a student’s recorded interview after traveling to the south in sabeghi h., et al. 7 j med ethics hist med. 2021(jul); 14: 9. journal of m edical ethics and h istory of m edicine 2012]. figure 1 is an example of mohajer photos that shows the intimate and informal learning climate in one of the programs. figure 1one of the informal classes of the mohajer group from the perspectives of the students, the pre-preparation done by the teacher before each specific encounter led to a better and deeper perception of different value-rich exposures when students were actually experiencing them. therefore, they were more motivated to experience that particular subject. in this respect participant no. 6 said while smiling: "the teacher talked about his last trip and the experiences he had with his students, and showed us some photos and videos. he used promotional teasers related to the trip and asked us to send him our opinions about the trip. actually, the teaser made us excited and curious." human interactions in a value system exposure to phenomena in the context of a group was a feature that made value-rich exposure effective in the students' experience. the specific identity, characteristics and performances of individuals in such a group were manifested in the students' lived world as a system that is influenced by the interactions of individuals with each other. mohajer students mentioned that they first looked at each exposure as a problem that had to be solved collectively. questioning, group discussion, and formation of small groups to analyze exposures were tactics always used by students. note a part of student’s written story no. 2: "after each short clip, the students’ opinions are asked, from the most delicate details, such as the apprehensive smile of a mother or the ethical concept that comes to mind with a poem of rumi, to the most general and formal cases and the educational process. actually, we were learning from each other during brainstorming." students mentioned that the experience of being in the mohajer group with their friends was very enjoyable and made them understand some values better as they interacted with each other. as one participant said: "we all know that patience is very important in dealing with a sick person, but i realized the true depth of this concept with the mohajer group, when i saw patience in m.’s behaviors. i now realize that i have not been patient! m. is patient, because she behaved that way." students achieved a collective and lasting identity, which kept them in the group and value-rich exposures in medical education: phenomenology of practice according to… 8 j med ethics hist med. 2021(jul); 14: 9. journal of m edical ethics and h istory of m edicine accelerated interactions for learning from their exposures; this was referred to as the mohajer identity. students considered belonging to the mohajer group and gaining the mohajer identity as a value that affected their behaviors. as stated by participant no. 6: "i feel that i am part of a community that is going to do something, and this affects the decisions i make, the things i do, and how i behave." interactions with people who are committed to values are another part of the value-rich exposure process. students mentioned this as a value-laden exposure that facilitated the transfer and perception of values. “we visited mrs. t., who was truly sincere and honest… the level of her sincerity was unbelievable. i realized how sincere and honest some people are and i think these characteristics are very important in a physician" [from a student’s recorded interview after traveling to the south in 2012]. acquiring values in a real-life environment this theme highlights the importance of students' presence in real-life situations and submerging in value-rich exposures. based on this dimension of the phenomenon under study, real exposures are like a launching pad for acquiring values and receiving their true effects in real life, which have an important impact on the students' deep learning. as participant no. 6 stated: "learning in a certain environment made that subject stick to our mind. it is like geo tag on my cell phone. learning in specific environments also tags that climate on the content and triggers long-lasting learning.” figure 2 is another example that shows the group’s interaction in a real environment. figure 2a picture showing the groups interaction another student wrote: "i can hear, see, and touch an event in a direct exposure. then the words and the values engraved in my mind find their places and meanings." according to the results of this study, exposures designed to transfer values have been like a thousand-piece puzzle. students gradually find the different pieces and finally come up with value-rich concepts. as participant no. 3 said: "it is as if the teacher plots a puzzle, and i put the pieces together, so that i can see the image better. then, i can realize that there is something beyond this simple trip. i can get something more from previous experiences and move toward future horizons. it is important to know what i have in my hands to take the next steps." seeking values in oneself sabeghi h., et al. 9 j med ethics hist med. 2021(jul); 14: 9. journal of m edical ethics and h istory of m edicine mohajer students believed that their valuerich exposures, in addition to their external experiences revived their inner values, so they should strive to preserve them. seeking values in oneself indicates that the student migrates to himself/herself while exposed to different value-rich concepts and practicing moral values. the students’ achievements lead them to make a covenant with themselves and their friends to protect their inner values. therefore, this is how they find the main source of all values and go in search of themselves. note two participants’ comments: “all the elements, the cases, and the exposures were like removing the dust from my true self, the dust that has collected on that purity, and has been there since the descent.” "it was the mohajer group that made me think about my core values. the conditions were provided for me to think about those values. i could love myself more, think about myself and human values more, and in short, i started to search for every valuable thing i knew." the students participating in this study believed that following their exposures, they acquired values that were so beautiful and precious to them, so that they made a covenant to keep this valuable investment. as one student said after the 2011 trip to the south: "on the last day of our trip, we promised not to trample on this beautiful feeling, and to be responsible for what we had learned. something great had happened and we could not allow it to fade away. we have to continue our journey, but in other forms and ways, so that we can keep that good feeling." discussion our study mainly aimed to explain the concept of “value-rich exposure” in medical ethics education based on the lived experiences of medical students, which was manifested in the obtained themes. according to our findings, learning in the shadow of a supportive mentor, a wellorchestrated, value-rich program, human interactions in a value system, acquiring values in a real-life environment, and seeking values within oneself are dimensions of a value-rich exposure program. one of the most important dimensions of value-rich exposure is a supportive mentor. various studies show that the mentor, as a role model and provider of learning opportunities, plays an important role in students’ learning (18 20). in fact, the mentor guides and supports students on the path of excellence. role modeling is the most effective technique for developing professionalism (18), and therefore medical ethics education depends on perfect role models who articulate values in their behaviors and demonstrate enthusiasm and good practice (2). “human interactions in a value system” were a major theme of this study. like the solar system that contains planets whose weights affect each other, and the behavior of each planet alongside the others has led to one of the most beautiful creations in the value-rich exposures in medical education: phenomenology of practice according to… 10 j med ethics hist med. 2021(jul); 14: 9. journal of m edical ethics and h istory of m edicine universe, the mohajer group is also a value system that is formed by the interactions of group members. from the participants' viewpoints, what helped them to better perceive the value-rich exposures was the experience they obtained with their peers, as well as the use of group discussion and reflective analysis. close peers, as the strongest aspect of any curriculum, can enhance students’ perception of professionalism (21). in addition, the use of small groups is an effective way to reinforce values in medical students and leads to the transfer of basic values of the medical profession such as compassion and respect (22). students' interactions with people who are committed to values can convey those values to them. in fact, interactions with people provide opportunities for students to practice cooperation, trust and empathy, and lead to normative adjustment of students (20). in this regard, godbold and lees stated that students must recognize the role and importance of the values of people who are working together and giving services (10), which can be achieved through group interactions. “a well-orchestrated, value-rich program” was another theme that emerged from the data. movement is like a complete part of a larger piece of music that has a beginning and an end. in the present study, the different parts of the program experienced by the students were like movements that together represented a well-orchestrated, value-rich program. curriculum is an interactive process that includes ideas, values, people and material resources that occur in a particular context (23). in this study the participants experienced value-rich exposures following a dynamic curriculum, which included a combination of scientific and value-based topics in different environments and times presented by using student-centered methods. the subthemes "unique learning methods" and the "program’s desiderata" are in line with the items referred to in the association for medical education in europe (amee) guideline no. 23 as curriculum desiderata that play an important role in students’ education (23). another important issue was the role of climate, which is the spirit of the university environment. a truly successful learning experience requires climate planning and preparation. the mentor should check the climate in advance and plan the activities. he/she should also provide students with brief information about that particular climate and specify the expected activities (24, 25). these concepts emerged in the subtheme of value preloading. the fourth theme was “acquiring values in a real-life environment”. the learning environment is a behavioral stimulus, and must be dynamic and in line with educational goals. the educational environment should be an external manifestation of the curriculum and help make it operational (23). students in our study believed that each real environment that was used for a specific exposure facilitated their perceptions of the values. studies have shown that the educational environment has an effect on achieving educational goals, happiness, motivation, learning and success (20, 24). another subtheme revealed in this study was sabeghi h., et al. 11 j med ethics hist med. 2021(jul); 14: 9. journal of m edical ethics and h istory of m edicine “gradual exposures to achieve a deep perception of values”. this is an important issue in dealing with value-based concepts, and the mentor should systematically select the cases and gradually provide them to the students to reach the core topic. the most complex issue should be raised at the end and should be proportionate to the students’ previous knowledge and educational level. this method leads to discussion and exchange of views among students at a higher cognitive level and thus a better perception of the topic under consideration (26). the theme “seeking values in oneself” refers to the fact that after a value-rich exposure, the student becomes sensitive and seeks values within himself/herself through a selfreflective process. human nature is full of value-rich qualities, but these may gradually fade in the material world. achieving inner values requires effort, practice and protection. the first step is to draw one's attention to inner values, and the best stimulus to achieve them is real value-rich exposures. the basic principle of valuebased education is that the personal value system serves as a solid foundation for a practitioner in a sound decision-making process. therefore, teaching values should begin with students' awareness and perception of their value systems (4). students can better understand their own values and beliefs through self-reflective methods that help them to make more appropriate decisions (10). the mohajer group has been a successful experience in shahid beheshti university of medical sciences. the researchers were convinced of the success of this program in medical ethics education and aimed to introduce the method as “value-rich exposure”. therefore, it is necessary to conduct further studies in other cultures to develop knowledge related to this phenomenon and generalize the results. conclusion teachers, peers, clinical experiences, different exposures during patient care and personal values are the main factors contributing to the development of professional values in medical students. this study provides in-depth insight into what medical students experience following value-rich exposures and points out some issues that can be considered by medical education planners to improve the quality of ethics education for medical students. these findings can guide medical ethics curricula and enhance elective opportunities for medical students to experience values in authentic situations through active and reflective learning. our study identified different dimensions of value-rich exposure based on the lived experiences of the medical students who participated in our single institution, 10-year longitudinal program (mohajer) using a grassroots effort to improve medical ethics education. ethical considerations the ethics committee of shahid beheshti university of medical sciences approved value-rich exposures in medical education: phenomenology of practice according to… 12 j med ethics hist med. 2021(jul); 14: 9. journal of m edical ethics and h istory of m edicine study under code of ethics no. ir.sbmu.sme.rec.1398.047. acknowledgements we are grateful to all mohajer students who shared their valuable experiences. conflicts of interests the authors declare no conflict of interests. sabeghi h., et al. 13 j med ethics hist med. 2021(jul); 14: 9. journal of m edical ethics and h istory of m edicine references 1. wright-st clair va, newcombe db. values and ethics in practice-based decision making. can j occup ther. 2014; 81(3): 154-62. 2. ssebunnya gm. beyond the hidden curriculum: the challenging search for authentic values in medical ethics education. south african journal of bioethics and law. 2013; 6(2): 48-51. 3. marzorati c, pravettoni g. value as the key concept in the health care system: how it has influenced medical practice and clinical decision-making processes. j multidiscip healthc. 2017; 10: 101-6. 4. grundstein-amado r. values education: a new direction for medical education. j med ethics. 1995; 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9(3): 235-45. 25. fredholm a, manninen k, hjelmqvist h, silén c. authenticity made visible in medical students’ experiences of feeling like a doctor. int j med educ. 2019; 10: 113-21. 26. dong h, sherer r, lio j, jiang i, cooper b. twelve tips for using clinical cases to teach medical ethics. med teach. 2018; 40(6): 633-8. abstract introduction references hhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh copyright © 2023 tehran university of medical sciences. this work is licensed under a creative commons attribution-non commercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. keywords: self-citation; scientometric; researchers. dear editor, human beings used to pile up their experiences to shape human knowledge and apply them in problem solving. in the modern world, accumulation of research findings and written scientific records dramatically contributed to the formation of applicable knowledge. in order to document scholarly works, scientists and researchers were required to cite earlier studies. occasionally, prolific authors cited their own works too; this, however, tended to become canonical for authors of scholarly articles, irrespective of their specialized research interests. but it was intentionally practiced, particularly after citations turned into a yardstick for authors’ ranking and reputation from that point on,self *corresponding author mostafa rad address: iranian research center on healthy aging, department of nursing, nursing and midwifery school, sabzevar university of medical sciences, shuhada hasteei blvd., sabzevar, iran. postal code: 9617913112 tel: (+98) 51 44 01 83 14 email: radm@medsab.ac.ir received: 20 jan 2023 accepted: 1 april 2023 published: 12 jun 2023 citation to this article: shomoossi n, rad m. self-citation: to do or not to do? j med ethics hist med. 2023; 16: 1. -citation turned into a double-edged sword. on the one hand, authors who repeatedly refer to their own works in the ‘references’ section of their publications are not few; this occasionally reflects their established and highly specialized research routes over long years of their academic career. these elite scholars have already established a spectacular place in the world of science, in terms of dealing with one single professional area, where other scholars also cite their scholarly works as well. under these circumstances, citations to their works vividly reflect their scientific impact. on the other hand, the second category consists of authors who fancifully cite their own works in the hope of maximizing their academic reputation in metric terms by inflating the ‘references’ section, in order to self-citation: to do or not to do? 1. associate professor, department of english, school of medicine, sabzevar university of medical sciences, iran. 2. associate professor, department of nursing, nursing and midwifery school, iranian research center on healthy aging, sabzevar university of medical sciences, sabzevar, iran. nematullah shomoossi1, mostafa rad2* mailto:radm@medsab.ac.ir self-citation: to do or not to do? j. med. ethics. hist. med. 2023 (jun); 16: 1. 2 to improve indicators such as the h-index. of course, in scientometric studies, self-citation by 20 percent is conservatively allowed for researchers as a tolerable limit, while beyond that is considered illogical and inappropriate (1). the question is, to what extent are authors really allowed to cite their own publications? scientific views in this regard unanimously emphasize the relevance of the work and the technical focus of the manuscript. in other words, irrelevant references in a context and placement of awkward patches on a manuscript may aggravate this violation. to avoid such pitfalls, a previous review suggested authors’ cooperation with experienced copy editors and technical translators, since the latter can help bar authors from making severe mistakes. in addition, since plagiarism software can barely detect and report overindulgence in self-citation, it seems essential for manuscript reviewers to carefully watch out for the issue (2). in addition, a solemnly stressed point may be the need for training novice researchers regarding the subtlety of this matter. the indirect training effect of comments posed by peer reviewers may turn into a valuable asset for novice researchers in the long run. another alternative is to help junior researchers to start modelling the role of highly prolific researchers with established academic positions who avoided meandering from one discipline to another; this is undoubtedly a point to be emphasized and presented to impatient researchers wishing to rise to fame overnight. early career researchers might be successfully directed into a lifelong career where they are empowered to both publish and shine academically. but overemphasis on avoiding self-citation may apprehend most of these less experienced researchers to totally pause self-citation of some really valuable references. in many cases, despite the relevance and specialist scope of their own published articles, they may prefer to sidestep the self-citation trap (3). that is why we stress ‘both the necessity and subtlety of self-citation’ up to an acceptable load, particularly for inexperienced researchers. this, in turn, will shed light on the road ahead of them, in addition to giving them the courage to discern the desire to develop a specialized future path in line with the global knowledge growth at the edge of science (4). apparently, too much stress on avoiding selfcitation has concealed its positive inspirational shomoossi n., et al. 3 j. med. ethics. hist. med. 2023 (jun); 16: 1. aspect for the younger generation of researchers. therefore, it is suggested that the motivational aspect of self-citation be expressed in a more logical way, and early career researchers become cognizant of its importance, necessity and harms. last but not least, the training of peer reviewers and journal editors should be at the top of the training plan. in short, the necessity and subtlety of selfcitation is to be particularly studied to enrich its status in academic publishing. acknowledgements there are no acknowledgements conflicts of interests there are no conflicts of interests. references: 1. aksnes dw, langfeldt l, wouters p. citations, citation indicators, and research quality: an overview of basic concepts and theories. sage open. 2019; 9(1): 2158244019829575. 2. shomoossi, n. collaboration of translators with medical authors: a qualitative enquiry into writing articles in english. acta facultatis medicae naissensis. 2013; 30(1): 45-7. 3. huang mh, lin wy. probing the effect of author self-citations on h index: a case study of environmental engineering. journal of information science. 2011; 37(5): 453-61. 4. koushan m, pejhan a, shomoossi n, shomoossi a. ethical considerations in publishing medical articles in iranian journals. acta facultatis medicae naissensis. 2014; 31(2): 105-11. hhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh copyright © 2022 tehran university of medical sciences. this work is licensed under a creative commons attribution-non commercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. keywords: palliative care; autonomy; ethics. introduction: the objective of palliative care is to provide holistic care to enhance the quality of life by addressing physical, psychological, social and spiritual suffering. in palliative care, the family is part of the team and should be cared for and supported, and communication is the key in the process, especially at the final stage (1). maintaining patients’ autonomy at the end of life is a challenging subject that needs to be addressed using a contextualized approach. one alternative demarche in setting care goals and shared decisionmaking may be "relational autonomy". to this end, the case of an end-stage patient in the need of palliative care and the related ethical challenges are presented below. case presentation: *corresponding author mamak tahmasebi address: cancer research center, cancer institute, imam khomeini complex, end of keshavarz blvd., tehran, iran. postal code: 1419733141 tel: (+98) 21 61 19 25 30 email: mtahmasebi@tums.ac.ir received: 7 nov 2022 accepted: 13 dec 2022 published: 28 dec 2022 citation to this article: tahmasebi m. ethics and palliative care: a case of patients’ autonomy. j med ethics hist med. 2022; 15: 16. mrs. a. was a 40-year-old woman with advanced pancreatic cancer. she was a housewife and the mother of a 10-year-old son. she was admitted to the emergency department for severe abdominal pain. after relative and temporary control of her symptoms, she was transferred to the oncology unit for further evaluation. the surgical team diagnosed malignant bowel obstruction secondary to carcinomatous peritonitis and announced it inoperable. the pain gradually aggregated and remained uncontrollable except temporarily and through morphine injections. the attending oncologist consulted. ethics and palliative care: a case of patient’s autonomy palliative medicine fellowship; cancer institute of iran; imam khomeini hospital complex; tehran university of medical sciences; tehran; iran. mamak tahmasebi ethics and palliative care: a case of patients’ autonomy j. med. ethics. hist. med. 2022 (dec); 15: 16. 2 palliative care to assist with managing her severe abdominal pain, stating, “the patient’s husband does not allow any opioid injection.” approaching her bedside as a palliative care physician, i noticed that she was agonized and would not even let me touch her abdomen for better evaluation. her husband was a 45-year-old middle-class worker. he held his wife's hand compassionately when i introduced myself. i asked the patient’s permission to give her a morphine injection so that we could have some qualified time for talking and physical examination. immediately, her husband responded, "no! you have permission only for a non-opioid medication. i don't want to see her drowsy and confused anymore." in situations like this, we are faced with the following questions: 1. does the spouse have the right to make decisions about the patient's pain management? 2. are there ethical issues relating to morphine prescriptions? 3. do health-care providers (physicians and nurses) have the right to prescribe and use medications without informing patients and/or their families? discussion when discussing the right to make decisions, we are actually talking about respect for autonomy, one of the fundamental principles of medical ethics. there are three types of autonomy in the literature: isolated autonomy, voluntary diminished autonomy, and relational autonomy. as a concept, isolated autonomy is connected to self-interest, independent of relational or other considerations (2). the voluntary diminished autonomy approach is common among patients who evade their responsibility to make decisions because they are concerned about being harmed by excessively candid diagnostic or prognostic information. some patients may not wish to know in detail the nature, extent and likely prognosis of their disease (3). finally, since most people live in cultural and familial contexts, they voluntarily consider the impact of their decisions on valued relationships and seek the counsel of family members or other significant stakeholders in their lives; this is referred to as relational autonomy (4). sometimes patients’ autonomy is compromised due to severe physical decline, cognitive impairment, and/or emotional distress. in these situations, decision-making is automatically tahmasebi m. et al. 3 j. med. ethics. hist. med. 2022 ( dec); 15: 16. resigned to other people, such as a family member, a surrogate or a health-care team member (5, 6). mrs. a.’s autonomy was compromised, partly due to severe physical decline and partly secondary to the specific bond between the couple. mrs. a. respected her husband's values despite the high cost of tolerating severe physical pain, but accepted morphine injections when her husband was not around. in decision-making situations, human beings are inseparable from their sociocultural identities, including notions of gender and power (7). whether mrs. a. decided to set aside personal wishes for the good of her husband or as a means to maintain peace and harmony with her loved one is a subject that needs to be explored. it can also be argued that the same scenario could happen if the husband were in bed instead of her. in this case we need to answer a couple of important questions, such as: “did he realize that she would be dead in a few days?” and “did he want her to be comfortable?” there are some myths and misconceptions about morphine and other opioids, for instance that they cause addiction or hasten death (8). a properly titrated dose of morphine does not cause respiratory depression, the most concerning side effect of opioid drugs. terminally ill patients are especially at risk for opioid-induced sedation, cognitive impairment, and delirium. some of these neurological side effects are self-limiting, especially in opioid naïve patients, and some are frequently managed by correction of identifiable and reversible factors such as rehydration. we should find out the reason why mrs. a.’s husband fears his wife receiving morphine or being sleepy; if she loves him and knows that he cares for her, it may be that they simply wish to communicate with each other. the mental pain of loss is another explanation in this situation: the husband is afraid of his own confusion and dependence on his wife, but this has become, by proxy, the issue of morphine. these questions could be answered through an honest conversation between mrs. a.’s husband and the physician. in an empathic atmosphere, mrs. a.’s and her husband’s care goals should be explored and aligned with the existing reality. in any case, relief from physical suffering is usually the most achievable intervention at the end of life. all things considered, nothing but the truth is acceptable, even when the aim is to bring temporary comfort to the patient. in this case, mrs. a. is a competent person who does not want a ethics and palliative care: a case of patients’ autonomy j. med. ethics. hist. med. 2022 (dec); 15: 16. 4 morphine injection for whatever reason, for instance to avoid conflict with her husband or to maintain peace and harmony with her loved ones. her decision may cause moral distress in healthcare providers and consequently amoral action; for example, they may hide the morphine injection from her husband. in this situation, support should be provided to health-care team members to help them comprehend the patient's decision to align with the family (9). conclusion physicians concentrate mostly on the disease rather than patients and their families. with the exception of psychologists maybe, health-care team members are mainly focused on relieving physical symptoms as a means to provide optimal care. patients have a right to adequate relief of their pain and this right is derived from the principles of beneficence, nonmaleficence, justice and specifically respect for patient autonomy. at the same time, respect for relational autonomy should be seen as a part of patient autonomy and noted in decision-making. the concerns of patients and their families need to be addressed, and any intervention (from prescribing antibiotics to analgesics like morphine) should be fully explained if necessary. recognition of and respect for patients’ values, wishes and preferences are part of health-care providers' duties. as a final point, it should be mentioned that interprofessional communication is the best way to avoid moral distress and align all team members' care goals. acknowledgements there are no acknowledgements conflicts of interests there are no conflicts of interests. tahmasebi m. et al. 5 j. med. ethics. hist. med. 2022 ( dec); 15: 16. reference: 1. laryionava k, winkler ec. dealing with family conflicts in decision-making in end-of-life care of advanced cancer patients. current oncology reports. 2021 nov;23(11):1-6. 2. gillon r. ethics needs principles—four can encompass the rest—and respect for autonomy should be “first among equals." j med ethics. 2003; 29:307-12. 3. helft pr. necessary collusion: prognostic communication with advanced cancer patients. j clin oncol. 2005; 23:3146-50. 4. ho a. relational autonomy or undue pressure? family's role in medical decision-making. scand j caring sci. 2008; 22:128-35 5. tonelli mr, misak cj. compromised autonomy and the seriously ill patient. chest. 2010;137(4):926-931. 6. lewis j. does shared decision making respect a patient's relational autonomy? journal of evaluation in clinical practice. 2019 dec;25(6):1063-9. 7. quill te and miller fg. palliative care and ethics. oxford university press; 2014 8. bemand‐qureshi l, gishen f, tookman a. opioid use in palliative care: new developments and guidelines. prescriber. 2019;30(4):25-31. 9. blackler l. compromised autonomy: when families pressure patients to change their wishes. journal of hospice & palliative nursing. 2016 aug 1;18(4):184-91. ferdos 180 mohammadreza ardalan journal of medical ethics and history of medicine review article a review of ferdous al-hekma fil-tibb by ali ibn raban tabari mohammadreza ardalan1*, kazem khodadoust2, elmira mostafidi3 1 kidney research center, tabriz university of medical sciences, tabriz, iran; 2 philosophy and history of medicine research center, tabriz university of medical sciences, tabriz, iran; 3 kidney research center, and department of pathology, imamreza hospital, tabriz university of medical sciences, tabriz, iran. corresponding author: mohammadreza ardalan address: daneshgah street, imamreza hospital, kidney research center, tabriz, iran. email: ardalan34@yahoo.com tel: 98 9141168518 fax: 98 411 3366579 received: 27 sep 2014 accepted: 1 may 2015 published: 17 may 2015 j med ethics hist med, 2015, 8:7 © 2015 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract t ferdous al-hekma (paradise of wisdom) is one of the oldest medical texts in the islamic world written in arabic in 850 ad by ali ibn raban tabari. he was a persian physician who moved from tabaristan (mazandaran province of modern day iran) to samarra during the reign of the abbasid caliph al-mutawakkil (847-861 ad). we studied the book of ferdous al-hekma fil-tibb, in an attempt to comprehend its general outlook on diseases of different organs, their classifications and the associated signs and symptoms. the book is one of the earliest medical pandects of the period of translation, adaptation and expansion of knowledge in the islamic world during the 9th century ad. tabari was mainly influenced by hippocrates, galen and aristotle, as well as his contemporaries johanna ibn massavieh and hunayn ibn ishaq. the book is written in thirty chapters in a total number of 308 subtitles. in each part there is an introduction to the symptomatology, followed by organ specific diseases and therapeutic recommendations. symptoms and physical signs of different diseases are vividly described in ferdous al-hekma, and some of them are even understandable for contemporary medical students. keywords: ferdous al-hekma, paradise of wisdom, raban tabari, abbasid caliph mailto:ardalan34@yahoo.com j med ethics hist med 8:7 may, 2015 jmehm.tums.ac.ir mohammadreza ardalan et al. page 2 of 6 (page number not for citation purposes) introduction ferdous al-hekma (paradise of wisdom) is one of the oldest medical texts in the islamic world written in 850 ad in arabic. the writer, ali ibn raban tabari (?-882 ad), was a persian muslim who moved from tabaristan (the present mazandaran province of iran) to samarra during the rule of the abbasid caliph al-mutawakkil (847-861 ad) (1, 2) (figure 1). the ninth century was the beginning of the nationalistic rebellion movements of bābak khorramdin (xorramdin pāpak) in azerbaijan (816837 ad), and the great achievements of yaqub leis saffar (840-879 ad) in sistan. the saffarids recaptured major territories of persia from the abbasid caliph and appointed naser ibn ahmad samani as the ruler of balkh in transoxiana. these movements marked the revival of persian art, culture, science and language in the following century (2, 3). in the opening pages of his book tabari writes about the period and being forced to migrate to the court of the abbasid caliph (4) (figure 2). his words are: … “a bitter event led me to leave my motherland and a nobleman ordered me his companionship, and finally i entered the city of samarra in the third year of almutavakkil’s rule …” (4). tabari was a master of arabo-greek and persian medical knowledge and his work is the oldest technical medical book written by a persian physician in arabic (3). figure 1coin of the abbasid caliph al-mutawakkil (847 ad). during his reign ali ibn raban tabari moved from tabaristan to baghdad (malek museum, tehran, iran). figure 2local rulers of tabaristan tried to continue and preserve persian sasanid traditions up to two centuries after arab conquest of persia. a coin that shows crown and wings, 775-780 ad. (malek museum, tehran-iran) tabari was mainly influenced by hippocrates and galen, and at the beginning of his book he acknowledges galen, hippocrates and aristotle and recognizes the inspirations and guidance of his contemporaries including johanna ibn massavieh and hunayn ibn ishaq. tabari completed his book in the third year of the reign of caliph al-mutawakkil (probably in 850 ad). he was the teacher of rhazes j med ethics hist med 8:7 may, 2015 jmehm.tums.ac.ir mohammadreza ardalan et al. page 3 of 6 (page number not for citation purposes) and may have died in 882 ad (4, 5). the name of ali ibn raban tabari has been mentioned by ibn al-nadim (died 998 ad) in his book al-fehrest, and he has also listed some of tabari’s writings including: ferdous al-hekma, essay on possessions, medicines and herbs. in his book tabaghat pezeshkan (physicians and their ranking), ibn abi usaibia has attributed two other works to tabari, including one on health, and one on the understanding the life. in the books of tarikh-e tabarestan (history of tabaristan) and kashf alzonon, the two pandects bahr al-favaa’ed (ocean of advantages) and din va daolat (power and religion) are attributed to tabari (3). ferdous al-hekma is written in thirty chapters in a total number of 308 subtitles. the first five chapters are mainly dedicated to temperaments, humors and the general aspects of health. then the diseases of different organs and their treatments are discussed in detail. in each part there is an introduction to symptomatology (4, 5). the importance of this book in the development of medicine was first discovered by the british orientalist edward granville browne (1862-1926) (6). with the recommendation and encouragement of e.g. browne, in 1922 m.z. seddiqi collated and compared the three versions of ferdous al-hekma, including the british museum manuscript, the berlin manuscript, and the indian gotha manuscript. in 1928 a complete copy based on the findings of seddiqi was published in arabic by kaviani publications in berlin. years later this version was translated into persian by s.a. madani and a.h. broujerdi and published by mehramin publications in tehran in 2008 (4). what follows is based on the english translation of excerpts from the abovementioned persian translation of ferdous al-hekma. in this work we studied the persian translation of ferdous al-hekma thoroughly and tried to find the passages on symptoms, signs and physical examinations associated with different disorders. we tried to comprehend the content of those passages and compared them against modern medicine. at the same time we studied the main historical sources on early islamic periods to get a more vivid outlook on the period. passages a general outlook on clinical medicine in the opening pages of his book tabari writes about his main objectives and outlooks as a thinker and physician, and offers valuable ethical messages. “it is my wish that anyone who reads this book, thinks about it deeply and kindly corrects my flaws, and i shall be indebted to such persons… (5). [medicine] is the science of protecting health and preventing pain and suffering, and this is unattainable unless science and practice are joined… (4). this practice [medicine] is called hekmat, which is derived from divinity. therefore no one deserves to experience such nobility unless he is adorned with generosity, kindness and devotion and is not driven by greed. a physician should be compassionate toward his patients… (5). he should alert his colleagues to their flaws, and in doing so, he will gain a high standing among them… (4). a physician should prescribe medicine after physical examinations and should never be arrogant and take excessive pride in his skills. as hippocrates asserts, “life is short and knowledge is long, opportunities are fleeting, time is passing, experiences are perilous and destiny is strict…” (4). signs of internal diseases there are seven signs of internal diseases: 1) those that appear on the face. yellow complexion, pale lips and pedal edema denote liver coldness, darkness of the face and blanched lips indicate spleen edema, and redness of the face along with a high fever indicate lung inflammation; 2) signs that can be found on extremities. for example pain in the right clavicle indicates a liver problem; 3) signs that should be sought by palpation. for instance a round area of inflammation in the lower ribs area denotes liver inflammation and if the pain area is rectangular, it indicates inflammation of the liver capsule; 4) decreased appetite; 5) [the ability of] excretion along with coughing is a sign of lung infection; 6) discomfort in different organs; and 7) signs that can be found by asking the patient about his disease…. as hippocrates says, “the disease by itself guides us…” (4). in this passage there is an interesting distinction between disease signs and symptoms, and a vivid description of the different stages of physical examination including inspection and palpation. tabari also mentions some important general and organ-specific signs that can be used to diagnose diseases of different organs. the section on the referral pain of the liver in the clavicle is very interesting and can be found in modern books of medicine under the topic of physical examination. signs of paralysis and convulsion if all extremities are paralyzed and only the face is spared, the disease pertains to the vertebral column, but if all parts of the body are involved, the brain is damaged…. if there is hemifacial paralysis, there will be mobility on the normal side and the intact muscles will retract the affected side toward themselves… (4). there is a relatively accurate description of facial paralysis and the consideration that the more deviated side of the face actually is the normal side. it is interesting that this condition was well known to a persian physician in the 9th century, but has been named after the scottish anatomist charles bells (1774-1842) (7). signs of intestinal disease and diarrhea if the pain is in the upper umbilical area, the small intestine is involved… and if the pain is in the subumbilical area, the lower (large) intestine is j med ethics hist med 8:7 may, 2015 jmehm.tums.ac.ir mohammadreza ardalan et al. page 4 of 6 (page number not for citation purposes) involved. if the pain is intermittent, the upper (small) or lower intestines are involved… (4). the distinction between large and small intestinal pathology is difficult and even modern textbooks on physical examination consider the abdominal surface distribution of pain as a guide to find the source of pain. for example duodenal pain often happens in subxiphoid areas. involvement of the third part of the duodenum, jejunum and also proximal ileum pain often radiate around the umbilicus (8). on dyspnea and asthma respiratory organs include the lung, larynx and a partition that exists between the chest and the abdomen and is called the diaphragm… and in pleuritis the pain radiates to the neck or the brain and disturbs consciousness…. (4). in the paragraph above, the anatomical considerations about the radiating pattern of pain are interesting as these symptoms are used in contemporary medicine as well. signs of stomach disease and ulcers if the pain appears on the interscapular areas of the back, it may have originated from the esophagus because the stomach is adjacent to the lumbar area. if we feel such pain while eating spicy food, it is a sign of stomach inlet ulcer, and if the painful area is lower, the ulcer is located inside the stomach, and if the pain originates in the duodenum, it is felt within te abdomen…(4) in the above-mentioned passages, it is noticeable that reflux esophagitis and esophageal spasm were considered a cause of chest pain that can mimic angina. peptic ulcer pain could radiate to the back and the upper left quadrant. hoarseness and recurrent laryngitis could also be a sign of gastroesophageal reflux (8). signs of liver disease the patient is thirsty, his mouth is dry, appetite is decreased, urine is [deep yellow], and his pulse is rapid… if inflammation appears in the upper surface of the liver, the patient feels pain on the right clavicle [particularly] during respiration. pain on the right side and coughing happens because the congestion is adjacent to the lung and the diaphragm…. if the inflammation develops on the lower part of the liver, it is less painful than congestion in the upper part... if the congestion happens on the lateral surface of the liver, it is similar to the first type… (4). liver pain can be hard to identify and localize because pain from abdominal organs, such as the liver, is often experienced as a vague pain in the right hypochondrium and epigastrium, which may lead one to suspect liver abscess or cancer. patients with liver disease may report more abdominal pain than other individuals, and the pain is worse after meals. biliary colic and acute cholecystitis must also be considered in patients with liver disease because the prevalence of gallstones is increased in patients with cirrhosis. pyogenic liver abscess could present with fever and upper right quadrant pain, while sub diaphragmatic abscess could present with dyspnea, chest pain and even hemoptysis. irritation of the central part of the diaphragm radiates to the shoulder. the combination of lower chest pain and ipsilateral shoulder pain is highly suggestive of diaphragmatic pleural disease. mediastinal pain is less severe and is located in midline and radiates to the back in the interscapular area. it is very interesting that this pattern of referral pain has been described in modern textbooks as well (9, 10). signs of hemorrhage in upper and lower organs blood that is vomited originates from the stomach, and blood that comes from the lung or pharynx is clotted. blood from the lung is dark and is associated with pain and coughing… and is mixed with puss… and is more diluted and foamy… (4) in the above-mentioned passages there is an interesting distinction between hematemesis and hemoptysis. the latter can be caused by a wide range of disorders, but massive hemoptysis is most frequently caused by tuberculosis, bronchiectasis, lung abscess, cancer, and aspergilloma. these conditions were probably common in those periods (10, 11). signs of pain in the large intestine if someone has large intestine problems…, he feels the pain in his kidney. large intestine pain happens in the lateral part of the abdomen and is expandable… but kidney pain is constant and remains confined to one area, does not spread and is [often] located above the waist… and if [the patient] lies in the prone position, he feels heaviness in the kidney area…. in patients who complain from flatulence and intestinal air entrapment, if you palpate the affected area, you can feel a lump…. if air entrapment is the cause of pain, it radiates from one part to the other part…. in constipation the patient feels severe pain, pressure and a tearing sensation … (4). the passage above contains some very interesting information. flatulence and air entrapment within the intestinal loop are sometimes mistakenly diagnosed as kidney pain, a fact that has been pointed out in modern physical examination books (12). pain that originates from the right colon and transverse colon pain radiate toward the subumbilical region, as is the case in ulcerative colitis. in partial obstruction of recto-sigmoid colon the pain is distributed in the lower left abdominal quadrant (8). types of pulses in different diseases: …in pleural infection the pulse is rapid and full, although often it is not completely full, but it is rapid. if the pulse rate is increased it means that the lung is involved… sometimes the patients’ pulse converts to serrated pulse that is not regular and changes, and it is similar to the teeth of a saw… the pulse of persons with lung inflation and infection is j med ethics hist med 8:7 may, 2015 jmehm.tums.ac.ir mohammadreza ardalan et al. page 5 of 6 (page number not for citation purposes) small and rapid and moves like a wave… (4). tachycardia is a sign of fever, but decreased intravascular volume, hypoxia and pain are some other causes of tachycardia in a patient with cardiothoracic disease. it could also be an early sign of pleural effusion, pericarditis and myocardial involvements (7). discussion in a review of the passages above, we found that ferdous al-hekma is full of considerations about the physical signs and symptomatology of diseases. ferdous al-hekma is one of the first compendiums that introduced greco-roman medicine to the islamic world. during the greek period and the medieval times, diseases were considered to be the result of an imbalance in the four humors (6), and the concept of anatomy-based nosology of the disease did not yet exist. hippocrates (370-460 bc) developed the principles of clinical observation and interpretation of patients’ complaints. the next great greek physician lived 500 years after hippocrates and was galen of pergamum (129-216 ad). his ideas influenced medical thinking for the next 1500 years and were accepted as the ultimate truth until vesalius (7). the idea of anatomical thinking took many years to develop, and was constantly suffocated by the overfull legacy of humors pathology. vesalius and his work the humani corporis fabrica libri septem were a new start. in this work, vesalius described his own observations rather than justify his anatomical findings through galen’s theories. his works were promoted by giovanni battista morgagni in the 18th century. such revolutionary thinking established that diseases are not the product of unbalanced humors, but rather originate from organs. viennese physician leopold auenbrugger (1722-1809) started to use the percussion of the chest as a diagnostic tool, an innovation that was later revived by jean nicolas corvisart. physicians have always tried to examine the diseased organ by using their senses, and with those ideas joseph skoda (1805-1881) invented auscultation. a strong connection between physical diagnosis and autopsy later created a great achievement in physical diagnosis (9). it should be noted that some of the physical signs discussed by tabari in ferdous al-hekma are described so vividly that they are understandable by contemporary medical students (10, 11). ferdous al-hekma is a junction between the early translation movement and the adaptation and expansion of medical knowledge in the islamic world. tabari’s very close predecessor was hunayn ibn ishaq (800-877 ad), a great nestorian physician and translator of galen’s works from greek to arabic and syriac in the early 9th century. he dedicated his first work, which was the translation of a part of galen’s book on dissection in 829 ad, to gabriel ibn bakhtisho (died 829 ad), the great physician of bait-al-hekma and physician of caliph al-ma’mun (813-833 ad). another important influence on tabari was johanna ibn massavieh, who was also a persian christian physician and gabriel ibn bakhtisho’s student. he was a renowned physician in the islamic world during the 9th century and died in 857 ad in samarra (12). greco-roman medicine was preserved and expanded in the arabic language as it was the lingua franca of the islamic world during the dark ages (500 to 1050) and early middle ages. in these centuries europe entered a period of intellectual darkness while the islamic world was a sanctuary for scientific ideas to flourish. ferdous al-hekma created a new arena for other great medical compendiums to appear in the islamic world (11, 13). in ferdous al-hekma the considerations on physical signs are concise, direct and practical. the chapters devoted to examination of pulse and urine and dental medicine, however, are not as detailed as they are in hidayat al-mutaallimin fi al-tibb and alhawi by rhazes (14-16). the major novelty of ferdous al-hekma is the considerations about the signs and symptoms of diseases, as is obvious in the passages that have been presented in this article. in conclusion, ferdous al-hekma fil-tibb (paradise of wisdom in medicine) by ali ibn raban tabari shows the strength and depth of medical knowledge in the early islamic period. greco-roman medical heritage was introduced to the islamic world and then reentered europe during the middle ages, and the achievements in islamic medicine greatly influenced the modern scientific movements in the following years. j med ethics hist med 8:7 may, 2015 jmehm.tums.ac.ir mohammadreza ardalan et al. page 6 of 6 (page number not for citation purposes) references 1. shoja mm, tubbs rs. history of anatomy in persia. j anat 2007; 210(4): 359-78. 2. payandeh a. [tarikh tabari]. mohammad ibn jarir tabari asatir, 5th edition. 1375. 3. ibn isfandiyar. [tarikh-etabaristan], edited by iqbal ashtiani a. tehran: kolalleh khavar publication; 1931. 4. madani sa, broujerdi ah. [ferdous al-hekma]. tehran: mehramin publication; 2008. [in persian] 5. kiani h. ferdous al-hekma fi al-teb one of the first medical documents in islamic civilization. res hist med 2013; 2(3):109-12. 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166: 289-93. 15. ardalan mr, shoja mm, tubbs rs, eknoyan g. diseases of the kidney in medieval persia the--hidayat of alakawayni. nephrol dial transplant 2007; 22: 3413-21. 16. khodadoust k, ardalan m, pourabbas r, abdolrahimi m. dental and oral diseases in medieval persia, lessons from hedayat akhawayni. j med ethics hist med 2013; 6(9): 1-7. hhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh copyright © 2022 tehran university of medical sciences. this work is licensed under a creative commons attribution-non commercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. abstract due to the high value of human life, the occurrence of even one error that leads to death or complications is of great consequence and requires serious attention. although significant efforts have been made to ensure patient safety, serious medical errors continue to exist. this study aimed to identify the factors associated with the recurrence of medical errors and strategies to prevent them through a scoping review. data were gathered through a scoping review of pubmed, embase, scopus, and cochrane library databases during august 2020. articles related to factors influencing the recurrence of errors despite the available information, as well as articles related to measures taken worldwide to prevent them, were included in study. overall, 32 articles were selected out of the 3422 primary papers. two main categories of factors were identified as influential in error recurrence: human factors (fatigue, stress, inadequate knowledge) and environmental and organizational factors (ineffective management, distractions, poor teamwork). *corresponding author aidin aryankhesal address: no. 6, rashid yasemi st., vali-e asr ave., tehran, iran. postal code: 19967138831 tel: (+98) 21 88 77 20 86 email: aryankhesal.a@iums.ac.ir received: 8 feb 2022 accepted: 24 jul 2022 published: 25 oct 2022 citation to this article: aghighi n, aryankhesal a, raeissi p. factors affecting the recurrence of medical errors in hospitals and the preventive strategies: a scoping review. j med ethics hist med. 2022; 15: 7. the six effective strategies for preventing error recurrence included the use of electronic systems, attention to human behaviors, proper workplace management, workplace culture, training, and teamwork. it was concluded that using a combination of methods related to health management, psychology, behavioral sciences and electronic systems can be effective in preventing the recurrence of errors. keywords: medical errors; medical mistakes; patient safety; hospitals. factors affecting the recurrence of medical errors in hospitals and the preventive strategies: a scoping review 1. phd candidate in health services management, department of health services management, school of health management and information sciences, iran university of medical sciences, tehran, iran. 2. professor, department of health services management, school of health management and information sciences, iran university of medical science, tehran, iran. 3. professor, department of health services management, school of health management and information sciences, iran university of medical sciences, tehran, iran. negar aghighi 1, aidin aryankhesal 2*, pouran raeissi 3 mailto:aryankhesal.a@iums.ac.ir factors affecting the recurrence of medical errors in hospitals and the preventive … j. med. ethics. hist. med. 2022 (oct); 15: 7. 2 introduction medical errors are unavoidable occurrences in health systems that can adversely affect patient safety (1). years after the american institute of medicine's prominent report, "to err is human" (2), which addressed the importance of medical errors for the first time, there are still serious concerns about patient safety (3). patient safety is a fundamental right that must be guaranteed when visiting or hospitalizing patients. it is rather significant to investigate the possible causes and preventive measures for medical errors. in addition, medical error prevention can help to reduce adverse after-effects such as permanent disability, complications and death (4). clinicians have the moral obligation to maximize benefits and minimize harm while providing treatments or services to patients. clinicians also have an ethical responsibility not to inflict harm on patients intentionally or through carelessness (5). preventing medical errors requires the establishment and management of value-based ethical environments. such environments describe ethical policies that focus on employee’s commitment to values and norms related to practices (6). as reported by the institute of medicine, an estimated 44000 98000 deaths in the usa every year are attributed to medical errors (2). patient safety and quality of care are seriously affected by medical errors in hospitals. the epidemiology of medical error injuries remains a pressing global issue. in the united states, a recent report reviewing previous studies ranked unpleasant occurrences, especially medical errors, as the third leading cause of death (7). in particular, up to 1.1% of hospital admissions have resulted in deaths due to medical errors. in 2013, more than 400,000 deaths were caused by medical errors (8). in the uk, 101 medication errors occur per 1,000 drug prescription cases (9), and it is also estimated that drug errors cause 12,000 deaths per year according to the national health service (nhs) (10). the number of reported events increased from 135,356 between october and december 2005 to 508,409 during the same period in 2017 (11). over the years, the world health organization (who) has developed patient safety guidelines to prevent medical malpractice, including preventing patient fall , patient identification, hand hygiene, and safe surgery (12). the joint patient safety group has introduced several patient safety goals aghighi n., et al. 3 j. med. ethics. hist. med. 2022 (oct); 15: 7. to help healthcare providers create a safer environment for patients as well as themselves (13). however, despite these efforts, the rate of medical errors leading to disability and significant mortality is high (14). moreover, we still encounter errors that have detailed guidelines dedicated to them and should not keep recurring. while emphasizing the enormous burden of harm to patients seeking treatment, the world health organization has stated that over the past 15 years, global efforts to reduce harm to patients have not been effective despite pioneering work in some healthcare centers (15, 12). recurrence of errors in this study refers to errors that 1) have been discovered once in the study environment, 2) are caused by factors that have been analyzed and for which specific preventive guidelines exist, and 3) continue to occur in spite of training and sensitization (figure 1). it appears that the measures currently being taken to reduce medical errors are not sufficiently coherent and need to be reviewed to prevent the recurrence of errors that occur frequently. given the widespread efforts that have been made to prevent medical errors worldwide, the high frequency of errors has led to the hypothesis that there may be factors other than those currently known. therefore, a scoping review was needed to identify the factors that have been considered at the international level in the field of error recurrence. this study aimed to identify international actions regarding factors related to the recurrence and prevention of medical errors in hospitals and to identify any existing knowledge gaps. factors affecting the recurrence of medical errors in hospitals and the preventive … j. med. ethics. hist. med. 2022 (oct); 15: 7. 4 methods a scoping review was conducted based on the framework outlined by arksey and o’malley’s method. the purpose of a scoping review is to summarize “a range of evidence to convey the breadth and depth of a field”. (16). 1) identifying the research question this study addresses two main questions: 1) what factors can play a role in the recurrence of errors besides the ones already known to prevent error recurrence, and 2) what measures have been taken worldwide to prevent the recurrence of errors. 2) identifying relevant studies to select related studies, the following keywords were used in pubmed, embase, scopus, and cochrane library databases without time limit. the database research was done in august 2020, and the search strategy is shown in table 1. table 1: search strategy a manual search was also performed to identify additional relevant studies. in september 2020, in line with our scoping review methodology, we conducted a second comprehensive database search to confirm and complement the results of the first literature search. we developed our search string based on a primary set of relevant records identified in the first search. variations of the search string were then tested against a second set of relevant records. to validate the accuracy of the selection process, all authors screened the same 32 publications, discussed the results, and amended the screening and data extraction conducted before the beginning of the screening. disagreements on study selection and data extraction were resolved through consensus and discussion among the authors. (“medical mistakes”[tiab] or (errors[tiab] and medical[tiab]) or (error[tiab] and medical[tiab]) or “medical error”[tiab] or “medical mistake”[tiab] or “wrong-procedure errors”[tiab] or “wrong procedure errors”[tiab] or “wrong-procedure error”[tiab] or “wrong-site surgery”[tiab] or “wrong-site surgery”[tiab] or “wrong-site surgeries”[tiab] or “surgical errors”[tiab] or “surgical error”[tiab] or “wrong-patient surgery”[tiab] or “wrong patient surgery”[tiab] or “wrong-patient surgeries”[tiab] or “never event”[tiab] or “never events”[tiab] or “medication error”[tiab] or “medication errors”[tiab] or “near miss”[tiab] or “patient fall”[tiab] or “wrong medicine”[tiab] or “learning from error”[tiab] or “root cause analysis”[tiab]) and (repeat[tiab] or repetition[tiab] or occurrence[tiab] or “re-occurrence”[tiab]) aghighi n., et al. 5 j. med. ethics. hist. med. 2022 (oct); 15: 7. 3) study selection articles were included if they 1) dealt with the factors affecting the recurrence of the error, 2) presented strategies to prevent the recurrence of the error, or 3) were based on research conducted in hospital settings. the initially included papers were excluded if they 1) had been conducted in rehabilitation units and primary care centers, 2) only reported the incidence of errors, or 3) lacked a full text. due to the need for a comprehensive study, the type of article or study method did not affect the selection of articles. finally, 32 articles with the desired characteristics were selected out of the 3422 initially retrieved papers. the final inclusion of studies was achieved by consensus among the authors (figure 2). figure 2. the prisma diagram of the included papers factors affecting the recurrence of medical errors in hospitals and the preventive … j. med. ethics. hist. med. 2022 (oct); 15: 7. 6 4) charting the data two authors jointly developed a data charting form to determine which variables to extract. the authors independently charted the data, discussed the results, and continuously updated the datacharting form in an iterative process. two authors independently charted data from each eligible article. any disagreement was resolved through discussion between the two authors or further adjudication by a third author. critical appraisal of the included studies and meta-analysis across studies were not undertaken due to methodological heterogeneity. data extraction was conducted based on the jbi reviewer's manual (17), including authors’ names, year of publication, country of origin, aims of the study, overview of methods, and the results such as factors affecting the recurrence of medical errors, and those related to strategies for prevention of their recurrence. 5) collating, summarizing and reporting the results at this stage, a peer check was performed and each researcher checked the codes and validated the data. the findings were categorized, summarized and reported in such a way that all articles related to similar categories were put together and, after careful study, placed in related categories. lastly, the reports were provided. this study was registered under the number ir.iums.rec.1399.774 and is available in the research system of iran university of medical sciences (https://research.iums.ac.ir /), but for external access, permission must be obtained from iran university of medical sciences. results thirty-two articles were selected without time limitation in august 2020. the majority were from the us (n = 13) and australia (n = 3). other countries with less than three studies included the uk, austria, spain, iran, portugal, germany, italy, japan, denmark, france, south korea, israel and thailand. a vast majority of the studies used crosssectional analyses (n = 11) and review studies (n = 11) (table 2). http://ethics.research.ac.ir/ir.iums.rec.1399.774 https://research.iums.ac.ir/ aghighi n., et al. 7 j. med. ethics. hist. med. 2022 (oct); 15: 7. table 2. summary of findings of selected articles authors, publication year country aim of the study method results flynn, e.a. 1999 (18) us investigating the relationship between interruptions and distribution of errors cross-sectional study 1. pharmacists who were more distracted had higher error rates than those who were less distracted. 2. distraction has a significant effect on distribution of errors de carvalho, m. 2002 (19) portugal investigating medical errors, predisposing factors and prevention in the neonatal ward literature review and bibliographic review in medline 1. environmental factors, physical factors and physiological factors contribute to errors. 2. using technology such as electronic order entry (cpoe) and barcodes can prevent errors. 3. automatic detection of side effects is useful in error prevention meinberg, e.g. 2003 (20) us determining the incidence of wrong-site surgery cross-sectional study using the sign your site campaign caused a 45% reduction in wrong-site surgery in the united states, and almost everyone takes steps to prevent this type of medical error. bates, d. 2004 (4) us identifying solutions to prevent medication errors cross-sectional study some measures for prevention: 1) including training on medication errors in the university curriculum 2) focusing on improving secure systems 3) utilizing modern technology 4) using clinical pharmacists 5) creating innovative safety plans berman, a. 2004 (21) us identifying ways to reduce the lookalike and soundalike errors literature review the most common cause of medication errors is human factors such as dysfunction, lack of knowledge, errors in preparation and calculation, and slips and loss of memory. meaney, m.e. 2004 (22) germany filling the gap about the organizational ethics committees and their impact on patient safety descriptive research 1. ethics committees can be effective in achieving a safety culture. 2. patient safety culture depends on the teamwork culture. 3. patient safety culture should include internal and psychological factors and daily behaviors related to patient safety, factors affecting the recurrence of medical errors in hospitals and the preventive … j. med. ethics. hist. med. 2022 (oct); 15: 7. 8 table 2. summary of findings of selected articles (continued) authors, publication year country aim of the study method results deans, c. 2005 (23) australia identifying and describing the incidence, type and causes of medication errors cross-sectional study with regard to reasons for recurring errors: 1. handwriting illegibility and misreading 2. stress and fatigue have been reported 3. interruptions and distractions 4. lack of knowledge ziv, a. 2005 (24) israel investigating the effect of simulation-based medical education (sbme) on the occurrence of medical errors literature review 1. the main feature of sbme is its unique approach to making mistakes (and learning from them). 2. accountability should be a key. jirapaet, v. 2006 (25) thailand describing the barriers that nurses face when providing nursing services qualitative descriptive methodology factors associated with error recurrence are: 1) insufficient knowledge of patient safety in neonatal wards 2) inadequate staffing 3) multitude of tasks 4) poor team communication hovor, c. 2007 (26) us evaluating medication errors using the bayesian causal network model literature review the bayesian causal network model identifies behavioral and systemic factors that may increase the risk of drug misuse, misdiagnosis and missed doses, as well as drug interactions and drug errors. hakimzada, a.f. 2008 (27) us examining the nature of errors and their consequences for patient safety qualitative grounded theory 1. some causes of medical errors are stress in the workplace, heavy workload, and the tendency to adopt shortcuts. 2. while in some cases technological solutions can improve the situation, they can sometimes lead to more errors, or automate errors in the system. aghighi n., et al. 9 j. med. ethics. hist. med. 2022 (oct); 15: 7. table 2. summary of findings of selected articles (continued) authors, publication year country aim of the study method results brandão, p. 2011 (14) portugal providing solutions to reduce side effects by identifying and eliminating the root causes of errors descriptive research 1. accumulation data on errors alone does not help much to improve the system and reduce errors. 2. learning from errors can be facilitated by using mathematical-logical operators. 3. the electronic system of the eindhoven classification model can be sutable. agrawal, a. 2012 (28) us learning from root cause analysis descriptive research root cause analysis some reasons for repeating an error include: 1) failure to provide instructions to stakeholders in time (despite the existence of related guidelines for some years) 2) lack of official supervision over the implementation of safety protocols 3) poor teamwork between doctors and nurses charpiat, b. 2012 (15) france investigating the data on the nature and frequency of medication errors review based on searching pubmed and cat-inist databases 1. electronic methods did not prevent drug errors and led to new types of errors. 2. the possibility of providing duplicate prescriptions can cause errors. 3. there are defects in human-machine communication. frith, k.h. 2012 (29) us investigating the relationship between nursing staff and the incidence of medication errors cross-sectional study . 1. increasing the number of rn hours and decreasing or eliminating lpn hours can be a strategy to reduce medication errors. 2. nursing staff is an important human resource to keep patients safe from medication errors steyrer, j. 2013 (30) austria investigating the effect of production pressure and workload on patient safety prospective, observational, crosssectional study 1. no significant relationship was observed between safety tools and error rate. 2. safety atmosphere affects the error rate. 3. heavy workload has a devastating effect on patient safety. factors affecting the recurrence of medical errors in hospitals and the preventive … j. med. ethics. hist. med. 2022 (oct); 15: 7. 10 table 2. summary of findings of selected articles (continued) authors, publication year country aim of the study method results barrington, m.j. 2015 (31) australia identifying preventive strategies in wrong-site anesthetic blocks literature review and medline search strategies prevention strategies for local anesthesia in the wrong place include: 1) individual and systemic accountability 2) paying attention to time-out 3) continuous audits 4) markings in action positions 5) using valid checklists 6) using strong documentation 7) improving team communication fraser, s.g. 2015 (32) uk describing the reasons for the occurrence of wrong-site procedure errors and ways to prevent them descriptive research some prevention strategies include: 1) using campaigns to encourage action marking 2) establishing the pre-operation approval process 3) enforcing patient participation in marking the operation site 4) establishing time out immediately before starting the operation 5) using electronic systems such as barcoding stein, j.e. 2015 (33) us introducing human factors science and its applicability to teamwork descriptive research 1. classifying human factors and describing unsafe behaviors and actions are some tools to understand the nature of errors. 2. human behaviors must be known. chiarini, m. 2017 (3) italy evaluating the effect of knowledge and attitude of nursing students on failure cross-sectional study 1. the culture of error is important in medicine. 2. patient safety culture and prevention of medical errors should be included in the university education of medical personnel. hartfordbeynon, j. 2017 (35) uk identifying wrong-site blocks and reducing their occurrence an audit of regional anesthetics and compliance with sb4yb 1. training campaigns such as the sb4yb campaign must be encouraged. 2. who involvement in patient safety issues increases compliance in achieving the goals of preventing error recurrence. aghighi n., et al. 11 j. med. ethics. hist. med. 2022 (oct); 15: 7. table 2. summary of findings of selected articles (continued) authors, publication year country aim of the study method results hwang, j.i. 2017 (36) south korea addressing the importance of systems thinking in nurses and its relationship with the recurrence of medical errors cross-sectional study 1. the ability to think systemically plays a role in reducing and reporting medical errors. 2. the skill of systemic thinking has a role in improving the quality and safety of patient care. 3. nurses' competence to think systemically should contribute to patient safety. babaei, m. 2018 (37) iran evaluating the relationship between personalityrelated factors and problem-solving ability, and medical errors questionnaire case control study 1. people who made fewer medical errors scored significantly higher on the three factors of extroversion, conscientiousness and agreement. 2. people who made more medical errors scored higher on neuroticism. 3. people who made no medical errors scored higher on the three problem-solving scales. vrklevski, l.p. 2018 (38) australia evaluating the impact of rca (root cause analysis) on improving patient outcomes. literature review 1. physicians' rate of adopting the rca recommendations is low. 2. there is weak evidence that the implementation of rca recommendations leads to safer patient care. 3. the rca often makes recommendations that replicate existing policies abbasi, f. 2019 (39) iran determining the correlation between workplace culture and learning from errors descriptiveanalytical study 1. there was a positive correlation between workplace culture and learning from error. 2. there was an inverse relationship between workplace culture and occurrence of medication errors. tigard, d.w. 2019 (40) germany trying to prove the importance of responsibility in medical errors instead of preventing blame descriptive research 1. it is necessary to resist moving away from the concepts related to blame. the position of blaming should be maintained in order to increase accountability. factors affecting the recurrence of medical errors in hospitals and the preventive … j. med. ethics. hist. med. 2022 (oct); 15: 7. 12 table 2. summary of findings of selected articles (continued) authors, publication year country aim of the study method results bowden, v. 2019 (13) us describing nursespecific present at the time of a patient fall retrospective cohort study 1. increasing the number of nurses reduces the risk of patient fall. 2. nurses’ level of experience and work experience affects the rate of patient fall. in other words, the more experienced the nurse is, the less likely the patient is to fall. lee, y.j. 2019 (41) south korea investigating the effect of nursenurse and nursephysician relationship cross-sectional questionnaire survey optimal collaboration between physician and nurse is effective in reducing medical errors. honno, k. 2020 (42) japan investigating the relationship between depression and near miss among elst emergency technicians cross-sectional study 1. stress and depression were the main risk factors for medical errors. 2. proper management of the work environment can lead to the provision of safe services. koleva, s.i. 2020 (43) us exploring some common factors contributing to never events in surgery literature review some factors associated with error recurrence include: 1) weak communication 2) fatigue 3) lack of specialized personnel 4) operating room interruptions 5) number of surgical cases 6) issues related to employees 7) working hours 8) fatigue latzke, m. 2020 (44) austria examining the effect of safety climate and team processes non-interventional, observational multicenter 1. safety climate and team processes are comparatively important determinants of adverse events occurrence. martin delgado, j. 2020 (45) spain investigating the effect of root cause analysis in preventing error recurrence systematic review 1. the main weakness of rca is its recommendations. 2. poorly designed rcas may not be enough to prevent new errors from occurring, and may even lead to new errors. two groups of results were found in the present study: a) factors related to the recurrence of medical errors, and b) strategies to prevent the recurrence of medical errors. a) factors related to the recurrence of medical errors two categories of human, and environmental and organizational factors were identified, along with six items, explained below. human factors fatigue: in some studies, fatigue has been identified as the most important cause of error and its recurrence (19, 23, 31). in one study, fatigue was aghighi n., et al. 13 j. med. ethics. hist. med. 2022 (oct); 15: 7. reported as a contributing factor to anesthesia errors (28). also, high workload and insufficient sleep lead to fatigue, which increases the frequency of mistakes (19,27, 30). stress: according to studies, stress is one of the most important factors in the occurrence and recurrence of medical errors (19, 23, 27, 42). we also found that people with neuroticism (including anxiety, anger, irritability, vulnerability and depression) were more likely to make medical errors (37). inadequate knowledge: insufficient knowledge and skills are the most common cause of medication errors (21). in addition, inadequate knowledge can lead to stress and fatigue and increase medical errors (23). studies conducted in the neonatal ward and operating room have shown that lack of sufficient knowledge and skills leads to the recurrence of medical errors (25, 43). environmental and organizational factors ineffective management: in this category, the following factors were found to lead to medical error recurrence: existence of strong authority in the organization that suppresses the possibility of identifying and learning from errors (43); expansion of hierarchical boundaries in an organization (such as a hospital) that requires a team structure (28); failure to provide timely and correct patient safety instructions and the results of root cause analysis (rca) to stakeholders (28, 38); lack of formal oversight of the implementation of safety protocols, and their failure to become an automatic part of the workflow of employees (28); not considering reminders (such as system alarms) and dependence on incomplete human memory, (28). various distractions: according to the studies, distraction of the medical staff caused by unnecessary visits to hospital wards, unnecessary telephone calls, staff irregularities, and irregular placement of equipment and medications, leads to surgical, anesthesia and medication errors (18, 23, 31). poor teamwork: poor team communication is one of the most important factors in error recurrence and may cause harm to patients (25, 31, 43). such weak connections are usually due to poor teamwork between physicians and nurses, which endangers patient safety (25, 43). b) strategies to prevent the recurrence of medical errors according to the studies, six factors were identified as effective in preventing the recurrence of errors, including: 1) use of electronic systems, 2) attention to human behaviors, 3) workplace culture, 4) factors affecting the recurrence of medical errors in hospitals and the preventive … j. med. ethics. hist. med. 2022 (oct); 15: 7. 14 proper workplace management, 5) training, and 6) paying attention to teamwork. use of electronic systems: the findings of several studies have emphasized the importance of using electronic systems such as cpoe (computerized provider order entry) and barcode systems to prevent the recurrence of errors (14, 19, 21, 23, 28, 32, 46). the barcode system can reduce misdiagnosed drugs, prevent misidentification of the patient and misuse of time, and reduce missed and wrong dose errors (46). therefore, the installation of barcoded wristbands for all patients should be considered at the time of admission (21). also, e-prescriptions significantly reduce medication errors and do not put patients at risk for illegible handwriting and related causes (23). such technologies do not replace specialists involved in patient care, but rather organize information and allow specialists to perform valuable tasks such as complex decision-making and communication while the system performs repetitive and tedious tasks (26). attention to human behaviors: numerous studies have addressed human factors and behavioral issues as a strategy to prevent the recurrence of errors (19, 24, 31, 33, 36, 37, 40, 43). based on one study, extrovert, conscientious people with strict work ethics committed fewer errors, and those with problem-solving skills did not commit medical errors (37). in addition, the ability to think systematically plays a role in reducing the incidence of medical errors (36). several studies have found a significant relationship between having a deep understanding of anthropological factors and a reduced amount of incurring "never events" (33, 43). moreover, in order to eliminate human errors, we should have knowledge of human behaviors and consider the two categories of schematic behaviors and attention-related behaviors. schematic behaviors are reflective and can be considered in error reduction by using checklists and attracting public attention. attention-related behaviors, on the other hand, are related to problem-solving skills, and are therefore more difficult to control and require professional supervision and training to reduce errors (34). in some studies, individual and organizational responsibility and accountability have been found to be effective in reducing errors (24, 31, 40). proper workplace management: one of the main components of management is supervision. some procedures that have prevented the recurrence of errors include continuous audits, implementation of powerful documentation such as valid checklists for safe surgery and anesthesia (31, 32, 39), and aghighi n., et al. 15 j. med. ethics. hist. med. 2022 (oct); 15: 7. strict supervision of compliance and corrective measures (28). proper alignment of forces and increased use of experienced and more educated staff have also been effective in preventing errors. examples of such measures include increasing the working hours of rn nurses and reducing the working hours of lpn nurses. also, increasing the number of nurses has reduced the rate of patient fall (13). hospitals can also help reduce medical errors through stronger and more reliable safety management, including error reporting, learning from errors, information transparency, and providing timely error feedback (23, 43). workplace culture: according to studies, medical errors will be reduced in the presence of proper workplace culture (22, 28, 30, 34, 39, 44). in one study, a positive relationship was found between workplace culture and learning from errors (39), and other studies have identified a positive relationship between culture and teamwork (22, 44). training: numerous studies have shown that training in different areas is effective in preventing errors (20, 32, 34, 35, 39, 46). studies have emphasized the importance of including error training in the university curriculum as part of the education of medical staff to fully acquaint them with the issue before starting work, stating that this will ultimately help reduce medical errors (34, 46). training campaigns with varied and specific topics in the field of patient safety have been very useful in reducing errors (for instance the campaign of "sign your site") due to the extent of these campaigns (20, 32, 35). in addition, using educational models such as the potential risk assessment model (26) and the eidenhaven classification model (14) will improve learning from errors and reduce medical errors. although rca is used to provide solutions to prevent the recurrence of errors, it appears that this method cannot prevent errors from recurring (38, 45). one study found that physicians' participation in rca recommendations was low (38) and that the rca often provided recommendations that replicated existing policies or previous recommendations (38, 45). paying attention to teamwork: doing the right thing as a team is effective in preventing mistakes (28, 31, 32, 41, 44). teamwork is especially significant between physicians and nurses, and in areas such as the operating room and among the surgical team members (28, 31, 37, 41). therefore, various team-building programs can be used to increase teamwork skills among staff (28). factors affecting the recurrence of medical errors in hospitals and the preventive … j. med. ethics. hist. med. 2022 (oct); 15: 7. 16 discussion based on our review, two main categories of factors (human, and environmental and organizational) and their six sub-categories were identified as associated with error recurrence. the sub-categories were fatigue, stress, inadequate knowledge, existence of various distractions, poor teamwork, and ineffective management. in the field of error prevention strategies, six factors were identified, including the use of electronic systems, attention to human behaviors, proper workplace management, appropriate workplace culture, training, and attention to teamwork. fatigue and stress were identified as significant factors associated with error recurrence (21, 28, 31, 37, 39, 46). it seems that even if error prevention measures are implemented, efforts in this area will not be successful unless issues such as fatigue and stress are addressed. inadequate knowledge was another factor that led to error recurrence (18, 19, 23, 39), and therefore we found it essential that well-informed personnel be employed in relevant departments. neuroticism was yet another factor to be considered when hiring staff, because neurotic people were more likely to make medical errors. in the field of environmental and organizational factors, poor teamwork was shown to lead to the recurrence of medical errors (18, 23, 46). paying attention to the cooperative nature of hospital duties is a point that must be constantly emphasized, and all team members must be committed to it. in addition, hospital management should prioritize strengthening team skills in training programs. therefore, different methods of reinforcing teamwork must be employed, particularly between physicians and nurses. distraction was found to be another factor associated with error recurrence (27, 39, 46), so interruptions must be carefully identified and removed (including all irregularities in departments and units). distraction alone can overshadow all efforts to prevent errors, and therefore strategies to avoid it and enhance attention and concentration in the workplace will be effective in preventing the recurrence of errors. in this regard, improving environmental conditions need to be on health managers’ agenda. in the area of ineffective management, the existence of strong authority in the organization suppresses mental communication and prevents active learning from mistakes by creating fear among staff and hierarchical boundaries, leading to the recurrence of mistakes. this indicates the need to create a friendly atmosphere (18, 29), which encourages learning from errors and supports aghighi n., et al. 17 j. med. ethics. hist. med. 2022 (oct); 15: 7. retelling them, and can eventually prevent error recurrence. prevention of medical errors within an organization requires systematic management strategies. healthcare providers need education and training to understand the importance of reporting medical errors. it is the ethical duty of organizations to create an environment where healthcare providers feel supported in reporting, disclosing and discussing errors (47). other factors related to error recurrence are lack of proper and complete sharing of protocols, and lack of learning from errors (32). communication researchers suggest that the ways healthcare providers 'story' their experiences of mistakes can help to understand medical errors (48). hence, it is necessary to create a smooth and organized structure. this structure should ensure that all stakeholders have access to essential information including patient safety instructions and the results of error analysis. in addition, this information should become an automated part of their workflow. according to strategies pertaining to the field of prevention, human factors such as problem-solving skills, systemic thinking ability and personality traits (18, 26, 28, 34, 43, 46), and training in these skills and abilities should be considered in academic and in-service training programs. the reason is that in a hospital setting where staff are constantly confronted with multiple incidents, having such skills enhances effectiveness. furthermore, personality traits should be considered in the recruitment of staff. in addition to preventing errors from recurring, the use of electronic systems (14, 19, 28, 32, 35, 39, 42) such as barcoding and cpoe, as well as electronic alarms, can be very useful, since they allow staff to focus on sensitive tasks with more ease and efficacy. in a study conducted to examine whether physicians’ use of electronic systems promotes patient satisfaction or blame for medical outcomes, it was found that using a decision support system was very effective in reducing blame after medical errors (49). according to these studies, proper management of the work environment and ensuring the correct performance of activities through valid checklists (32, 42, 44, 46), seriousness in following compliance and corrective actions, and hiring experienced and well-educated personnel can prevent errors from recurring. in the field of education, error training should be included in the university curriculum (22, 29). in addition, training campaigns to prevent the recurrence of errors have been very useful because they focus on specific topics (such as sign your site) factors affecting the recurrence of medical errors in hospitals and the preventive … j. med. ethics. hist. med. 2022 (oct); 15: 7. 18 (20, 33, 42). also, promotion of such campaigns among large groups of stakeholders has been effective in creating a culture of that issue. although rca used to be considered an effective strategy to prevent the recurrence of errors, our review did not find confirming evidence (29, 40). it seems that there should be revisions regarding the use of this method to avoid repeating previous recommendations. limitations this scoping review should be read in the light of certain limitations. we conducted a literature search in four major electronic databases: pubmed, embase, scopus, and cochrane library, but did not have access to the cinahl database. furthermore, we did not search “gray” literature. in line with the scoping review methodology, we did not assess the risk of bias of the included studies. although we observed methodological heterogeneity in the included studies, we did not include or exclude studies based on quality assessment, which is necessary for a systematic review. therefore, caution is advised when drawing conclusions based on the combined data from this study conclusion this study aimed to identify the factors associated with error recurrence and strategies to prevent it; because it seemed that despite years of preventive measures against medical errors, these errors are still repeated. this study showed that other factors, most of which are contextual and have psychological dimensions, affect the recurrence of errors. therefore, it is important to identify the reasons and remove the main factors leading to their recurrence. clearly, it is not sufficient to use methods such as rca in this field, and one can hope for the effectiveness of patient safety efforts if and when these factors are eliminated. this study found that using a combination of methods related to health management, psychology and behavioral sciences, as well as electronic systems can be effective in preventing the recurrence of errors. it should be added that further studies are needed to focus on the root causes of recurring errors. acknowledgements due to the review nature of the study, this section is not applicable. conflict of interests the authors have no conflict of interests to declare. aghighi n., et al. 19 j. med. ethics. hist. med. 2022 (oct); 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qualitative studies: the necessity to develop a specific guideline mahnaz sanjari1, fatemeh bahramnezhad1, fatemeh khoshnava fomani1, mahnaz shoghi2, mohammad ali cheraghi3* 1nursing phd candidate, school of nursing and midwifery, tehran university of medical sciences, tehran, iran; 2assistant professor, school of nursing and midwifery, iran university of medical sciences, tehran, iran; 3associate professor, school of nursing and midwifery, tehran university of medical sciences, tehran, iran. corresponding author: mohammad ali cheraghi address: school of nursing and midwifery, tehran university of medical sciences, tehran, iran. email: mcheraghi@tums.ac.ir tel: 98 21 66933600 fax: 98 21 66941668 received: 01 jan 2014 accepted: 07 jul 2014 published: 04 aug 2014 j med ethics hist med, 2014, 7:14 © 2014 mahnaz sanjari et al.; licensee tehran univ. med. sci. abstract considering the nature of qualitative studies, the interaction between researchers and participants can be ethically challenging for the former, as they are personally involved in different stages of the study. therefore, formulation of specific ethical guidelines in this respect seems to be essential. the present paper aimed to discuss the necessity to develop explicit guidelines for conducting qualitative studies with regard to the researchers’ role. for this purpose, a literature review was carried out in domestic and international databases by related keywords. health care providers who carry out qualitative research have an immense responsibility. as there is no statistical analysis in qualitative studies, the researcher has to both evaluate what he or she observes and to interpret it. providing researchers with the necessary skills and applying stringent supervision can lead to better extraction of reliable information from qualitative studies. this article presents a debate in order to illustrate how researchers could cover the ethical challenges of qualitative studies and provide applicable and trustworthy outcomes. researchers face ethical challenges in all stages of the study, from designing to reporting. these include anonymity, confidentiality, informed consent, researchers’ potential impact on the participants and vice versa. it seems of paramount importance that health care providers, educators and clinicians be well informed of all the different aspects of their roles when acting as qualitative researchers. hence, these adroit roles need to be well defined, and the use of practical guidelines and protocols in all stages of qualitative studies should be encouraged. keywords: qualitative research, ethical challenges, researcher’s role, guideline mailto:mcheraghi@tums.ac.ir j med ethics hist med 7:14 aug, 2014 jmehm.tums.ac.ir mahnaz sanjari et al. page 2 of 6 (page number not for citation purposes) introduction in the recent millennium, the constant trend of change in the demands of the community as well as transforming the trend of knowledge production has highlighted the necessity for researchers to adopt a more comprehensive approach. increasingly, many academic disciplines are utilizing qualitative research (qr) as the qualitative method investigating the why and how of the process of a developed concept (1, 2). qualitative research is sometimes defined as interpretive research, and as interpretations can be incorrect or biased, the findings may be controversial (3). however, qualitative research is not only useful as the first stage of quantitative research, but can also play a key role in ‘validating’ it or in providing a different viewpoint on the same social phenomena (4). qualitative studies tend to use methods that result in text production rather than numerical outputs. given that the researcher is considered to be the research instrument, and the plan of inquiry needs to be developed and altered as the study progresses, a qualitative researcher cannot depend upon traditional approaches to address certain concerns such as bias and credibility. therefore, learning from a series of mistakes is often considered an integral part of qualitative research (5, 6). in this study, a literature review was carried out in international electronic databases including pubmed, web of sciences, cumulative index to nursing and allied health literature (cinahl), scopus, ebsco, embase and science direct without any time limitation, using the search terms "qualitative research", "researchers' role", "ethical challenges" and "ethical guidelines". these keywords were also searched on national electronic databases including scientific information database (sid), iran medex and medical articles library (medlib) using the same strategy. authors of the present article endeavor to shine a light on the ethical issues affecting researchers and propose strategies to face the ethical challenges of qualitative studies, so as to provide applicable and trustworthy outcomes. this could be the basis for the formulation of specific ethical guidelines in this regard. an overview on qualitative research in health care up to the 1970s, qualitative research was solely employed by anthropologists and sociologists. during the 1970s and 1980s, however, it was favored by various disciplines and experts of different branches of science and humanity such as health care, psychology, nursing, management, political science, education, and communication studies (2, 7). qualitative research has been conducted in the field of nursing in order to identify, describe and explain related concepts, experiences and phenomena and to develop the nursing knowledge. nursing professionals simultaneously introduced qualitative research to their peers. since 1970, qualitative research has been performed to achieve the concepts of patient care and other main perceptions in the nursing profession. qualitative studies provide nurses with sensitivity to the lived experiences of individuals from different nursing care aspects (4, 8). role of researchers in qualitative studies in the case of nurses who perform qualitative research, ethical issues are raised when the nursepatient relationship in the research area leads to some degree of therapeutic communication for the participants (9). thus, nurse researchers must be aware of the impact of the questioning on the participants, and in order to decrease such harmful effects on human subjects, the "reflexive approach" is recommended (10). in qualitative studies researchers are often required to clarify their role in the research process (11). in the qr procedure the researcher is involved in all stages of the study from defining a concept to design, interview, transcription, analysis, verification and reporting the concepts and themes. therefore, whenever instruments are involved in qualitative research, a human being will be an integral part of the process (12). it is argued that humans have increasingly become the "instrument of choice" for naturalistic research due to certain characteristics: they are highly responsive to environmental stimuli, have the ability to interact with the situation, pull together different pieces of information at multiple levels simultaneously, and perceive situations holistically; moreover, they are able to process findings the instant they become available, can present immediate feedback, and feel unusual responses. nevertheless, researchers need to improve the abilities that make them appropriate human instruments and consequently, their interpersonal skills are of major importance in natural settings and study processes (table 1) (13, 14). j med ethics hist med 7:14 aug, 2014 jmehm.tums.ac.ir mahnaz sanjari et al. page 3 of 6 (page number not for citation purposes) table 1. researcher’s role in qualitative methods at a glance qualitative method researcher's role phenomenology the main task of researchers in the phenomenological method is transformation of data to live the experience. they bring individual experiences into words in data collection, and then attempt to understand those experiences based on the statements, and to categorize the themes in the next stage. in the last stage, investigators record the essence in writing, which results in a comprehensive description of the phenomena (6, 15). grounded theory considering the significance of personal relations in grounded theory, researchers act as a component of daily events and must therefore be completely aware of their values. since there is no control in this natural field, investigators are not detached from the research process, and ought to be conscious of their prejudices and potential influence on the study. researchers need to be able to perform data admission and coding concurrently, and should consequently be equipped with proper analysis skills in order to criticize and conduct abstract thinking (16, 17). ethnography in ethnographic studies, researchers function as instruments that understand and analyze the culture. therefore, ethnographic investigators need to be immersed in the culture and to live among the study population. however, ethnographers have to be notified of their role as research instruments while collecting and analyzing data (18). ethical challenges in qualitative studies: the researcher-participant relationship the relationship and intimacy that is established between the researchers and participants in qualitative studies can raise a range of different ethical concerns, and qualitative researchers face dilemmas such as respect for privacy, establishment of honest and open interactions, and avoiding misrepresentations (19). ethically challenging situations may emerge if researchers have to deal with contradicting issues and choose between different methodological strategies in conflict arises. in such cases, disagreements among different components such as participants, researchers, researchers’ discipline, the funding body and the society may be inevitable (20, 21). some important ethical concerns that should be taken into account while carrying out qualitative research are: anonymity, confidentiality and informed consent (22). according to richards and schwartz’ findings (22), the term ‘confidentiality’ conveys different meanings for health care practitioners and researchers. for health care practitioners, confidentiality means that no personal information is to be revealed except in certain situations. for researchers, however, the duty of confidentiality is less clear and involves elaboration of the form of outcome that might be expected from the study (22, 23). the researcher must endeavor to minimize the possibility of intrusion into the autonomy of study participants by all means. when highly sensitive issues are concerned, children and other vulnerable individuals should have access to an advocate who is present during initial phases of the study, and ideally, during data gathering sessions. it is sometimes even necessary that the researcher clarify in writing which persons can have access to the initial data and how the data might be used (24, 25). informed consent has been recognized as an integral part of ethics in research carried out in different fields. for qualitative researchers, it is of the utmost importance to specify in advance which data will be collected and how they are to be used (26). the principle of informed consent stresses the researcher’s responsibility to completely inform participants of different aspects of the research in comprehensible language. clarifications need to include the following issues: the nature of the study, the participants’ potential role, the identity of the researcher and the financing body, the objective of the research, and how the results will be published and used (27). informed consent naturally requires ongoing negotiation of the terms of agreement as the study progresses (26). many people consider it necessary to participate in research that their peers, community and/or society may benefit from. therefore, qualitative health researchers need to clarify that the research they carry out will benefit science and can contribute to the improvement of health policy (5). research design the qualitative method is utilized to explain, clarify and elaborate the meanings of different aspects of the human life experience. therefore, researchers can interpret people’s experiences because they are involved in human activities. the principle of ‘no harm’ to participants ought to be considered by researchers, who should be aware of the potential harms that might be inflicted upon study subjects. obviously, sometimes a conflict j med ethics hist med 7:14 aug, 2014 jmehm.tums.ac.ir mahnaz sanjari et al. page 4 of 6 (page number not for citation purposes) between the right to know (defended on the basis of benefits to the society) and the right of privacy (advocated based on the rights of the individual) may happen (27, 28). there are several effective strategies to protect personal information, for instance secure data storage methods, removal of identifier components, biographical details amendments and pseudonyms (applicable to names of individuals, places and organizations) (27). researchers have the responsibility of protecting all participants in a study from potentially harmful consequences that might affect them as a result of their participation. it is getting increasingly common for research ethics committees to seek documented proof of consent in a written, signed, and ideally, witnessed form. researchers can only do their best to protect their respondent’s identity and hold the information strictly confidential as there would be no guarantee for it otherwise (29). furthermore, in investigations of sensitive topics where written consent puts the informants at risk, audio recorded oral consent would be more appropriate (30). development of personal relationships with participants may be inevitable while collecting certain data. therefore, researchers should seriously consider the potential impact they may have on the participants and vice versa, and details of such interactions should be clearly mentioned in research proposals (23). overall, the role of the researcher as (a) stranger, (b) visitor, (c) initiator, (d) insider-expert or other should be well defined and explained (3). as brenner quoted kvale state that, preparing an ethical protocol can cover issues in a qualitative research project from planning through reporting (30). data gathering and data analysis in qualitative research, data are collected with a focus on multifaceted interviews and narratives to produce a description of the experiences. the researchers, therefore, play the role of a mediator between the experiences of the respondents and the community of concerned people (28, 31). the postinterview comment sheet could assist the researcher to note the feelings of informants, as well as interpretations and comments that occurred during the interview (32). data collection needs to be as overt as possible, and findings should be recorded. although there is no guarantee of absolute confidentiality, openly recording field notes assists participants to decide what they wish to have on the record. in health care research, the problem may be even more exaggerated as the researcher is sometimes the health provider as well (33). in comparison with other research methods, ethnography has singular characteristics. when a researcher aims to study the culture of certain people, living amongst them is inevitable. this method of collecting data is a subject of debate from an ethical point of view. long presence of the researcher amongst people of a particular culture necessitates informed consent. participants should always be aware of the information that has been obtained and is being recorded, and consent to it. sometimes this cannot be achieved easily and conflicts may happen, as in studies of cultural and ethnic characteristics (18). the physical presence of the researchers within the culture requires them to be responsible for their role and potential consequences on the field. for instance, when criminals or a group of war veterans suffering from a disease are the subject of a study, the risks involved in living amongst them should be considered. ethnographers must be vigilant about any distractions stemming from close interactions that can be potentially harmful to participants in the long run (33, 34). researchers can benefit from supervision sessions directed at learning, mentoring and skill development, all of which can foster their ability to carry out research without risking their health. adequate professional supervision (which may be outside of the university) can be of service to researchers in dealing with the potential stress associated with the study (35 37). in order to gain explicit data, ethnographers need to know the role of instrument details. there are eleven steps defined in ethnography which are meant to assist researchers. these steps include participant observation, ethnographic record, descriptive observation, taxonomic analysis, selected observation, componential analysis, discovering the cultural theme, cultural inventory, and finally writing ethnography (38, 39). researchers should always be aware of the precise reason for involvement in a study in order to prevent undesirable personal issues. the probability of exposure to vicarious trauma as a result of the interviews needs to be evaluated. interviewers should be properly scheduled to provide the researcher with sufficient recovery time and reduce the risk of emotional exhaustion, while allowing ample time for analysis of the objective and emotional aspects of the research. it is also necessary for the researcher to be familiar with signs of extreme fatigue and be prepared to take necessary measures before too much harm is done (40 42). conclusion in qualitative studies, researchers have a great responsibility and play many different roles. it is argued that qualitative research that deals with sensitive topics in depth can pose emotional and other risks to both participants and researchers. clear protocols for dealing with distress should be in place so that both parties involved in research can use them if necessary. it is not usually easy to predict what topics are likely to lead to distress, j med ethics hist med 7:14 aug, 2014 jmehm.tums.ac.ir mahnaz sanjari et al. page 5 of 6 (page number not for citation purposes) and researchers should therefore receive sufficient training in predicting traumatic situations. preventive measures for researchers who carry out sensitive qualitative studies should include official arrangements for a peer support program consisting of a list of researchers who are involved, or a constellation of researcher support activities aiming at improving psychological fitness in the form of a professional confidence building module. other such measures include offering adequate supervision to provide opportunities for selfdevelopment and self-care, and facilitating the process of self-reflection and self-monitoring. strategies for emotional distancing need to be considered and adopted if the research topic or participants have the potential to be emotionally challenging. an appropriate planning should be in place before the commencement of the fieldwork, and it must be perfectly clear how the study should be conducted and what level of relationship development is necessary. measures must also be taken so that levels of self-disclosure, objective displays of emotion during the interviews, and strategies to end the relationships are well defined and communicated. one of the most prominent tasks of qualitative researchers is to minimize the flaws in observation and endeavor to gain truthful knowledge. therefore, it is necessary for researchers to continuously update their investigation skills in terms of methodology and find novel techniques to better carry out studies in the field of health and sociology. as explained before, qualitative research is carried out in natural settings, which requires researchers to work in close collaboration with other members of the team and under direct supervision to discuss and resolve issues as they arise. therefore, development of practical strategies and communicating them to researchers can be of great benefit and assist them in conducting more perceptive qualitative studies. it is noteworthy that such research should be directed towards making a difference in people’s lives, improving care delivery in different settings and at all levels, and providing a framework for health sciences without any ethical disturbances. as a result of the extensive body of research in the field of medical sciences, patients comprise a large proportion of the public who are frequently subjects of studies. research ethics committees are formed to provide independent advice to participants, researchers, funders/sponsors and healthcare organizations on the extent to which research proposals comply with universally endorsed ethical standards. in the history of social and medical science, there have been a few research studies that seriously injured people, and many more in which their welfare was not sufficiently protected. nations and research associations have taken steps to prevent hurtful and intrusive research. to return to the matter of privacy, the researcher should not rely solely on the informant to identify possible intrusion, but needs to work at anticipating it in advance. confidentiality does not necessarily preclude intrusion, as anonymity by itself is not enough to protect a person’s privacy or prevent disclosure of personal issues. investigators should refrain from soliciting private information that is not closely related to the research question. considering the aforementioned challenges, it is recommended to conduct further research in order to provide meticulous and explicit ethical 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medical sciences. this work is licensed under a creative commons attribution-non commercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. original article abstract the quality of care crisis (qcc) is one of the most crucial crises the modern medicine is confronting, as the existential and psychological needs of patients have not been addressed and satisfied. several attempts have been made to find solutions for qcc, e.g., the marcum's recommendation to make physicians virtuous. most of the existing formulations for the qcc have regarded technology as one of the causes of this crisis and not part of its solution. although the authors agree with the role of technology in creating the crisis of care to some extent, in this article we try to present the crisis of care so that medical technology is an important part of its solution. for this purpose, we analyzed qcc from the philosophical perspectives of husserl and borgmann and put forward a novel proposal to take account of technology in qcc. in the first step, it is discussed that the role of technology in causing the crisis of care is due to the gap between the techno-scientific world and the life *corresponding author alireza monajemi address: 64th st., kurdistan highway, tehran, iran. tel: (+98) 21 88 04 68 91-93 email: monajemi@ihcs.ac.ir received: 20 feb 2022 accepted: 1 nov 2022 published: 28 dec 2022 citation to this article: babaii s, monajemi a. the neglected role of technology in quality of care crisis. j med ethics hist med. 2022; 15: 11. world of the patients. this formulation shows that the crisis-causing role of technology is not inherent. in the second step, it is tried to find a way to integrate technology into the solution to the crisis. in the proposed reframing, designing and applying technologies based on focal things and practices make it possible to develop technologies that are caring and are able to mitigate qcc. keywords: philosophy of medicine; medical technologies; the quality of care crisis; borgmann; lifeworld. the neglected role of technology in quality of care crisis 1. visiting fellow, university of tubingen, int. center for ethics in science and humanities izew. tubingen, germany. 2. associate professor, philosophy of science and technology department, institute for humanities and cultural studies (ihcs), tehran, iran. saeedeh babaii1, alireza monajemi2* the neglected role of technology in quality of care crisis j. med. ethics. hist. med. 2022 (dec); 15: 11. 2 introduction since the 19th century, technology has played a significant part in modern medicine. according to hofmann, "technology appears to have become a dominant paradigm in medicine by prescribing ways of detecting, identifying, and treating disease" (1). medical technologies have been integrated into the diagnosis, treatment, enhancement, palliation, and prevention of processes. because of technological and scientific development in medicine, the concept of clinical practice has been transformed. technologically mediated tests and images have become the main source of the physicians' judgment and decisionmaking. in addition, the introduction of new medical technologies, e.g., tele-care technologies, care robots, artificially intelligent diagnostic systems, etc., has altered the physicians', nurses', and families' tasks and responsibilities. therefore, the importance of technology in the practice of modern medicine is undeniable. one important role of technology is in the qualityof-care crisis (qcc). modern medicine is accused of not paying enough attention to all aspects of care for a patient and the existential and psychological needs of patients are not satisfied (2). technology has become an obstacle to patient/physician, patient/family, and physician/family relationships. patients do not receive sufficient care in terms of both manner and motivation in the hospital or at home, which has confronted modern medicine with a serious problem called care crisis. therefore, the crisis in the quality of care has been formulated in such a way that technology has been considered as one of the causative factors. medical technology has increased our knowledge of the human body more accurately. consequently, the concept of illness has reduced to malfunctioning of biological and biochemical processes in the body resulting in the dehumanization of medical practice. therefore, the patient's existential/subjective experience is not a crucial part of the physician's decision-making process (1). these technological interventions have resulted in a gap between patients and physicians and given the latter unrestricted power and authority causing existential caring problems for the patient. however, is the role of technology all bad and negative? does it mean that we have to discard medical technology in order to overcome qcc? can qcc not be formulated in another way? in the current formulation, is attention not paid to diagnostic technology resulting in overlooking babaii s., et al. 3 j. med. ethics. hist. med. 2022 (dec); 15:11. other medical technologies? how can we understand qcc in a way that technology can be part of the solution? in part three, we problematized the role of technology in qcc and scrutinized the transformation technology has caused in medical practice resulting in qcc. we argued that these changes were not the mere side effects of improper utilization of technology. however, the use of medical technologies has drastically contributed to the reconstruction of clinical relationships and our understanding of disease and patient. accordingly, additive and supplementary solutions would not be able to resolve the crisis. by reducing human interactions, technology has played a central part in disturbing the caring practice. the last part of the paper is devoted to reframing qcc according to the borgmann's theoretical framework where technology-based approaches are suggested to overcome this crisis. the quality of care crisis 1. care human beings are all vulnerable and dependent on one another demanding compassion and empathy (3). caring should be provided in accordance with a particular situation where the caregiver should participate in the feelings of the care-receiver and put him/herself in his/her place to observe the context from different angles (4). to care for people, one should know their needs and receive them on their own terms (5). performing care creates a close relationship between the caregiver and care-receiver in which the former is not entitled to dominate the latter and diminish his/her freedom. a caring relationship is based on integrity and respecting each other's dignity. 2. aspects of care in general, two main aspects can be recognized in a caring practice: motivational aspect: as for motivation, "the word caring can refer to being fond of someone, feeling sympathy or empathy for them, being concerned for their well-being, or having a professional commitment to seeing to their needs" (6, 7). the caregiver should understand and care about the care-receiver and his/her bodily and existential needs. the genuine feelings of empathy, compassion, support, and concern act as the motivational grounds for implementing behavioral care skills. behavioral aspect: the behavioral aspect of care requires physical and psychological abilities to express motivational care and perform practical and mechanical activities safely and efficiently to meet the care-receiver's needs (8). although one the neglected role of technology in quality of care crisis j. med. ethics. hist. med. 2022 (dec); 15: 11. 4 may genuinely care about others, it does not mean that they have the competency to perform tasks required to take care of them. in order to be a competent caregiver in medical practice, one should have particular skills such as the specialized knowledge and the ability to put that knowledge into practice, the ability to evaluate and learn from medical practice, the ability to manage the information and handle ambiguities to make sensible and moral judgments and decisions, the emotional intelligence to create a relationship, and the responsibility to carry out duties (9-11). 3. care in medicine two aspects of care mentioned above are complementary to each other. to reach the goal of medical practice, i.e., "healing and amelioration of suffering due to disease and relieve such suffering” (12) both aspects are required. as pellegrino maintains, healthcare professionals should meet patients' needs through a caring relationship. the caregiver should understand the meaning of illness for the patient and take into account her special situation and lived experience in order to satisfy the patient's existential and physical needs simultaneously. therefore, care has a fundamental strategic, not just a decorative, importance in the healthcare practice. at least, two issues could be put forward to take the quality of care in medical practice more seriously: ethical issues and epistemic issues. 3.1. ethical issues caring is not a one-way path. the caring relationship has a growing nature because first, it provides the care-receiver with a meaningful activity in his/her life and second, it helps the caregiver and care-receiver to realize their potentialities and experience fulfillment in their lives (5). the more empathic abilities the caregiver acquires, the more moral his/her behaviors and actions could be. according to peabody, trying to grasp what the disease means for the patient and his/her experience of illness shows the physician's interest in humanity (13). 3.2. epistemic issues observing an issue from different perspectives offers epistemic comprehensiveness to make better judgments. for example, a physician's knowledge of a patient may alter through a caring relationship that will prominently influence the process of diagnosis and treatment. one crucial element of this comprehensive clinical picture is to become familiar with the patient's life-world, e.g., -his/her home, work, relationships, friends, joys and sorrows, and hopes and fears(13). depending on merely one method for diagnosis and treatment of a disease, whether it is through babaii s., et al. 5 j. med. ethics. hist. med. 2022 (dec); 15:11. medical technologies, listening to the patient's narrative, relying on biomedical knowledge, having a conversation, observing, or empathizing with them, would not be sufficient. these various methods complement one another in forming a comprehensive “clinical picture” of the patient (13) and should therefore be implemented to make the most accurate decision about the patient. 4. qcc in medicine modern medicine has been incapable of showing sufficient care and concern about patients and their needs, both motivationally and behaviorally (2). in medical practice, the patient is usually not treated as a person suffering from an illness or a "lived body", but as a "biological organism" (14) or "a malfunctioning machine whose defective parts could be technologically replaced or repaired" (15). flexibility, creativity, questioning, and genuine listening are not appreciated enough in the clinical context (16). marcum discusses three levels of indifference to patients by medical professionals that motivate instrumental behavior towards patients: 1. inattentiveness to the patient's needs, 2. insensitivity to the patients' needs and feelings, and 3. acting mechanically and inhumanly regardless of the patients' suffering and his/her physical and existential needs (2). review of the role of technology in medicine recent trends in digital technologies have led to a proliferation of studies focusing on the ethical implications of these technologies in healthcare practice. in this regard, three distinct approaches towards the role of medical technology in clinical practice can be distinguished, including 1. optimistic approach: the achievements of medical technologies have exceedingly risen up expectations and hopes. for instance, eric topol in his book entitled “deep medicine” discusses how artificial intelligence systems have, to some extent, liberated clinicians by taking over multiple tasks, i.e. taking notes and facilitating diagnosis and treatment and provided them with new opportunities to interact with patients (17). 2. pessimistic approach: another group of scholars believes that technology has undermined the relationship between physicians and patients. in his book “digital doctor”, robert wachter warns clinicians about dehumanization due to the overcomputerization of the medical practice and calls computers and medicine "awkward companions" (18). kwiatkowski believes that theoretical science and technologization of medical practice have devalued the fundamentally important direct relationship between the physician and patient (19). the neglected role of technology in quality of care crisis j. med. ethics. hist. med. 2022 (dec); 15: 11. 6 3. neglecting approach: despite the pivotal role technology plays in modern medicine, some experts fail to acknowledge it in their reflections. for example, james marcum (2) provides a relatively comprehensive formulation of the quality-of-care crisis; however, when it comes to solving qcc, he is settled for making physicians virtuous to be able to perform motivational and behavioral care. in marcum's sense, a virtuous physician possesses both ethical and epistemic (and intellectual) virtues that allow him/her to provide good quality care. although marcum's solution may alleviate qcc partially, his negligence of other factors contributing to qcc makes his solution supplementary. the marcum's suggestion fails to address numerous obstacles including, but not limited to, the unreasonable proportion of the number of patients to the number of clinicians, which makes it difficult for them to care for patients in a holistic sense, the vast sociotechnical healthcare systems (consisting of patients, hospitals, technical artifacts, economic stakeholders, policymakers, etc.) with different human and non-human characteristics affecting medical care practice. discussion the caregivers' limited human capacities, e.g., time, energy, memory, etc. in the following section, the fundamental but relatively neglected role of technology in giving rise to qcc is discussed. critiques of technology in medicine perceiving a patient as a mere biological organism that only needs technical care has been embedded in the design of current medical technologies. nevertheless, changing this perception of human beings and consequently of caring about them will improve the design of medical technologies that are more sensitive to other aspects of care. this section will elaborate some of the consequences of using medical technologies as some of the reasons for qcc: 1. detachment from subjectivity before the dramatic use of medical technologies, doctors in their medical practice would mainly listen to the narrative of the suffering person's embodied complaints and subjective experience. nowadays, the patient's narrative is not regarded as an essential part of the healthcare practice (20). physicians rely highly on the data collected from technologically mediated tests and images. the patient's subjective experience of illness is babaii s., et al. 7 j. med. ethics. hist. med. 2022 (dec); 15:11. translated into malfunctioning of the physiological functions of the body (21). the individuality and unique first person perspective of the patient is substituted by the third person perspective of the objective data of the body parts produced by medical technologies (22). overlooking the meaning of illness for the patient and his/her existential needs leads to a distance between the patient and the physician (23). the patient is considered as an object abstracted from his/her life-world and individual narrative (1), whereas treating the body as a biological object (körper) is deficient without taking into account the body as a way of being-in-the-world (leib) (24). the individual and emotional needs are not addressed satisfactorily because of the overemphasis on objective medical knowledge based on healthcare technologies (25-27). 2. underrating empathy the distance between the patient and caregiver created by technology makes it difficult for them to shape an empathic, existential, and dialogical relationship, while empathy is a way of understanding the other person (28), a cognitive source for comprehending foreign subjects and their experience, and a motivation to care for them. as a form of emotional reasoning (29), empathy can help the doctor to address the reasons for the patient's suffering and make a more accurate diagnosis and clinical judgment. caring involves having concerns about someone that could be stimulated by an empathic relationship. consequently, being a good caregiver requires the ability to empathize with patients (28), since it provides one with the motivation to care for and engage with them (29). 3. ignorance of illness the expansion of medical knowledge due to technological advances has brought overconfidence for modern medicine; hence, technology is part of the existing problem (30). however, this knowledge suffers from inadequacy for the diagnosis and treatment of various illnesses. instead of focusing on the person's illness and discomfort, physicians look for some diseases in their physical body, and if no disease could be detected, the suffering person does not need care and treatment services and is consequently ignored by the medical institution (1). the qcc challenges the omniscience of technological medicine and illustrates its epistemic limitations that render medicine incompetent to tackle the situations it has no solution for, e.g., cases like chronic diseases, disabilities, and caring for elderlies that are not treatable and demand permanent care. the neglected role of technology in quality of care crisis j. med. ethics. hist. med. 2022 (dec); 15: 11. 8 4. hospitalization technology has enabled medicine to treat formerly non-medical aspects of human life like pregnancy, anxiety, depression, etc. as controllable conditions requiring medical intervention while they were formerly considered as socio-behavioral phenomena. this transformation is described as medicalization, which is induced by technologies, including biotechnologies, information technologies, pharmaceutical, marketing, advertisement industries, health insurance and managed care complexes (31). considering the fact that implementing medical technologies requires professional skills by clinicians, home care was replaced by hospitals. as a result of hospitalizing patients, they are separated from their families and support groups who have the highest motivation to care for them. hospitalization results in losing this part of care, while it cannot be replaced by the clinicians in virtue of the constraints in resources and human capacities to provide high-quality care. in hospitals, in order to enhance productivity and economic profit, high-tech machines, which are not highly dependent on human intervention, have become gradually important in patient care. for instance, monitors are used to check the patients' conditions whereas the nurses, who are supposed to show compassion and care for patients, have turned into operators for these machines responsible for observing the machines' data. if hospitalization is correspondent to the automatization of medical practice, the qcc is inevitable in view of the fact that human interactions, which are indispensable for motivational care, decline as a side effect of hospitalization. 5. problem of triage technology has transformed the meaning of normality and turned numerous biomedical conditions into diseases demanding therapeutic interventions (32). overdiagnosis may occur when healthy people who attend screening programs or receive tests during check-ups are diagnosed and treated for the early form of a disease that may never seriously harm them (33). overdiagnosis increases the number of "diseased people" who need unnecessary clinical services. on the one hand, the world's older population is growing dramatically and we are facing the shortage of younger healthcare personnel that are qualified to offer high-quality care. on the other hand, drug resources are not limitless, thus we ought to manage these resources. clinicians are obliged to consider not only the wellbeing of an individual patient, but also the economic and management aspects of their practice to realize fair distribution of resources among babaii s., et al. 9 j. med. ethics. hist. med. 2022 (dec); 15:11. possible patients (19, 34). in the absence of appropriate clinical management, some people who are in need of medical support may not benefit from the care services provided by the medical institution. the term "problem of triage" describes this situation (20, 35, 36). technology, through facilitating overdiagnosis, has speeded up the lack of human and non-human resources required for high-quality care. in addition, as a result of the economic and management calculations, patients might feel to have been left alone with their problems (19). reframing quality of care crisis so far, we tried to explore the various ways technology has given rise to qcc. however, we believe that these problems are the consequences of a more fundamental distorted approach towards designing and using technology. if we rethink and change the current approach, the above-mentioned contingent character of technology would turn into one that mitigates qcc. in this part, qcc is reframed from the perspective of philosophy of science and technology. by putting forward a twolevel argument based on the insights of philosophy of technology, a theoretical framework is provided for a new approach in designing healthcare technologies that could contribute to alleviating qcc: level 1: gap between life-world and world of science 1.1. scientific experience vs. lived experience in general, we can distinguish two forms of experience: scientific experience (erfahrung); and lived experience (erlebnis) (26). a scientific experience is one that is achieved in the domain of natural sciences and constitutes the basis of scientific knowledge. this type of experience is replicable, testable, and justifiable. one should eliminate historical and cultural aspects of an experience in order to make it objective enough to become repeatable in similar situations by anyone. yet, one may go through certain firsthand prescientific experiences that are new and unexpected. this type of experience implies that there was something in a situation that one had no discernment about. however, after facing this experience, they came to a richer understanding. nevertheless, in the scientific world, this form of experience is not taken into account. hence, one can make a distinction between two worlds: the world of science in which scientific experiences are important; and the life-world of lay people in which lived experiences are of value. the huge gap between these two worlds has given rise to the crisis of sciences (38). considerable shares of the achievements of natural sciences have not the neglected role of technology in quality of care crisis j. med. ethics. hist. med. 2022 (dec); 15: 11. 10 been implemented properly in the life-world of lay people; as a result, the communication between lay people and experts is disrupted. this is while science is the product of formulating the elements of life-world and should be eventually applied to that world and leave an impact on it. 1.2. two types of experiences in medicine in medicine, there is an obvious distinction between these two forms of experiences. medicine as a practice is intertwined with human beings and its success and functionality are evaluated by people according to the changes it would bring into their quality of life. the effectiveness of the medicine's scientific world is assessed, to some extent, by its impact on the patients' life-world. therefore, the quality of the relationship between the medicine's scientific world and the patients' life-world in the medical practice is crucially important. in medical practice, we may reduce the patients' narrative of their lived experience to abstract objective concepts and neglect their individuality and suffering. rather, we focus on the similarities between different patients' pains and symptoms. by drawing out the similarities between these experiences to develop scientific theories, the subjectivity of the lived experiences will become superfluous with no function in medical practice, which contributes to creating a gap between the medicine's scientific world and the patient's lifeworld. habermas formulates this by making a contrast between communicative rationality and instrumental rationality. while the instrumental rationality dominates the scientific world of medicine, abstracts it from public sphere, and 'colonizes the life-world' (39), the communicative understanding of the life-world of lay people is ignored in medical practice (40). 1.3. the birth of a crisis in our view, the disrupted relationship between the medical practice and the patient's life-world has resulted in the quality-of-care crisis. to solve this crisis, medicine should find its proper place in the patients' life-world and welcome their feedback in order to reach its goals, which is to decrease the patients' suffering and to care for them (12, 16). suffering is a subjective experience for the patient that is affected by the context of the patient's lifeworld and hid/her beliefs, perception of the disease, and the cultural, economic, and personal situation. however, in the scientific world of medicine, this context-dependency of suffering and the patient's phenomenological perception of illness are of no epistemological and ethical values. the mediation of technologies in some particular ways has caused over-authority of the medical babaii s., et al. 11 j. med. ethics. hist. med. 2022 (dec); 15:11. professionals to the extent that they feel no need for the patient's subjective narrative for diagnosis and treatment. however, the physician is not able to produce health only by using his/her scientific and technical skills and has to re-understand health based on the patient’s life-world. health is a way of being-in-the-world and being together with other people (41). care is a practice that supports the active engagement of the patient with his/her lifeworld, especially in chronic cases. the technical perception of care has resulted in designing technologies that focus on the technical and scientific aspects of the disease and the value of existential care is not embedded in most of the medical technologies. however, the mediation of technology in medical practice would not inevitably reduce the richness of this practice and caring relations. if technologies are designed in a way that they are more respectful to the value of care and be used for the right tasks, they can increase the quality of care and strengthen the care practice. therefore, technology could bridge the gap between the scientific world (of medicine) and the life-world (of the patient). but how technology can contribute to alleviating qcc instead of causing this crisis? in the following part, we present the second level of our argument as we believe that the concept of "focal things and practices" developed by albert borgmann is the key to answer this question. level 2: technology in focal practice 2.1. device paradigm replacing focality borgmann calls the modern age the age of device paradigm, which is characterized by a decrease in the engagement of human beings with nature and with each other (42). a device is described as an object detached from its world and context that has lost its meaning. on the contrary, a focal thing is attached to its context, which gives meaning to every part of the practice. focal things are engaged bodily and socially with the world, which would result in forming focal practices around them (42). in our view, a focal caring technology could be defined as a technology that consolidates the patient's engagement with his/her world and with others. because health is a way of being in the world together with other people and to reach health and healing, these engagements are inevitable. accordingly, we believe that a good technology is integrated with its context, can revive a focal practice, and helps it to propagate. considering the characteristics borgmann attributes to a focal practice, we claim that caring can be considered as a focal practice since it acquires all these characteristics: there is a relationship (engagement) the neglected role of technology in quality of care crisis j. med. ethics. hist. med. 2022 (dec); 15: 11. 12 between the caregiver and the care-receiver in a caring practice that contributes to their ethical growth and gives meaning to their lives. a focal practice is an integrated practice in which hardship and joy are merged, means and ends are intertwined, and the mind and the body are both engaged in performing the practice. in addition, in a focal practice, one can experience an engagement with the social environment (42). 2.2. technological emancipation borgmann believes that technology has disturbed focal practices in the device paradigm and has consequently raised several crises. because of violating the caring relationships, medical technologies are accused of giving rise to care crisis. however, if technology is installed properly in the heart of a focal practice, it can form and strengthen care and is therefore not regarded as a threat anymore. it can be argued that by integrating technology in a focal practice, it can contribute to shaping an effective relationship between the caregiver and care-receiver and play a major role in satisfying various needs of the care-receiver. such a technology does not disturb the caring practice by being an obstacle to caring relationships, preventing human beings from a dialogical empathic relationship, and ignoring the social environment. illness was formerly treated as a focal thing with a centering force to create a set of relations and focal practices to care for the patient. however, technology has disturbed these practices in many ways (like hospitalization, imaging and testing technologies, etc.). with hospitalization, patients are separated from their life-world and lose their families’ and friends' care while the role of family care is extremely important in some groups, for instance chronic patients, elderlies, and disabled people who need long term care. nonetheless, in modern medicine, these patients either are hospitalized or separated from their life-world or remain in their life-world at the cost of more suffering and becoming a burden to their families. thus, they go through feelings of being overwhelmed, over-dependent, and disrespected, and their autonomy and dignity is undermined. therefore, a caring technology should strengthen the humane interactions between caregivers and care-receivers in every possible way. 2.3. technology may overcome caring obstacles one of the main obstacles for professional caregivers to offer high-quality care is the lack of time. to mitigate this problem, we can assign technologies the tasks that do not call for human skills. by doing so, technology can offer extra time to caregivers to focus on social interactions with babaii s., et al. 13 j. med. ethics. hist. med. 2022 (dec); 15:11. care-receivers and make a deeper and more personalized relationship with them (17). in addition, technology may be helpful in tasks where human caregivers have bodily limitations and are fatigued to the extent that are not able to interact existentially with patients. these contributions of the technology to the care practice could provide human caregivers with the opportunity to focus on their humane skills such as empathy, creativity, compassion, intuition, understanding, etc. to offer further existential care. moreover, technology itself could be a platform in which human interactions are improved. online forums, tele-care technologies, etc. are some examples of "technology as focal thing" that facilitate the interaction between caregivers and care-receivers. they can also distribute the caring tasks between more agents by propagating and diversifying the care practices and simplifying the process of participation in them. therefore, they might mitigate the over-authority of physicians over patients and prevent them from misusing their unrestricted power. as a result, they provide patients with self-liberation by allocating parts of the caring tasks and responsibilities to other caregivers (the patients themselves, telecare workers, new friends with similar diseases, etc.) in the caring networks. however, it is necessary to improve the design of caring technologies in such a way to embed the value of care and its different aspects more prominently and prompt caring behaviors in people engaged in caring practices. we should think of innovations that translate the value of care in different contexts and help the caregivers and care-receivers to communicate more effectively. conclusion the present study was designed to: 1) critically reflect on the impacts of medical technologies on the healthcare practice and explore their role in raising care crisis and, 2) reframe the care crisis based on the borgmann's theoretical framework in order to open a new path to propose solutions for this crisis with the help of technology. the research indicated that most of the current medical technologies have violated the caring relationships between care-givers and patients and have distanced them. the resulting distance between these two parties has resulted in unmet existential and psychological needs of the patients. to find a holistic solution to this crisis, one should take into account the role of technology in this game. this paper sought to develop a new perspective to qcc and present a new philosophical ground for designing new caring technologies. the proposed the neglected role of technology in quality of care crisis j. med. ethics. hist. med. 2022 (dec); 15: 11. 14 reframing of qcc provides an insight for designing a new set of medical technologies, namely caring technologies, that are either caring focal things or integrated in a caring focal practice. it is recommended that further research be undertaken regarding the different concrete caring practices and various caring tasks that should be accomplished in order to determine which tasks could be carried out by caring technologies and what is the proper place of a caring technology in a specific caring practice. the most prominent innovation of this article is that it provides a theoretical framework based on which technology can be considered part of the solution to qcc. this achievement is very important as technology is considered a factor of crisis or has been completely ignored in the existing formulations. funding the study was not funded. conflict of interests the authors report there are no competing interests to declare. references 1. hofmann b. 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"new social movements in the health domain," in habermas, critical theory and health, routledge, 2001; pp. 119-142. 41. gadamer, h. g. the enigma of health. j. gaiger and n. walker (trans.), stanford, ct: stanford university press; 1996. 42. borgmann, a. technology and the character of contemporary life_ a philosophical inquiry, chicago: the university of chicago press; 1984. ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ original article copyright © 2021 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. journal of m edical ethics and h istory of m edicine initial drafting of telemedicine’s code of ethics through a stakeholders’ participatory process *corresponding author rita mojtahedzadeh address: no. 2, dlatshahi alley, naderi st., keshavarz blvd., tehran, iran. postal code: 1416614741 tel: (+98) 21 42 03 60 00 email: r_mojtahedzadeh@tums.ac.ir received: 1 jun 2021 accepted: 21 oct 2021 published: 9 dec 2021 citation to this article: shafizadeh h, larijani b, mojtahedzadeh r, ehsan shamsi gooshki e, nedjat s. initial drafting of telemedicine’s code of ethics through a stakeholders’ participatory process. j med ethics hist med. 2021; 14: 24. hamid shafizadeh1, bagher larijani2, rita mojtahedzadeh3*, ehsan shamsi gooshki4, saharnaz nedjat 5* 1.phd candidate of medical ethics, department of medical ethics, school of medicine, tehran university of medical sciences, tehran, iran. 2.professor, endocrinology and metabolism research center, endocrinology and metabolism clinical sciences institute, tehran university of medical sciences, tehran, iran. 3.associate professor, department of e-learning in medical education, center of excellence for e-learning in medical education, virtual school, tehran university of medical sciences, tehran, iran. 4.associate professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran; department of medical ethics, school of medicine, tehran university of medical sciences, tehran, iran. 5.professor, department of epidemiology and biostatistics, school of public health, tehran university of medical sciences, tehran, iran. abstract telemedicine can improve access to healthcare services; however, it has raised ethical concerns demanding special considerations. this study aimed at developing the codes of ethics for telemedicine, and hence several approved national and international ethical guidelines related to telemedicine practice were reviewed, and 48 semi-structured interviews were conducted with medical ethics and medical informatics experts as well as with physicians and patients who had telemedicine experiences. content analysis was then performed on the interviews’ transcripts and a draft on code of ethics was prepared, which was further reviewed by the experts in the focus group meetings to reach a consensus on the final document. the final document consisted of a preface, five considerations, and 25 ethical statements. considering the growing trend of adopting telemedicine worldwide, this document provides an ethical framework for those who use telemedicine in their medical practice. keywords: code of ethics; telemedicine; health services; iran. initial drafting of telemedicine’s code of ethics through a stakeholders’ participatory process 2 j med ethics hist med. 2021(december); 14:24. journal of m edical ethics and h istory of m edicine introduction facility of sharing personal and professional information has influenced health care provision and made telemedicine prevalent (1). telemedicine involves remote delivery of healthcare services, sharing related information through a variety of telecommunication technologies, facilitating synchronous or asynchronous communication, as well as data gathering and monitoring (2, 3). communication in telemedicine occurs between the patient and service provider for remote care delivery, or among service providers for consultation purposes (3, 4). telemedicine provides an opportunity to expand access to health services (1), especially in rural or deprived areas with a shortage of resources and specialists (2) or during covid -19 pandemic crisis limiting interpersonal faceto-face interactions (3). preferring telehealth services is not limited to homebound patients or rural residents, and patients with convenient access to face-to-face services may also prefer remote healthcare services (5), increasing as the public progressively adopts telecommunication technologies (1). moreover, widespread acceptance of telemedicine during covid-19 pandemic has resulted in its permanent integration into post-pandemic healthcare systems (3). observance of ethical standards in telemedicine has been considered by several national and international documents and biomedical ethicists. regardless of the service delivery media, healthcare providers and recipients should adhere to loyal communication and respect professional values (6). ethical concerns in telemedicine included the following subjects: patient autonomy (7, 8), obtaining informed consent (8, 9), physician-patient relationship (1, 7, 8), patient privacy and confidentiality (1, 7, 9, 10), identity issues (1), prudence of telecare (7-10), beneficence, monitoring and coordinating the treatment, one-size-fits-all service provision (1, 10), as well as documentation and data storage (7). several guidelines or codes of ethics have been developed to address these concerns (4, 10, 11). one such guideline is the world medical association (wma) “statement on telemedicine ethics”, developed as an international reference point. however, wma still recommends the development of national ethical codes or guidelines considering the telemedicine practice’s international agreements (4). reviewing the existing international ethical charters and codes shows that despite common concepts, cultural differences should be considered in developing telemedicine’s code of ethics. hence, such documents for another context cannot be unchangeably adopted, and contextual aspects and local stakeholders’ viewpoints must be included (2, 12). some national guidelines in iran provided general standards of medical ethics. the first version of the “patients’ rights charter” was ratified in 2001, and a more comprehensive version was notified and adopted by the ministry of health and medical education in 2009 (12). furthermore, the first "code of ethics for medical professionals” was approved by medical council of islamic republic of iran shafizadeh h., et al. 3 j med ethics hist med. 2021(december); 14: 24. journal of m edical ethics and h istory of m edicine in 2018 (13). general ethical and professional standards in these documents can be applied to telemedicine after customization; however, explicit national guidelines or specific ethical codes are not available, and hence this study aimed at developing the codes of ethics for telemedicine in iran. methods this study consisted of three main stages: (i) a non-systematic literature review, (ii) a qualitative study using semi-structured interviews, and (iii) a focus group discussion. pubmed, scopus and web of science databases were searched for relevant guidelines and ethical codes using search operators—boolean operators (and, or and not) —parenthesis, and truncation. the keywords as single terms or in combination with others were as follows: “telemedicine”, “tele-medicine”, “remote care”, “e-health”, “ethical codes”, “codes of ethics”, and “ethical guideline”. then, relevant guidelines or codes of ethics (4, 10, 11) were reviewed to develop interview questions. subsequently, interviews with telemedicine stakeholders were conducted, and content analysis on the interviews’ transcripts were performed to develop ethical considerations of telemedicine in iran. then, the preliminary draft of codes of ethics were prepared, which was further reviewed by the experts in the focus group meetings to reach a consensus on the final document. participants interviewees were purposively selected from four groups: (i) physicians with more than one-year telecare experience, (ii) medical ethics specialists, (iii) medical informatics specialists, and (iv) patients with at least one experience of receiving a formal telecare. interviews were continued until reaching data saturation in each of the abovementioned groups. finally, 10 medical ethics experts, 15 medical informatics experts, 15 physicians and 8 patients were interviewed. participants of the focus group sessions were 10 specialists in medical ethics or e-health as well as experienced physicians. semi-structured interviews after obtaining participants’ consent, semistructured face-to-face interviews were conducted, each lasting an average of 35 minutes. the predefined open-ended questions included the following items: “what is your understanding of telemedicine?”, “could you name benefits of telemedicine for the patient and society while focusing on the ethical aspects?”, “how can justice be respected in telemedicine?”, “could you name harmful aspects or disadvantages of telemedicine for the patient and society?”, “what do you think about the physician-patient communication in telecare regarding issues such as authentication, mutual trust and appropriateness of the tele-service?”, “what are the ethical challenges in telemedicine?”, and “ how is the information confidentiality maintained in telemedicine?” if necessary, the interviewees were asked more detailed initial drafting of telemedicine’s code of ethics through a stakeholders’ participatory process 4 j med ethics hist med. 2021(december); 14:24. journal of m edical ethics and h istory of m edicine questions to clarify, and interviews were audio recorded and transcribed verbatim. content analysis of interviews’ transcripts the graneheim and lundman’s method of qualitative content analysis was adopted to interpret the interviews (14). after repeatedly reading the transcripts to immerse in the data, the researchers followed the steps of defining the transcripts’ meaning units, open coding, grouping, categorizing, and abstracting of the transcripts (15). this process was reviewed to remove redundancies, and finally extract the main subcategories, categories and themes with appropriate headings describing the related content. the process was performed by two researchers to ensure inter coder credibility. the trustworthiness of the results was evaluated through credibility, transferability, dependability, and confirmability criteria (16-18). moreover, the interviewers built rapport with the interviewees. thick and contextualized description was employed to ensure transferability. dependability and confirmability were pursued through providing audit trail for coding records and coders try to set aside their assumptions. proposed codes of ethics for telemedicine a preliminary draft of codes based on the outcomes of the previous steps including literature review—especially wma statement on the ethics of telemedicine (4) — the upstream documents—namely the “patients' rights charter” of iran (12) — the “general guide to professional ethics for medical sciences staff” (13), and the qualitative study. to review the draft carefully to finalize, three, two-hour focus group sessions were held where each code was reviewed and participants expressed their views on the amendments or revisions; this process continued until participants reached a consensus. finally, the draft was reviewed by three experts in the field, in addition to the participants involved in the previous stages, to confirm its alliance with the results of content analysis and upstream documents. ethical considerations this study was approved by the ethics committee of tehran university of medical sciences (approval no. ir.tums.medicine.rec.1396.4329). the researchers elaborated the purpose of the study to the interviewees and in the focused group sessions, guaranteed the confidentiality of their information, and obtained their verbal informed consent. participants could withdraw at any time. result the demographic data of the study participants were presented in table 1. table 1interviewees’ characteristics group sex number of subject medical ethics specialists female 2 male 8 medical informatics specialists female 7 male 7 physicians female 4 male 9 patients female 3 male 8 after the content analysis of 48 interviews’ transcripts, 134 codes were extracted, which were further classified into two themes, shafizadeh h., et al. 5 j med ethics hist med. 2021(december); 14: 24. journal of m edical ethics and h istory of m edicine seven categories and 31 subcategories (table 2). the two themes included telemedicine’s positive and negative aspects from ethical perspective. categories’ descriptions and participants’ statements are as follows: table 2themes, categories and subcategories of ethical concerns in telemedicine themes categories subcategories p ositive aspects of telem edicine from ethical perspective increased autonomy and respect for dignity easier access to services more choices for provision or service usage more awareness more convenience in provision or service usage more effectiveness cost reduction time-saving quick access to patients’ records likelihood of 24-hour patient management increased likelihood of documenting provided services increased likelihood of reducing medical errors through technology’s enhanced features (e.g. artificial intelligence and medical sensors) increasing equity increased access increased service provision to deprived and remote areas increased service provision to individuals with disabilities increased provision of specialists’ services decreased administrative corruption n egative aspects of telem edicine from ethical perspective impact of disturbance or insufficiency in service provision on patient management increased likelihood of medical errors as a result of telecare tools’ limitations and malfunctions more difficulties in diagnosis as a result of low quality images and digital documents more difficulties in diagnosis due to inability to perform palpation physical exams increased stress due to unfamiliarity with telemedicine for physicians and patients the need to adapt to the new method of doctor-patient communication for both parties increased likelihood of medical information disclosure likelihood of hacking the transferred data likelihood of software tools’ low security likelihood of misusing the large amount of data increased likelihood of secret disclosure due to large number of staff involved in a telecare service increased likelihood of impersonation and deception increased likelihood of malingering ambiguity in an avatar’s identity increased likelihood of deception increased likelihood of being exposed to misleading advertisement ambiguities in legal and official status of telemedicine service provision ambiguity in medical errors’ compensation ambiguity in physicians’ payments ambiguity in determining the responsible body for medical errors theme 1: positive aspects of telemedicine from ethical perspective increased autonomy and respect for dignity: according to the interviewees, a greater variety of services can be accessible remotely to both service providers and recipients, and access to internet and feasibility to provide valid information increase recipients’ awareness. an initial drafting of telemedicine’s code of ethics through a stakeholders’ participatory process 6 j med ethics hist med. 2021(december); 14:24. journal of m edical ethics and h istory of m edicine interviewee said: “this wide range of teleservices brings autonomy and respects human dignity. when you are at home or office, you can easily access the services.” [participant no.6] more effectiveness: participants believed that telemedicine can reduce costs and save time, as well as can provide quick access to patients’ records and 24-hour patient management. a participant said: “telemedicine seems to reduce service latency and bring places closer together. provided telemedicine services can be easily documented with the use of technology. in addition, medical errors may occur less if advanced technologies, such as artificial intelligence and medical sensors, are used properly “. [participant no.22] another participant said: “technologies such as artificial intelligence can help resolve some telecare issues leading to malpractice. medical sensors are great, and help a lot in this regard.” [participant no.18] increasing equity: telemedicine increases access to healthcare services for all, including residents of deprived areas and patients with disabilities. in the absence of specialists, telemedicine is a sensible solution to provide a wide range of services. in addition, due to telemedicine’s convenient documentation and clarity of the process, less administrative corruption may occur compared to face-to-face systems. a participant stated: “less administrative corruption in telecare is beneficial for both people and government and guarantees justice.” [participant no.37] theme 2: negative aspects of telemedicine from ethical perspective impact of disturbance or insufficiency in service provision on patient management: telemedicine relies on technological tools that may not always be the most advanced ones, and technological tools may be exposed to malfunction or shortcomings. low quality images and digital files as well as lack of palpation physical exam may negatively affect diagnosis and treatment process, which may lead to medical errors. furthermore, physicians and patients may be more stressed during telemedicine services, especially when they have not already become familiar with this service type. a participant said: “technical problems can disrupt telecare services due to causing stress in both parties and affecting the care quality”. [participant no.8] furthermore, a participant, with telemedicine experience, said: “high levels of stress in patients may result in incorrect or inaccurate symptoms”. [participant no.18] the need to adapt to the new method of physician-patient communication for both parties may be another reason for the failure or insufficiency in services. increased likelihood of medical information disclosure: software tools may have low security and be prone to hacking, and hence extensive data collected from patient records may be misused in telemedicine. as more staff are involved in telemedicine process, such risks may increase. an interviewee said: “big data that is transferred during healthcare service should be protected shafizadeh h., et al. 7 j med ethics hist med. 2021(december); 14: 24. journal of m edical ethics and h istory of m edicine carefully. there are serious concerns regarding maintaining security of patients’ information.” [participant no.14] increased likelihood of impersonation and deception: hiding the real identity and using misguiding avatars can occur on internet virtual spaces, and hence malingering and deception are among unethical behaviors that should be prohibited in telecare. a participant said, “impersonation is more likely to occur in telecommunication, but safe systems can minimize the risks”. [participant no.32] misleading advertisement for delivering or receiving services is another concern in telemedicine. a participant addressed this issue: “telemedicine providers should have a well-defined process for evaluating the advertisements published on their systems because patients trust them as much as they trust the board of a clinic”. [participant no.4] ambiguities in legal and official status of telemedicine service provision: ambiguity in compensation of medical errors, physicians’ payments and determining the responsible body for medical errors fall into this category. a participant said: “insurance agencies and legal bodies haven’t developed appropriate frameworks for telemedicine. no defined regulation supports this emerging type of service”. [participant no.20] preliminary draft of codes of ethics for telemedicine the preliminary draft included a preface and 34 statements. four codes were merged into other statements and five codes were labeled as considerations in the focus group sessions. finally, the team agreed on a version included a preface, five ethical concerns and 25 ethical codes’ statement (table 3). table 3the codes of ethics for telemedicine in iran preface advances in computer sciences and communication technologies have affected all aspects of human life. moreover, ongoing progress of the biomedical sciences has introduced interdisciplinary disciplines such as telemedicine. providing telemedicine services requires compliance with well-defined guidelines including ethical guidelines. initial draft for telemedicine’s codes of ethics was prepared based the experts’ consensus and the upstream documents, namely the charter of patients' rights in iran and the general code of ethics for medical professionals. in compiling the codes, the following principles of professional medical ethics were considered: justice in healthcare, health services recipients’ right to choose service type, honesty and integrity, maintaining confidentiality and respect for privacy, patient safety, prioritizing the interests of health service recipients, respect for colleagues’ rights, and necessity of providing standard services. concerns 1 telemedicine providers must consider general ethical concerns surrounding the physician-patient relationship, which are not necessarily specific to telemedicine. 2 communication tools increase the interactions between service providers and service recipients; hence, these tools should be used appropriately to protect the clients’ rights as well as respect and improve community’s health and safety. 3 when necessary, the presence of health care providers at the patient's bedside is primarily preferred. 4 telemedicine dose not substitute in-person services; it can improve service quality and complement in-person services. 5 telemedicine services can be widely delivered, even with minimum equipment, namely phones or social initial drafting of telemedicine’s code of ethics through a stakeholders’ participatory process 8 j med ethics hist med. 2021(december); 14:24. journal of m edical ethics and h istory of m edicine media. this guideline aimed at systematizing these services and inspecting their ethical aspects. ethical codes 1 telemedicine service providers should be aware of the benefits and limitations of this technology-based practice. 2 telemedicine service providers should be aware of the relevant legal, technical, and ethical aspects. 3 telemedicine service providers should receive necessary licenses from the authorities. they should use licensed telemedicine tools if available, and avoid using unofficial and unlicensed tools to the possible extent. 4 in case of emergencies, when public communication tools are used as means of interaction, service providers should make every effort to save patient’s life. 5 when using informal and unlicensed environments and tools, telemedicine service providers should ensure clients' privacy, confidentiality, and safety. 6 telemedicine service providers should not collaborate with telemedicine platforms where unscientific and unprofessional medical advertising occurs. 7 telemedicine service providers should be aware of the ethnicity, culture and sensitivities of the clients receiving telemedicine services and pay attention to these considerations when providing services. 8 health care providers should choose the best service option according to the customer's circumstances. providing services through telemedicine can be considered when it does not cause restrictions or problems for the clients; in case of limitations, telemedicine is the best possible choice considering the client's conditions. when in-person visit is feasible, the healthcare provider is responsible for not being at the patient's bedside on time. 9 telemedicine service providers should fully identify themselves, state their type of specialty and declare their affiliation (if there is any). 10 telemedicine service providers should ensure the identity of the clients. 11 telemedicine service providers should provide clients with the necessary information about the telemedicine process and ensure that customers have an appropriate understanding of it. 12 telemedicine service providers must obtain the informed consent of the service recipients, and document service details in accordance with the services provided. written consent is required if high-risk interventions are to be performed. 13 client’s voluntarily contacting with telemedicine’s service providers is considered informed client consent. 14 if telemedicine services are delivered by a team of providers, the primary care physician or supervisor should ensure that the colleagues have sufficient mastery of the telemedicine’s technical, legal, and ethical aspects. 15 telemedicine service providers should ensure that the service delivery process is documented. if the employed telemedicine tools do not record the client's necessary information and documents, they should record the relevant important items themselves to be accountable for future enquiries. 16 telemedicine service providers should carefully observe privacy and confidentiality in disseminating information on cyberspace and official and unofficial telemedicine tools, requiring obtaining clients' informed consent. furthermore, information related to clients’ identity should not be published without their informed consent. 17 telemedicine service providers should record images of the client's sensitive body parts only if necessary for providing appropriate services. in such circumstances, the minimum possible number of images should be recorded. the client (or companions only if the client is unaware) must be explicitly informed and express their consent. 18 telemedicine service providers are responsible for ensuring the accuracy of the educational content and information they provide on telemedicine tools and platforms. 19 telemedicine service providers should support the clients who cannot properly use telemedicine tools, and, if necessary, train them or their companions to use the tools. 20 telemedicine service providers should inform the clients or their companions about the method and timing of the subsequent communications or follow-ups to prevent the client from abandoning future services. 21 in both emergencies and non-emergencies, telemedicine service providers should arrange for the clients’ follow-up and visits and notify them. 22 if follow-up or in-person visits are required, telemedicine service providers should explicitly state the situation and warn the clients or their companions. 23 telemedicine service providers should report technical, security, and operational deficiencies of telemedicine tools and software to the relevant authorities (licensing or regulatory) and keep a written shafizadeh h., et al. 9 j med ethics hist med. 2021(december); 14: 24. journal of m edical ethics and h istory of m edicine record of the deficiencies for documentation. 24 in the event of a harm or medical error, telemedicine service providers have the same responsibility as in-person service providers. 25 telemedicine service providers have full responsibility for all interventions, recommendations, and consultations they provide in telemedicine, and this responsibility dose not differ from that of in-person service providers. discussion in this study, the ethical considerations of telemedicine in iran were studied from the related stakeholders’ perspectives, and a draft of codes of ethics through a participatory process was developed. content analysis of interviews with stakeholders resulted in two themes, namely positive aspects of telemedicine from ethical perspective (including increased autonomy and dignity, more effectiveness, and increasing equity), and negative aspects of telemedicine from ethical perspective (including impact of disturbance or insufficiency in service provision on patient management, increased likelihood of medical information disclosure, increased likelihood of impersonation and deception, and ambiguities in legal and official status of telemedicine service provision. the final draft of codes of ethics consisted of a preface, five ethical concerns and 25 ethical codes’ statement. a review on articles from 2012 to 2017 shows classification of the ethical issues in telemedicine into four categories: technology, physician-patient relationship, confidentiality and security, and informed consent (19). another study in 2020 identified ethical concerns of telemedicine by reviewing publications over a 25-year period, namely accessibility, effectiveness, continuity of care and training (20). telemedicine codes of ethics should address these concerns; hence the present study interpreted its outcomes based on the abovementioned categories. technology technical issues included the quality of digital files and security. physicians are accountable for the quality of provided care and should report technological malfunctions to the authorities (19), highlighted in this draft (code no. 23) (table 3). in addition, secured and approved tools or websites should be used for providing telecare (21), and hence, according to code no. 3, using official licensed tools are preferred in providing telecare to guarantee security and official issues (table 3). patient-physician relationship creating a respectful and trusting environment between physician and patient is important for deciding on appropriate care and treatment (19) using the following strategies: transparency in obtaining informed consent, clearly describing the telecare process to the patient, and elaborating the patient’s right to withdraw from telemedicine (20). the final draft’s code no. 9 and code no. 11 (table 3) covered the above-mentioned ethical issues. confidentiality, privacy and security initial drafting of telemedicine’s code of ethics through a stakeholders’ participatory process 10 j med ethics hist med. 2021(december); 14:24. journal of m edical ethics and h istory of m edicine patients are often concerned about the confidentiality of their information, especially in asynchronous tele-services (20, 22). therefore, both patients and staff should be trained to follow security protocols (23), and service providers should be aware of the security standards of the telemedicine tools (10, 19); in the final draft, concern no. 2 and codes no. 5, 16 and 17 cover confidentiality, privacy and security, respectively. furthermore, code no. 10 stated that providers must ensure patients’ personal identity (table 3) to prohibit malingering and deception. informed consent patients should be aware of the benefits and drawbacks of telemedicine, and such informed autonomy allows them to decide on the service type according to their personal values and therapeutic goals (8, 9). physicians must be transparent with patients and detail tele-service process before any medical intervention (4, 10, 19). in the final draft, codes no. 12 and 13 addressed obtaining informed consent (table 3). accessibility although telemedicine service providers are responsible for the fair distribution of resources (9), they cannot solve all access problems (e.g., patients’ internet access). additionally, they should undertake caring for patients who are unfamiliar with telemedicine and do not know how to work with telemedicine tools until they have sufficient familiarity and suitable access (20). code no. 19 of the final draft addressed this responsibility of service providers (table 3). effectiveness, beneficence and adaptability effectiveness, beneficence, and adaptability of the provided remote services, for the patients and society, are among telemedicine’ major challenges (9). if the patient is not the main beneficiary in receiving services, telemedicine is not the treatment of choice (20); for example, when physicians must perform hand-on physical examinations or other types of nonverbal communication must be employed (8, 10). although other solutions may be available (e.g., having a qualified physician colleague at the patient bedside) (22), physicians are responsible for professionally judging whether telemedicine or in-person visits is the best choice for a given patient (4, 10, 20). then, they should decide on the appropriate type of remote services for the patients considering clinical manifestations, facilities, needs, preferences, and other individual variations (1, 10). such decisionmakings become more challenging when providing telecare is needed in emergencies (21). moreover, physicians are required to ensure that adequate and appropriate documentation is provided, and if the employed telemedicine tools do not have the options for recording, physicians must record all details themselves (4). in the final draft, concerns no. 3 and 4, and codes no. 4, 5, 6, 15 and 22 cover the aforementioned requirements (table 3). continuity of care due to a relatively constant access to technology, patients may misguidedly think that they have permanent access to telecare providers, causing problems as such shafizadeh h., et al. 11 j med ethics hist med. 2021(december); 14: 24. journal of m edical ethics and h istory of m edicine permanent access is infeasible (21). moreover, physicians should not abandon the patients, should clarify the follow-up plan, and should share contact information with the patients (4, 10, 20). codes no. 20 and 21 in the final draft addressed continuity of care (table 3). training and being well-informed physicians should become updated with telemedicine techniques, associated research, limitations, and benefits, as well as related legal and ethical aspects (10, 21, 24). furthermore, supervisor physicians are responsible for ensuring that the service provider team is qualified to provide decent, ethical and safe services (24). the importance of training was covered in the final draft’s codes no. 1, 2 and 14 (table 3). moreover, patients should become familiar with the telemedicine process and technological tools. physicians’ duty to ensure the accuracy of the provided information and training were addressed in codes no. 6 and 18 of the final draft (table 3). responsibilities in case of medical errors the final draft included 5 concerns and 25 codes, and all were explained in the previous subsections except concern no.1, codes no.24, and code no.25. concern no. 1 addressed telecare providers’ responsibility to follow the general ethical guidelines, even if they were not specifically developed for remote communications (e.g., telemedicine), as highlighted in the wma statement for telemedicine (4). moreover, code no. 24 and code no. 25 emphasized the full responsibility of health service providers in case of medical errors or misguide, in line with in-person medical care that was supported by the interviewees’ opinions and related literature (20). study strengths and limitations consensus development methods, recommended in the literature (2,12), were employed in this study. this study had several limitations. telemedicine has not yet been widely used in iran; and, in many cases, tele-services are provided on non-official platforms (e.g., social networks), where maintaining high standard ethical rules is unmanageable. hence, this study aimed at developing the codes of ethics supporting real, and standard telemedicine practices; however, these codes should be gradually revised to adapt changes in telemedicine in iran. moreover, more patients with various types of tele-service experiences and more physicians with various specialties and diverse experiences of telecare practices should be interviewed. variety in interviewees' experiences can provide more accurate expression of ethical concerns. furthermore, ethical considerations in telemedicine are not the sole responsibility of service providers, and telemedicine needs coordination among different professions as well as active commitment of relevant organizations and appropriate training and support (23). conclusion given the importance of ethical concerns in telemedicine, ethical guidelines or codes should be developed to provide a framework initial drafting of telemedicine’s code of ethics through a stakeholders’ participatory process 12 j med ethics hist med. 2021(december); 14:24. journal of m edical ethics and h istory of m edicine for the practitioners. thus, this work aimed at developing codes of ethics for telemedicine through a stakeholders’ participatory process. cultural and contextual differences should be considered in drafting code of ethics. the drafted code of ethics can be fulfilled by individual service providers. this draft needs to undergo the legitimization process to be nationally approved as a reference. acknowledgements the authors would like to thank the participants of the interviews and focus group sessions. conflicts of interests the authors declare that they have no conflict of interests. references 1. mehta sj. telemedicine’s potential ethical pitfalls. virtual mentor. 2014; 16(12): 1014-7. 2. jack c, mars m. telemedicine a need for ethical and legal guidelines in south africa. south african family practice. 2008; 50(2): 60-60d. 3. melvin mc, grant jr, marissa gs. telemedicine in orthopaedic surgery: challenges and opportunities. j bone joint surg am. 2020; 102(13): 1109-15. 4. anonymous, world medical association (wma) statement on the ethics of telemedicine. [cited dec 2021]; available from: https://www.wma.net/policies-post/wma-statement-on-the-ethics-oftelemedicine/ 5. uscher-pines l, mehrota a. analysis of teledoc use seems to indicate expanded access to care for patients without prior connection to a provider. health aff (millwood). 2014; 33(2): 258–64. 6. zahedi f, emami razavi sh, larijani b. a two-decade review of medical ethics in iran. iranian journal of public health. 2009; 38(suppl.1): 40-46. 7. atac a, kurt e, yurdakul s. an overview to ethical problems in telemedicine technology. procedia social and behavioral sciences. 2013; 103: 116-121. 8. kaplan b, litewka s. ethical challenges of telemedicine and telehealth. camb q healthc ethics. 2008; 17(4): 401-16. 9. barry gf. regulatory, legal, and ethical considerations of telemedicine. sleep med clin. 2020; 15(3): 409-16. 10. chaet d, clearfield r, sabin je, skimming k. ethical practice in telehealth and telemedicine. j gen intern med. 2017; 32(10): 1136-40. 11. anonymous. general ethical guidelines for good practice in telemedicine. [cited 2021 may 2]. available from: https://www.sada.co.za/media/documents/hpcsa_booklet_10_telemedicine.pdf 12. parsapoor a, bagheri a, larijani b. patient’s rights charter in iran. acta med iran. 2014; 52(1): 24-8. 13. shamsi gooshki e, parsapoor a, asghari a, et al. developing code of ethics for medical professionals, medical council of islamic republic of iran. arch iran med. 2020; 23(10): 658-664. 14. graneheim uh, lundman b. qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. nurse educ today. 2004; 24(2):105–12. 15. elo s, kyngas h. the qualitative content analysis process. j adv nurs. 2008; 62(1): 107-15. 16. lincoln y, guba eg. naturalistic inquiry. ca: sage; 1985. 17. shenton ak. strategies for ensuring trustworthiness in qualitative research projects. education for information. 2004; 22: 63-75. shafizadeh h., et al. 13 j med ethics hist med. 2021(december); 14: 24. journal of m edical ethics and h istory of m edicine 18. korstjens i, moser a. series: practical guidance to qualitative research. part 4: trustworthiness and publishing. eur j gen pract. 2018; 24(1): 120-4. 19. langarizadeh m, moghbeli f, aliabadi a. application of ethics for providing telemedicine services and information technology. med arch. 2017; 71(5): 351-5. 20. xu j, willging a, bramstedt ka. a scoping review of the ethical issues within telemedicine: lessons from covid-19 pandemic. journal of health and social sciences. 2021; 6(1): 31-40. 21. stoll j, muller ja, trachsel m. ethical issues in online psychotherapy: a narrative review. front psychiatry. 2019; 10: 993. 22. kuziemsky ce, hunter i, gogia sb, et al. ethics in telehealth: comparison between guidelines and practice-based experience -the case for learning health systems. yearb med inform. 2020; 29(1): 44-50. 23. cotet am, benjamin dk. medical regulation and health outcomes: the effect of the physician examination requirement. health econ. 2013; 22(4): 393-409. 24. pollard js, karimi ka, ficcaglia mb. ethical considerations in the design and implementation of a telehealth service delivery model. behavior analysis: research and practice. 2017; 17(4): 298-311. abstract introduction references 7-ic4 181 aniseh samadi.docx journal of medical ethics and history of medicine original article readability of informed consent forms in clinical trials conducted in a skin research center aniseh samadi1, fariba asghari2* 1md, pharmaceutical, cosmeceutical, and hygienic evaluation lab (dermalab), center for research and training in skin diseases and leprosy, tehran university of medical sciences, tehran, iran; 2associate professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. corresponding author: fariba asghari address: # 23. 16 azar st., keshavarz blvd, tehran, iran, postal code: 1417863181medical ethics and history of medicine research center, tehran university of medical sciences email: fasghari@tums.ac.ir tel: 98 21 66419661 fax: 98 21 66489832 received: 2 apr 2016 accepted: 18 may 2016 published: 3 jul 2016 j med ethics hist med, 2016, 9:7 © 2016 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract obtaining informed consents is one of the most fundamental principles in conducting a clinical trial. in order for the consent to be informed, the patient must receive and comprehend the information appropriately. complexity of the consent form is a common problem that has been shown to be a major barrier to comprehension for many patients. the objective of this study was to assess the readability of different templates of informed consent forms (icfs) used in clinical trials in the center for research and training in skin diseases and leprosy (crtsdl), tehran, iran. this study was conducted on icfs of 45 clinical trials of the crtsdl affiliated with tehran university of medical sciences. icfs were tested for reading difficulty, using the readability assessments formula adjusted for the persian language including the flesch–kincaid reading ease score, flesch–kincaid grade level, and gunning fog index. mean readability score of the whole text of icfs as well as their 7 main information parts were calculated. the mean ± sd flesch reading ease score for all icfs was 31.96 ± 5.62 that is in the difficult range. the mean ± sd grade level was calculated as 10.71 ± 1.8 (8.23–14.09) using the flesch–kincaid formula and 14.64 ± 1.22 (12.67–18.27) using the gunning fog index. these results indicate that the text is expected to be understandable for an average student in the 11th grade, while the ethics committee recommend grade level 8 as the standard readability level for icfs. the results showed that the readability scores of icfs assessed in our study were not in the acceptable range. this means they were too complex to be understood by the general population. ethics committees must examine the simplicity and readability of icfs used in clinical trials. keywords: clinical trials, informed consent, readability, literacy mailto:fasghari@tums.ac.ir aniseh samadi et al. jmehm.tums.ac.ir j med ethics hist med 9:7, 2016 page 2 of 9 introduction clinical trials are the gold standard for evaluating the new treatments and interventions for patients. although preclinical studies are carefully designed, all experimental trials carry some potential risks of harm (1). to protect study participants, ethical requirements mandate that the participants be sufficiently informed about the trial before they are considered eligible to take apart in it. obtaining informed consents is one of the most fundamental principles of a clinical trial and is viewed as the key to respecting participant’s autonomy (2). in fact, the value of an individual’s autonomy entitles him or her to accept or refuse any medical procedure (3). therefore, a correct informed consent process can help patients make an autonomous decision regarding the potential harms of participation in a research (4, 5). the most common method of providing patients with information is the written informed consent form (icf), while this information can be provided in many ways, such as oral discussion by the investigator and his study team, and multimedia presentations (6). in order for the consent to be informed, the patient must receive and comprehend the information appropriately. therefore, icfs not only must provide the legally necessary information, but must also be prepared in a way to be completely understood by the participants (6). if patients cannot read or comprehend written materials provided to them, they will be of limited use (7, 8). moreover, in order to improve patient comprehension of information, it is of great importance to discuss information with him/her verbally in addition to providing readable information forms. this could improve patients’ active participation in decision making and help them make wiser decisions (9). complexity of the consent form is a common problem that has been shown to be a major barrier to comprehension for many patients (10). the main factors of complexity include excessive length of the form, inadequate time to read the consent form, the reading level, and the format and layout of the form (11). low functional and health literacy is another major problem that may limit the comprehensibility of the icfs. health literacy is linked to literacy and entails individuals’ knowledge, motivation, and competency to access, understand, appraise, and apply health information in order to make judgments and decisions in everyday life concerning healthcare, disease prevention, and health promotion to maintain or improve quality of life (qol) (12). health literacy has direct correlation with patients’ capacity to participate in medical decision-making and their inclination toward participation in medical research. low literacy may affect the decision-making process and also compliance of patients (13). reading comprehension is defined as the capacity to understand the reading material content and integrate it with the basic information of the reader’s world knowledge. clearly, it is a complicated multidimensional process that involves several factors like the integral view of the graphic material, encoding of the physical qualities of a word or letters (structural interpretation memory), and inference (14). quantitative tools have been developed to evaluate the readability of written documents (15). these scoring systems give an indication of how easy a text is to read and have been used in several studies to evaluate icfs. the readability of icfs has been previously assessed in several studies and different countries (1, 11, 16, 17). most of these researches have focused on phase i trials where the potential risk ratio is especially low (18-20) and only a few studies have been dedicated to icfs across the different phases and types of clinical trials (1). unfortunately, most of the studies show that icfs and other written materials for patients are prepared at levels beyond patients' literacy level (21, 22). since 1999 obtaining written icfs has been a must in any interventional research involving human subjects in iran (23). however, the readability and understandability of iranian icfs have not yet been evaluated. the primary objective of this study was to assess the readability of icfs used in clinical trials in a skin research center in iran and determine whether there is a difference in readability between different templates of icfs used in this research center. method collection of icfs this study was conducted in the center for research and training in skin diseases and leprosy (crtsdl) that is affiliated to tehran university of medical sciences, tehran, iran, in 2015. this center is devoted to research and educational activities on various aspects of skin diseases and is a reference center for evaluation of pharmaceutical, cosmeceutical, and hygienic products. it is a referral center for the whole country in which more than 50 phase i to iii clinical trials are conducted annually. icfs were selected from among clinical trials conducted between 2008 and 2015 in field of dermatology in crtsdl independently or in cooperation with other research centers in other cities. in total, 45 different icfs were collected from the outpatient clinics of the secondary health-care level in tehran and two other cities (bam and mashhad, iran). we used all available icfs, except those which were too similar in terms of methodology and experiment benefits and risks. all the icfs were approved by the research ethics committee of the crtsdl. each research center has its own consent form template. due to many studies which have been aniseh samadi et al. jmehm.tums.ac.ir j med ethics hist med 9:7, 2016 page 3 of 9 performed in cooperation with other research centers and organizations, different templates of icfs have been used. the templates that were mainly used in the crtsdl during this period of time have been listed below. type 1: the template created and approved by the ethical committee of crtsdl type 2: the proposed format of the clinical trial center of tehran university of medical sciences (it is almost the same template proposed by the research ethics committee of tehran university of medical sciences) (24) type 3: the proposed format of the world health organization (who), used in joint projects with the who type 4: the template used in joint projects with mashhad university of medical sciences type 5: the template created by the leprosy department of the research center in cooperation with bam leprosy research center type 6: the template used in joint projects with a private dermatology outpatient clinic readability assessment the icfs assessed in our study included 6 main templates, depending on the 6 main cooperative research centers. readability assessment was conducted on the templates and on the specific information sections of each trial, as well as the whole icfs text (including the template text + information parts of the trial). the specific information sections of the trials were described as: 1) research description 2) voluntariness of participation 3) participation expectation 4) risks and benefits 5) confidentiality 6) principle investigators (pi) and contact information 7) costs, compensation, and claims in the present study, headings and sub-headings were omitted. in cases which the content within tables formed sentences, they were analyzed. in this study, three, one-hundred word sections were retrieved from near the beginning, in the middle, and near the end of documents, and the analysis was performed on this 300-word text. no computer program exists with readability formulas adjusted for the persian language, so all calculations were performed using microsoft excel. readability scores formulas were entered into the software and the scores were calculated for each icf. mean ± standard deviation of readability scores for each template as well as specific information sections of icfs were also calculated using microsoft excel. statistical differences in mean readability scores were tested using the univariate analysis of variances test. a pvalue of less than 0.05 was considered as significant difference. all the materials were in persian, and unlike some other languages (25), there is no formula specifically designed for persian texts. flesch reading-ease score (fres) (26), fleschkincaid reading grade level and age (27), and gunning fog index (28) were chosen as the units of measure to assess readability because these indices were commonly used in medical literature (29-32). the fres and gunning fog index have been adjusted for persian (33). the adjusted formulas as well as the international formula for the flesch– kincaid grade level are explained in appendix a. the interpretations of readability scores have been provided in detail in table 1. flesch reading ease score the fres is measured using word length and sentence length. in the fres test, higher scores indicate that the material is easier to read, but lower scores indicate that the passage is more difficult to read. flesch-kincaid reading grade level/age level the flesch–kincaid grade level formula translates the fres into the education grade level of the united states. their results show the grade level and age level of an individual who can understand the text. gunning fog index the gunning fog index is a measure of text readability based upon sentence length and difficult words in a passage. the ideal score for readability with the gunning fog index is 7 or 8. anything above 10 is too hard for most individuals to read. table 1interpretation of readability scores difficulty flesch reading ease score flesch-kincade grade level gunning fog index very easy 91-100 4 4.9 or lower easy 81-90 5 5-5.9 fairly easy 71-80 6 6-6.9 standard 61-70 7-8 7-7.9 fairly difficult 51-60 9-10 8-8.9 difficult 31-50 11-14 9-9.9 very difficult 0-30 15-16 10 or higher aniseh samadi et al. jmehm.tums.ac.ir j med ethics hist med 9:7, 2016 page 4 of 9 results in the present study, 45 icfs of clinical trials conducted from 2008 to 2015 were investigated. the mean ± standard deviation (sd) of fres for all icfs was 31.96 ± 5.62 (range: 15.80–46.07). the mean ± sd grade level was 10.71 ± 1.8 (range: 8.23– 14.09) using the flesch–kincaid formula and 14.64 ± 1.22 (range 12.67–18.27) using the gunning fog index. the interpretation of readability scores has been provided in table 1. the mean scores for each group of icfs and the readability scores of the templates are presented in table 2. readability on a grade level 8 was only found in 2.2% (n = 1) of all the icfs assessed using the flesch–kincaid grade level formula and none using the gunning fog index. most of the studies scored less than 20 (using fres). no icf was found to have a score higher than 60, which indicates a standard reading level (figure 1). readability of the icfs was similar across all used templates, and no statistical differences were found between them (table 2). the comparison of the templates and icfs showed that, in some cases, the readability score of the template was beyond the standard deviation range of the icf. this indicates that in templates type 2 and 3, there might be a significant difference in readability of the template and the related icf (table 2). as was mentioned before, the readability analysis was also conducted on 7 information sections of the icfs. comparisons of readability scores of various sections are shown in table 3. the findings indicate that readability level was similar across all assessed information sections. however, using fres formula, the lowest score (most difficult section of the icfs) belonged to the section related to "risks and benefits", and the highest score (the most readable section) belonged to the "expectations from the participant". moreover, the highest and lowest grade levels belonged to "risks and benefits" and "expectations from the participant". table 2distribution of informed consent forms, mean readability scores across different templates, and readability scores across template and the completed informed consent forms type description number flesch reading ease flesch-kincaid grade level flesch-kincaid age level gunning fog index template icf (mean ± sd) template icf (mean ± sd) template icf (mean ± sd) template icf (mean ± sd) 1 crtsdl* 16 28.90 34.28 ± 8.82 10.51 10.59 ± 1.39 16.71 (17 years) 16.79 ± 1.39 (17 years) 13.33 14.5 ± 1.36 2 ctc** 9 40.81 37.96 ± 15.21 8.69 9.97 ± 1.03 14.90 (15 years) 16.18 ± 0.95 (17 years) 12.15 14.4 ± 0.93 3 who*** 2 44.49 30.19 ± 7.42 7.76 11.39 ± 1.12 13.96 (14 years) 17.6 ± 1.05 (18 years) 10.54 16.51 ± 1.93 4 mums**** 2 27.90 19.3 ± 10.20 11.03 13.12 ± 2.18 17.23 (18 years) 19.33 ± 2.32 (18 years) 15.15 17.87 ± 2.75 5 bam 11 30.80 31.71 ± 13.12 10.33 10.89 ± 1.54 16.53 (17 years) 17.1 ± 1.90 (18 years) 14.14 14.43 ± 1.86 6 private clinic 5 42.22 26.87 ± 15.31 8.49 11.49 ± 1.33 14.70 (15 years) 17.49 ± 2.90 (18 years) 13.88 13.87 ± 2.12 p-value across different templates 0.886227 0.499452 0.499452 0.351126 * center for research and training in skin diseases and leprosy **clinical trial center of tehran university of medical sciences ***world health organization **** mashhad university of medical sciences aniseh samadi et al. jmehm.tums.ac.ir j med ethics hist med 9:7, 2016 page 5 of 9 figure 1. categorical prevalence of flesch reading ease score of informed consent forms table 3comparison of readability score of various information sections of informed consent forms (mean with 95% confidence interval) about the trial voluntary participation expectation risks and benefits confidentiality principle investigators and contact information costs, compensation and claims anova p-value flesch reading ease 31.76 ± 3.51 31.9 ± 2.51 36.15 ± 4.20 21.35 ± 4.29 29.93 ± 3.62 33.44 ± 3.43 29.22 ± 3.98 0.423 fleschkincaid grade level 13.17 ± 0.99 10.38 ± 0.55 10.35 ± 0.62 16.49 ± 1.69 10.63 ± 0.41 10.29 ± 0.66 11.27 ± 0.77 0.951 fleschkincaid age level 18.17 ± 0.99 (19 years) 16.59 ± 0.55 (17 years) 16.56±0.62 (17 years) 22.69 ± 0.69 (23 years) 16.83 ± 0.41 (17 years) 16.49 ± 0.66 (17 years) 17.48 ± 0.77 (18 years) 0.282 gunning fog index 15.35 ± 0.90 14.32 ± 1.14 12.67 ± 0.78 16.81 ± 2.10 15.44 ± 0.69 12.72 ± 0.82 16.51 ± 1.83 0.981 discussion readability level of informed consent forms this study assessed the readability of icfs used in clinical trials in the crtsdl. according to the recommendation of ethics committees, the standard readability of icfs ranged from 5th-grade reading level to 10th-grade level (mode: 8th grade) (30). therefore, the readability of icfs assessed in our study was not in the acceptable range (grade level 11) and they are probably too complex to be understood by the general population. moreover, for other assessment tools, regarding the acceptable range of readability scores of icfs (table 1), icfs were categorized as “difficult” to understand. as was previously mentioned, low functional and health literacy is a problem that may limit the comprehensibility of the icfs. about 25% of american adults are classified as having low literacy skills. american literacy surveys indicate that at least 40 million adults are functionally illiterate (left school before grade 7) and 50 million are only marginally literate (34). the data from the european health literacy survey show that nearly half of the europeans surveyed had inadequate or problematic health literacy (35). although there has not been a definite survey about health literacy in iran, it is estimated that the extent of this problem in iran is even greater. according to the report of the statistical center of iran in 2013, 20 million adults in iran are functionally illiterate and have left school in primary level (38% of adults), of whom 3.5 million are completely illiterate (36). unfortunately, in case of icfs assessed in our study, there was no information about the literacy level of the participants. however, the education level of the average iranian patient in some other studies was determined as around the 5th grade (37). it, therefore, appears that the readability of icfs in this study is probably above the education level of the average patient population. 26 6 10 3 0 5 10 15 20 25 30 less than 20 (very difficult ) 20-30 (very difficult ) 30-40 (difficult ) 40-60 (fairly difficult ) icfs count fl ec sh r ea di ng e as e sc or e aniseh samadi et al. jmehm.tums.ac.ir j med ethics hist med 9:7, 2016 page 6 of 9 the study was conducted in tehran (the capital city) and two other cities of iran (mashhad and bam); thus, the participants might not to be an appropriate representative of the iranian population. however, the rate of literacy among the study participants in other cities cannot be too different. no other icfs readability assessment report was found in iran to compare our finding with. nevertheless, in one similar report on educational pamphlets in hospitals conducted in rasht in 2013, the reported score using flesch-kincaid formula was almost the same we found in this study (grade level 12 in comparison with grade level 11 in this study) (38). this shows that poor level of readability is detectable in icfs in addition to other written health related materials. in comparison with similar studies in other countries, in which fress of between 45 and 60 were obtained, the icfs assessed in our study were less readable. although most studies reported nonstandard readability level for the icfs of trials, their readability levels were much better than those obtained in the present study (1, 12, 34). information-focused readability assessments in case of information-focused readability, the best scores belonged to information related to "expectations from the participant" and the worst to the information related to "risks and benefits". however, the difference was not statistically significant. in the review of literature, no document that assessed the readability of specific sections of the consent forms was found. this was the unique characteristic of the present study. there were only a few studies that focused on the length of the specific sections of icfs. findings showed that in this study, the length of the selected sections were noticeably short. for instance, the “risks and benefits” section consisted of 58.70 words, while in other reported papers, this section consisted of at least 318 words (1). although the excessive length of the icfs could be a barrier to comprehension for many patients (11), summarizing important sections like “risks and benefits” could certainly result in the participants’ lack of awareness of the potential harms. different templates of informed consent forms as was mentioned, the assessments were performed on 6 icf templates used in the crtsdl. although the national committee of medical research ethics has worked in iran since 2002, it has not suggested a unique template for consent forms for medical clinical trials. therefore, research centers mostly follow the suggested format of their own regional ethics committee. general readability assessment showed no statistical difference between the used templates; but comparison of the templates and icfs showed significant differences in some cases. in icf type 2 and 3 (the proposed formats of the clinical trial center of tehran university of medical sciences and who), the readability of the original templates seem significantly higher than the icfs. this finding may indicate that, in some cases, icfs become less readable when filled with difficult texts especially medical jargons. however, the results show that even templates developed by ethics committees are too difficult to be understood by the general population. this shows that ethics committees should pay more attention to the readability of icfs and provide more understandable templates. one limitation of this study was that we did not have access to the icf of all trials conducted during this 6 year period. some of the pis were not available, so their permission to access their trial documents could not be obtained. some of the trials were conducted in cooperation with cosmeceutical and hygienic manufacturing companies and the permission of the company was required in addition to the pis in order to access the trial documents. the other limitation of this study was that the readability of icfs in one specific field (dermatology) were analyzed, while some published papers deal with icfs from different medical fields (12, 39). furthermore, there were some limitations regarding readability formulas themselves, such as lack of consideration of the influence of visual and design factors or readers’ prior knowledge and motivation (16). it is essential that icfs are written in clear, direct language to ensure comprehension. words longer than three syllables, long sentences, passive sentences, and medical vocabulary could affect the readability standards. strategies to simplify language include using short, familiar words or simple synonyms, limiting the use of polysyllabic words, and keeping sentence length less than 12 words and paragraph length less than 7 lines (40). conclusion icfs assessed in the present study were too complex to be understood by the general population. the results of this study showed the necessity of ethics committees’ attention to readability of icf templates prepared by different research centers. ethics committees should also ensure that the icfs appropriately define complex scientific concepts through simple concepts so that they can be read and comprehended by the typical subject. this assessment should be conducted more carefully in important sections like information related to "risks and benefits. ethics committees could also use the results of this study to prepare a standard guideline for research centers to provide more understandable icf templates. declaration of conflicting interests the authors declare that there is no conflict of interest. aniseh samadi et al. jmehm.tums.ac.ir j med ethics hist med 9:7, 2016 page 7 of 9 references 1. cheung wy, pond gr, heslegrave rj, enright k, potanina l, siu ll. the contents and readability of informed consent forms for oncology clinical trials. am j clin oncol 2010; 33(4): 387-92. 2. o'neill o. some limits of informed consent. med ethics 2003; 29(1): 4-7. 3. giampieri m. communication and informed consent in elderly people. minerva anestesiol 2012; 78(2): 236-42. 4. anonymous. wma declaration of helsinki. ethical principles for medical research involving human subjects. http://www.wma.net/en/30publications/10policies/b3/index.html.pdf?print-media-type&footer-right=[page]/[topage] (accessed in 2016) 5. anonymous. us national institute for 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[in persain] 39. vučemilo l, borovečki a. readability and content assessment of informed consent forms for medical procedures in croatia. plos one 2015; 10(9): e0138017. 40. wittenberg km, dickler hb. universal use of short and readable informed consent documents: how do we get there? https://www.aamc.org/download/75282/data/hdicklermtgsumrpt53007.pdf (accessed in 2016) http://ec.europa.eu/chafea/documents/news/comparative_report_on_health_literacy_in_eight_eu_member_states.pdf https://www.amar.org.ir/portals/1/yearbook/1391/15.pdf https://www.aamc.org/download/75282/data/hdicklermtgsumrpt53007.pdf aniseh samadi et al. jmehm.tums.ac.ir j med ethics hist med 9:7, 2016 page 9 of 9 appendix a adjusted formula for the flesch reading ease score (fres) for the persian language: flesch reading ease score = 262.835 – (1.015 x asl) – (0.846 x asw) asl = average sentence length (i.e., the number of words divided by the number of sentences) asw = average number of syllables per word (i.e., the number of syllables divided by the number of words) the flesch–kincaid grade level formula: flesch–kincaid grade level = (0.39 x asl) + (11.8 x asw) 15.59 asl = average sentence length (i.e., the number of words divided by the number of sentences) asw = average number of syllables per word (i.e., the number of syllables divided by the number of words) the flesch–kincaid age level formula: flesch–kincaid age level = (0.39 x asl) + (11.8 x asw) 10.59 asl = average sentence length (i.e., the number of words divided by the number of sentences) asw = average number of syllables per word (i.e., the number of syllables divided by the number of words) the gunning fog grade level formula: gunning fog grade level = 0.4 (asl + phw) asl = average sentence length (i.e., number of words divided by the number of sentences) phw = percentage of difficult words note: the adjustment for the persian language was performed on the definition of difficult words not on the formula. journal of medical ethics and history of medicine unsatisfied patient’s rights: a survey on the views of patients, nurses and physicians alireza parsapoor¹, kazem mohammad², hussein malek afzali², farshid ala’eddini³, bagher larijani4* 1.phd student, medical ethics and history of medicine research center, and department of medical ethics, faculty of medicine, tehran university of medical sciences, tehran, iran. 2.professor, faculty of public health, tehran university of medical sciences, tehran, iran. 3.epidemiologist, tehran university of medical sciences tehran, iran. 4.professor, endocrinology and metabolism research center, tehran university of medical sciences and medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. *corresponding author: bagher larijani address: no.21, 16 azar ave., keshavarz blvd., tehran, iran. tel: (+98) 21 66 41 96 61 email: mehr@tums.ac.ir received: 05 dec 2011 accepted: 24 jan 2012 published: 29 mar 2012 j med ethics hist med. 2012; 5:4. http://journals.tums.ac.ir/abs/20749 © 2012 alireza parsapoor et al.; licensee tehran univ. med. sci. abstract neglecting patients’ rights in a health care system can give rise to a challenging situation between health care providers and patients. the purpose of this study was to compare the views of patients as recipients of healthcare services and physicians and nurses, as healthcare providers, regarding the unsatisfied demands of different aspects of patients' rights in 3 hospitals representing three types of settings (teaching, private, and public). this was a cross-sectional descriptive analytical study. data were gathered using a questionnaire which was filled out by an interviewer for the patients and self-administered for nurses and physicians. the research venues were one general teaching hospital, one first class private hospital, and one non-teaching public hospital, and all 3 were in tehran. the questionnaire consisted of some general questions about respondents' demographics, and 21 questions concerning the importance of patients' rights, and how well patients’ rights were observed. overall, 143 patients, 143 nurses (response rate: 61%) and 82 physicians (response rate: 27.5%) completed the questionnaire. the degrees of unsatisfied demands were different depending on the various views within each group regarding the degree of importance and observance of each right, which was measured by the likert’s scale ranging from 0.0 (no importance, no observance) to 10.0 (absolutely important, full observance). concerning the non-normal distribution, the collected data were analyzed by non-parametric tests using the spss software (ver. 11.5). results showed that the studied groups had significantly different views. the most prominent issue concerned patients' to make an informed decision, which was particularly unsatisfactory in the teaching hospital. the results of this research indicate that healthcare providers, especially physicians, need to be informed to show more respect for patients' rights in terms of access to clinical information and making decisions. the results demonstrated that there was a significant difference between the opinions of patients and health care providers regarding the extent of unsatisfied demands of patients’ rights. according to the patients, the level of unsatisfied demands of these rights is far higher than that expressed by physicians. keywords: patient’s rights, medical ethics, views, iran. j med ethics hist med 2012, 5:4 alireza parsapoor et al. page 2 of 9 (page number not for citation purposes) introduction following great advances in biomedical scienc es and technologies in the recent decades in iran, considerable research has been carried out in biomedical ethics with a focus on policy making, medical education, and research [1, 2]. the field of patients’ rights can be considered one of the most important aspects of medical ethics research, and respecting patients’ rights can be claimed to be one of its most important facets in healthcare provision [3, 4]. although assessment of observance of patient’s rights in health care provision systems provides a framework for managers, it cannot depict a clear picture of the neglected rights. this could happen because patients have different opinions regarding the priority of different rights over one another [5]. on the other hand, comparing the views of healthcare providers and patients about the extent of adherence to patients’ right can notify the hospital management system about neglected rights. the current study was designed and carried out from 2007 to 2009 in order to shed some light on the issue of respecting patients’ rights in iran. in this study, the difference between the "importance" and "observance" of each right was used as an indicator for in-depth assessment of how well patients’ right are satisfied. a comprehensive literature review showed that several studies have been carried out on the awareness of various groups regarding different aspects of patient’s rights and the impacts of demographic, environmental and cultural factors on this awareness [6-12]. since various factors affect peoples' perception of the importance and ob servance of different aspects of patient’s rights, in this study, the views of all involved groups including patients, physicians, and nurses towards the services provided in hospitals were compared. it is worth noting that none of the indexes used in this study regarding the unsatisfied demands of patient’s rights was based on the methods and findings of previous studies. method the protocol of this study was approved by the research ethics committee of tehran university of medical sciences. the current study was a cross-sectional descrip tive and analytic one. data collection was per formed using a questionnaire which was filled out by an interviewer for the patients, and personally by physicians and nurses. in order to determine the validity of the questionnaire, its content was prepared based on a comprehensive literature review and the questions were modified through formal consultation with a group of experts in the field. to ensure reliability, differences in the mean scores were assessed using test-retest analysis. to increase the reliability of data collection, all interviews were completed by a single interviewer. this field study included three differently fund ed and managed hospitals which were selected based on feasibility and cooperation of their directors; a teaching general hospital, a private hospital and a public general hospital, all located in tehran, iran. detailed information of the study groups is tabulated in table 1. the questionnaire included a number of gen eral questions aiming at collecting the participants’ demographic information, and 21 questions were allocated to analyze their view of the importance and observance of patient’s rights. the patients were selected from the surgery and internal medicine wards of the hospitals. patients with moderate to severe pain and moderate to severe cognitive problems as well as those who had been hospitalized for less than 24 hours were excluded from the study. an informed consent was obtained from all patients after explaining the objectives of the study and prior to the interview. data collection and compiling took 3 months. the inclusion criteria for the physicians and nurses included being involved in clinical service delivery in any ward at one of the three above-mentioned hospitals. furthermore, it was emphasized that their answers should be according to the type of hospital (teach ing, private, or public). the views of participants about the importance and observance of each right were assessed on a likert’s scale from zero (no importance, no observance) to 10 (absolutely important, full observance). finally, the differences between the importance and observance scores were calculated as the index of unsatisfied patients’ rights from the viewpoints of all three participant groups (patients, nurses and physicians). in presenting and interpreting the results of this study, we calculated means, standard deviations (sd) and medians for describing quantitative variables, and numbers and percentages for describing qualitative ones. to compare results among hospitals, among the three groups of the study (patients, physicians and nurses), and other independent variables, non-parametric tests were used. this was mainly because of the fact that the importance and observance variables were graded using the scores from zero to ten and showed non normal distribution. when the independent variable had two groups (such as gender), the mann whitney test was used, and if the independent variable had more than two groups (such as hospital), the kruskal-wallis test was utilized. in analysis of the results, given the accuracy of the study, where the difference in the mean scores was more than two, statistically significant differences (p < 0/05) were considered clinically significant. j med ethics hist med 2012, 5:4 alireza parsapoor et al. page 3 of 9 (page number not for citation purposes) results this field study provided information regarding patients’, physicians’, and nurses’ views on the level of importance and observance patients’ rights in different hospitals (teaching, private, and public). in the patients’ groups, men outnumbered wom en in the private hospital (35 out of the 52 patients were male), while the number of interviewed women was higher in the teaching (23 out of 41) and public (28 out of 50) hospitals. the age of the patients ranged between 14 and 80 years (mean 46.57±17.36 and median 46.00 years). the mean was 51.36 years for men and 41.29 years for the women, indicating a significant difference between two groups (p < 0.001). of the respondents, 120 were married and 21 were single, and there were no significant differ ences between men and women or among patients from different hospitals in this regard. the number of illiterate patients was significantly higher in the public hospital than in the other two hospitals (p < 0.001). also, the number of patients with a high school diploma or a bachelor's degree was signifi cantly higher in the private hospital than in the other two hospitals (p < 0.001). the age of the physicians ranged between 28 and 68 years, and the mean was 45.33±10.017 years. distribution of working experience among the physicians of the three hospitals was not statistical ly significantly different. moreover, there was no significant difference between the gender groups in this regard. the age of the nurses ranged between 23 and 58 years (33.22±7.4 years). working duration in hospital in this group ranged between 4 and 384 months (mean 115.26 months). there was no statistically significant difference in the distribu tion of gender, age, marital status and service track record among the nurses in the three hospitals. the results of this study revealed that the differ ent groups had different views concerning unsatis fied patient’s rights in different aspects. in present ing the results of the study, the questions can be divided into four categories: first category: patients' right to respect, privacy, and non-discriminatory health service provision. second category: patients' right to access their clinical information. third category: patients’ rights in terms of choosing and deciding freely. fourth category: patients' right to complain and the necessity of declaring medical errors. the first category: the results shown in table 2 are mainly about patients' right to respect, privacy, and non discriminatory health service provision. in all three hospitals, the scores on unsatisfied rights were almost zero, and even negative in some cases. however, the attitudes of physicians and nurses were relatively negative concerning the neglected rights. however, their attitudes were significantly negative in the teaching hospital in comparison with the other ones. the second category: table 3 shows the results about the rights of patients to access their own information regarding their disease. in this study, apart from service location, all the groups of participants had consensus on the high level of unsatisfied rights; this was highest and lowest in the teaching hospital and private hospital, respectively. also physicians reported lower unsatisfied rights in comparison with the patients in all the three hospitals; differences between these two groups were statistically significant in some cases. the calculated indexes for nurses were between these two groups. however, as for answering patients’ questions about their disease, the lowest and highest values pertained to the patients and nurses, respectively. the third category: table 4 shows the results of the assessment of patient’s rights in terms of choosing and deciding freely. overall, according to patients and nurses, the index of unsatisfied rights were significantly higher than those calculated for physicians in case of patients right to choose their care provider (the main physician) and participate diagnostic and therapeutic decision making.. however, there was a significant difference in this regard among the three different hospitals (highest in the private hospital as compared with the other two). the fourth category: table 5 shows the unsatisfied rights in regards to a complaint system and revealing medical errors. in general, the unsatisfied rights regarding a complaint system were less pronounced in the private hospital according to the physicians and nurses, and they were similar in the two other hospitals from the viewpoints of all three partici pant groups. regarding disclosing medical errors to the pa tients, no significant difference was noted between the views of nurses and physicians. however, regarding the necessity of observance in terms of reversible errors, the physicians’ views were different in the public hospital compared to that in the other two hospitals. overall, the physicians of the public hospital reported more unsatisfied rights in comparison with the physicians of other two hospitals. j med ethics hist med 2012, 5:4 alireza parsapoor et al. page 4 of 9 (page number not for citation purposes) discussion a review of the opinions of the three groups (patients, physicians and nurses) in three types of healthcare centers revealed different views among them concerning unsatisfied patients’ rights in different respects. the results of the detailed analysis of the above-mentioned rights are as follows: the first category (patients' right to respect, privacy, and non-discrimination): there existed consensus over the proper ob servance of patients’ rights among all the patients from three different hospitals. the different scores of unsatisfied rights by healthcare providers and recipients aredemonstrated in table 2. this could be explained by different facts, including the higher importance of the issue for health care providers, different viewpoints of health care providers compared to the patients, long lasting memory of the incidences of discrimination, and great expecta tions of the health care providers in selected hospitals about the necessity of non-discriminatory health care provision. it needs also to be mentioned that violating patient's rights in this respect is a great concern from an ethical point of view. moreover, the notable amount of unsatisfied rights in this category in teaching hospitals of iran indicates that the issue needs to be addressed promptly. the second category (the right of patients to access their own information): the high scores of unsatisfied rights in terms of this category necessitate paying due attention to information transition management between physician and patient. the report of an study conducted by british patients association (2005) on the views of 1000 healthy individuals (older than 18 years) and 344 patients suffering from chronic diseases demon strated that approximately 90 percent of the participants believed that they received the required information regarding their treatment and its risks or advantages. in the same study, 60%, 10%, and 8% of patients had received a copy of their medical records from their physician, had access to limited information, and did not have any access to their clinical information, respectively [13]. in a questionnaire study carried out in singapore on the attitude and practice of 475 physicians in regards with the interaction between physicians and patients, approximately 85% of the physicians expressed they would provide an appropriate answer to their patients’ questions about their diseases, and only 24% would not do so. in contrast, 32% of the physicians always disclosed the truth about the disease and its prognosis. as for explaining possible risks and complications, 92% of the physicians mentioned they would discuss common complications, 29% disclosed all possible complications, and 10% said they would only mention important complications to patients [9]. according to the results of a study carried out by ducinskiene (2006), a significant discrepancy existed between healthcare physicians’ report in terms of different issues, including informing patients of the prognosis of their disease, its potential complications, and possible alternative treatment options (80% – 98%). several other studies have demonstrated that patients were less informed of the mentioned issues [14-17]. it appears that this category of rights is less satisfied. underestimation of physicians about such unsatis fied rights increases concerns, showing their misunderstanding of patient’s actual demands. on the other hand, the amount of unsatisfied rights was much higher in the teaching hospital than the other two, so it requires special considerations. also for better understanding of nurses about the patients’ informative needs, their estimations could be more realistic to improve the patients’ information level. our findings showed that patients acquire their needed information through asking questions actively and believe that the medical team is accountable; this is not approved by healthcare providers especially in teaching hospitals. based on the results of this study, preparing information dissemination packages concerning the standards of patients’ access to therapeutic and non-therapeutic services, teaching communicative skills to therapeutic teams for proper transfer of information about diagnostic and therapeutic measures and introducing a proper therapeutic team to the care receiver can be greatly helpful. the third category (patients' rights in terms of choosing and deciding freely): considering the structure and governance of teaching hospitals, it seems quite natural that patients do not necessarily have the ability to choose their physicians. in fact in teaching hospi tals of iran, patients should be examined by students and residents before physicians. this is only acceptable if patients are properly informed of the situation at the time of admission. however, it could be suggested that in an ideal situation, patients should be able to choose their intern, resident, and faculty physician through a hierar chical framework even in a teaching hospital. this aspect was not analyzed in this study. according to a study carried out by the british patients associa tion [13], about 80% of the patients considered themselves capable of choosing their general practitioners, while this proportion was only 45% regarding consultant specialists. in terms of having access to a second opinion regarding the diagnosis of their disease, 40% of the participants believed that they had such access, 27% expressed that it j med ethics hist med 2012, 5:4 alireza parsapoor et al. page 5 of 9 (page number not for citation purposes) was difficult to have such access, and 30% were completely unaware of this possibility. the most frequently neglected patients’ right in all three hospitals concerned their contribution to diagnostic and therapeutic plans. in one study, researchers found that although nurses believed that patients should participate in clinical decision making processes, they did not practically apply this in their clinical practice [18]. findings of another study on ethical medical issues with a focus on written informed consents conducted by ibrahim basagaolgu et al showed that the 29% of the patients of the general surgery ward did not recall receiving any form regarding an informed consent [19], 56% were confident that they had never received any such form, and 15% had no idea such a form existed. the reason for this was explained to be due to the fact that many written consent forms were filled in by relatives of the patients without their being informed of it. interest ingly, it was observed that only one patient was unconscious during the admission. on the other hand, only 19% of the patients who personally signed the form had read it before signing. as for the question “who collected the signed forms?”, only 23% of the patients could remember the person who collected them (surgeon, nurse or receptionist). it has been demonstrated that although patients wish to access the information regarding alternative treatment options, they tend not to participate in the decision-making processes. findings of several studies have demonstrated that healthcare profes sionals should introduce measures to encourage patients to contribute to the clinical decision making process more proactively [20]. it could be suggested that producing specifically designed informed consent forms can play an important role in improving the health care system from an ethical point of view. the fourth category (patient’s right regarding complaints and reporting medical errors): according to the findings of this study, it seems that the healthcare providers are more aware of the existence of a complaint system. thus, more effective information dissemination is needed for patients to remind them of this system. in light of the importance of such issues, public hospitals need to implement effective measures so that they can achieve patient centeredness by improving patient satisfaction. the relatively low response rate of the physi cians can be considered one of the major limita tions of this study and a source of information bias. however, we endeavored to minimize this limita tion by asking directors of the hospitals to demand their employees’ contribution in writing. furthermore, due to the executive limitations, it was not possible for us to study some aspects of patients’ rights. for example, as private hospitals in iran are not involved in any research activity, it was not possible to investigate research related ethical issues. furthermore, we refrained from asking patients about their views of medical errors as it was anticipated that it would induce stress. therefore, some elements of patients’ rights were not properly investigated in our study. in order to achieve more accurate results which can be generalized to the whole health care system, conducting further studies on larger cohorts selected from different types of hospital seems necessary. conclusion based on the result of this study, it seems that healthcare providers, particularly the medical group, should receive supplementary training to observe patients' rights to access information and their rights to choose and make decisions, because the physicians in this study had a more optimistic view about the situation in comparison with the patients. also, the following measures could play signifi cant roles in improving the patient’s rights status: preparing proper forms for disseminating the standards and the conditions of serving at medical centers, expounding patient’s rights, preparing special informed consent forms for disseminating proper information and improving the conditions required for participation of the patients in decision-making processes, submitting the final revision of the question naire of this study to hospital authorities for internal evaluation of the different aspects of patients rights in the medical centers, organizing complaint systems at medical cen ters, and performing similar studies and comparing the viewpoints of providers and recipients of healthcare services. acknowledgement authors wish to extend thanks to directors, managers, medical practitioners, and nursing staff of the three participating hospitals as well as patients who kindly participated in the study. they specifically would like to express their gratitude to drs. pooneh salari and fariba asghari for their valuable comments, ms. heydarian for conducting the interviews, ms. karimi for typing the contents, and ms. aghaee for the administrative coordination of the study. funding: this study received funding from tehran university of medical sciences (tehran, iran). j med ethics hist med 2012, 5:4 alireza parsapoor et al. page 6 of 9 (page number not for citation purposes) table 1: number (response rate percentage) of respondents in each study group. hospital model health care stakeholders teaching general hospital private hospital public general hospital total patients 41(100) 52(100) 50(100) 143(100) physicians 22(24) 49(32.6) 11(18.9) 82(27.5) nurses 28(56) 74(74) 41(43.9) 143(61.3) table 2: results on the unsatisfied patients’ rights to receive respectful and non-discriminatory service hospital model health care providers public general hospital private hospital teaching general hospital p value total non-discriminatory health service patients 0.00±0.00 0.06±0.42 0.37±1.70 0.152 0.013±0.9 physicians 0.56±0.73 0.58±1.87 2.67±2.56 0.001* 1.18±2.19 nurses 1.44±1.79 0.82±2.03 2.48±3.12 0.008* 1.34±2.29 p 0.00* 0.045* 0.000* ---0.000* respect for religious, national, ethnic, cultural background of the patients patients 0.04±0.28 0.96±3.42 -0.60±2.27 0.108 0.51±0.42 physicians 0.25±0.89 0.72±1.40 2.33±2.42 0.003* 1.21±1.93 nurses -0.26±1.89 0.39±0.814 1.88±1.51 0.000* 1.76±2.58 p 0.431 0.001* 0.000* --0.000* observance of patients’ privacy patients 0.38±1.32 -1.42±3.48 -0.03±3.27 0.005* -0.39±0.93 physicians 1.88±2.70 0.88±1.83 3.55±3.333 0.002* 1.94±2.79 nurses 0.68±2.31 1.19±1.73 2.50±2.66 0.004* 1.63±4.31 p 0.120 0.000 * 0.000* --0.000* * shows a significant p value. all data are demonstrated as mean±sd. j med ethics hist med 2012, 5:4 alireza parsapoor et al. page 7 of 9 (page number not for citation purposes) table 3: results on the unsatisfied patients’ rights to access their own information hospital model stake holder group public general hospital private hospital teaching general hospital p value total informing patients of their rights patients 5.98±4.13 3.65±4.63 6.38±3.77 0.004* 5.23±4.37 physicians 1.33±3.16 0.41±2.63 4.80±2.93 0.000* 1.73±3.34 nurses 4.47±3.33 2.20±2.14 3.63±3.44 0.001* 3.18±2.97 p 0.300 0.000* 0.011* --0.000* providing sufficient information about the disease and its prognosis patients 1.86±3.76 2.12±3.88 3.98±5.46 0.49 2.56±4.41 physicians 0.11±0.60 0.58±2.17 3.27±2.66 0.000* 1.30±2.53 nurses 1.82±2.46 1/75±2/17 3.50±3.24 0.011* 2.10±2.56 p 0.289 0.024* 0.809 --0.038* informing the patients about their disease by health care providers patients 0.14±2.24 -0/04±3/53 1.13±3.72 0.192 0.35±3.20 physicians 0.00±1.00 0.60±2.05 2.95±2.63 0.000* 1.5±2.42 nurses 1.97±1.80 1.14±1.80 3.32±2.84 0.000* 1.83±2.19 p 0.000* 0.052 0.016* --0.000* informing patients of the responsibility of different members of the health care provision team patients 4.48±4.84 2.31±5.66 6.27±5.08 0.002* 4.20±5.42 physicians 0.56±1.67 -0.74±3.09 3.14±3.08 0.000* 0.57±3.39 nurses 1.74±2.28 0.67±3.09 2.77±3.12 0.000* 1.42±2.37 p 0.001* 0.001* 0.001* ---0.000* introducing health care provision team to the patients patients 2.92±5.19 0.79±6.16 2.74±5.77 0.127 2.07±5.76 physicians 0.22±1.30 -0.45±3.58 2.41±3.00 0.005* 0.52±3.42 nurses 0.97±3.41 0.59±2.49 2.00±3.51 0.144 0.98±3.03 p 0.056 0.352 0.822 --0.032 providing sufficient information about the therapeutic plan for competent patients patients 2.80±3.97 1.77±4.60 5.15±5.10 0.002* 3.10±4.72 physicians 0.56±1.01 0.49±1.94 2.95±2.40 0.000* 1.23±4.72 nurses 1.41±1.83 0.13±10.22 3.58±2.79 0.135 p 0.040* 0.443 0.083 --0.009* explaining common risks and side effects to patients patients 6.54±4.50 4.13±488 7.85±3.95 0.000* 6.04±4.72 physicians 0.67±0.87 0.40±2.32 2.73±2.27 0.001* 1.12±2.40 nurses 1.62±2.10 1.95±2.31 3.15±2.46 0.025* 1.23±7.40 p 0.000* 0.000* 0.000* --0.000* provision of information about less common side effects patients 5.68±4.83 4.12±5.19 6.65±4.68 0.046* 5.38v4.99 physicians 0.43±2.23 -0.71±2.71 1.50±3.50 0.030* 0.19±3.10 nurses 1.03±3.22 1.45±2.98 3.58±2.94 0.003* 2.09±2.32 p 0.000* 0.000* 0.000* --0.000* patients’ access to content of their medical records patients 0.78±5.35 0.62±5.71 -0.13±4.10 0.465 physicians -0.57±2.57 -001±2.90 0.10±4.21 0.903 nurses 0.78±5.35 -0.62±5.71 -0.13±4.10 0.018* 1.92±3.60 p 0.723 0.723 0.221 ---0.985 necessity of informing the patients about their rights upon admission patients ----------- physicians 0.50±2.27 1.35±3.00 3.62±3.90 0.021* 2.00±3.42 nurses 3.16±3.89 1.81±2.22 4.69±3.21 0.00* 2.84±3.21 p 0.070 0.400 0.306 --0.101 * shows a significant p value. all are presented as mean±sd. j med ethics hist med 2012, 5:4 alireza parsapoor et al. page 8 of 9 (page number not for citation purposes) table 4: results the unsatisfied patients’ rights regarding their freedom to choose their health care provider hospital model stake holder group public general hospital private hospital teaching general hospital p value total having the option to choose care-providers (management consultant) by patients patients 3.17±4.66 -0.18±4.62 2.06±5.94 0.055 1.62±5.17 physicians 0.89±1.83 0.31±2.11 1.74±3.54 0.126 0.75±2.57 nurses 3.03±3.39 1.21±3.00 3.88±4.16 0.002* 2.31±3.53 p 0.287 0.094 0.265 --0.036* seeking the opinion and involving the competent patient in diagnostic and treatment measures patients 3.10±4.10 3.19±5.25 5.56±5.10 0.032* 3.82±4.92 physicians 0.63±1.77 0.42±2.37 3.09±2.41 0.000* 1.38±2.61 nurses 1.78±2.41 1.06±2.27 3.38±2.89 0.000* 1.77±3.16 p 0.068 0.001* 0.029* --0.00* possibility of leaving the hospital with personal consent against the advice of the treatment team patients ---------- physicians 0.11±2.62 -1.07±1.96 0.73±1.93 0.004* -0.39±2.17 nurses -0.23±2.37 -0.93±2.60 -0.12±2.67 0.277 2.92±3.94 p 0.703 0.769 0.224 --0.684 possibility of consulting with physicians other than the treating physician by the patient patients ---------- physicians 0.88±1.64 0.19±2.04 2.91±2.64 0.000* 1.24±2.53 nurses 2.54±3.11 0.61±2.11 3.08±2.67 0.000* 1.75±2.78 p 0.150 0.367 0.828 --2.33 * shows a significant p value. all data are presented as mean±sd. table 5: results of the unsatisfied patients’ rights in regards to a complaint system and revealing medical errors. hospital model stake holder group public general hospital private hospital teaching general hospital p value total an effective complaint management system is in place in the hospital patients 2.20±6.36 3.67±5.91 3.11±5.21 0.819 3.14±5.7 physicians 0.38±1.30 -0.16±2.13 2.91±2.81 0.000* 0.81±2.5 nurses 1.32±3.54 0.56±1.88 3.68±2.64 0.000* 1.42±2.8 p 0.630 0.000* 0.706 --0.004* revealing the compensated (corrected) errors to the patients by the responsible person physicians -1.43±4.43 1.70±2.63 2.48±4.01 0.041* 1.60±3.5 nurses 0.58±5.08 1.40±3.32 3.69±4.63 0.14 0.48±1.5 p 0.334 0.676 0.347 --0.965 disclosing compensable (non-corrected) medical error to patients by the responsible person physicians -1.50±3.38 1.86±2.13 2.81±3.86 0.005* 1.74±3.2 nurses 0.95±3.21 1.42±3.54 4.42±3.23 0.000* 1.31±2.2 p 0.059 0.542 0.125 ---0.725 disclosing irreversible medical errors (non corrected) to patients by the responsible person physicians -2.63±3.38 2.68±3.14 4.10±3.52 0.000* 2.40±4 nurses 2.69±4.27 2.14±3.69 4.48±3.43 0.011* 0.04±3.7 p 0.002* 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59(10): 679-82. 18. keatinge d, bellchambers h, bujack e, cholowski k, conway j, neal p. communication: principal barrier to nurse consumer partnerships. int j nurs pract 2002; 8(1): 16-22. 19. basagaoglu i, sari n. patient attitude about ethical issues confronted during the clinical education of medical students, with emphasis on informed consent. www.ishim.net/ishimj/jishim4_7_8/vol4no7/ibrahim_sari.doc, (accessed in 2011). 20. beisecker ae, beisecker td. patient information-seeking behaviors when communicating with doctors. med care 1990; 28(1): 19-28. journal of medical ethics and history of medicine original article nursing students' perceptions of teachers' uncivil behaviors: a qualitative research anahita masoumpoor1, fariba borhani2*, abbas abbaszadeh3, maryam rassouli4 1department of pediatric nursing, school of nursing and midwifery, shahid beheshti university of medical sciences, tehran, iran. 2associate professor, medical ethics and law research center, department of medical-surgical nursing, school of nursing and midwifery, shahid beheshti university of medical sciences, tehran, iran. 3professor, department of medical-surgical nursing, school of nursing and midwifery, shahid beheshti university of medical sciences, tehran, iran. 4associate professor, department of pediatric nursing, school of nursing and midwifery, shahid beheshti university of medical sciences, tehran, iran. corresponding author: fariba borhani address: vali asr ave., hashemi rafsanjani cross road, niayesh complex, school of nursing and midwifery, shahid beheshti university of medical sciences, tehran, iran. email: faribaborhani@msn.com tel: +98913-3439254 received: 29 apr 2017 accepted: 17 oct 2017 published: 5 nov 2017 j med ethics hist med, 2017, 10:10 © 2017 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract one of the main issues in nursing education that teachers and students frequently encounter is uncivil behaviors. this type of behavior is destructive for the teaching and learning environment. as teachers play an important role in nursing students' education and are ultimately their role models, the identification of these behaviors in nursing teachers appears to be essential. this study was conducted to determine nursing students' perceptions of their teachers' uncivil behaviors. the present study was conducted using a qualitative approach and content analysis. a total of 13 nursing students were selected through purposive sampling, and deep and semi-structured interviews were conducted with them. content analysis was performed using an inductive approach. three main categories were obtained through data analysis; disruptive behaviors affecting communication climate (subthemes: humiliation, the lack of supportiveness, and distrust), disruptive behaviors affecting ethical climate (subthemes: selfcenteredness, coercion and aggression, and harassment), and disruptive behaviors affecting learning climate (subthemes: poor teaching skills, poor time management, and indiscipline). given that human dignity takes precedence over education, any action causing humiliation and embarrassment can have inverse effects on the students and may harm them. these behaviors taint the educational role. since students select their teachers as their role models, the impact of teachers' uncivil behaviors on students cannot be neglected. neglecting these behaviors might lead to their persistence in the clinical setting and irreparable damage to patients, who are the ultimate recipients of care. keywords: uncivil behavior, student perception, nursing teachers, qualitative research j med ethics hist med 10: 10, november, 2017 jmehm.tums.ac.ir anahita masoumpoor et al. page 2 of 7 introduction there has been a dramatic increase in the incidence of uncivil behaviors in nursing education compared to the past (1-3). the majority of students and teachers consider uncivil behaviors in nursing education as a serious threat (4, 5). destructive uncivil behaviors are serious problems in nursing education that require constant attention and assessment. these behaviors jeopardize the peacefulness of the teachers, students, and the academia (6), have destructive effects on the students and the teachers, and hurt teaching and learning environment and the student-teacher relationship to a degree that might lead to the violation of the rights of all students (3, 7). however, civil behavior is respect for others in the face of disagreement, dispute, and debate (8). these uncivil behaviors cause psychological and physical disturbances for those involved, and might turn into threatening situations if neglected (9). previous studies have reported teachers' uncivil behaviors to manifest themselves in the form of canceling classes without prior notice, coming to class unprepared for teaching, not allowing free discussion in the classroom, acting cold and indifferent, humiliating and scolding the students, rushing through the topics, humiliation, unfairness, imposing their own will, indifference toward the students (3, 10), and being unavailable (4). amanda has reported that behaviors such as late arrival, coming into the class unprepared, giving dirty looks to impolite students, and disrespecting students provoke retaliation in the students (10). teachers' uncivil behaviors are not limited to the examples mentioned and also include teaching incompetence (10), immodesty, poor teaching skills (11), and poor communication skills (12, 13). students have reported experiences of vulnerability (14), helplessness, stress, sleep disorders (15), and depression (16) when exposed to teachers' uncivil behaviors (17-19) and have the notion that teachers wish to get rid of them (8). teachers may inadvertently provoke retaliation in the students by such uncivil behaviors as late arrival, coming to the class unprepared for learning, giving dirty looks to impolite students, and disrespecting students (20, 21). some teachers commit uncivil behaviors knowingly or unknowingly, which is proof that it is possible for teachers to cause uncivil behaviors in their colleagues in the academic setting (12). teachers' manner of responding to the students can exacerbate or abate the tensions (7). occasionally, they do not realize that the act of humiliating and embarrassing students may unintentionally cause conflict and hostility (22). the conflicts between the teachers and the students disconnect the students from learning process (3), and can deteriorate the learning environment and lead to poor performance and violations in the workplace (23). it is not surprising that people who commit uncivil behaviors in academic settings continue this behavior in the workplace (24). previous studies indicate that teachers are concerned about the growing frequency of these behaviors in nursing education settings (14). these behaviors can disturb those involved, jeopardize the teaching and learning environment, and cause hostility (25). considering the humanitarian objectives of nursing as a profession, the need for focusing on the ultimate beneficiaries (i.e., the patients), and the importance of developing civility in all communities, especially in nursing education settings, it seems that identifying these behaviors in various societies (including iran) can provide invaluable information on this topic. to diminish uncivil behaviors, creation of a safe and dependable environment should be given priority (24). the first step is identification of these behaviors, reduction of the conflicts caused by them, understanding of the feelings and perspectives of the students, and hearing their views. identifying these behaviors and taking measures to reduce them are therefore necessary steps for creating a standard educational setting. the present study was designed to determine students' perceptions of teachers' uncivil behaviors. method the present study used directed qualitative content analysis and purposive sampling to investigate the perception of nursing students regarding teachers' uncivil behaviors. in this qualitative approach, the phenomena must be investigated in their natural context. the nursing schools of tehran university of medical sciences, iran university of medical sciences, shahid beheshti university of medical sciences, islamic azad university, and shahed university (tehran, iran) were selected. participants were selected through purposive sampling. the interviews were held in a quiet room in the nursing schools or hospitals. sampling continued until data saturation, which occurred in the 11th interview, when no further new data could be obtained and previous codes were being repeated. the students had completed at least two semesters of their studies, entered the clinical setting, and received clinical training in nursing schools of the selected medical universities in tehran. the data extracted from each interview guided the subsequent interviews. after ethical approval and obtaining written informed consent from the participants, in-depth and semistructured interviews were conducted to collect the data. the researcher first briefed participants on the study objectives, and then, introduced herself at the beginning of each interview and asked participants to fill out and sign informed consent forms for participation in the study and the recording of their voices. participants were also briefed on the study objectives, the reason for recording the interviews, j med ethics hist med 10: 10, november, 2017 jmehm.tums.ac.ir anahita masoumpoor et al. page 3 of 7 the voluntary nature of their participation, and the confidentiality of their data and identities. for greater assurance, two more interviews were conducted, which resulted in no new data. interviews were begun with the questions "have you witnessed abnormal and disrespectful behaviors from your teachers during your education?", "how did these behaviors affect you?", "on what occasions did you experience these behaviors?" and "could you describe one of these experiences." in order to obtain more data and clarify certain issues, some probing questions were also asked, and continued with more specific questions. field notes were taken during the interviews. each interview lasted between 30 and 60 minutes. all interviews were recorded on tape and the transcripts were typed, reviewed, and coded at the end of each interview. to observe the principle of confidentiality, participants’ names were not revealed. instead, each of them was given a specific number and their important characteristics such as age, sex, and level of education were recorded, and promptly transcribed verbatim and typed. to immerse in the data, the researcher reviewed the interviews several times and coded them. data were analyzed simultaneously and continuously by collecting information. semantic units were extracted in the form of initial codes or open codes from the interviews. the codes were reread several times and placed in subcategories on the basis of similarity and proportion of the participant expressing the same topic. next, the subcategories were compared with each other and those with similar characteristics were combined to create wider categories, which were presented once more. some of the measures taken to enhance data accuracy included prolonged engrossment in the topic, confirmation of findings by the participants, and observer reviews. to ensure dependability of the data, in addition to the members of the research team, three experts, who were members of the research team, were asked to evaluate the interviews, coding, and categories. to enhance transferability, the entire process of the research and all the work done in the course of the study were prepared in clear and accurate written form to enable others to track and study the population characteristics. the qualitative content analysis method used in the study included 8 stages proposed by wildemuth (26). to ensure the confirmability of the data, parts of the interviews were checked along with the extracted codes and subthemes both externally and by 4 postgraduate nursing students familiar with qualitative studies. to allow for future references to the study, the stages and processes of the research were carefully recorded and reported. results a total of 13 (10 female and 3 male) students were interviewed. to obtain a wider variety of experiences, maximum variation sampling was used in the selection of participants in terms of their year of study (3rd to 8th semester), age (19-25 years old), and gender. participants' rich, in-depth descriptions yielded extraction of 384 initial codes, which were then reduced to 70 after eliminations and integrations at different stages. finally the 70 codes were converted to 3 themes and 9 subthemes (table 1). each theme will be explained with its relevant subthemes in the following. table 1: the themes and subthemes extracted from the interviews theme subtheme disruptive behaviors affecting communication climate humiliation lack of supportiveness distrust disruptive behaviors affecting ethical climate self-centeredness coercion and aggression harassment disruptive behaviors affecting learning climate poor teaching skills poor time management indiscipline theme 1: the first main theme extracted was disruptive behaviors affecting communication climate, which included behaviors that cause the break-up of communication, and the subthemes of humiliation, lack of supportiveness, and distrust. humiliation signifies the belittling and disrespecting of others. in the experience of the majority of the students, calling others unpleasant names or attributes taints their self-esteem. participants emphasized the need for teachers to respect their students. one participant said: [during the training, some instructors argued with us in the presence of the patients, and scolded us, and so, the patients would not allow us to care for them, and would tell us that we did not know how to do our job, and humiliated us this way. but the instructor could have simply pulled us aside and told us about our mistake in private.] (participant no.1) another participant said: [one time, one of the students was having difficulty understanding what the teacher was trying to convey, and so, the teacher called him a dumbass, and the student turned beetroot. is it okay for a teacher to embarrass a j med ethics hist med 10: 10, november, 2017 jmehm.tums.ac.ir anahita masoumpoor et al. page 4 of 7 student by calling him a dumbass?] (participant no. 2) the next subtheme was lack of supportiveness. the best way for establishing a good relationship with the students is for the teachers to give them emotional support. participants' experiences showed that teachers' supportiveness enhances the students' self-esteem and motivation for learning; the effect of factors such as pleasantness, openness to criticism, flexibility, fairness, modesty, understanding, and empathy should not be neglected on learning, the communication of knowledge, and the overall development of the student and the university. they considered the teachers' lack of supportiveness and their disregard for the students' wishes as disheartening. one participant asserted: [the teachers never support us when we need them to, and ignore our problems.] (participant no. 5) another subtheme was distrust. distrust signifies the lack of a strong belief in a person's credibility, honesty, and capability. in the experience of some students, some teachers doubt their students and do not believe their words. one participant said: [the teachers believe only themselves, and never trust in what their students have to say.] (participant no. 4) the second main theme extracted was disruptive behavior affecting the ethical climate, which included the subthemes of self-centeredness, coercion and aggression, and harassment. self-centeredness is an inimical behavior in which a person considers only his own interest and wishes and never feels accountable toward others. in the experience of some participants, the teachers are unfair and act according to their own impulses. one participant said: [some teachers give good grades to the students they like and low grades to those they do not, just to trouble them.] (participant no. 1) coercion and aggression was another subtheme of this theme. coercion signifies forcing others into a situation against their will. in the experience of participants, coercion and aggression lead to poor communication and distanced the students from the teachers out of fear. on the contrary, an amicable and respectful relationship can hearten the students to make greater efforts to resolve their mistakes. one participant said: [one of the teachers used to literally throw the book at us and shout if we could not give a satisfactory answer to her questions. of course, we do not know everything; we are here to learn.] (participant no. 8) harassment was another subtheme, which signifies behaviors that harass others and deprive them of their right to peacefulness. some participants discussed being harassed by their teachers, which made the girl students particularly uncomfortable. one participant revealed: [one of our man teachers would give away his phone number, so we would become friends with him.] (participant no. 7) another participant said: [one of the teachers in our second semester used to get on my nerves with his roving eyes.] (participant no. 9) the third main theme was disruptive behavior affecting the learning climate, which tends to interfere with appropriate teaching and effective learning, and included the three subthemes of poor teaching skills, poor time management, and indiscipline. one of the subthemes of this theme was poor teaching skills, which signifies the teachers' lack of efforts for promotion of knowledge and skills in others. in the experience of the participants, the teachers' knowledge and teaching techniques are what count in increasing students’ interest in learning. they also asserted that uncreative teaching methods, especially simple lectures, make the class boring and do not motivate the students. one participant argued: [some teachers only read the slides out loud, and do not expand on the subject or use modern teaching techniques, which make lectures super boring for us.] (participant no. 2) poor time management was another subtheme of this theme. in the experience of the participants, some teachers do not plan their classes ahead of time and often run out of time by wasting it, and then, request additional sessions. one participant said: [teachers spend a great deal of time telling us anecdotes, and so, they run out of time. so, the students get tired and can no longer concentrate. some teachers keep us longer to finish a topic, and if they cannot, they ask for additional sessions.] (participant no. 6) the last subtheme of this theme was indiscipline. in the experience of participants, teachers are considered as role models by the students. how can an undisciplined teacher expect discipline from his students? one participant remarked: [some teachers arrive late to the classroom.] (participant no. 3) discussion the results of the present study showed that nursing students experience uncivil behaviors from their teachers in three themes, namely disruptive behaviors affecting communication climate, ethical climate, and learning climate. a study conducted by clark et al., however, revealed two themes, including destructive behaviors and threatening behaviors (9). a number of the subthemes extracted in the present study show clear differences and similarities with the themes extracted in previous studies, which will be addressed in detail. humiliation was a subtheme of non-supportive behaviors that was frequently referred to in different forms by the majority of the students interviewed. the students described the major part of being humiliated to have occurred in the form of the teacher ignoring their identity and character or feeling superior to the students and explained that it included becoming the target of the teacher's ridicule, insult, and sarcasm, and not getting responses to their questions. the results of other studies have shown that students consider humiliating behaviors the same as uncivil behaviors and communication as a means of committing civil j med ethics hist med 10: 10, november, 2017 jmehm.tums.ac.ir anahita masoumpoor et al. page 5 of 7 behaviors (27). studies conducted in the us by tantleff-dunn et al. (7) and luparell (3) showed that students experienced humiliation as a result of the teacher not responding to their questions and neglecting them. the lack of supportiveness was another subtheme that was experienced in the form of the teacher's general indifference and the lack of attention to the students' requests. clark and springer referred to this subtheme as the teacher's refusal to respond to the students' requests (4). distrust was another subtheme frequently referred to by the students. although other studies have not directly addressed this subtheme, teachers' inflexibility and bullheadedness were noted several times (28, 29), which may have been due to the teachers' distrust in the students caused by their lying, trickery, and cheating in the exams. in the present study, the teachers' distrust in the students was attributed to the students' dishonesty. self-centeredness was another subtheme discussed by the majority of the students. according to victor and cullen, in moral theory, self-centeredness is in line with egoism, which indicates an inconsideration for others (30). in the present study, selfcenteredness was manifested as grading the students according to one’s own preferences or presumptions, and in some cases as humiliating the students and making them apologize, which might be due to the teachers' sense of superiority over the students. coercion and aggression comprised another subtheme of inimical behaviors, which were said to be manifested in the form of imposing one’s own beliefs, throwing books and arguing with the students. clark and carnosso confirm some teachers' tendency to use coercion and aggression on their students (8). harassment was another subtheme of inimical behaviors. the students described this behavior as manifesting in the form of the teacher giving his phone number to students of the opposite sex and having roving eyes directed at them. gallo confirmed some teachers' tendency to harass their students by the cellphone or through emails (11). in the islamic culture of iran, interaction between sexes is clearly defined according to the four principles of ashram and non-ashram and halal (allowed) and harm (forbidden); observing these principles is a duty of every iranian muslim. on another note, the main reason for attending university is to acquire knowledge, and interaction with the other sex in the academia is solely for educational purposes, and any friendships that may develop should be toward an educational goal or else be the prelude to achieving educational goals (31). any behavior or relationship that distances the student from this goal is considered a diversion from the path of communication for the purpose of education (32). poor teaching skills of the teacher was a subtheme of threatening behaviors; students referred to the teachers' lack of knowledge, not using different teaching techniques, and reading tedious slides out loud, and also the use of inexperienced teachers. the students believed that teacher's high scientific capabilities and their use of modern teaching techniques creates enthusiasm in them for learning and encourages them to acquire knowledge and skills. clark also confirms the manifestation of the poor teaching skills of some teachers in the form of using ineffective methods and diversion from the topic of class (33). poor time management was another subtheme, which was frequently expressed by the students to take place in the form of wasting time by irrelevant chatter, having no teaching plans, and requests for additional sessions. it is worth noting that no studies were found on this issue, which might be due to the limited number of studies conducted on the topic. the cause may also be that the need for time management is so deeply felt in other countries, that it has become an integral part of their life along with respect for others' rights (34), and the lack of time management has been considered an act of indiscipline (35,36). indiscipline was a subtheme of tainting behaviors, which was manifested as late arrival to class, early dismissal of class, taking care of personal chores inside the class, and not coming to class prepared for teaching. as teachers are role models for their students, their disciplinary conduct makes students observe discipline as a duty and a norm in educational settings. clark confirmed indiscipline to manifest itself in the form of late arrival to class, early dismissal of the class, and coming to the class unprepared to teach (13). the results of the present study cannot be taken as fully reflecting the perceptions of the entire community of nursing students in iran. however, since the university admission system in iran is centralized rather than localized, and since the education system is also centralized, the same perceptions can be assumed to exist in other parts of the country. the findings of the present study can therefore be indicative of the perceptions of the majority of nursing students across the country. conclusion the results of the present study indicate that uncivil behaviors in nursing education and their destructive consequences are not issues that can be ignored. neglecting these abnormal behaviors may lead to aggressive and hostile behaviors. these behaviors might become the norm and form part of the culture of the society over time. given that teachers play a guiding role for students in addition to their educational role, their contribution to the formation of these behaviors cannot be overlooked. since the educational environment, and especially teachers, play a major role in fostering committed, ethical, and devoted nurses, and since patients are the ultimate group that benefit from these improvements, it is j med ethics hist med 10: 10, november, 2017 jmehm.tums.ac.ir anahita masoumpoor et al. page 6 of 7 upon the authorities of the healthcare system to take every necessary measure for promoting civil behaviors and ending the growing trend of uncivil behaviors in nursing education settings for the ultimate purpose of fostering committed and efficient nurses and ensuring patient safety and health. acknowledgements the present study is part of a phd dissertation, with the code sbmu.rec.1393.638, approved by the research council and ethics committee of shahid beheshti university of medical sciences (code of ethics: irsbmu.retech.rec.1395.587). the present study is the result of the generous guidance and the sincere endeavors of professors who helped in carrying out the research. the authors would like to express their gratitude to all the students and officials of the nursing and midwifery schools of shahid beheshti university of medical sciences, tehran university of medical sciences, iran university of medical sciences, islamic azad university, and shahed university. conflicting interests there were no potential conflicts of interest with respect to the research, authorship, and article publication. j med ethics hist med 10: 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farahani1, mina gaeeni2*, nooreddin mohammadi3, naima seyedfatemi1 1associate professor, faculty of nursing and midwifery, iran university of medical sciences, tehran, iran; 2nursing phd candidate, faculty of nursing and midwifery, iran university of medical sciences, tehran, iran; 3assistant professor, faculty of nursing and midwifery, iran university of medical sciences, tehran, iran. corresponding author: mina gaeeni address: iran university of medical sciences, faculty of nursing and midwifery, department of nursing email: mkaeeni@yahoo.com tel: 98 0912 5520819 fax: 98 02188201978 received: 05 feb 2014 accepted: 14 jun 2014 published: 20 jun 2014 j med ethics hist med, 2014, 7:9 © 2014 mansoureh a farahani et al.; licensee tehran univ. med. sci. abstract receiving information related to patients hospitalized in the intensive care unit is among the most important needs of the family members of such patients. when health care professionals should decide whether to be honest or to give hope, giving information becomes an ethical challenge. we conducted a research to study the ethical approaches of iranian nurses to giving information to the family members of patients in the intensive care units. this research was conducted in the intensive care units of three teaching hospitals in iran. it employed a qualitative approach involving semi-structured and in-depth interviews with a purposive sample of 12 nurses to identify the ethical approaches to giving information to family members of the intensive care unit patients. a conventional content analysis of the data produced two categories and five subcategories. the two categories were as follows: a) informational support, and b) emotional support. informational support had 2 subcategories consisting of being honest in giving information, and providing complete and understandable information. emotional support in giving information had 3 sub-categories consisting of gradual revelation, empathy and assurance. findings of the study indicated that ethical approaches to giving information can be in the form of either informational support or emotional support, based on patients’ conditions and prognoses, their families’ emotional state, the necessity of providing a calm atmosphere in the icu and the hospital, and other patients and their families’ peace. findings of the present study can be used as a basis for further studies and for offering ethical guidelines in giving information to the families of patients hospitalized in the icu. keywords: intensive care unit (icu), family members, nursing ethics, giving information mailto:mkaeeni@yahoo.com j med ethics hist med 7:9 jun, 2014 jmehm.tums.ac.ir mansoureh a farahani et al. page 2 of 7 (page number not for citation purposes) introduction as the first social institution, each family bears culture, roles and special structures signifying the physical, mental, social, spiritual and cultural health of its members. any disorder in these areas will lead to a holistic disorder (1 4). one of the changes affecting the family is when one of its members is hospitalized. when a patient is hospitalized in the intensive care unit due to a serious illness or a life threatening condition, the effect of this phenomenon becomes more severe (5). a patient’s critical situation and unclear prognosis can cause reactions such as fear, anxiety, physical and mental fatigue, hopelessness, disappointment and frustration in family members (5 9). when one of the family members is hospitalized in the intensive care unit, the family will have some needs (10); information, assurance, empathy and mental support are among these needs (11-13). the results of a review prioritizing the needs of the family members of patients in the intensive care unit show that receiving information about the patient is among the most important needs of such families (14). the results of another study also show that most of the stress and anxiety in patients’ family members is due to inadequate information about prognosis and treatment, and lack of familiarity with the environment and the complicated equipment in the intensive care unit (15). researchers also asserted that the uncertainty and lack of information experienced by patients’ family members is an important factor in increasing their depression and anxiety (16). giving information to the family members of patients in the intensive care unit equips them with a better understanding of the stressful situation and decreases their level of anxiety (17). using confrontation sources and strategies and giving information to the family members of the patients hospitalized in the icu also helps them to better adapt when confronted with such stressful conditions and can bring their expectations about their patients’ prognosis closer to reality (18-20). health care professionals working in the intensive care unit are confronted with lots of ethical challenges because of the complications in giving care (21). families of patients hospitalized in the intensive care unit often want their questions to be answered honestly and comprehensibly. they also want to be informed about changes in the clinical conditions of the patients as soon as possible (22). in contrast, because of the instability of patients’ clinical condition and their family members’ emotional state, health care professionals tend to give general and ambiguous information about the patients’ condition to protect their families against anxiety and stress (23). sometimes health care professionals should decide whether to be honest or to give hope (24), and that is when giving information becomes an ethical challenge (25). literature review on the information needs of the families of patients in the icu) (10, 13, 26-30). revealed a lack of studies on ethical approaches to giving information to family members of such patients. therefore, further studies for identification of nurses’ approaches can provide the basic knowledge for ethical family-centered care in nursing. method this qualitative study adopted a conventional qualitative content analysis approach. this method is one of the approaches of qualitative research and also of qualitative data analysis (31); it examines written, spoken or visual messages consisting of raw data that are summarized and then categorized. in conventional content analysis data provides the basis for developing categories and their names (32). the study was conducted in the intensive care units of three teaching hospitals in iran (a total of 26 beds), where patients were admitted due to various medical conditions such as medicalsurgical problems, neurosurgical problems and trauma. participants participants were selected by purposive sampling method. in this research, sampling was done from nurses with maximum variation (sex, level of education, and job experience) to the point of data saturation. selection criteria for nurses were having iranian nationality, a minimum of one-year work experience in the critical care unit, and being interested in participating in the study. ethical considerations after approaching the participants and explaining the objectives of the study and also obtaining their consent, the researcher began to collect the data. ethical principles such as autonomy of the participants, confidentiality and anonymity were considered throughout the study. letters of recommendation were obtained from the research deputy of the university affiliated with each hospital. ethical approval was obtained from the ethics committee of iran university of medical sciences. data collection in this study, semi-structured and face-to-face interviews were conducted with 12 nurses. the duration of the interviews varied between 35 and 85 minutes with a mean of 60 minutes. interviews continued until data saturation was attained. at the beginning of the interview, the nurses were asked a general question: “what is your experience in giving information to patients’ families?” in order j med ethics hist med 7:9 jun, 2014 jmehm.tums.ac.ir mansoureh a farahani et al. page 3 of 7 (page number not for citation purposes) to obtain more information, the interviews continued with probing questions. all interviews were audio recorded and then transcribed verbatim in order to analyze data. data analysis for data analysis, the researcher used conventional content analysis according to the graneheim and lundman method (33). this approach is usually appropriate when existing theory or research literature on a phenomenon is limited. researchers used inductive category development, i.e., avoided using preconceived categories and instead allowed the categories to flow from the data. researchers also immersed themselves in the data to allow new insights to emerge (32). according to the content analysis process, at first each interview was read again and again carefully in order to gain a universal and primary understanding of the important underlined statements. meaning units were then determined through investigating participants’ experiences in the interview texts. in the next phase, the meaning units were extracted through condensation and were labeled as codes. participants’ statements and implicit concepts were used for coding. codes were compared for similarities and differences within the same interview and in different interviews, and then categorization of codes was done accordingly. in the following stage, categories and subcategories were examined under supervision of experts who were experienced in qualitative analysis. rigor of the study concepts of credibility, confirmability, auditability and transferability were used to measure the trustworthiness of the data (34). credibility of the data in this study was evaluated through member check, peer check and prolonged engagement. after the analysis, the participants were contacted and given a full transcript of their respective coded interviews with a summary of the emergent categories to approve interpretations of the researchers. an expert supervisor and two doctoral students of nursing checked the study process. prolonged engagement with the participants within the research field for a period of 9 months helped us in gaining the participants' trust and a better understanding of their world. we saved all evidence and documents securely to maintain auditability. moreover, we carried out a thick description of the context adequately so that a judgment of transferability could be made by readers. results of the twelve nurses who participated in this study, 8 were female and 4 were male. the mean age of the study participants was 40.42 ± 2.16 years, and their work experience in critical care ranged from 4 to 12 years. the results of the data analysis identified two main categories: informational support and emotional support (table 1). informational support one of the categories clarified in this study was informational support. this category had two subcategories: being honest in giving information, and giving complete and understandable information. based on the data from the interviews, it became clear that using informational support in giving information can act as an effective moderating factor in decreasing anxiety and concern. honesty is a characteristic that families expect from physicians when receiving information. family members demand to be informed of the patients’ condition and of whatever the health care professionals know. in brief, they seek out honesty and trustworthiness in the process of their interaction with health care professionals. in this respect, one of the nurses said: “families insist on receiving correct information and expect the nurses to tell them the truth. if they feel any falsehood in the information they are offered, they will lose their faith in the personnel including the doctor and the nurse” [participant no. 2]. giving complete and understandable information was the second subcategory of informational support. in this regard, many of the nurses said that information must be offered completely and understandably. they also asserted that if the provided information meets the knowledge level of patients’ families, they can better understand it, and their interpretations will be accurate. this can decrease the level of their anxiety and concern. in this regard, one of the nurses said: “the families of patients in the icu suffer from severe stress and anxiety, and if they cannot attain thorough and precise information about their patients’ situation, their stress gets intensified, which can negatively affect their relation with the health care providers” [participant no. 5]. many nurses commented on misinterpretation or misunderstanding of the information and incomprehensible information. in this respect, a nurse said: ”sometimes the interpretations are different. unfortunately, because of misinterpretation, sometimes families become more disappointed or more hopeful” [participant no. 3]. in this regard, health care professionals’ statements showed that incomplete information given by physicians and nurses to patients’ family members could cause confusion and ambiguity. one nurse said: “the information that the nurse offers may not be complete, and this may lead to contradictory information” [participant no. 12]. nurses also announced that there was a disagreement between nurses and physicians in terms of giving information to patients and their families. they believed that the main reasons for this disagreement were lack of communication and coordination between physicians and nurses, j med ethics hist med 7:9 jun, 2014 jmehm.tums.ac.ir mansoureh a farahani et al. page 4 of 7 (page number not for citation purposes) physicians’ reluctance to provide information to patients’ families, and nurses’ de-motivation. one of the nurses said: “one reason why health care professionals aren’t functioning properly is because of the personnel’s fatigue. another reason is that the personnel see nobody appreciates what they’ve done and families are grateful to physicians, and the nurses’ role as the most important factor in patient care in the icu is not highlighted. the life of a patient in the icu is at the hands of the nurses. lack of motivation in nurses can affect their relationship with the patients’ families” [participant no. 9]. emotional support the second category identified in this study was emotional support. this category had three subcategories: gradual revelation, empathy, and assurance. most of the interviews highlighted the fact that emotional support in giving information can be one of the moderating factors of stress and anxiety in patients’ families. one of the subcategories of emotional support in giving information was gradual revelation. information control by health care providers was one of the strategies hidden in gradual revelation. there were many reasons to choose this strategy (that is, information control). families’ mental and emotional condition, patients’ instability, physicians’ reluctance to give thorough information and constrictions related to the organization (such as the special conditions of the intensive care unit) are to name a few. in this regard, one of the nurses said: “under certain circumstances, we can’t tell the truth to the patients’ families about their illness or the possible consequences due to the situation in the ward. for example, if a patient suffers from brain death and the news is given to his family abruptly, they may react in a negative way and make the ward and the hospital agitated, which can badly affect other patients and their families. as nurses, we can inform the families within the nursing scope of practice and based on the hospital regulations, and we aren’t allowed to give them detailed information about the medical scope. in such cases, they are referred to the doctors” [participant no. 8]. the second subcategory of emotional support in giving information was empathy. in nursing, especially in emotional family-centered care, empathizing with families is a crucial factor in giving care. most of the nurses participating in this study believed that patients’ families needed health care professionals to sympathize with them and to give them the necessary information in an empathic and effective relationship. they declared that an empathic and sympathetic relationship kept families hopeful and to a great extent decreased their mental suffering and protected them against emotional vulnerability. the following statements show such effects: “when families talk to physicians and nurses, especially the icu personnel, and ask about patients’ conditions, if the doctors or nurses explain the patients’ conditions clearly, if they have empathy with the families and ask them to be patient, they can bring the families some hope” [participant no. 1]. from the viewpoint of the nurses, assurance was another factor related to emotional support in giving information. compassion, empathy and giving honest answers to the questions of patients’ families are among the factors which can create security and assurance in families. concerning assurance, one of the nurses said: “if we have an empathic and honest relation with the families of these patients, and if we show them that we understand them, we will be able to create a connection and will have their cooperation accompanied by a feeling of security and trust. when such an atmosphere is created, whatever the health care providers pick is accepted by the families, and they trust us” [participant no. 11]. table1categories, subcategories and codes demonstrating the ethical approaches to giving information to family members of the intensive care unit patients categories subcategories codes informational support being honest in giving information giving complete and understandable information honesty, informing patients’ family members honestly, telling the truth, offering real information complete information, giving clear and plain information emotional support gradual revelation empathy assurance informing patients’ families based on the existing conditions empathy in informing patients’ families, empathy through health care providers’ empathic relationship showing empathy through health care providers’ availability, creating emotional security by providing appropriate answers to the questions. j med ethics hist med 7:9 jun, 2014 jmehm.tums.ac.ir mansoureh a farahani et al. page 5 of 7 (page number not for citation purposes) discussion this qualitative study showed different categories of iranian nurses ethical approaches to giving information to icu patients’ families. the results of the data analysis identified two categories and five subcategories. informational support was the approach employed by most of the nurses in this study, and the strategies used in this approach were generally satisfactory and acceptable to families. the findings of a study by azoulay et al., which showed families’ dissatisfaction with the quantity and quality of the received information, also confirmed the importance of informational support (35). one of the strategies mentioned in informational support was health care professionals’ honesty in giving information to patients’ family members. bond et al. reported that families wanted their questions about the patients’ conditions to be answered honestly and realistically (36). the challenge offered here is that patients’ family members expect health care providers to treat them honestly, and health care providers eschew giving thorough and honest information due to reasons such as the mental and emotional state of the family members and patients’ unstable conditions. in fact, they are dubious to choose to be honest. if they tell the truth, there is a possibility that the family will not be able to tolerate the pressure. similarly, in cases where an accurate prognosis is not possible, giving true and thorough information could create false hopes and lead to mental suffering in patients’ family members. a study showed that withholding the truth can be effective in protecting individuals against mental after-effects such as losing hope and its consequent suffering (37). the most important need of families is to receive real and appropriate information about patients’ prognosis based on the current situation. on the other hand, health care professionals believe that general and ambiguous information should be given to families based on the patients’ prognosis and instability. in this regard, the findings of two studies showed that one of the major concerns of all family members is receiving truthful and complete information that allows building realistic hope (38, 39). it is inferred from the statements of health care providers that withholding the truth does not mean to lie, but to use gradual revelation as a form of emotional support. in such situations, it is difficult to determine which approach should be used in giving information to the patients' families and whether to tell the truth or not. based on the reasons extracted from participants’ attitudes, telling the truth can be ethical in some circumstances and unethical in others. issues such as patients’ stability, families’ emotional situation and the existing conditions in the icu and the hospital can determine the health care professionals’ ethical decisions in this regard. moreover, studies have shown that although families expect correct and complete information, physicians and nurses are not always able to accommodate them. this is due to the patients’ unstable situation at the time of hospitalization in the icu and lack of comprehensive information about their prognosis (2, 40). another strategy in informational support was to give complete and understandable information, which was mostly demanded by patients’ families. health care providers used the information control strategy. they determined the family member to whom information should be given and the method of providing information. this manner of giving information was sometimes in sharp contrast with the needs of the families. in a study health care providers confessed that families need information about changes in their patients’ condition and they have the right to receive understandable information, but they cannot bear to receive all the information at once. therefore, information must be constantly and gradually offered (37). most participants viewed empathy as one of the subcategories of emotional support. an empathic and honest interaction with the families can make them hopeful about their patients’ situation. it is never meant to give them false hope, but through appropriate interaction, health care providers can equip family members with internal powers to confront critical moments and prepare them to accept the patients’ situation. based on the results of a study, an empathic and trusted relationship is one of the necessities of nursing care in the icu (41). giving contradictory information to families results in distrust, frequent questioning and requests to stay by the patient in the icu. as bond et al. mentioned, when families receive contradictory information, they try to use strategies such as visiting the patient and participating in the process of care in order to test the accuracy of the received information (36). another study revealed the interplay between perceived hope and health care providers’ approaches to giving information, and confirmed that contradictory information created false hopes in families and caused them to lose their trust in health care providers (38). in general, based on the findings of the present study, the patients’ conditions and prognoses, families’ emotional state, the necessity of providing a calm atmosphere in the icu and the hospital, and other patients and their families’ peace determine the appropriate and ethical approaches to give information to the families of patients in icu. conclusion this study revealed a small portion of ethical approaches to giving information to the families of patients in the icu. the results of this study j med ethics hist med 7:9 jun, 2014 jmehm.tums.ac.ir mansoureh a farahani et al. page 6 of 7 (page number not for citation purposes) showed two ethical approaches to giving information: informational support and emotional support. generally, health care professionals should give complete and understandable information to the families of icu patients as far as conditions of the patients, families and the hospital permit. since the present study focused on the ethical approaches to giving information to the families of patients in the icu, different dimensions of each of the strategies in these approaches were not studied here. therefore, it is recommended that more studies be conducted on the abovementioned dimensions of ethical approaches to giving information, especially on how to tell the truth to the families of patients in the icu. it is also necessary to conduct studies on providing and employing guidelines for confronting ethical challenges in giving information to the families of patients in the icu. acknowledgement this study is part of a nursing phd dissertation supported by iran university of medical sciences. the authors appreciate the cooperation of all the authorities in iran university of medical sciences. the authors also wish to thank all nurses for their sincere cooperation during the different stages of this study. references 1. rabia siahkali s, pourmeamari mh, khaleghdoost mohamadi t, eskandari f, avazeh a. study on effective factors on patients' family members anxiety in intensive care units. j zanjan univ med sci 2010; 18(70): 91-101. 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verhaeghe st, van zuuren fj, defloor t, duijnstee ms, grypdonck mh. how does information influence hope in family members of traumatic coma patients in intensive care unit? j clin nurs 2007; 16(8): 1488-97. 39. serio cd, kreutzer js, witol ad. family needs after traumatic brain injury: a factor analytic study of the family needs questionnaire. brain inj 1997; 11(1): 1-9. 40. 40. burr g. contextualizing critical care family needs through triangulation: an australian study. intensive crit care nurs 1998; 14(4): 161-9. 41. söderström im, benzein e, saveman bi. nurses’ experiences of interaction with family members in intensive care units. scand j caring sci 2003; 17(2): 185–92. journal of medical ethics and history of medicine original article a conceptual model of physician-patient relationships: a qualitative study mohammad reza razzaghi 1 , leila afshar 2* 1 professor, laser application in medical sciences research center, shahid beheshti university of medical sciences, tehran, iran; 2 assistant professor, department of medical ethics, shahid beheshti university of medical sciences, tehran, iran. corresponding author: leila afshar address: department of medical ethics, shams alley, vali asr ave.,tehran, iran email: leilaafshar@sbmu.ac.ir tel/fax: 982188773521 received: 12 mar 2016 accepted: 24 oct 2016 published: 8 nov 2016 j med ethics hist med, 2016, 9:14 © 2016 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract in any clinical encounter, an effective physician-patient relationship is necessary for achieving the desired outcome. this outcome is successful treatment, and therefore, the relationship should be a healing one. in addition, in the islamic view, the physician is a manifestation of god’s healing attribute, which is usually undermined in everyday therapeutic communications. yet there are few empirical data about this experience and how it occurs in the clinical context. this study was conducted to develop a model of physician-patient relationship, with the healing process at its core. our goal was to explain the nature and characteristics of this encounter. in islamic teachings, healing is defined as “cure” when possible and if not, reducing pain and suffering and ultimately finding a meaning in the illness experience. this study was a qualitative inquiry. data were collected through 17 open-ended, semi-structured interviews with physicians who had an effective relationship with their patients. the participants’ experiences and their perception regarding the relationship were subjected to grounded theory content analysis. for establishing the trustworthiness of the data collection and analysis we used triangulation, peer review, and member checking. the findings showed that the components of the patient-physician healing relationship could be categorized in the four key processes of valuing the patient as a person, effective management of power imbalance, commitment, and the physician’s competence and character. this leads to forming the three necessary relational elements of trust, peace and hope, and being acknowledged. their importance has been better demonstrated in a relationship which incorporates the spiritual aspects of patient care and also physician’s satisfaction. the physician-patient relationship has a central role in patient outcome. this relationship has an understandable structure and its components may have an effective impact on promoting the patient’s experience of the health system. keywords: physician-patient relationship, healing relationship, qualitative research, islam mailto:leilaafshar@sbmu.ac.ir j med ethics hist med 9: 14 november, 2016 jmehm.tums.ac.ir mohammadreza razzaghi et al. page 2 of 7 introduction the physician-patient relationship is a clinical encounter and its effective outcome has a direct impact on the quality of care (1) and achievement of a successful treatment. hence, a healing relation must be formed between a physician and his/her patient. however, today, the physician-patient relationship undermined and the medical professional is considered as the technician and the patient is considered as the machine (1). nevertheless, the establishment of an effective communication with the patient requires an understanding of the fact that the patient is not just a set of symptoms of a damaged organ, but a human with dignity and his or her own concerns and aspirations, who is in search of help and healing. the importance of such an effective therapeutic relation should not be ignored. moreover, in most cases, accurate diagnosis and effective treatment of the patient are directly dependent on the quality of the mentioned relationship. the development of such a relationship would allow the patient to share his/her most personal and private information with the physician in a safe and intimate environment. the scientific impact of the common philosophy of medicine which underestimates the patient’s body to a set of organs cannot be denied since such an approach has led to many developments in the field of medicine (2). although dissenting voices are heard in modern medicine, there has been clear evidence of the importance of this relationship in the ancient medical history of iran, especially in the islamic period (3). this strong background gives us the opportunity to explain and design a model of physician-patient relationship. human relationships have a crucial status and people’s rights, good conduct, and trusteeship have been emphasized in islam. islam considers the physician-patient relationship as a value-based and sacred one, because of knowing the physician to be a manifestation of god's healing attribute. the goal of the physician-patient relationship, as any other relationship, is maturity, integrity, and excellence (4, 5). during the past decades, there has been a struggle over the physician-patient relationship and its impact on the medical decision-making process, and so, on the therapeutic outcome. this struggle is often defined as a conflict between patient’s autonomy and his/her health in other words, the values of the patient and the values of the health care providers. based on this conflict, four models of physicianpatient relationship have been proposed (6). however, based on the type of relationship, its purpose, effectiveness of the physician’s role, and the existing expectations, each relationship between a physician and his/her patient is unique (7). this relationship is also influenced by cultural elements (7). yet, we know little empirically about this experience and how it occurs in the clinician-patient relationship. for this reason, it is necessary to redefine and design the specific relational model of every society based on its own components. the core of the medical practice is communication and the purpose of this communication is patient’s healing and satisfaction and physician’s integrity. on this basis, all elements of the relationship should be formed in line with the ultimate goal of medicine, i.e. the best and most righteous possible action for each patient. this means that the nature and characteristics of the physician-patient relationship can be drawn through identification of its fundamental concepts and based on these elements a conceptual model could be proposed. the impacts of the cultural and value system on human relationships provide the possibility of designing a model based on an iranian-islamic pattern for therapeutic relationship. in this study, healing was defined as cure if possible, and when cure is not achievable, trying to reduce the patient’s suffering and or finding a meaning in the patient’s experience. this study was conducted to explore the positive effect of the physician-patient relationships. our focus on physician-patient relationships is because of its potentiality to improve the physician’s professional conduct and the patient’s satisfaction. method the aim of this study was to explain and propose a physician-patient relationship model and its components. the focus of the study was healing relationship due to its potential capacity to enhance the patient’s satisfaction and physician’s integrity. therefore, the qualitative paradigm was chosen and utilized. data were collected through 17 open-ended semi-structured interviews with physicians who had effective relationships with their patients. the physician’s perception regarding the relationship was subjected to grounded theory content analysis. the participants were selected from different medical specialties and the sampling process continued until data saturation. the physicians were selected based on the quality of their relationship with the patients who were the exemplars in this issue. data collection was performed through semistructured interviews. for this purpose, an interview guideline was prepared with a number of general open-ended questions to help the researcher. the objective of the research and its methodology were explained to each participant in a separate meeting before the interview and their oral informed consents were obtained. the place and time of the interviews were determined by the participants and the durations of the interviews varied between 60 and 90 minutes based on participants’ willingness. after each interview, the researcher documented all recorded files and field notes. all statements and expressions of the participants were completely j med ethics hist med 9: 14 november, 2016 jmehm.tums.ac.ir mohammadreza razzaghi et al. page 3 of 7 rewritten verbatim in microsoft word and coding was done on three levels. through this method, the initial codes, sub-categories, and themes were extracted from the data. it is worth noting that the first step of analysis of initial codes was extracted from a thousand semantic unites. in later stages, the codes were gradually reduced by removing the identical and overlapping codes and they were gradually categorized into the classes and sub-classes explained in the following sections (8, 9). data-source triangulation was performed by collecting data from physicians who practice in different fields. for establishing the trustworthiness of the data collection and analysis we used triangulation, peer review, and member checking. an expert colleague in qualitative methods examined the interview transcripts, coding sheets, and the synopsis of the findings. in this peer review process the analysis was identified complete and logical, based on the interview sheets, the study findings were accurate. for the member checking 2 of the participants revised the data and affirmed that the findings were consistent with their experiences. results in this study, according to the data transcription, saturation was achieved after 17 interviews. participants were specialists in fields that naturally dealt with chronic or life-threatening diseases and had effective relationships with their patients over time. the physician-patient relationship in the healing process based on the findings of this study, which are provided entirely in table 1, the physician-patient relationship model consists of four components. these components conduce to three relational outcomes, all of which come under a common theme. table 1physician-patient relationship components definition sub-category category accepting the patient as a person non-judgmental behavior valuing the patient effective communication with patients based on their individual character communication effective listening, appreciating the patient’s experience of illness and empathy effective presence engaging patients in diagnostic and therapeutic decision-making shared decision-making the balance of power explaining medical terminology in an understandable language for the patient and educating them to follow the care tasks educating the patient using authority to encourage the patient to follow medical advice guidance constant communication with patients over time the continuity of the relationship commitment being present in critical situations presence being present even if cure is not possible fidelity physician’s confidence in the the diagnostic and therapeutic plan self-confidence physician’s character and competencies the ability to be aware of his/her emotions and control them managing the emotions the ability to consider the internal and external forcible factors mindfulness the physician’s expert knowledge scientific knowledge components of the physician-patient relationship model valuing the patient the first component of the model is the amount of value which the physician considers for his/her patient. this category includes three sub-categories of non-judgmental behavior, connecting with the patient, and effective presence. the valuing process begins with a non-judgmental stance and respecting the patient’s dignity. this includes all patients from different cultural and social classes and with different diseases. it was stated by one of the participants: [i have the same attitude toward all my patients with different cultural levels ..... my colleagues have often told me that you cannot work in this cultural community, but i want to do my valuable work and it does not matter for me where i am working.] another interviewee stated: [as a physician, i cannot transfer my message correctly unless i have come to understand and believe that i am responsible for the health of people who are sitting in front of me, and i must respect it.] another participant said: [we have to respect patients whether they are children or adults.] participants also said that building an effective communication requires the consideration of the characteristics of the individual patient and acknowledgment of common humanistic experiences. in this regard, one participant said: [children sometimes say we do not want to see another physician until you come back; i have nothing to give them it is just an emotional j med ethics hist med 9: 14 november, 2016 jmehm.tums.ac.ir mohammadreza razzaghi et al. page 4 of 7 relationship.] another participant stated: [i always try to build an empathetic relationship with my patients and their family, it helps develop trust.]. this type of relationship results in the consideration of the patient as a person and not just a diseased body. in this regard, one physician indicated: [i must be both physically and psychologically helpful for my patients.] in fact, this type of treatment results in an integrated picture of the patient as body, mind, and spirit. the third sub-category of valuation is effective presence at the bedside of patients or full attention to them. in this regard, one participant mentioned: [i propose complete care for my patients with full attention; this will prevent many problems.] the full and active presence of the physician in the clinical encounter will result in a good relationship and trust. as one participant stated: [when you speak with the parents, calming the mother, this simple activity changes everything ..... sometimes just active listening is enough…. to create an empathetic relationship.] furthermore, understanding the patient’s experience of illness and suffering requires the physician’s full presence. this will enable the physician to communicate with patients in an empathetic manner. [i feel a sense of peace" another participant said: "if patients feel that you are tired or you are not fully present, they will not trust you and the treatment will not be effective.] the balance of power the participants of this study reported that they had often tried to empower the patients or their family. sometimes, this has been done by engaging the patients in therapeutic decision-making. as one said: [explaining the issues to the patients or their family is very effective and often results in their following the treatment.] another way to prevail over the power imbalance is educating the patients. this begins with the explanation and translation of medical terminology into a comprehensible language for the patient and educating them to follow the care tasks. one participant remarked: [i tell patients that they have to connect with me every week, even after finishing the drugs. the patient’s health status will improve with only simple recommendations. because it is my verbal communication that will assure the patients; and in this method i will educate my patients.] another participant said: [i have to talk with each patient in their own language. the doctor should have the skills to convey his message.] sometimes it is necessary for physicians to use their power and authority to encourage the patients who do not accept responsibility for their treatment. for example, one participant mentioned: [i say to my patients that if you think you can trust me, listen to me and obey my recommendations, and then, we will move ahead together.] physicians who participated in this study mentioned that they intuitively understand with which patients and at what time it is necessary to use their power and authority. this depends on the patient’s needs and the type of physician-patient relationship. commitment the common feature of physicians participating in this study was working in one place for years. this leads to constant communication with the patients. this form of communication between a physician and patients, in turn, creates an intimacy that it is called a sense of family relationship. in this regard, one participant said: [i always tell to my students that you should think the patient is your sister.]. another participant asserted: [i think doctors need to have a sense of a close relationship with the patient.] the experience of a long-term relationship between the physician and his/her patient, especially in health crisis events, leads to the formation of a common history, and thus, a strong and rich therapeutic relationship between them. doctors show their commitment to their patients through care activities. some of these activities, in our current medical context, are extraordinary, like home visiting or phone calls. others fit in the context of routine daily actions; however, in their opinion these activities are signs of respect for the patient. for example, one participant noted: [when a patient is seriously ill, i may call him/her ten times a day to ensure his/her wellbeing.] another participant said: [i visited a patient who could not move at home, then, i gave him my phone number, and based on my experiences, step by step i told him what to do and this led him to trust me, and his outcome was much better than the expectations.] another participant said: [one of the things i do is that each day after seeing the last patient in my office, i call all patients who have called me. this results in them trusting me.] these caring and supporting activities reflect the commitment of physicians to their patients, which, in addition to medication and medical technologies, could influence the outcome of the healing process. physician’s character and competencies if the physician is confident of his/her diagnosis and treatment, this confidence will effectively transfer to the patient. this self-confidence is an important component of the healing relationship. the physician’s self-confidence will led to a sense of confidence in the patient. the physician’s ability to manage and control his/her emotions needs some fundamental skills such as understanding their own emotions and having appropriate emotional reactions to patients in order to keep calm. in this regard, one of the participants stated: [management does not mean that a person is the manager of an office; he/she should manage him/herself.] mindfulness is another important feature that is defined as continuous awareness of what is happening at different levels. it means to be able to j med ethics hist med 9: 14 november, 2016 jmehm.tums.ac.ir mohammadreza razzaghi et al. page 5 of 7 recognize if the patient’s words originate from his/her deepest emotions of fear, anxiety, regret, or guilt. finally, expert knowledge is important in building an effective communication. the patient must be able to trust the physician’s knowledge and skills, and at the same time must understand the physician’s limitations and the necessity of consulting with other medical practitioners. in this regard, one participant said: [even if the patient dies, the patient's family knows that i have done all i had to; i have consulted with everyone regarding what was necessary.] relational outcomes if the mentioned components are applied appropriately, trust and peace and hope are achieved, and the patient is acknowledged, which are called relational outcomes and are necessary for the healing process. trust trust will form as a result of the process of valuation and commitment over time. one of the participants stated: [the patients must find their trusted physician; otherwise, they will not have faith in the medications and treatment.] the patients’ trust in their physicians does not mean that medical errors will not occur, but this trust indicates that the physician has done all that is within his/her power and at the same time acknowledges his/her limitations. one subject remarked: [the patient understands that i have done all i can, even if the desired outcome was not achieved.] peace and hope a therapeutic relationship can bring peace to the patients and their families. this does not always mean that cure is possible, but sometimes it means that there is hope of a few more good days, and provides opportunity for gratitude and forgiveness. in difficult situations, physicians act differently. in an effective communication and healing relationship, the patient feels the physician’s empathy and sympathy and understands it. they do not seek false hope; however, the patient will have a pleasant experience unless there was no effective treatment. in this regard, one participant said: [if we could explain the nature of the disease to the patient’s family and if we could explain death, then, they would be ready to go. they could understand where they were going and what was going on.] feeling the physician’s attention another outcome of effective communication is the patients’ sense of being acknowledged. this feeling results from valuing the patient and is based on the physician’s commitment. in such a situation, the physician recognizes the patient as a person and remembers him/her. in this regard, a physician stated: [the better the physician and patient know each other, the more desirable the outcomes achieved will be.] theme as noted above, to understand the foundation of an effective healing relationship, we should consider the cultural context. accordingly, in the iranian society, mentioning the islamic concepts of human relationship can improve the quantity of health relationship and can enrich the components of the physician-patient relationship. in this context, a basic element and a prerequisite to respecting human dignity is viewing every human being as a creation of god. in this regard, one participant said: [when you cannot do anything for your patient, it is time for spiritual care ..... this means that it is your intent that shapes the relationship]. another participant stated: [a small part of the therapeutic relationship is physical; the more profound a physician’s perception of his work is, the deeper his relation with his patients will be and it will be a part of his life.] another participant said: [spiritual and emotional pleasures are constant and are associated with our religious beliefs.] another physician said: [i believe that this work is god’s desire, it is god’s kindness that the patients’ need our knowledge and skills.] discussion the findings of this study showed that physicians, who had experience of effective communication with their patients, understood the therapeutic relationship and healing process in almost same way. in their view, healing means cure when it is possible, and reducing patient’s suffering and finding a meaning beyond the illness experience when cure is not possible. the focal center of this healing relationship is neither the physician nor the patient, but is their therapeutic relationship or “the between” (10) and is based on the common underlying beliefs, trust, and hope (11). this therapeutic relationship consists of understandable components which are valuing the patient, commitment to the patient, managing the power imbalance, and physician’s character and competencies. these components will form the three relational elements of trust, peace and hope, and being acknowledged. the present study tried to propose a model for therapeutic relationship based on the experiences of the research participants. in order to determine the effect of this model in the current situation of medical practice, we can evaluate it at three levels. first, the therapeutic physicianpatient relationship could enhance the patient’s quality of life. mutual trust, peace, and being acknowledged as the results of this relationship are equally important for both patients and physicians. second, some aspects of this relationship are related to the nature and severity of the disease and the type of required treatments (12, 13); however the patient’s and physician’s system of belief also play an important role in this regard (14). j med ethics hist med 9: 14 november, 2016 jmehm.tums.ac.ir mohammadreza razzaghi et al. page 6 of 7 third, the healing relationship affects both parties (patients and physicians). a number of physicians who participated in this study had experienced working in difficult situations (such as the battlefield or severely deprived areas) and they were satisfied with memorizing them. this experience is opposed to the cases that are reported from the physicians’ current behaviors (15). this indicates that such an enriched experience and relationship left its positive impact on their life and work. finally, it can be said that an effective and healing relationship is based on a system of belief that acknowledges the value of the human being and his/her inherent dignity, and accordingly considers clinical medicine as a favor which gives meaning to the physician’s life. it could be proposed that the solution to some health system problems could be found in redefining the physician-patient healing relationship. conclusion it can be concluded that the structure of the physician-patient healing relationships is comprehensible and may lead to valuable patientcentered outcomes. moreover, this discernible and understandable structure has important impacts on treatment. furthermore, this conceptual model can be generalized to other therapeutic relations in the health system. evidently, this study had some limitations. first, the participants were chosen selectively and are not considered significant indicators of the population of physicians. nevertheless, it can be explained that the intention of this study was to provide a preferred model of doctor-patient communication, and for this purpose, it was necessary to choose a targeted selection of participants. accordingly, the proposed model of the study does not explain the current situation, but if experimental studies confirm its effectiveness, it could be a standard to achieve. acknowledgments we acknowledge all physicians who participate in this study. ethical considerations in respect to ethical considerations and research ethics, the names of all physicians in this study are confidential and verbal consent was obtained before scheduling the interviews. this study was sponsored by the academy of medical sciences of the islamic republic of iran as a research project. j med ethics hist med 9: 14 november, 2016 jmehm.tums.ac.ir mohammadreza razzaghi et al. page 7 of 7 references 1. mendoza md, smith sg, eder mm, hickner j. the seventh element of quality: the doctor-patient relationship. fam med 2011; 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[in persian] 4. isfahai mm. physicians consideration and compassionate. iran j med ethics hist med 2009; 2(1): 1-6. [in persian] 5. arawi t. the ethics of the muslim physician and the legacy of muhammad (pbuh). journal of the islamic medical association of north america 2011; 43(1): 35-8. 6. emanuel ej, emanuel ll. four models of the physicianpatient relationship. jama 1992; 267(16): 2221-6. 7. asemani o. a review of the models of physician-patient relationship and its challenges. iran j med ethics hist med 2012; 5(4): 3650. [in persian] 8. elo s, kyngas h. the qualitative content analysis process. j adv nurs 2008; 62(1): 107-15. 9. strauss a, corbin jm. basics of qualitative research techniques and procedures of developing grounded theory. sage publications; 1998. 10. desmond w. being and the between. albany, ny: state university of new york press; 1995. 11. tresolini c, and the pew-fetzer task force. health professions education and relationship centered care. san francisco, ca: pew health professions commission; 1994. 12. krumholz hm, butler j, miller j, et al. prognostic importance of emotional support for elderly patients hospitalized with heart failure. circulation 1998; 97(10): 958–64. 13. house js, landis kr, umberson d. social relationships and health. science 1988; 241(4865): 540–45. 14. roberts ah, kewman dg, mercier l, hovell m. the power of nonspecific effects in healing implications for pyschosocial and biological treatments. clin psychol rev 1993; 13(5): 375–91. 15. geyman jp. health care in america: can our ailing system be healed? boston, ma: butterworth-heinemann; 2002. journal of medical ethics and history of medicine review article breaking bad news protocol for cancer disclosure: an iranian version parvaneh abazari1, fariba taleghani2, simin hematti3, azadeh malekian4, fariborz mokarian5, sayyed mohammad reza hakimian6, maryam ehsani7* 1assistant professor, nursing and midwifery care research center, faculty of nursing and midwifery, isfahan university of medical sciences, isfahan, iran. 2professor, nursing and midwifery care research center, faculty of nursing and midwifery, isfahan university of medical sciences, isfahan, iran. 3associate professor, department of radiotherapy and oncology, faculty of medicine, isfahan university of medical sciences, isfahan, iran. 4researcher, psychosomatic research center, isfahan university of medical sciences, isfahan, iran. 5assistant professor, cancer prevention research center, isfahan university of medical sciences, isfahan, iran. 6cancer prevention research center, isfahan university of medical sciences, isfahan, iran. 7assistant professor, nursing department, islamic azad university complex, tonekabon, iran. corresponding author: maryam ehsani address: 3rd km of chaloos road, vali abad, tonekabon, iran, postal box: 4684161167 email: my.ehsani@gmail.com tel: 09125336596 received: 21 jun 2017 accepted: 2 dec 2017 published: 19 dec 2017 j med ethics hist med, 2017, 10:13 © 2017 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract in iran, as in many asian and middle eastern countries, a significant proportion of cancer patients are never informed of their illness. one solution that has been proposed to tackle this challenge is to develop a localized protocol on cancer diagnosis disclosure based on the culture and values of community members, and train healthcare team members to deliver the bad news using this protocol. this article introduces a localized protocol for disclosure of bad news to cancer patients in iran. this protocol consists of six steps, including assessment, planning, preparation, disclosure, support and conclusion. in the drafting of this protocol an attempt was made to meticulously consider the cultural features of the iranian society. although breaking bad news will never be easy, having an appropriate plan of action based on individual’s attitudes, considerably helps health-care professionals, and provides more satisfaction in patients. keywords: breaking bad news, protocol, cancer disclosure, iranian version j med ethics hist med 10: 13, december, 2017 jmehm.tums.ac.ir parvaneh abazari et al. page 2 of 7 introduction today, in many western countries, honest and full disclosure of medical information is a common and accepted procedure, and since standards of medical ethics lay great emphasis on patients’ rights and their independence, physicians deliver bad news to their patients honestly and directly (1, 2). in fact, disclosure of bad news is no more a matter of concern in western countries, and the only important issue is the best way in which the healthcare team should deliver the news; in many asian countries, however, the phenomenon of breaking bad news is faced with several challenges, as there is still no consensus on whether bad news should be delivered to the patients or not (3, 4). in iran, studies show that around 40 percent of patients do not get informed of their disease (5). while the majority of iranian cancer patients prefer to be aware of the nature of their disease, they do not get informed (6, 7) regarding the importance and necessity of bad news disclosure, many researchers today are looking for patterns to help them with proper and scientific implementation of this task with the least emotional and psychological impact on patients and their families (8). adopting a systematic strategy for breaking bad news is a demanding task. the lack of such a strategy or a roadmap to control patients’ reactions when disclosing the news may cause physicians not to reveal all aspects of the news or even to give false hope to patients. this would decrease patients’ confidence in physicians and make them unwilling to participate in clinical decisions (9). despite the fact that such protocols and guidelines have been used in western countries for a long time to train healthcare teams for bad news disclosure, in many asian countries, including iran, there are no such protocols in effect. since bad news disclosure or truth telling is a purely cultural issue bearing on the values and beliefs of every single society (1, 4, 8, 10-15), various studies conducted in iran commonly emphasize the necessity of developing a localized protocol for bad news disclosure and recognize the lack of such a protocol as an obstacle in effective implementation of the procedure (7, 8, 13, 16, 17). considering the importance of local and culturebased guidelines for disclosure of bad news in an effective way, this review article aims to introduce a protocol based on the iranian culture to disclose cancer diagnosis to patients. method the protocol introduced in this paper is part of the last author’s phd dissertation, which was developed using a consecutive mixed-methods (qualitativequantitative) study (18-20). truth telling protocol for cancer patients this protocol is developed for breaking the bad news of cancer diagnosis to cancer patients and their family members, and includes six steps: assessment, planning, preparation, disclosure, support, and conclusion. the minimum members comprising the bad news disclosure team are: an oncologist or surgeon, a nurse trained in care of cancer patients, and a clinical psychologist. 1) assessment this step is run by a nurse along with a psychologist, and the patients and one of their closest family members provide the required basic information on the individual characteristics of the patients. the information would include education, occupation, religious beliefs, history of psychological diseases and receiving psychiatric drugs, patients’ desire to get informed about their illness, and the willingness of family members to provide the patients with such information. the information is assessed by the nurse, except for the history of psychological diseases and how the patients have dealt with the previous challenges in their life. one of the main duties of the nurse at this stage is to clarify the following: 1. does the patient wish to be informed of the diagnosis? 2. if the answer to the first question is “yes”, which one of his/her family members does he/she prefer to be advised of the diagnosis as well? 3. if the answer to the first question is “no” (i.e., the patient is not willing to receive this information), who does he/she prefer to have this information? 4. does the closest family member of the patient wish to disclose the diagnosis to the the patient when the latter is willing to receive it? 2) planning based on the patients’ answers and the reactions of their closest family members to the questions raised in the previous step, three situations may occur for which the nurse has to plan in advance: a. both the patient and their closest family member wish to get informed of the diagnosis: in this situation there is no challenge in telling the truth to them and the nurse only needs to provide the required conditions for the “truth-telling” session, and without going through the "family preparation" step, will directly enter the "environment preparation" step. b. the patient wishes to learn about the diagnosis, but the family is reluctant to tell the truth: this is a relatively difficult situation that is very common in the culture of asian countries and the middle east, including iran. in this case, and before preparing the requirements for “truth telling”, the nurse has to arrange a meeting with the patient’s family to obtain their consent and convince them of the necessity of telling the truth to the patient, so that she can perform the other steps of the protocol. j med ethics hist med 10: 13, december, 2017 jmehm.tums.ac.ir parvaneh abazari et al. page 3 of 7 c. the patient is not willing to know about his/her illness and prefers that other family members receive the information: patients should be assured that information on their diagnosis would be disclosed to them at their preferred time and to the extent that they choose. in this case, the nurse should make arrangements for the truth-telling session with the patient’s close family member(s), so that at first the "environment preparation" and then the other protocol steps are performed. it should be noted that in situation (c) after the "environment preparation" stage, all protocol steps should be performed focusing on the patient’s close family member(s), since the patient would not attend the truth-telling session in accordance with his/her request. 3) preparation the preparation step consists of three sub steps: family preparation, environment preparation, and patient preparation. a. family preparation if the data obtained in the “assessment” step are indicative of situation (b), it is necessary to arrange a "family preparation" session. this session should be held in the room designated for truth-telling, or if necessary, in the physician’s office in the ward, in the presence of a close family member and the nurse. the main purpose of this session is to investigate the reasons behind the family’s opposition by breaking the cancer news to the patient as well as persuading the former of the necessity of disclosing the diagnosis to the patient in an appropriate and proper way. it is essential for this room to be in a suitable condition, for instance there should be chairs, drinking water and tissue paper, and silence should be respected during the session as well. this stage is fully run by the nurse, but in rare cases, such as the family’s excessive insistence on secrecy, the nurse can ask for the help of the physician or the psychologist. furthermore, it is extremely important that the nurse and others who conduct the session observe the following points: respect the patient’s family members as well as the fact that their views toward truth-telling and patient’s autonomy could be totally different from their own. verify the family’s personal, cultural and religious reasons for concealing the diagnosis from the patient as well as their concerns about truth-telling to the patient through the following questions: “why don’t you want the patient to be informed of his/her disease?” “what do you think that i’m going to tell the patient that makes you worried?” “i know you're worried about what we are going to discuss with the patient, but we will certainly disclose any information to patients unless they themselves are not willing to receive it.” assure the patient's family that information on the diagnosis would be disclosed to the patient only to the extent that the patient requests and not beyond it. make the patient's family aware that despite their attempts to keep the diagnosis from the patient, the latter would often find out; therefore, it is the patient’s right to be informed in a suitable and appropriate way and not in an unexpected and indirect manner. explain to the family that the purpose of talking to patients is not a hasty disclosure of the diagnosis, but rather a review of their current information, recognizing their correct and incorrect understandings of the disease and knowing their level of readiness to get further informed about it. regarding the patient's religious beliefs and background, the conductor(s) of the session can benefit from islamic teachings and their clear viewpoints on patients’ right to know about their disease and decide freely about the issues in their lives. islamic concepts such as seeking forgiveness and making a will before death all indicate the fact that patients should be aware of their condition so that they themselves can plan for their life. b. environment preparation providing the suitable environment for truth telling is also among the duties of the nurse. at this stage it is necessary to pay attention to the following points: a private, comfortable, clean room should be used for the purpose of disclosing the cancer diagnosis to the patient. there should be no disturbing factors such as telephone or cellphone ring tones. before the session, enough chairs must be placed in the room so that all attendees including the patient, their family members and the healthcare team can take a seat. if the patient is lying on the bed, the nurse should put a chair next to his/her bed and invite the close relatives to sit as well before starting the session. there must be some tissue paper, bottles of water and glasses in the room. c. patient preparation after the preliminaries mentioned above in the previous steps, the truth-telling session to the patient and his/her family members will be held in the presence of the truth-telling team members and under the supervision of the team physician. the nurse must make the necessary arrangements to fix the time and place of the session. before the truthtelling session, team members should have a short meeting without the presence of the patient and his/her family and review the information and the results obtained in the previous steps. when the session begins and after introducing the team members as well as the purpose of the session, the physician should ask relevant questions in order to collect a clear view of the patient’s understanding of his/her medical condition. this stage is one of the main steps of the interview and demands high concentration and good listening skills. some of the questions that the physician can ask at this stage include: what information did your previous physician give j med ethics hist med 10: 13, december, 2017 jmehm.tums.ac.ir parvaneh abazari et al. page 4 of 7 you about your illness/surgery? what do you know about your disease? the patient’s answers to these questions should be carefully considered, because they can provide important information on his/her perception of the illness, emotional condition and the phrases and words used by him/her when speaking to the physician (for example, some patients at this stage prefer to use terms such as mass, tumor, benign or malignant, infection, anemia and so on to describe their disease). physicians should not disclose the news to patients hurriedly and without preparing them. if the patient pretends to be unaware of the disease or talks about it with excessive optimism that indicates denial of unpleasant realities, the physician should avoid disclosing the bad news of cancer diagnosis that day and postpone it until future sessions. 4) disclosure similar to the patient preparation step, the main task of disclosing the news of cancer diagnosis is up to the patient's physician at this stage. some of the important recommendations in this regard are: simple, clear and non-medical language should be used to tell the truth to the patients. relevant information must be disclosed step by step and in small chunks. the physician must make sure that the patient has clearly understood the information by asking questions such as "you see what i mean?" it may help to use eye contact with patients and their family members, sit close to patients and use touch techniques such as putting your hands on their shoulder or holding their hands (if the patient and the physician are of the same sex and there are no cultural barriers). the physician should replace the word "cancer" with words such as "malignant mass" or "malignant tumor" when disclosing the cancer diagnosis. although disclosure of the news should be straight and clear, it is advisable to use an expression of compassion, empathy and respect when breaking the news. information about the prognosis can only be given when directly requested by the patient and his/her family, and upon establishing that the patient is ready and has the right understanding to receive it. the physician must avoid talking about death. if the patient or the family members need to know about the estimated time of death in order to make some important decisions, rather than giving them a definite time, for example saying, "you would survive for 6 months", the physician can give them a time range that is the average of the patients' life expectancy, such as "from some days to several weeks" or "from some months to several years." information on the prognosis must be provided with an emphasis on the positive aspects rather than negative ones. in other words, the physician should highlight what can be done rather than the things that cannot be controlled by the healthcare team members. it is important to talk to the patient and his/her family about the uncertainty of the prognosis. for example, the physician can say, “i can just tell you things that usually happen to patients who suffer from a disease like yours, but i cannot predict what will happen to you with certainty”. 5) support all members of the truth-telling team, especially the announcer of the bad news who is the patient's physician, play an active role in this step of the protocol. after disclosing the cancer diagnosis, the physician should try to provide sufficient emotional support to the patient and his/her family members. in some cases, after disclosing the news and answering the patient’s questions, the physician assigns the session to the nurse and the psychologist. they will in turn prepare the patient and his/her family members to properly express their emotions by providing further explanation, resolving the misconceptions, finding the source of anxiety and helping them to express their feelings more and more. one of the most important measures at this stage is to confirm the patient's emotions. a good technique for doing so is "empathic response" presented by buckman (9), and consists of three main steps: a. listen carefully and recognize the emotions the following questions can be used to discover and make sure what emotions the patient is experiencing: how did you feel after receiving the news? did you get nervous? b. identify the cause or source of the emotions to explore the reasons for the emotions observed in the patient, questions such as the following can be asked: which part of the news you received made you more concerned? c. when talking to the patient, show him/her that you have been able to make a connection between the two steps above. reassure the patient that his/her emotions and the reasons for them are well understood by the healthcare team, for instance by stating: the result of the scan was a great shock to us. this part of the news was certainly very disappointing. immediately after completing the three steps of empathic response, confirm the patient’s emotions through sentences such as the following: i understand that it is very difficult to accept such news some other points that can be taken into account for supporting patients and families after disclosing the news are as follows: beside the serious pursuit of medical treatment, the role of “prayer” and “trust in god” should be emphasized. in iranian culture, physicians usually j med ethics hist med 10: 13, december, 2017 jmehm.tums.ac.ir parvaneh abazari et al. page 5 of 7 say that they only play an intermediary role in the preservation of human life and the will of god is above everything. the patient and his/her family need to be given realistic (and not false) hope. after disclosing the news and if the patient and the family are willing, a counseling session may be held in the presence of the psychologist and the nurse. the purpose is to offer more emotional and spiritual support as well as complementary explanation and training to patients and their families. during this session, the psychologist can assess the concerns of the patient and the family and provide appropriate solutions, whereas the nurse can help to resolve any possible misunderstandings and give additional answers to their possible questions about the disease, treatment and the side-effects while offering emotional support. holding such a session entirely depends on patients and their family conditions after receiving the news of cancer diagnosis. after the news is delivered by the physician, the patient or their family may be in a poor psychological state to receive further information, or conversely, they may be willing to talk about their feelings or to learn more. patients and their families should be assured that they can have the session whenever they wish, and they should be advised on when, where, and how to contact the healthcare team members to receive the required information. 6) conclusion at the end of the truth-telling session, the conductors can do the following to conclude the session: summarize all the main points of the session and put emphasis on the most important items that were raised, especially the treatment and care programs. reaffirm that the healthcare team will be present in the various stages of the disease and treatment and would not leave the patient alone. urge the patient and his/her family to ask any questions they have about what has been discussed. provide a summary of the essential information to the patient and his/her family members in writing. before letting the patient leave the truth-telling session, especially when the session is held at the physician’s office and the patient is not hospitalized, verify his/her safety; for instance, see if they can drive home safely, or if there is any risk of committing suicide. discussion perception of bad news is influenced by the beliefs and attitudes of each society. thus, developing localized protocols tailored to each community's cultural infrastructure, and training healthcare teams on how to use these guidelines can be a valuable step toward a more effective implementation of the truthtelling process to the patients. some steps in this protocol (including patient and environment preparation, disclosure, support and conclusion) are similar to those in other breaking bad news protocols that have been developed in other countries. examples of these protocols and guidelines are “setting; perception; invitation; knowledge; empathy; strategy and summary” (spikes) (9), “interview; gather; assess and achieve; decide, disclosure and discuss” (igad)(2), “background; rapport; explore; announce; kindling and summarize” (breaks) (21), and the guideline for breaking news of prognosis and end-of-life to adults in advanced stages of a life-limiting illness (22). the abovementioned steps are similar in principles such as: investigating patients’ awareness of their disease (9, 2, 21, 22); assessing patients’ willingness to get informed about their illness (9, 2, 22); providing the appropriate setting for diagnosis disclosure (9, 21, 22); disclosing the bad news using a simple, nontechnical language and a step-by-step process with respect and empathy (9,2, 21,22); offering emotional support after the news disclosure (9,2,22); and summarizing the provided information (9, 21,22). it should be noted that despite these similarities, there are significant differences between the current protocol and western guidelines, some of which will appear below. the researchers believe that one of the most important differences between this protocol and the protocols in western countries lies in the consideration for the views of patients’ close relatives in informing the former about their illness. given the priority of the principle of “respect for autonomy” in western communities, consideration for the relatives’ views is not common in the protocols and guidelines developed in those countries. in asia and the middle east, however, the principle of “no harm” is superior to the principle of “respect for autonomy” and the family plays a very important role in deciding whether or not to inform the patient (14); therefore, it is essential in iran to consider the opinions of patients’ close family members as well when breaking the news, and this has been included in the present protocol. in their guideline for breaking bad news in muslim societies, salem and salem refer to the family and their efforts to conceal the diagnosis from the patient in the assessment phase, but ultimately leave it to the physicians to decide whether, to what extent and to whom to disclose the diagnosis (2). in the present protocol, in addition to the “assessment” phase, the two steps of “planning” and “family preparation” are included. moreover, the researchers have made an effort to respect the patients’ wishes regarding whether or not to disclose the diagnosis to them. if the patient requests to be informed, but the family members are opposed to truth-telling, then attempts are made to obtain their consent for disclosure of the diagnosis to the patient by holding a family meeting. replacing the term “cancer” with less negative words like “malignant mass” or “malignant tumor” when disclosing the bad news is one of the items in j med ethics hist med 10: 13, december, 2017 jmehm.tums.ac.ir parvaneh abazari et al. page 6 of 7 the current protocol that contradicts the western guidelines’ emphasis on avoiding euphemism. this is because of significant cultural differences between western and non-western countries. in eastern and asian countries, the word “cancer” is associated with misconceptions such as incurable and fatal diseases, and is a harbinger of fear, anxiety and suffering for individuals (23-26). accordingly, the findings of various studies in these countries, including iran, show that there is a tendency to avoid using the word “cancer” among patients, their families and members of the healthcare team. moreover, they prefer to receive the cancer diagnosis news indirectly and with less-negatively charged words, for instance mass or tumor. it is generally believed that euphemism reduces the distress caused by the news and induces a positive feeling in the patient because of the emotional support offered by the physicians, and helps them to have an easier transition from health into the disease (21-23, 26-28). narayanan et al. also approves euphemism for telling the truth to the patient, stating, “using euphemism is a good technique, but it should not cause any confusion and uncertainty in the patient” (21). not mentioning death and its approximate time when disclosing bad news is another principle emphasized in the present protocol. in iran, due to cultural and religious reasons, most people prefer that the physician not talk about death while disclosing their diagnosis. the reason for people's unwillingness to talk about death may be attributed to their beliefs and attitudes. muslims believe that despite all the efforts made by the healthcare team to treat and control the disease, death and life are almost completely in the hands of the lord and it is only he who has the divine power to determine the time of death. therefore, they prefer not to discuss this otherworldly phenomenon which humans have not much control over. attar and malekian state, “some people’s religious beliefs cause them to consider it inappropriate for physicians to comment on the life span of the patient or how long they expect the patient to survive, and would get annoyed if physicians discusses such issues” (28). emphasizing religious principles while disclosing the bad news by members of the healthcare team was among other issues underpinned in the present protocol. different sources confirm that the tendency toward religion and spirituality is an important adaptive strategy that contributes to patients’ better compatibility with their illness. in addition, the spiritual health of cancer patients is directly related to their lower depression, greater enjoyment of life, higher quality of life, and less disappointment at the late stages of their disease (28-30). there is no denying the positive impact of spiritual and religious beliefs on the psychological state of individuals in difficult moments of life including the crisis following a cancer diagnosis. therefore, it is recommended that physicians and nurses try to benefit from these beliefs, even in terms of positive and optimistic sentences such as "everything is in the hands of god" and "god is merciful" when telling the truth (2, 16 ( . although the protocols already developed by western countries put emphasis on investigating the individual, cultural, or religious backgrounds of the patient before breaking the bad news, they do not recommend using religious phrases to disclose the news (13). conclusion the protocol presented in this article is a local guideline for training healthcare team members as well as implementing the process of bad news disclosure to cancer patients in iran. this protocol consists of six main steps: assessment, planning, preparation, disclosure, support and finally conclusion. in developing the present protocol, the researchers did their best to take into account the religious and cultural viewpoints of the iranian society toward cancer and its consequences, as well as the differences between iran and western countries. in addition, another strong point of this protocol is that its implementation is based on interprofessional team collaboration. it is hoped that this protocol could be manipulated as a useful guideline in training the members of the healthcare team, and through its effective implementation in disclosure of bad news to cancer patients, reduce the many complications caused by hearing such adverse news. j med ethics hist med 10: 13, december, 2017 jmehm.tums.ac.ir parvaneh abazari et al. page 7 of 7 references 1. al-mohaimeed aa, sharaf fk. breaking bad news issues: a survey among physicians. oman med j. 2013; 28: 20-25. 2. salem a, salem af. breaking bad news: current prospective and practical guideline for muslim countries. j canc educ. 2013; 28: 790-94. 3. tabak n, itzhaki m, sharon d, barnoy s. intentions of nurses and nursing students to tell the whole truth to patients and family members. j clin nurs. 2013; 22(9-10): 1434-41. 4. xue d, wheeler jl, abernethy ap. cultural differences in truth-telling to cancer patients: chinese and american approaches to the disclosure of 'bad news'. prog palliat care. 2011; 19: 125-31. 5. faridhosseini f, samimi ardestani m, shirkhani f .disclosure of cancer diagnosis: what iranian patients do prefer? ann gen psychiatry. 2010; 9(suppl 1):s165. 6. motlagh a, yaraei n, mafi ar, et al. attitude of cancer patients toward diagnosis disclosure and their preference for clinical decision-making: a national survey. arch iran med. 2014; 17: 232-40. 7. karimi rozveh a, nabi amjad r, karimi rozveh j, rasouli d. attitudes toward telling the truth to cancer patients in iran: a review article. int j hematol oncol stem cell res. 2017; 11(3): 17884. 8. janbabaei g, hesamzadeh a, esmaeili r. a review of approaches for disclosing cancer diagnosis to the patients. clin exc. 2014; 3(1): 12-28. [in persian] 9. buckman ra. breaking bad news: the s-p-i-k-e-s strategy. community oncology. 2005; 2(2): 138-142. 10. costantini a, baile wf, lenzi r, et al. overcoming cultural barriers to giving bad news: feasibility of training to promote truth-telling to cancer patients. j cancer educ. 2009; 24(3): 180-5. 11. arbabi m, roozdar a, taher m, et al. how to break bad news: physicians' and nurses' attitutes. iran j psychiatry. 2010; 5(4): 128-33. 12. arbabi m, rozdar a, taher m, et al. patients' preference to hear cancer diagnosis. iran j psychiatry. 2013; 9(1): 8-13. 13. labaf a, jahanshir a, baradaran h, shahvaraninasab a. is it appropriate to use western guidelines for beaking bad news in non-western emergency departments? a patients' perspective. clin ethics. 2015; 10: 13-21. 14. zahedi f. the challenges of truth telling across cultures: a case study. j med ethics history med. 2011; 4: 1-9. 15. kagawa-singer m. teaching culturally component communication with diverse ethcis patients and families. new york: springer; 2013. 16. jalali m, nasiri a, abedi h. patients and family members' experience regarding receiving bad news from health providers. j med ethics hist med. 2014; 7, 83-93. 17. valizadeh l, zamanzadeh v, sayadi l, taleghani f, howard f, jeddia a. truth-telling and hematopoietic stem cell transplanation: iranian nurses' experiences. nurs ethics. 2014; 21(5): 518-29. 18. ehsani m. developing and implementing truth telling protocol for cancer patients: a mixed-methods study. isfahan. isfahan university of medical sciences; 2017. 19. ehsani m, taleghani f, hematti s, abazari p. perceptions of patients, families, physicians and nurses regarding challenges in cancer disclosure: a descriptive qualitative study. euro j oncol nurs. 2016; 25: 55-61. 20. abazari p, taleghani f, hematti s, ehsani m. exploring perceptions and preferences of patients, families, physicians, and nurses regarding cancer disclosure: a descriptive qualitative study. support care cancer. 2016; 24(11), 4651-9. 21. narayanan v, bista b, koshy c. 'breaks' protocol for breaking bad news. indian j palliat care. 2010; 16: 61-5. 22. clayton jm, hancock k, butow pn, et al. clinical practice guidelines for communicating prognosis and end-of-life issued with adults in the advanced stages of a life-limiting illness, and their caregivers. med j aust. 2007; 186(suppl 12): s77, s79, s83-108. 23. tsoussis s, papadogiorgaki m, markodimitraki e, et al. disclosure of cancer diagnosis: the greek experience. j buon. 2013; 18(2): 516-26. 24. bou khalil r. attitudes, beliefs and perceptions regarding truth disclosure of cancer-related information in the middle east: a review. palliat support care. 2013; 11(1): 69-78. 25. aein f, delaram m. giving bad news: a qualitative research exploration. iran red crescent med j. 2014; 16(6): e8197. 26. zamanzadeh v, rahmani a, valizadeh l, et al. the taboo of cancer: the experinces of cancer disclosure by iranian patients, their family members and physicians. psychooncology. 2013; 22(2), 396-402. 27. barclay js, blackhall l, tulsky j. communication strategies and cultural issues in the delivery of bad news. j palliat med. 2007; 10(4): 958-77. 28. attari a, malekiyan a. how to break bad news. tehran: nashreghatreh; 2009. [ in persian] 29. lim j, yi j. the effect of religiosity, spirituality and social support on quality of life: a comparison between korean american and korean breast and gynecological cancer survivors. oncol nurs forum. 2009; 36(6): 699-708. 30. norris l, walseman k, puchalski cm. communicating about spiritual issues with cancer patients. new york: springer; 2013. patients' satisfaction with inpatient services provided in hospitals affiliated to tehran university of medical sciences, iran, during 2011-2013 journal of medical ethics and history of medicine page 1 of 10 original article patients' satisfaction with inpatient services provided in hospitals affiliated to tehran university of medical sciences, iran, during 2011-2013 jalil makarem1, bagher larijani2, kobra joodaki3*, sahar ghaderi4, fatemeh nayeri5, masoud mohammadpoor6 1assistant professor, department of anaesthesiology, imam khomeini complex, tehran university of medical sciences, tehran, iran; 2professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran; 3phd candidate in medical ethics, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran; 4researcher; 5associate professor, family health institute, maternal-fetal & neonatal research center, tehran university of medical sciences, tehran, iran; 6assistant professor, department of pediatrics, children’s medical center, tehran university of medical sciences, tehran, iran. corresponding author: kobra joodaki address: 23# 16 azar ave, keshavarz blvd, tehran, iran. email: k_joodaki@yahoo.com tel: 98 21 66419661 fax: 98 21 66983134 received: 18 may 2015 accepted: 26 sep 2015 published: 11 jun 2016 j med ethics hist med, 2016, 9:6 © 2016 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract implementation of patient feedback is considered as a critical part of effective and efficient management in developed countries. the main objectives of this study were to assess patient satisfaction with the services provided in hospitals affiliated to tehran university of medical sciences, iran, identify areas of patient dissatisfaction, and find ways to improve patient satisfaction with hospital services. this cross-sectional study was conducted in 3 phases. after 2 initial preparation phases, the valid instrument was applied through telephone interviews with 21476 participants from 26 hospitals during august, 2011 to february, 2013.using the satisfaction survey tool, information of patient's demographic characteristics were collected and patient satisfaction with 15 areas of hospital services and the intent to return the same hospitals were assessed. the mean score of overall satisfaction with hospital services was 16.86 ± 2.72 out of 20. it was found that 58% of participants were highly satisfied with the services provided. comparison of mean scores showed physician and medical services (17.75 ± 4.02), laboratory and radiology services (17.67 ± 3.66), and privacy and religious issues (17.55 ± 4.32) had the highest satisfaction. the patients were the most dissatisfied with the food services (15.50 ± 5.54). it was also found that 83.7% of the participants intended to return to the same hospital in case of need, which supported the measured satisfaction level. patient satisfaction in hospitals affiliated to tehran university of medical sciences was high. it seems that the present study, with its large sample size, has sufficient reliability to express the patient satisfaction status. moreover, appropriate measures should be taken in some areas (food, cost, and etc.) to increase patient satisfaction. keywords: patient satisfaction, inpatient care, hospital service quality j med ethics hist med 9:6, 2016 jmehm.tums.ac.ir jalil makarem et al. page 2 of 10 introduction the new health care system in the world is moving from a set of purely provider-based systems to receiver-based systems. in this regard, patients' satisfaction is an essential component of quality assessment (1). recognizing opinions of users and service recipients is a quick and inexpensive way to determine which parts of the service require improvements in terms of quality (2). in addition, the results of these studies may aid insurance payers, regulatory institutions, and validation agencies, as well as hospital authorities and consumers (3). various definitions around patients’ satisfaction have been proposed during the last 30 years. moreover, the basis of these definitions dates back to theories introduced in 1980, in which investigators proposed 5 broad perspectives on satisfaction (4). these perspectives include the discrepancy and transgression theories (1981), expectancy-value theory (1982), determinants and components theory (1983) multiple models theory (1983), and healthcare quality theory (1980) (4). in summary, satisfaction is a complex concept that may be linked to various factors social values (5). satisfaction can also be described as a subjective concept that is assessed differently by different people. people may even develop different definitions of satisfaction at different times (6). a review conducted in 2001 postulated that most studies conducted on satisfaction have focused on the 5 axes of nurses, physicians, food, services, and care. most popular instruments used in this study can be named as adapted servqual, the press ganey associates instrument and picker questionnaires (3). there are various methods for assessing patients' satisfaction including using electronic forms, phone calls, and face to face interviews with patients (3, 7). performing the satisfaction survey using a questionnaire has the features of posing more questions, reducing the possibility of bias, and also cost-effectiveness. although, sending and receiving questionnaires and low return rates are thought as the major problems of this approach (3). telephone follow-up of discharged patients has been proposed in many articles as an accessible and low cost method (7-9) in which a lower time delay is reported compared to other methods (3). other benefits of post-discharge telephone follow-up are opportunities for direct communication and exchange of information with patients, provision of education and explanation to patients if needed, early detection of complications in patients and management of symptoms and problems, assuring patients, improving the quality of health services, and increasing patient satisfaction and awareness of patients' opinions about the health care delivery system (8, 10). in many countries, through special attention to the post-discharge period and precise planning, service delivery not only proceeds after discharge, but also patient's treatment and recovery are well monitored by interacting closely with patients. moreover, the patients are questioned about the quality of medical, nursing, laboratory, preclinical, and accommodation and food services. this aids healthcare providers in improving and enhancing service delivery to patients (11). surveying patient satisfaction is also helpful in the identification of strengths and weaknesses of each hospital and creates an atmosphere of constructive competition among health care providers in hospitals to enhance the quality of services (12, 13). very little is known about the iranian patients' satisfaction. moreover, lack of comprehensive studies and continuous assessment in this field has led to many problems. thus, despite the efforts of health care providers, they are still unable to take advantage of patients' opinions in order to improve service quality. in recent years, several studies have been conducted to assess patient satisfaction; however, they were cross-sectional studies, which frequently suffer from sample size limitations, and/or correlation study (14-19). this study is the first continuous research assessing satisfaction with a valid and large sample size and has responded well to the needs in this area in order to manage the health system in iran. in this study, using post-discharge telephone followup, patients were asked to express their opinions about the health services available to them. subsequently, the causes of discomfort were identified and feedback on the strengths and weaknesses of different services were reported to hospital management. based on these outcomes, improving the quality of medical care in university hospitals were targeted. method this was a cross-sectional study carried out in 20112013. the target population consisted of patients discharged from 26 hospitals affiliated to tehran university of medical sciences (tums), tehran, iran. this study was performed during the merge of tehran university of medical sciences and iran university of medical sciences; therefore all the twenty six hospitals were affiliated to tums. the study was designed in the form of 3 phases. permission to carry out the study was obtained from the research committee of tehran university of medical sciences with the project code of 91-01-66-16650. in the first phase, described as launching, a valid and reliable researcher-made questionnaire was used for data gathering. the preliminary technical preparations for the study included the collection of initial information such as statistics of admissions and discharges from affiliated hospitals, and recruitment and training of project partners for telephone interviews with patients. the initial data gathering form was well studied and reviewed by 10 faculty members who specialized in j med ethics hist med 9:6, 2016 jmehm.tums.ac.ir jalil makarem et al. page 3 of 10 the field of quality assessment and patient satisfaction. then, the required modifications and necessary changes were made and content and formal validity of the instrument was approved by an experts group. the second phase, pilot implementation, was implemented with the following procedures. after coordination with authorities of 3 university affiliated hospitals, the project was performed in the form of 2 pilot studies on 30 patients (to assess construct validity) and on 300 patients (to identify and resolve study implementation problems). accordingly, the necessary changes in the data collection form and method were applied. after reexamining, cronbach's alpha of 0.87 was calculated for the present questionnaire (α = 0.87). in the third phase, final implementation, the project was implemented on a consistent basis in all the hospitals affiliated to tehran university of medical sciences. in this study, we examined all patients with a history of hospitalization in hospitals affiliated to tehran university of medical sciences in the timeframe of august, 2011 to february, 2013. the studied hospitals included arash, imam khomeini, shariati, baharlou, rasoul akram, akbarabadi, ali asghar, amir a'lam, bahrami, farabi, firouzgar, hasheminejad, mirza kuchak khan, hazrat fatemeh, rouzbeh, sina, shahid motahari, razi, vali-e-asr, shafa yahyaeian, ziaeian, and shahid rajaee hospitals, and tehran psychiatric institute, cancer institute, children's medical centre, and tehran heart center. note that patients hospitalized in emergency wards were excluded from our study. in the present study, 10% of the study population were selected using a systematic sampling method, and they were telephoned during the first 3 days after discharge from the aforementioned healthcare units. the satisfaction survey form used in this study consisted of 3 main parts. the first part included patients' demographic characteristics such as age, gender, place of residence, and relation of responding person to the patient. the second part consisted of 5 variables related to hospitalization (name of the admitting hospital and ward, length of hospitalization). the third part extracted answers to 15 questions which assessed different aspects of patient satisfaction with hospitals. patients rated their satisfaction level with a number between 0 and 20. this rating system was used due to the ease of understanding grading between 0 and 20 as individual respondents. patients' satisfaction was determined in terms of satisfaction scope in the domains of physicians, nurses, laboratory and radiology services, ancillary staff services, administrative staff, guardians, clarification of the disease by medical personnel, getting well after discharge, food, administrative procedures before admission, hospital accommodation, hospital sanitary procedures, compliance with legal and ethical issues and patient's religious boundaries, availability of medical facilities, discharge administrative procedures, and hospital costs. the participants were asked in regards to their reason for choosing the hospital for treatment, and the intent to return to the same hospital in the case of need and the main reasons for this intent. in addition, the effect of cost-effectiveness in hospital choice was reviewed. an average of 15 minutes (at least 10 minutes) was dedicated to each interview for every person. at the beginning of each interview, the operator introduced herself to the participants, explained the objectives of the project, and obtained a verbal consent of participation to continue the study. in case of patient’s reluctance to cooperate in the study, another participant discharged from the same hospital was replaced using random sampling. during this period, a total of 22727 patients were contacted. of these, 96.1% were willing to participate in the study. descriptive analysis of the data was carried out using spss software (spss inc., chicago, il, usa) and student’s t-test, anova, and the pearson correlation. results twenty one thousand four hundred seventy six patients participated in this study. the distribution of participants in different hospitals is shown in table 1. table1. number of participants according to hospitals number of participantshospital name number of participantshospital name number of participantshospital name 1870akbar abadi321hazrat fatemeh186razi 349ali asghar1051 tehran heart center 102rouzbeh 989amir a'lam422 mirza kuchak khan 1640shariati 859arash134shahid motahari843sina 737baharlou1058shahid rajaee1249 children's medical centre 602bahrami1262rasoul akram1421vali-e-asr 1080cancer institute76 iran psychiatric institute 563shafa yahyaeian 622ziaeian746firouzgar518hasheminejad 21476total1154farabi1622imam khomeini j med ethics hist med 9:6, 2016 jmehm.tums.ac.ir jalil makarem et al. page 4 of 10 distribution of age, gender, and other variables of participants were assessed (table 2). the correlations between patients' satisfaction and their demographic characteristics were studied and the existence of significant differences was assessed, the most important of which are presented in table 2. table 2. distribution of demographic characteristics and significant differences/ correlation between/with overall satisfaction results of significant testssatisfaction score (mean ± sd) percentagefrequency demographic characteristics * ---16.66 ± 2.83 16.86 ± 2.70 44 54 9436 11981 gender male female spearman (c coefficient) = -0.029 (p = 0.001) 17.06 ± 2.44 16.67 ± 2.84 16.77 ± 2.78 16.55 ± 3.04 23.3 48.9 20.3 7.5 4906 10279 4258 1572 age (year) > 20 20-49 50-69 < 70 (t-test for equality of variance) t = -5.36 (p = 0.001) 16.78 ± 2.75 16.99 ± 2.67 61.1 38.9 13009 8283 residency tehran other cities (t-test for equality of variance) t = 5.77 (p = 0.001) 16.87 ± 2.70 16.65 ± 2.83 51 49 11628 9987 respondent patient relatives median: 3 days range: 1-191 days the length of stay in hospital *no significant differences between gender-based satisfaction scores the mean score of participants' satisfaction in all areas of hospital services was 16.86 ± 2.72 out of 20. accordingly, overall satisfaction rate of 58.4% of participants was higher than 17 and was lower than 10 in only 2.8% (table 3). as shown in table 4, patient satisfaction was assessed in each service area. among the surveyed areas, the physician domain had the highest satisfaction score. in the second place was the area of laboratory and radiology services, and next was compliance with legal and ethical issues. the lowest satisfaction score was reported in the area of hospital food. furthermore, the hospital accommodation and paid fees, respectively, were among the lowest satisfaction scores. table 3. the distribution of participants in the satisfaction scores group overall satisfaction score frequency percentage < 10 (low satisfaction or not satisfied) 594 2.8 10-14.99 (moderate satisfaction) 3450 16.2 15-16.99 (moderate to high satisfaction) 4812 22.6 17-20 (high satisfaction) 12436 58.4 total 21292 100 table 4. satisfaction rate in each scope service area mean score ± sd the percentage of participants with high satisfaction (score = 17-20) the percentage of participants with low satisfaction (score < 10) physicians 17.75 ± 4.02 77.8 7.3 laboratory and radiology services 17.67 ± 3.66 73.6 6.4 legal and ethical issues 17.55 ± 4.32 76 9.1 ancillary staff services 17.54 ± 3.78 71.7 7.1 administrative procedures of discharge 17.48 ± 3.95 72.2 8 availability of medical facilities 17.45 ± 4.25 73.8 9.4 administrative staff 17.40 ± 3.87 70.2 7.1 guardians 17.38 ± 4.13 70.4 8.1 j med ethics hist med 9:6, 2016 jmehm.tums.ac.ir jalil makarem et al. page 5 of 10 nursing services 16.82 ± 4.40 65.7 10.6 administrative procedures before admission 16.71 ± 4.64 65.6 12.6 hospital sanitary procedures 16.52 ± 4.75 62 12.2 clarification of the disease by medical personnel 16.43 ± 5.45 66.9 14.9 getting well after discharge 16.42 ± 4.75 62.1 12 hospital costs 16.23 ± 4.82 6.1 15.7 hospital accommodation 16.15 ± 4.85 57.4 14.3 food services 15.50 ± 5.54 54.9 19 in this study, the most important reasons for choosing the hospital by the participants were explored. these reasons were, respectively, recommended by acquaintances or relatives (24%), referred by doctor to the admitting ward (18.5%), and previous hospitalization (8.7%). the least important factor in hospital choice was declared by patients as acceptance of their insurance (1%) (figure 1). figure 1. distribution of participants based on reasons for choosing the hospital 0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00% percentage of participants j med ethics hist med 9:6, 2016 jmehm.tums.ac.ir jalil makarem et al. page 6 of 10 in the present study, 83.7% of the participants stated that in case of relapse and the need for more health care they will choose the same hospital. the most commonly cited reasons for reselection of the same hospital were satisfaction with physicians, overall satisfaction with hospital, and satisfaction with dealing with patients, nursing care, and hospital facilities. however, 16.3% of patients said they will not come back to the same hospital in case of needing future care. the most important reasons noted were dissatisfaction with physicians, interaction with patients, and nursing care, poor sanitary conditions in the hospital, and hospital charges (figure 2). in figure 3, the impact of cost on the hospital choice by the participants is presented. figure 2. distribution of participants based on the intention to return to the same hospital if needed figure 3. the impact of costs on hospital choice 83.70% 16.30% intend to return to the same hospital intend to never return 0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00% 35.00% 40.00% very high high moderate low the impact of costs on the hospital choice j med ethics hist med 9:6, 2016 jmehm.tums.ac.ir jalil makarem et al. page 7 of 10 discussion and conclusion the purpose of this study was to investigate the causes and domains of patients' dissatisfaction with hospitals affiliated to tehran university of medical sciences. the present study was also aimed at providing guidelines to improve hospital services and to increase patient satisfaction. an average satisfaction of 16.86 ± 2.72 with the overall services provided to patients was reported, and 50.8% of participants reported high satisfaction with health care services, which was consistent with results of previous studies (20, 21). among the demographic characteristics of the participants, increasing age and duration of hospitalization were associated with lower satisfaction. participants in the age group of older than 70 years had the lowest levels of satisfaction, which was inconsistent with the results of many studies (22-25). this is justified considering chronic diseases in elderly patients and their lower health level compared to young patients (23, 25, 26). no significant statistical differences were observed in terms of gender, which is consistent with many studies (22-24). nevertheless, some studies have reported higher satisfaction in women (9, 27), and sometimes in men (23). in many studies, duration of hospitalization had negatively impacted patients' satisfaction (28, 29). several studies reported no negative impact of treatment duration and patient satisfaction which can be due to ensuring continuity of treatment and concerns about the lack of sufficient information to continue treatment and care at home (27, 30). satisfaction among patients who live in tehran has been reported as lower than other cities. overall, patients' relatives have reported lower satisfaction scores in terms of the services. review of studies have shown that providing clear and consistent communication with physicians and getting answers to questions, and use of spiritual support can be effective in reducing anxiety, and therefore, increasing satisfaction among patients' relatives (3133). in several studies, patients' satisfaction had a significant association with their intention of returning to the same hospital or recommending it to others (34, 35). in this study, 83.7% of participants said that in case of future need of medical services they will choose the same hospital, which confirms the degree of satisfaction to services received. this is more or less proportional to the statistics published in previous studies. in this study, the main reasons of participants for their intention to return were satisfaction with physicians, overall satisfaction with hospital, and satisfaction with interaction with patients, nursing care, and hospital facilities. a study has shown that the only predictor which is significantly associated with patients' intention to return to the same healthcare center is satisfaction with clarifications provided by physicians and expected time for waiting to be visited by physicians (35). the findings of this study showed that the most common ways of hospital choosing from the perspective of the patients are, respectively, recommendation by others, referred by doctor, and previous hospitalization. these findings are consistent with previous studies claiming that, due to lack of available public information, communication channels such as friends and relatives of the patient are the most influential channels for choosing a hospital (36, 37). acceptance of insurance had the least impact on participants' choice. this finding can be justified due to acceptance of all types of insurance in hospitals affiliated to tehran university of medical sciences. the main reason for the high level of patient satisfaction may be satisfaction with performance of clinicians. in previous studies physicians’ performance has been proposed as one of the most important predictors of patients’ satisfaction (14). physician’s attitude toward the patient has a dramatic impact; this can be detailed as compassion and willingness to provide information and clarification for patients (38). furthermore, previous studies have noted the importance of healthcare providers' and caregivers' attitudes to be even more than their technical skills (39-42). based on the above findings, identifying approaches to increasing physician empathy and continuous education of communication strategies to clinical staff are recommended in order to improve patient satisfaction. in the following ranks, the area of radiology and laboratory services in the hospital was assessed as strongly suitable by patients. this finding was in agreement with that of the study by sanders (43). the most important factors in satisfaction with radiology services were appropriate scheduling and short waiting time (44-46). improvement of staff interactions plays an important role in increasing patient satisfaction in this domain (45-47). compliance with spiritual issues was the third most important factor shaping patients’ satisfaction. taking ethical and religious issues into account clearly influences patients’ satisfaction, especially for patients with severe pain, chronic diseases, and life threatening complications (48-50). in this study, the lowest satisfaction score of hospital services was assigned to the domain of nutrition and accommodation. in a study conducted in mashhad, it was shown that patients' satisfaction is affected by nutrition as well as the quality of hospital rooms (51). in contrast, in most studies abroad, patients' satisfaction with hospital food services have been reported as higher than 80%, or have been rated as good or very good (52, 53). this indicates that special attention to nutritional status and accommodation in public hospitals is essential. in j med ethics hist med 9:6, 2016 jmehm.tums.ac.ir jalil makarem et al. page 8 of 10 addition, periodic surveys of patients to benefit from their opinions about the quality of nutrition and accommodation, while attending to the principles of good and healthy nutrition, are effective and fruitful in improving the healthcare services. it has been shown that the physical environment of hospitals (hospital services) is effective in patient satisfaction (54, 55). our suggestions for the improvement of the rate of patient satisfaction are respecting the physical privacy of patients during hospitalization and improving their accommodation requirements. we recommend the improvement of accommodation in terms of sufficient space, lighting, noise reduction, standard health services, and provision of sufficient restrooms and adequate number of personnel to aid patients’ everyday activities, and renewal of old constructions according to international standards and requirements of iranian patients and medical staff. in the present study, the main reasons for patients' dissatisfaction were high hospital charges, lack of health recovery, lack of provision of information about the treatment process and clarification of information for patients. due to fundamental differences in insurance regulations and hospital charges between iran and most advanced countries, comparing of patients' satisfaction of cost-effectiveness is not feasible. undoubtedly, eliminating direct financial transactions with patients, improving insurance services, extending insurance coverage, and providing free treatment can have a significant impact on patients' satisfaction. in an article has been concluded that despite the relationship between satisfaction and treatment outcome, when patients are asked to rank their satisfaction of healthcare services, they pay more attention to their health status after treatment rather on improvement of symptoms (56). however, future studies should place more emphasis on early symptoms of improvement rather than treatment outcome. many studies have addressed the importance of providing information and education for patients (57), and in many cases, similar to our findings, patients feel unsatisfied with the domain of provision of adequate clarification and information by caregivers (54, 58). the lowest level of satisfaction with hospital staff was assigned to nurses. note that a clear definition of nursing practices and their specific tasks is not provided for patients. nurses also play very significant roles in patient satisfaction whether in terms of nursing care or overall healthcare services provided to patients (38, 59, 60). incorporation of patients’ preferences into treatment decisions by physicians and nurses can enhance their satisfaction (59). characteristics of a good relationship between care providers (physicians and especially nurses) and patients are common understanding, respect, trust, honesty, and a sense of good humor and amiability (60). previous studies have stressed that provision of individual-centered services by nurses and more attention from nurses can enhance the satisfaction level (38, 54, 61). technical and clinical skills of nurses are also an important factor in patient satisfaction (61). furthermore, providing adequate information and skills, cooperating with physicians during testing and treatment (54), and especially healing and reducing patients' pain significantly increase satisfaction (62). in studies carried out in iran, a variety of factors are proposed as leading to patients' dissatisfaction such as educating patients (15), responding to questions and requests of patients (16-18), and communication skills (19). therefore, it seems that exploring reasons for low satisfaction with nursing services in hospitals affiliated to tehran university of medical sciences necessities more detailed and specific investigations. moreover, in continuation of this study, there is a need to integrate more precise studies to explore different aspects of dissatisfaction in various domains and to explore various associated factors. in addition, using specialized questionnaires in specific populations, such as psychiatric patients, is essential to obtain more reliable data. it seems that, due to the large sample size of this study, it possesses enough reliability to assess the status of satisfaction among patients. although in some areas (nutrition, accommodations, and etcetera), it is essential that, as soon as possible, the necessary steps be taken to enhance satisfaction with healthcare provisions. acknowledgement we would like to sincerely thank the authorities of tehran university of medical sciences for their efficient suggestions and uninterrupted support, and the information technology department staff of the university for their efforts and help. we are also thankful to the related personnel in the studied hospitals who have contributed to the completion of this project. j med ethics hist med 9:6, 2016 jmehm.tums.ac.ir jalil makarem et al. page 9 of 10 references 1. lliffe s, wilcock j, manthorpe j, et al. can clinicians benefit from patient satisfaction surveys? evaluating the nsf for older people, 2005-2006. j r soc med 2008; 101(12): 598-604. 2. williams t, schutt-aine j, cuca y. measuring family planning service quality through client satisfaction exit interviews. int fam plan perspect 2000; 26(2): 63-71. 3. castle ng, brown j, hepner ka, hays rd. review of the literature on survey instruments 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1992; 6(4): 9-24. jmehm-10--9.docx journal of medical ethics and history of medicine original article the pattern of educator voice in clinical counseling in an educational hospital in shiraz, iran: a conversation analysis ahmad kalateh sadati1, kamran bagheri lankarani2* 1assistant professor, department of social sciences, yazd university, yazd, iran. 2professor, health policy research center, institute of health, shiraz university of medical sciences, shiraz, iran. corresponding author: kamran bagheri lankarani address: building no 2, eighth floor, school of medicine, zand avenue, shiraz, iran, postal code: 71348-45794. email: lankaran@sums.ac.ir tel/ fax: + 98 71 32309615 received: 9 feb 2017 accepted: 3 oct 2017 published: 18 oct 2017 j med ethics hist med, 2017, 10:9 © 2017 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract doctor-patient interaction (dpi) includes different voices, of which the educator voice is of considerable importance. physicians employ this voice to educate patients and their caregivers by providing them with information in order to change the patients’ behavior and improve their health status. the subject has not yet been fully understood, and therefore the present study was conducted to explore the pattern of educator voice. for this purpose, conversation analysis (ca) of 33 recorded clinical consultations was performed in outpatient educational clinics in shiraz, iran between april 2014 and september 2014. in this qualitative study, all utterances, repetitions, lexical forms, chuckles and speech particles were considered and interpreted as social actions. interpretations were based on inductive data-driven analysis with the aim to find recurring patterns of educator voice. the results showed educator voice to have two general features: descriptive and prescriptive. however, the pattern of educator voice comprised characteristics such as superficiality, marginalization of patients, one-dimensional approach, ignoring a healthy lifestyle, and robotic nature. the findings of this study clearly demonstrated a deficiency in the educator voice and inadequacy in patient-centered dialogue. in this setting, the educator voice was related to a distortion of dpi through the physicians’ dominance, leading them to ignore their professional obligation to educate patients. therefore, policies in this regard should take more account of enriching the educator voice through training medical students and faculty members in communication skills. keywords: clinical consultation, doctor-patient interaction, educator voice, conversation analysis mailto:lankaran@sums.ac.ir j med ethics hist med 10: 9, october, 2017 jmehm.tums.ac.ir kamran bagheri lankarani et al. page 2 of 8 introduction the educated patient is a person who is trained in different aspects of therapeutic measures and health, and is informed about promotion of clinical health by a doctor (1). education improves patients’ satisfaction with the doctor-patient interaction (dpi), the quality of care, and the reduced health care costs resulting from patients’ enhanced knowledge of health issues (2). redman believes that the main goal of patient education should be to direct the application of physician's prescribed actions (3). the clinical setting is partly responsible for educating patients, since the goals of clinical teaching and learning are based on patients’ assessment, evaluation, diagnosis, prognosis, and individuals’ needs in relation to intervention (4). the desirable interaction between doctor and patient makes it possible to design better educational strategies and training. this empowers physicians to interact with their patients using greater technical and relational efficiency (5). thus, dpi is crucial in medical research and sociology of medicine, and plays an important role in the education of patient (6 8). based on sociological theories, there are different voices in every dpi (7 9) that work in conjunction with each consultation. an important voice is the educator voice (ev) that conveys various kinds of medical information to patients in the hope of getting a better understanding of their health problem. the principal function of ev is to bring about patients’ compliance and consequently facilitate communication of medical information (7). promoting patients’ understanding to follow the appropriate treatment is the primary purpose of ev as a component of dpi that facilitates health awareness and education of patients. patient education is the most important issue of the health system in developed countries. visser et al. showed that patient education represents a general feature of healthcare in the uk, belgium, germany, and netherlands (10). in addition, it is defined as a rightful (11), and an ethical (12) issue. in iran, however, although updated texts underlining the importance of patient education are included in medical education syllabus, there is as yet no information about the pattern and quality of patient education in relation to dpi, which is shown by recent studies to be distorted (6, 13, 14). in this form of interaction, the consultation is conducted within a few minutes, followed by the patient leaving the physician’s office with only a written prescription, and there is usually little or no communication between the doctor and patient (13). in clinical settings, patient education is realized through dpi, which adequately informs the patient about his/her health. therefore, the aim of the present study was to explore the pattern of ev in clinical settings and address the way the doctors educate patients during consultation and also the general characteristics of ev. method this was a qualitative study based on conversation analysis (ca) derived from ethno-methodology. ca is a traditional method in sociology introduced by goffman (15) and published as early as 1974 by schegloff and sacks (16). in sociology it has been defined as the science of natural observation (17-19) aiming to study the subjects by detailed inspection of tape recordings and their transcriptions (16). ca identifies the patterns of behavior as well as interactional strategies, and explores the association between certain interaction styles and outcomes (20). the data were collected between april 2014 and september 2014 in one outpatient educational clinics, affiliated with shiraz university of medical sciences (sums). the hospital included endocrinology, anesthesiology, general surgery, gynecology, neurology, urology, dermatology, and internal medicine clinics. all specialties in this clinic except for neurology and gynecology were included. the number of samples was determined based on saturation. purposeful sampling was carried out with variations in some parts. inclusion criteria for selecting specialists comprised having more than 3 years of teaching and clinical experience, being a member of the university at the time of the study, and not being retired or employed at other medical training facilities. having briefed the specialists about the objective of the present research, 9 physicians with 7 different specialties agreed to participate in the study. at this stage, the surgeons expressed their unwillingness to cooperate and were therefore excluded. the researcher obtained consent from 50 patients to make the recordings. the recorded data were then transcribed by an independent researcher who was aware of the aim of the study, and was also familiar with ca and the method of transcribing data in conversation form. the data transcription included all repetitions, elisions of lexical forms, use of temporal regulators, chuckles, utterances such as “ahem, yeah, you know, right”, and speech particles like “uh, oh”, etc., specifically short syllabic devices. although transcription is a selective process (16), the conversations were fully transcribed. overall, 50 conversations were transcribed of which 33 were analyzed based on saturation criteria (21, 22, 23). inclusion criteria for selecting conversations comprised lasting more than three minutes and involving all specialties, with the most frequent conversations receiving priority. after transcription, an inductive data-driven analysis was conducted to find recurring patterns of interaction. analysts developed conversation-related rules or models to explain the frequencies of the patterns. on the other hand, the conversations were evaluated as social actions, since human social actions are thoroughly structured and organized by j med ethics hist med 10: 9, october, 2017 jmehm.tums.ac.ir kamran bagheri lankarani et al. page 3 of 8 conversation. therefore, transcribed data were analyzed considering meaningful episodes of talk and their interpretations, a step that was repeated in subsequent stages (16). generally, conversation analysis involved all utterances and many aspects of non-verbal behavior in relation to social actions of various kinds, and those features that are generally linked with broader activities arising during consultation (20). however, in this study, video recordings were not used, and only the verbal data were analyzed. therefore, researchers emphasized the pattern of ev as a social action that occurred during the verbal interaction of both parties. the validity of the study was confirmed in three ways. the first step was member check, reflecting the researcher’s feedback on interpretations by some of the participants (22). for this purpose, researchers presented the findings to participating physicians to obtain their validation of the extracted rules. the patients, on the other hand, could not be accessed, and therefore the results were verbally obtained from 17 patients who referred to the clinics and confirmed the findings. second, trustworthiness was observed during the study by ensuring subjectivity and reflexivity, adequacy of data, and efficiency of the interpretation strategies (22). in this context, we shared our findings with the research team concerning the rules extracted from the data, and fully agreed with them on inter-subjectivity characteristics. third, the credibility was ensured by member check and peer debriefing on the foregoing items, and involving original informants or others with similar responsibilities (23). we then checked the initial findings with the aforementioned participants and reached a collective agreement in each step. in addition, reflexivity was observed by emphasizing production of knowledge and minimizing prejudgments by researchers, a process carried out through continuous monitoring the results of the study. with regard to ethical considerations, alongside obtaining the consent of participants for taking part in the study, attempts were made to maintain anonymity of the participants and confidentiality in all stages, from data collection to the final research report. furthermore, the study was approved by the ethics committee of shiraz university, iran in 2014. it should be noted that the transcriber pattern in this research is based on the models proposed by atkinson and heritage (24) and heritage (25). results results showed that 7 specialties participated in this study. the characteristics of the participants are shown in table 1. table 1characteristics of the research participants type of specialty number(s) of participants gender practical experience (year) internist 1 male 4 infectious disease specialist 1 male 9 endocrinologist 1 female 4 urologists 3 male 12 (one of the participants) 5 (2 of the participants) dermatologist 1 male 15 anesthesiologists 1 female 17 rehabilitation specialist 1 male 11 with regard to the ev in clinical conversations, the obtained results were expected to address the general quality of ev and its characteristics during consultations by answering the following questions: 1. how do doctors educate patients during consultation sessions? based on the conversations, doctors educated their patients by descriptive and prescriptive methods. descriptive voice is related to informing patients about the existing situation, whereas prescriptive approach refers to patients’ duties and obligations. descriptive voice: in this voice, a doctor tells the patient about the etiologies of illnesses, duration of treatment, stages involved in the recovery process, and the graphs concerning paraclinical results. as an instance, see consultation 14 below, offered to a patient with h. pylori infection. note that in all the following samples, d will be used to represent the doctor and p the patient: d: yeah, duodenal ulcer is not usually cancerous. p: ok… d: typically it recovers faster. p: oh… really? d: yes, usually. you don’t have to do another endoscopy if symptoms of infection with h. pylori and peptic ulcer disappear. p: thanks! as shown in these interactions, the physician uses j med ethics hist med 10: 9, october, 2017 jmehm.tums.ac.ir kamran bagheri lankarani et al. page 4 of 8 paraclinical data to convince the patient that his condition has improved, and also ensures him that there is no need for a second endoscopy. in addition, sometimes physicians inform their patients about the course of the illness and possible treatments. for example, in consultation 22 involving renal colic, the physician informs the patient in the following way: d: your urine analysis report shows that there is some blood in your urine, but that’s ok… it seems that your kidneys are clean. p: no, this isn’t the last test. d: this one is the latest. p: yeah, this is it. d: have you seen a stone pass through your urine lately? p: no. d: this is also good news, probably it has passed. in this situation, the physician refers to the urine analysis in order to inform the patient that the renal stone has probably passed. thus, in this short conversation, the physician explains the process of the illness to the patient. sometime the physician talks about the prognosis of illness in descriptive voice. for example, a physician in consultation 6 states: d: your kidneys are better, your anemia is ok too, but your blood sugar… is not under control. in this statement, the physician seeks to explain the overall condition to the patient. additionally, the physician informs the patient that his/her blood sugar needs to be checked regularly. prescriptive voice: here, the doctor includes various issues concerning the patient’s duties such as next referral, paraclinical tests, graphs, medication prescription and self-care. this is the main part of ev that deals with promotion of health by prescribing medication as well as reminding the patients to have healthy behavior. however, the dominant issues to be considered comprise medication and further tests. for example, in consultation 9 concerning a woman with acne, the physician’s instructions and prescription were as follows: d: these are the tests that you should do on the third and fifth day of your menstruation period. i have prescribed some medications. take a capsule with your lunch every other day. if you get parched lips, use a chap stick, and see me in one month with your tests results. consultation 16, offered to a woman with advanced breast cancer, was dominated by paraclinical data and the following prescription: d: this is a sleeping pill that you should take before going to bed, but if you take it at dinnertime, you should go to bed immediately. i have also ordered a chest x-ray. remember to hold your breath while it is being taken. please see me in three weeks, and bring your x-ray results. as can be seen above, the consultation included prescribing medication, taking an x-ray, and setting a future appointment. 2. what are the general characteristics of ev? considering the aforementioned characteristics and the critical analysis of ev and the transcripts, several flaws were detected in the consultations, which had the following characteristics. superficiality ev can be superficial, because it may not focus on important issues. nevertheless, such issues are not difficult to address and can be resolved by evaluating the consultation sessions that contained nothing concrete. for example, diabetes is a chronic disease that needs special education. in consultation 6, an illiterate elderly woman referred to an endocrinologist who discussed many issues such as the patient’s history, medication and the range of blood test without offering any training or education. the patient only learnt from her physician that she had high blood sugar denoted by an fbs of 303. the physician did not pay any attention to other aspects of the educational needs of an illiterate, elderly woman such as diet or exercise. at the end of this consultation the physician changed the patient’s medication and asked for a retest of blood sugar. d: um… the tests are not good. your blood sugar is high. now, i’ll change your pill. take this new pill. p: thank you. d: goodbye for now. marginalization of patients consultations showed that ev is merely based on the physician’s domination, where the doctor makes a decision about a patient’s education without his/her involvement. for example, in consultation 33, regarding a woman with numbness in her shoulder, the patient had previously been prescribed to do the nerve conduction velocity (ncv) test. based on her test results, her physician recommended surgical operation, but she refused to comply due to her fear of having no one to look after her and uncertainty about the diagnosis. she then asked her doctor for an alternative procedure. since the physician’s opinion was based on the ncv results, he tried to ensure her that what he recommended was the best choice, and although he was aware of the patient’s doubts, he insisted that she should comply. in this connection, the underlying verbal exchanges between the doctor and the patient are worthy of consideration: d: why don’t you want to undergo the operation? p: well, i think i may not (really) need an operation, am i (not) right? d: according to this nerve strip (ncv), you should do it! p: well, isn’t there anything else to do? d: you see, nothing is certain. what i mean is that this nerve strip (ncv) says you need to undergo operation, and scientifically speaking, i am sure we will be able to achieve good results. p: yeah. d: a patient like you should undergo this operation. if you disagree or resist, you won’t get the desired j med ethics hist med 10: 9, october, 2017 jmehm.tums.ac.ir kamran bagheri lankarani et al. page 5 of 8 outcome. p: but i won’t do it. d: listen! resistance means you are avoiding the operation, which should be performed under any circumstances. in this consultation, due to the dominance of the physician’s voice, the ev is asymmetric. in other words, the descriptive voice is based on the nerve strip and the physician’s prescription and dominance, as well as his insistence on a surgical option without paying any attention to the patient’s concerns. in this situation, the slightest doubt in the patient’s mind can lead to the failure of ev. the reality is that the patient is deeply marginalized, and her wisdom and knowledge is being completely ignored by the physician. overall, when no attention is paid to the patient’s standpoints, the consultation will likely fail and creates psychological pressure on the patient. of the 33 consultations in this study, there was only one case in which the physician (an urologist) provided adequate explanations to reduce psychological stress on the patient’s family member. in this case (consultation 23), the patient’s son had tried to conceal his mother’s illness, which was a kidney tumor. one-dimensional approach another critical characteristic of all consultations was that they were one-dimensional, in that the physician’s approach was merely based on his/her specialty domain. for example, a surgeon only paid attention to the surgical procedure, an attitude predominant in several fields of medicine. in this case, other disciplines are generally ignored, unless the patient complains. for example, in consultation 6 that was offered to a diabetic patient, the physician did not pay any attention to the effects of high blood sugar on other organs such as the heart, eyes and the nervous system. another example pertains to consultation 18 involving a patient with spinal cord injury who was afflicted with a testicular and urinal infection. in this case, the patient’s son talked about his father’s digestive problem due to antibiotic consumption, but the physician ignored his concerns and proceeded to conclude the session. the conversation between the patient’s son (ps) and the doctor is presented below: ps: thank you. aren’t you going to prescribe any drugs? d: no, there is no need for drugs at the moment, just use the previous ones. ps: well, those cause diarrhea! d: if that is the case, clindamycin should not be taken. ps: isn’t there any alternative medicine; something that alleviates his stomach discomfort and painful bowel movement? these conditions are annoying to others. d: ok, have a good day! ignoring a healthy lifestyle a healthy lifestyle is one of the most important dimensions of the educator voice that has to be considered by a physician. this includes proper information on healthy behavior, diet, exercise, and hygiene. however, an evaluation of the consultations revealed that a healthy lifestyle was generally ignored and the doctor’s duty was simply limited to prescribing medication, although in some sporadic cases this issue was touched upon by the physician. for example, in consultation 4 involving a patient with anal fissure, the physician indicated that being overweight is the main cause of the problem, but her advice was limited to the following statements: d: how much do you weigh? p: umm… 73 kg. d: you are slightly overweight. yeah, you’re too young to be this weight. patient’s mother: he doesn’t eat much but he gains weight. d: he does not have enough exercise. in this conversation, the physician’s statements focused on her observation and did not provide any solution to the problem in order to promote a healthy lifestyle. in other consultations, such as those with diabetic, elderly and obese patients, recommendations with regard to a healthy lifestyle were totally overlooked. the robotic nature of consultations this theme means that essentially all consultations were based on paraclinical observations and only occasionally did they include physical examinations or active conversations. in this situation, patients felt that the consultations were meaningless. a robotic consultation frequently involves routine exchanges such as “let me see your echo test results”; “your tests are incomplete according to the ultrasound”; “have you brought your previous tests?”; “your previous test results were better than the present report”; “you should do another test and come back in one month”; “i will prescribe a re-test”; “repeat the test”; “just do these tests”; “for the time being, your treatment depends on the results of these tests”; “bring the results to me later”; “an endoscopy retest might be needed”; “let me check your blood sugar too”; “i also recommend a mammography”; “you should get scanned in two months” and so on. these types of clinical approaches can be evaluated from several aspects, but when viewed as ev, they appear robotic. in this case, the physician merely relies on paraclinical data and ignores the other features of a consultation. therefore, the question is, what happens if the paraclinical data is not accurate or is misleading, a situation that does not clearly define the impact of ev. discussion this study shows that the ev employed by physicians is expressed in either descriptive or prescriptive manners. in this context, those characteristics of ev that are related to the nature of j med ethics hist med 10: 9, october, 2017 jmehm.tums.ac.ir kamran bagheri lankarani et al. page 6 of 8 the dpi include superficiality, marginalization of patients, one-dimensional approach, ignoring a healthy lifestyle, and the robotic nature of consultations. generally, a weakness or lack of educational aspects was detected in the doctorpatient communication within the context of this research. as shown by several studies, dpi is distorted and asymmetrical (6, 13, 14) due to the paternalistic quality of the doctor-patient relationship (6). in this regard, another study showed that patients experienced interactions with unexpected, unprofessional, instrumental, and non-cooperative features (26). these findings are totally in line with our study, in that they confirm the inappropriate patterns of ev and dpi, and an irrational relationship that disregards the patients’ educational needs. for example, the physician visits the patient as a faceless and inattentive robot with weak interaction skills (14), and this is a situation that reflects an asymmetrical power relationship in dpi (6). therefore, under these circumstances, the discourse prevailing a doctor’s visit is expressed as his or her active dominance resulting in marginalization of patients, one-dimensional approach, and the robotic nature of dpi. despite the doctor’s dominance, the modern approach underlines patients’ concern for acquiring an understanding of their disease (27). in this approach, a physician is compelled to consider the patient’s worries and apprehensions, a situation that involves the patient in the treatment process. accordingly, ev can be improved by minimizing patient marginalization and the robotic traits of the consultation, and listening to the patient’s viewpoints attentively instead. cordella critically reviewed the nature of ev in clinical counseling and discussed the deficiencies in 7 consultation sessions, posing a number of main questions including: “are we to understand the absence of the ev in those consultations in which seven patients were deprived of the opportunity to acquire a better understanding of their health condition?”; “will this limit their chances of adequately looking after themselves?”; “is the absence of patient education in almost one-third of the consultations contradictory to the basic teaching principles of the institution where the study was conducted?”; and “if we accept that the silencing of ev may be a problem, what could be its underlying cause, and how should it be interpreted?” (7). our investigation confirms cordella’s findings, while regarding her last question, the cause can be explained as follows: it is difficult to determine whether or not we are faced with the silent ev. even though ev is silent overall, some physicians tried to respond to the patients’ questions as thoroughly as possible. generally speaking, it seems that an obvious deficiency in ev lowers the patient’s confidence. however, if physicians actively assist patients in the information gathering process, it will result in an improved relationship, which is a potential gain for all collaborative parties (28). patients’ mistrust in their doctor has been reported by several studies (14, 27, 29). in addition, research has shown that the recent health sector evolution plan in iran has intensified a distorted dpi (30). in this situation, it is clear that the silent ev generally leads to patients’ reduced confidence in dpi and their non-compliance to prescriptive voice. according to the findings of the present study, which to our knowledge is the first on this highly important topic, the existing ev is unacceptable. the obtained results can provide a guideline for future studies comprising qualitative or quantitative approaches. it also shows that distorted dpi is related to a deficiency in ev, an area to be evaluated in future quantitative studies. finally, because of the significance of ev, this research recommends that health policy makers pay more attention to providing the means for better patient education throughout the country. one limitation of this study was the way in which the conversations were recorded. in fact, recording affects doctors’ manners of consultation and dialogue. however, the researchers did not find any other alternative for data collection. this is an important and basic restriction of qualitative studies since the participants are aware of the recording and data collection, even though in this case the researcher did not interfere with the natural course of the dialogs. thus, although recording the data considerably reduced the bias, it could have affected the quality of consultation, and the resulting pattern may not show some aspects of the existing behavioral patterns in dpi. another limitation of the present research was that the type of disease, the patient’s gender and even the way the patient interacts with the physician affect the dpi, but such factors tend to be ignored in qualitative studies due to the very nature of this type of research. conclusion ev is an important part of any clinical consultation. in this context, some issues that were noted with ev included superficiality, marginalization of patients, one-dimensional approach, ignoring a healthy lifestyle, and the robotic nature of consultations. these characteristics created a substantial problem in dpi, one important function of which was to promote the patient’s health-related awareness. the silent ev does not occur frequently, but the findings of this study showed an obvious deficiency in the current state of ev. an important point is that those in charge of the iranian health system should be aware of the weaknesses in clinical consultation and solve the problems scientifically. in this regard, health policy makers should pay more attention to effective ev with regard to training medical students j med ethics hist med 10: 9, october, 2017 jmehm.tums.ac.ir kamran bagheri lankarani et al. page 7 of 8 and faculty members in communication skills. since these are not included in the current curriculum of medical education, it is recommended that the authorities solve the problem by holding related courses for all medical groups in the short term, and by defining such courses in the long term. acknowledgments this study is extracted from the data of phd dissertation of ahmad kelateh sadati in sociology (2014) entitled “critical narrative analysis of physician-patient communication at shahid faghihi hospital” and was approved (no.1069353) at shiraz university. the research was a study to develop knowledge and does not seek to object the physicians’ efforts who work hard to serve patients. the researchers wish to thank all of the participants of the study. j med ethics hist med 10: 9, october, 2017 jmehm.tums.ac.ir kamran bagheri lankarani et al. page 8 of 8 references 1. hoving c, visser a, mullen pd, van den borne b. a history of patient education by health professionals in europe and north america: from authority to shared decision 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agenda. j med internet res. 2001; 3(2): e15. 29. kalateh sadati a, iman mt, lankarani kb. medical paraclinical standards, political economy of clinic, and patients’ clinical dependency; a critical conversation analysis of clinical counseling in south of iran. int j community based nurs midwifery. 2014; 2(3): 157–68. 30. kalateh sadati a. money based reform and distorted doctor-patient interaction: a critique of the recent health sector evolution plan in iran. iran j public health. 2017; 46(4): 583-84. hhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh copyright © 2023 tehran university of medical sciences. this work is licensed under a creative commons attribution-non commercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. original article abstract the concept of individual freedom has complex and multifaceted dimensions that significantly affect the limits of permissible government interventions aimed at restricting such freedoms and maintaining public health. therefore, the boundary between individual freedom and the social obligations of the government must be carefully clarified. during the covid-19 pandemic, the need for such clarifications clearly increased. this study intended to investigate the concept of freedom according to major theories and to observe their application in analyzing the relations between individuals and the government in the health system, particularly during public health emergencies. the findings revealed that “justice-based”, “development-based” and “accountability-based” conceptions of freedom provide a more appropriate rationale for implementation of public health restrictive measures by health authorities during infectious disease outbreaks including pandemics such as covid-19. *corresponding author ehsan shamsi gooshki address: no. 23, 16 azar st., keshavarz blvd., tehran, iran. postal code: 1417863181 tel: (+98) 21 66 41 96 61 email: shamsi@tums.ac.ir received: 1 dec 2022 accepted: 19 jun 2023 published: 18 jul 2023 citation to this article: moazzen v, shamsi gooshki e. the extent of government intervention in the public health system and individual freedoms during the covid-19 pandemic: a theoretical analysis. j med ethics hist med. 2023; 16:4. even in minimal governments that are built upon a free-market system and unrestricted conception of individuals’ freedom, such public health interventions are justifiable in the light of the ‘catastrophic moral horror’ where there is an extreme risk to the health of citizens. keywords: covid-19; individual freedom; government intervention; public health measures. the extent of government intervention in the public health system and individual freedoms during the covid-19 pandemic: a theoretical analysis 1. visiting professor, department of public and international law, law faculty, farabi campus, university of tehran, tehran, iran. 2. associate professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran;associate professor, medical ethics department, school of medicine, tehran university of medical sciences, tehran, iran; lecturer, monash bioethics center, monash university, melbourne, australia. vahid moazzen1, ehsan shamsi gooshki*2 the extent of government intervention in the public health…. j. med. ethics. hist. med. 2023 (july); 16: 4. 2 introduction the covid-19 pandemic has fueled the longlasting debate around the classic conflict between individuals’ freedom and the public good. according to who's coronavirus dashboard, this pandemic caused the illness of nearly 765 million and the death of nearly 6.9 million people worldwide in the span of more than 3 years, from january 2020 (the official announcement of the beginning of the pandemic) to may 2023 (the official date of its termination). however, it can safely be assumed that the real numbers of infection and death cases were even higher. there has long been a deep alignment of speech and appreciation of the high status of freedom among various philosophers and systems of thought. as aristotle put it, “flourishing and capacity are clearly in connection with the quality of life and major human freedoms” (1). in this interpretation of the concept of freedom, individual role-playing and social arrangements strongly complement each other, indicating the need for clarifying the boundary between individual freedoms and social obligations. this translates into avoiding the use of pretexts such as protecting individual freedoms that restrict others’ freedom, or exercising authority in a negative manner, for instance by violating the fundamental rights and freedoms of citizens. citizens not only need a government that respects individual rights and provides them with the necessary and legal protection against aggression and the risk of being violated, but in some circumstances, they also need to be protected against government intervention (2). threats to public health such as infectious disease outbreaks shed light on this dual role of governments in protecting or interfering with citizens’ fundamental rights. the level of social freedom in a particular context is another significant factor in such situations. while individuals’ fundamental rights are always an essential part of such discussions in public health areas in some biopolitical systems, such considerations are not seriously taken into account in other political contexts. also, there is no doubt that in addition to personal consequences, an individual's health-care choices have social ramifications as well (3). therefore, addressing the scope of government competencies in providing or protecting public services such as health on the one hand and putting restrictions on some rights and fundamental freedoms of citizens on the other could be the central focus of the constitution; the reason is that moazzen v., et al. 3 j. med. ethics. hist. med. 2023 (july); 16: 4. both theories of ‘the necessity of protecting freedom as an ultimate value’ and ‘the inevitability of restricting freedoms through the actions of state guardian measures’ have their own justifications. the natural human right to freedom supports the principle of non-intervention. in contrast, there are many reasons that support government intervention in the health sector and limiting the freedoms of individuals, for instance reducing social inequalities by interfering with the free market system or imposing travel bans or lockdowns in order to decrease the social transmission of viruses in cases such as the covid-19 pandemic (4). therefore, establishing a balance between these two tasks of the government (i.e., respect for the fundamental rights and freedoms of citizens while ensuring the right to health for the public) is of crucial importance. on the other hand, besides the fact that assumptions have a major effect on the discussions about government intervention in each area, the nature of the government should be considered (e.g., democratic, modern, and legitimate); this is mainly because measures taken by, for instance, a legitimate government are more likely to be perceived as justified by citizens than those imposed by a non-democratic political system (5). the subject of this research is also related to the biopolitics theory of michel foucault. indeed, one of the effects of the covid-19 pandemic has been to bring the notion of “biopolitics” borrowed from michel foucault back to the forefront of the discussions, since the recent pandemic led to an unprecedented expansion of all forms of government interventions and obligations. according to foucault's conception of biopolitics, killing is no longer considered the utmost realization of power, but totalizing the body is. the former power exercised through infliction of death and symbolized by the power of the ruler is entirely replaced with ‘totalizing subjects’ and ‘discipline’, and by mentioning issues such as birth, longevity, public health, housing and immigration in the political and economic domains. in this regard, political powers have developed various techniques to totalize bodies and control individuals and communities (6). accordingly, this study intends to analyze the relationship between individual freedoms and government authority, as the representative of the collective interest, in the health system, and examine its effect on the realization of social justice, which has grown in importance since the onset of the covid-19 pandemic. the extent of government intervention in the public health…. j. med. ethics. hist. med. 2023 (july); 16: 4. 4 methods the current study adopted a descriptive-analytical approach using several relevant theories that are somehow generalizable to the field of health and can be considered a prominent representative of different schools of thought. this method involved investigation of various interpretations of the concept of freedom in the fields of health, welfare and social justice, including those offered by amartya kumar sen, john rawls, and robert nozick. the main purpose of this article was to examine the level of intervention of governments, the concept of freedom, and its relationship with the surrounding environment; it also aimed to clarify the boundaries of freedom and regulate the relations between the government and the individual in the health system during public health emergencies such as infectious disease outbreaks. results governments are responsible for ensuring ‘the right to freedom’ and ‘the right to enjoy the highest attainable level of health’. this has also been emphasized in various international documents, including the who constitution (1946), and the general comment no.14 on ‘the right to the highest attainable standard of health’ (2000). in cases such as increasing the taxes on goods like cigarettes and alcoholic or non-alcoholic highsugar drinks, or imposing restrictive measures such as lockdowns, travel bans, physical distancing, obligatory vaccination and issuance of vaccine certificates during infectious disease outbreaks, it is not possible for governments to ensure the highest level of both of these rights. the reason is that ensuring the right to health as a collective good and a basic human right often necessitates governmental paternalistic measures to limit the freedom of citizens, which is highlighted in human rights documents as another fundamental value with a high status. both health and freedom hold an increasingly significant place in modern societies and are constantly expanding in scope. the dominant understanding of freedom is moving from the concept of negative freedom toward that of positive freedom, which particularly strengthens individuals’ interests in governments’ interventions. at the same time, the general understanding of health is shifting toward a broader sense to include various aspects of human life. interestingly, in new theories of health such as nussbaum and powers and faden who emphasize various aspects of human “capabilities” or “wellbeing”, freedom is considered a basic property of health and is essential for a just health system (7, 8). moazzen v., et al. 5 j. med. ethics. hist. med. 2023 (july); 16: 4. freedom and management of health systems during infectious disease outbreaks freedom by itself is desirable for humans and has always been praised as one of the most important and highest human values (9). according to kant, an order or rule has moral value only if it is rooted in free will and has been determined by virtue of sound nature (5). it is noteworthy that among the various types of freedom, there is a class called ‘instrumental freedoms’. these types of freedoms directly enhance people's capabilities, complement each other, and can reinforce one other. without being the primary goal of development, these freedoms are regarded as the main tool of development and help people to live as they wish. freedom is an essential factor for conceptualizing the perspectives, visions and goals of development. in addition, moral and legal issues are closely related to cultural and philosophical paradigms in any society (10). for this reason, paying attention to the concept of freedom in various countries can indicate the perceptions and functions of governments. one of the most obvious areas is explanation of the limits of the guardianship actions of governments and the fundamental rights and freedoms of citizens. in his book development as freedom (1999), amartya kumar sen focuses on drawing a relationship between freedom and development based on individual responsibility. john rawls, on the other hand, defends and promotes the theory of the “welfare state” relying on social justice in his book, a theory of justice (1971), while robert nozick supports a minimal state in anarchy, state, and utopia (1974). freedom and its interactions with the environment have provided a way that can be helpful in explaining the limits of freedoms and regulating the relationship between the government and the individual in the health system. it is essential that public health authorities take the concept of freedom into consideration when responding to a public health emergency that calls for restrictive measures such as lockdowns, travel bans, obligatory vaccination, obligatory testing, mask-wearing or physical distancing. this issue is even more significant when such interventions are discussed in socio-political context with a prominent level of government intervention in the daily life of citizens. in such situations, there is a higher risk of neglecting the value of freedom when discussing restrictive measures to be implemented to control the spread of infectious disease outbreaks. it is crucial to consider the value of freedom in such situations since health-care authorities and professionals, regardless of their political affiliation and philosophical interests, are the extent of government intervention in the public health…. j. med. ethics. hist. med. 2023 (july); 16: 4. 6 naturally more concerned about the physical health of people and the number of infected, hospitalized or dead people due to diseases. as a result, they have the tendency to be less sensitive about other aspects of human life that could be seriously impacted by imposing restrictions, for instance the effects of isolation on citizens’ mental health or the effect of school closure on the future of children. this position of health-care professionals is understandable since they are in direct contact with seriously ill and even dying patients. to ensure balanced decision-making, it is recommended that people with social and philosophical perspectives be included in the policymaking process and representatives of civil society be given chairs at the table. discussion development-based and accountability-based freedom this interpretation of the concept of freedom was proposed by amartya kumar sen, who believes that the relationship between freedom and responsibility is a two-way communication; in other words, accountability depends on freedom, and freedom is a necessary and sufficient condition for responsibility (1). he believes that the natural differences among people must be considered as they affect the quality of life they expect. unlike john rawls who sets the standard for basic social products, amartya sen introduces a criterion called the “capability approach” (11). two meanings emerge from the concept of responsibility in amartya sen's theory. in the first sense, a person is considered responsible for a particular action, and the correctness or badness of his/her action is judged based on this responsibility. thus, responsibility has a moral and legal aspect that can be attributed to the agent. in the second sense, a person acts responsibly when he/she is aware of the importance of acting in a particular context and knows that his/her behavior will have consequences, even if he/she never knows what those consequences will be. in this sense, responsibility is "the ability to respond" to a situation rather than "react" to that situation (12). in the capability approach, freedom is the focus, and development is nothing but an increase of fundamental human freedoms (7). in order to examine the application of amartya sen's theory in creating a balance between individuals’ right to health choices and the government's duty to provide public health services, certain aspects of his theory will be mentioned below. while basing freedom on the development process, amartya sen believes that moazzen v., et al. 7 j. med. ethics. hist. med. 2023 (july); 16: 4. individuals are committed and responsible for their health choices toward the society, and that imposition of restrictions over the health choice freedoms of individuals by the collective wisdom (government) in its own exclusive way is possible and legitimate. he argues that a theory of justice must be based on a general and rational agreement, and therefore justice can be achieved in the society through collective reasoning rather than individual decisions, which are often made based on anger and personal desire (13). as mentioned earlier, inclusion of civil society representatives and non-medical experts and humanities thinkers in the decision-making process is essential for reaching a more balanced decision through a broader outlook on the concept of freedom. the significance of including different stakeholders and social groups in policymaking regarding restrictive measures during public health emergencies such as the covid-19 is further highlighted by amartya sen's formulation for freedom, which includes concepts of accountability and collective reasoning. a world health organization policy brief on good ethical governance of the health system during the covid-19 pandemic also emphasizes the importance of procedural principles of transparency, accountability and inclusion/participation while considering the substantial values of well-being, respect, equity and solidarity (14). in this regard, transparency and inclusion of the public in discussions about public health measures are basic requirements for holding the members of the society accountable for their health-related choices. in addition, it could be argued that the lowest possible level of obligation would be the most effective way to maintain this accountability in a developed society. in the absence of real participation of citizens in the policy-making process, a desirable outcome cannot be achieved through implementation of public health restrictive measures. in addition, providing the highest level of freedom for the citizens makes it possible to hold them accountable. freedom with minimal government intervention according to libertarian thinkers such as robert nozick, the government is absolutely barred from entering the realm of economic redistribution in any form and under any circumstances, and government intervention is legitimate only when social self-regulatory mechanisms are insufficient or ineffective (15). nozick's entitlement theory of justice has been formed based on the principle that the distribution of wealth, income and assets is only fair if everyone in the society is entitled to their assets (16). in fact, the extent of government intervention in the public health…. j. med. ethics. hist. med. 2023 (july); 16: 4. 8 unlike rawls, nozick believes that humans should be able to enjoy all the natural benefits and pleasures of life without restriction (17). an examination of nozick's views on the concepts of government and freedom produces no suitable basis for supporting the patriarchal government in the area of health, except in the case of ‘catastrophic moral horror’ as the only part of his theory that emphasizes the importance of the government's role in the health system. according to nozick's theory, the entitlement people gain through exercising their rights cannot be underestimated because of the consequences; however, these consequences may be unpleasant. he believes the only exception to be ‘catastrophic moral horror’. according to this view, in some cases, excessive sanctification of authoritarian rights can lead to deprivation of fundamental freedoms that are necessary for people to achieve their valuable aspirations such as escaping death, proper nutrition, maintaining health, etc. (16). thus, in nozick's theory, the only area that discusses serious moral horrors has the potential to be used as a basis for supporting the guardianship of governments in restricting the rights and freedoms of citizens in the health system. it could be argued that even within theories that strongly emphasize individual freedom and allow only minimal government intervention, restricting individuals’ freedom could be justified when catastrophic consequences are expected, although such restrictions are saved for truly catastrophic situations. the way that one liberal government or political system defines and interprets a “catastrophic” situation would be crucial in this regard. in addition, risk evaluation is a core point in determining catastrophic situations, and therefore experimental and scientific evidence plays a vital role in such discussions. reliance on scientific evidence is important in all discussions about imposing restrictive public health measures on the daily procedures of affected communities, but when the only reason for implementing such measures is to avoid a catastrophe, evidence-based decision-making becomes even more important. certain periods during the covid-19 pandemic when the risk of collapse of the health-care system was high are examples of catastrophic situations with devastating consequences. as a result even health-care systems within libertarian contexts would find theoretical ground to impose some restrictions to control infectious disease outbreaks or similar public health emergencies. justice-oriented freedom john rawls’ "theory of justice" is tied to the concept of "fairness". in rawls' view, the quality moazzen v., et al. 9 j. med. ethics. hist. med. 2023 (july); 16: 4. of human life is primarily influenced by societies’ political, social and economic institutions (18). this provides the grounds for imposing restrictions on the achievements of better-off individuals and allowing people with poorer public and social assistance to be eligible for assistence. for this reason, governments must be able to guarantee a decent life for every citizen while exercising minimal force and coercion (19). although rawls' theory does not directly address the subject of health, some interpretations of his theory (20) provide a good theoretical basis for assessing social health inequalities and for treating health as an important precondition for social equity. he sees the focus on health differently based on the indirect mechanisms of the basic social institutions that cause health inequalities (21). according to this view, premature death, illness, disability and a reduction in people’s normal functioning limit the range of opportunities available to them for a decent life plan (22). therefore, the establishment of a universal public insurance system is among the duties of the government (23). it seems that rawls’ theory of health justice, later expanded by his followers (mainly norman daniels), provides a better ground for government intervention in times of infectious disease outbreaks. the reason is that these theorists believe citizens to be normally healthy and perfect, and since a great deal of suffering often accompanies accidents and illnesses, community intervention may be needed to restore the health of individuals by providing medical services (24). this theory could be interpreted in a way that implementation of restrictive public health measures limiting individuals’ freedom might be justified in protecting the people. such restrictive measures could be considered as a kind of health service to minimize the effect of public health emergencies on the general population. conclusion this study aimed to determine how various theories of individual freedom could be interpreted in the time of public health emergencies such as the covid-19 pandemic, when health policymakers face the dilemma of restricting individual freedom on one hand and protecting the health of the public on the other. according to the findings, despite the fundamental differences in the foundations of theories on individual freedom represented by famous thinkers such as rawls, nozick and amartya sen, the intervention of government and social justice could be justified. such interventions may include mandatory testing, mask-wearing, the extent of government intervention in the public health…. j. med. ethics. hist. med. 2023 (july); 16: 4. 10 vaccination, school closure, lockdowns, travel bans and restrictions, mandating vaccine certificates for social movement and travel, quarantine and isolation. it appears that even minimal governments can justify such interventions when faced with extreme risks to the health of citizens. emphasizing collective and social values, the interdependence of individuals, and a positive perception of freedom, rawls and amartya sen consider man to be inherently a social being whose rights and freedoms are not independent of the government. according to them, governments can and should, through the law and the means at their disposal, provide the foundations for the freedom of individuals to grow and increase their ability to pursue their goals. in addition, providing the highest level of freedom for citizens makes it possible to hold them accountable. therefore, our findings showed that the substantive and procedural principles introduced for ethical governance of pandemic response could be aligned with the two theories mentioned above. the findings revealed that “justice-based”, “development-based” and “accountability-based” conceptions of freedom provide a more appropriate rationale for implementation of restrictive measures by health authorities during infectious disease outbreaks including pandemics such as covid-19. thus, even in minimal governments that are built upon a free-market system and unrestricted conception of individual freedoms, such public health interventions are justifiable in the light of the ‘catastrophic moral horror’ concept where there is an extreme risk to the health of citizens. funding the study was not funded. acknowledgements there is no acknowledgements. conflict of interests the authors report there are no competing interests to declare. moazzen v., et al. 11 j. med. ethics. hist. med. 2023 (july); 16: 4. references 1. sen a. development as freedom, 2nded. uk: oxford university press; 2001. 2. kellermann aj, de hann j, de vries f. financial supervision in the 21st century. germany: springer book; 2013. 3. habibnejhad s a, moazzen v. ethical challenges of restrictions on citizens’ health choices by the government. ijmehm. 2020; 13: 306-18. 4. heskett j. what is the government’s role in us health care? usa: harvard business school; 2007. 5. burdine jn, mcleroy kb, gottlieb n h. ethical dilemmas in health promotion: an introduction. health educ q. 1987;14(1):7-9. 6. braun k. bio politics and temporality in arendt and foucault. time & society. 2007; 16(1): 5-23. 7. nussbaum mc. capabilities as fundamental entitlements: sen and social justice. feminist economics. 2003; 9(2-3): 33–59. 8. powers m, faden rr. social justice: the moral foundations of public health and health policy. uk: oxford university press; 2006. 9. kelman s. regulation and paternalism. public policy. 1981; 29(2): 219-54. 10. tschudin v. ethics in nursing, the caring relationship. 3rded. uk: butterworth-heinemann: 2003. 11. sugden r. welfare, resources, and capabilities: a review of inequality re-examined by amartya sen. journal of economic literature. 1993; 31:1947-62. 12. harlan b. capability as opportunity: how amartya sen revises equal opportunity. the journal of religious ethics. 2002; 30(1):107-35. 13. sen a. the idea of justice. usa: belknap press of harvard university press; 2011. 14. who. ethical framework for who’s work in the act-accelerator. [cited on 2023]; available from: file:///c:/users/user/downloads/who-2019-ncov-act-accelerator-ethical-framework2021.1-eng-1.pdf 15. thomas r, unruh l. the economics of health reconsidered. usa: health administration press; 1998. 16. nozick r. anarchy, state, and utopia. usa: basic books press; 1974. the extent of government intervention in the public health…. j. med. ethics. hist. med. 2023 (july); 16: 4. 12 17. sandel mj. liberalism and the limits of justice. 2nded. uk: cambridge university press; 2012. 18. rawls j. political liberalism. usa: columbia university press; 2005. 19. cohen ga. on the currency of egalitarian justice. usa: princeton university press. 2011. 20. daniels n, kennedy bp, kawachi i. why justice is good for our health: the social determinants of health inequalities. daedalus.1999; 128(4):215-51. 21. rawls j. a theory of justice. usa: harvard university press;1999. 22. crandall je. adlers concept of social interest theory, measurement, and implications for adjustment. journal of personality and social psychology.1980; 39(3): 481-95. 23. daniels n, sabin j. limits to health care: fair procedures, democratic deliberation, and the legitimacy problem for insurers. philos public aff. 1997; 26(4): 303-50. 24. berlin i. four essays on liberty. uk: oxford university press; 1969. ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ original article copyright © 2021 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. journal of m edical ethics and h istory of m edicine the second strategic plan of medical ethics: a national report *corresponding author bagher larijani address: no. 10, next to shariati hospital, jalal al-ahmad st., chamran hwy., tehran, iran. postal code: 1411713136 tel: (+98) 21 88 63 12 95 -7 email: emrc@sina.tums.ac.ir received: 10 jul 2021 accepted: 25 nov 2021 published: 2 dec 2021 citation to this article: parsapour a, shamsi gooshki e, malekafzali h, zahedi f, larijani b. the second strategic plan of medical ethics: a national report. j med ethics hist med. 2021; 14: 17. alireza parsapour1, ehsan shamsi gooshki1, hossein malekafzali2, farzaneh zahedi3, bagher larijani4* 1.assistant professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. 2.professor, department of epidemiology and biostatistics, school of public health, tehran university of medical sciences, tehran, iran. 3.researcher, endocrinology and metabolism research center, endocrinology and metabolism clinical sciences institute ,tehran university of medical sciences, tehran, iran. 4.professor, endocrinology and metabolism research center, endocrinology and metabolism clinical sciences institute ,tehran university of medical sciences, tehran, iran. abstract medical ethics faces several challenges in different aspects of education, research, and treatment in medicine and healthcare practice. design and implementation of a national strategic plan can pave the way for the development of a roadmap in various countries to strengthen ethics and address these challenges. to create a comprehensive plan compatible with the iranian healthcare system, a multidisciplinary team of main stakeholders compiled a national strategic plan of medical ethics following several focus group discussion sessions and two workshops (2014-2017). ultimately, the plan was confirmed by the supreme council for the medical ethics of the ministry of health and medical education. the current paper is a national report of the process and the medical ethics strategic plan in iran. we have also tracked signs of progress and achievements in the country. in conclusion, this valuable effort has led to significant success in the implementation of medical ethics in clinical medicine, medical research, and education by using all the resources in our country. the participation of all the stakeholders, especially healthcare professionals in this way is required. keywords: strategic plan; medical ethics; health policy; islamic ethics; iran. the second strategic plan of medical ethics: a national report 2 j med ethics hist med. 2021(december); 14:17. journal of m edical ethics and h istory of m edicine introduction along with other advancements in healthcare during the recent decades in iran (1, 2), there have been great efforts to strengthen medical and healthcare ethics to build up the country’s ethics capacity (3, 4). accordingly, some progress has been made in various fields of research, education, and clinical ethics in iran in the past years (5, 6). medical knowledge and related technologies are rapidly evolving in all disciplines. this requires the close attention of policymakers, healthcare professionals, and bioethicists to provide proper ethical responsiveness and support. moreover, establishing and sustaining an ethical infrastructure at the national level is necessary to solve the controversial and complex issues that have emerged in the field of bioethics in the past decades. strategic planning of the ethics activities to address the key priorities is one of the elements on which the success of integrative ethics initiatives relies (7). medical ethics strategic planning paves the way for the integration of ethics in the healthcare environment and strengthening ethics in various fields. there are several advantages to strategic planning in the field of medical ethics. these include assessment of the current situation, evaluation of strengths and weaknesses, ability to set goals at the national level, and empowerment of ethical infrastructure to ensure ethical standards in healthcare practice, education, and research. activities toward integration, sustainability, and accountability in clinical bioethics have been carried out through strategic planning in several countries. for instance, the clinical ethics group at the joint centre for bioethics at the university of toronto has formulated its strategy to “foster an ethical climate and strengthen ethics capacity broadly throughout healthcare settings as well as create models in clinical bioethics that are excellent and effective” (8). to address the demands in iran, the first strategic plan in the field of medical ethics was introduced and implemented by the ministry of health and medical education (mohme) in 2002 (4). the vision, mission, specific goals, and main activities of the plan were reviewed in a paper published in the developing world bioethics journal in 2006 (4). to review the progress and discuss the achievements and challenges, several workshops and expert panels were held. the academy of medical sciences of the islamic republic of iran1 (ams), in collaboration with the medical ethics and history of medicine research center (mehmrc) of the tehran university of medical sciences (tums), medical council2 of the islamic republic of iran, and supreme council of medical ethics of mohme made substantial efforts to compile the second version of the country’s national strategic plan for medical ethics (2015-2017). the supreme council of medical ethics, known as the highest-level medical ethics 1 . http://www.ams.ac.ir 2 . http://irimc.org/?lang=en parsapour a., et al. 3 j med ethics hist med. 2021(december); 14: 17. journal of m edical ethics and h istory of m edicine authoritative body inside mohme, has been involved in developing this strategic plan. this was done through active and organized participation of the council secretariat and some key members of the council. all the documents and information required for the development of the strategic plan have been provided by this secretariat for the project team. it is worth mentioning that the second strategic plan is not merely an update of the first one. this article reviews the second national strategic plan for medical ethics and discusses its advantages in comparison to the initial version. we will also mention some similar plans in other countries. methods the draft of the strategic plan was prepared by the “philosophy, ethics and biomedical sciences department” of the ams in collaboration with the mehmrc of the tums following several focus group discussion sessions. the first outline of the strategic plan was prepared by the steering committee of the project, which consisted of the vice president and secretary of the supreme council of medical ethics, secretary of the national committee for ethics in biomedical research, one professor of methodology, and the chairman of medical ethics group of iranian ams. the first draft was discussed in two workshops on 9th and 30th january 2014. the 55-member advisory group who discussed and expanded that first outline consisted of 31 medical ethics specialists and ph.d. candidates, 13 specialists of various medical sciences disciplines, six specialists from the legal and forensic aspects of medical practice, one religious’ scholar, and one philosopher. following a series of study group meetings at the ams, the second draft was introduced during the annual summit of the chairmen of medical sciences universities, and their opinions were gathered. the third draft was assessed and finalized by holding a workshop on 14th october in 2015. ultimately, the compiled national strategic plan of medical ethics was confirmed by the supreme council for medical ethics of mohme, then published and widely disseminated as a booklet in summer 2017. experts from various fields of medicine, medical ethics, law, and jurisprudence participated in the workshops and other sessions. individuals who contributed to this review process are listed in the acknowledgments section. result the “philosophy, ethics, and biomedical sciences department” of the ams decided to reassess the national medical ethics strategic plan in collaboration with other stakeholders after 11 years. the creation of the strategic plan was initiated by contemplating the vision and the mission (table 1). the second strategic plan of medical ethics: a national report 4 j med ethics hist med. 2021(december); 14:17. journal of m edical ethics and h istory of m edicine table 1vision and mission statement of national medical ethics strategic plan element definition vision to institutionalize knowledge and practice of medical ethics based on the islamic and humane values reflected in all individuals and all pillars of the iranian health system, aiming to establish a responsive system with the utmost respect for human dignity. mission to strive for achieving thorough knowledge and inclusive management (including needs assessment, policymaking, planning, implementation, monitoring, evaluation, and rescheduling) of medical ethics in the fields of education, research, and health services according to the islamic-iranian values and by respecting for human dignity and justice in health. swots analysis the analysis of strengths (s), weaknesses (w), opportunities (o), and threats (t) (swots) was conducted as a key component of the strategic planning process. swots’ analysis was carried out comprehensively to identify the internal (strengths and weaknesses) and external (opportunities and threats) factors that intervene with achieving the goals set for the plan. table 2 summarizes the output of swots analysis based on a wide spectrum of the contributing factors. goals, objectives and activities as the next step, the measurable goals and objectives towards the fulfillment of the mission were defined and the related activities were stated. the goals were prioritized based on the existing infrastructure and resources. table 3 illustrates the defined eight main goals. table 2medical ethics swots analysis. strengths • the presence of executives' decision-makers and professionals with insights on the islamiciranian model of progress. • the stakeholders’ attention towards new issues of medical ethics. • feeling the need to work on the new issues of medical ethics due to the raised cultural awareness and knowledge of the health services recipients and their increasing demands as well as the development of science and technology in medical sciences. • existence of departments for education, research, and services related to medical ethics. • existence of a former version of the strategic plan, the national comprehensive health plan, and other high-level documents. • specified structures in the field of medical ethics in the country and the possibility of the formation of new structures based on the emerging needs. • educating and training the ethics professionals and promoting the presence of the graduates in medical ethics-related fields. • availability of scientific resources related to medical ethics. • availability of guidelines and codes on issues related to medical ethics. • possibility of studying in medical ethics-related fields. • possibility of centralized policy-making in the field of medical ethics. parsapour a., et al. 5 j med ethics hist med. 2021(december); 14: 17. journal of m edical ethics and h istory of m edicine w eaknesses • lack of transparency in the national macro-management policies in the field of medical ethics and instability of the administratorship in the related fields. • lack of a coherent theoretical islamic–iranian framework to address medical ethics issues in practice. • limited access to basic and applied research and updated original iranian-islamic literature in medical ethics. • lack of communication, interdisciplinary, inter-sectoral cooperation, and interaction, particularly between the universities and the islamic seminaries. • inadequate numbers of medical ethics experts and uncertainty of their position in the organizational chart of the healthcare system. • insufficient access to the international scientific resources and communications in the related fields. • unavailability of the necessary resources to support medical ethics research. • weakness of the educational content and implementation processes of medical ethics educational curriculums. • ignoring the professional ethical capability in recruiting, the assessment, and promotion of the learners, faculty members, and providers of health services. • lack of appropriate and consistent rules, regulations, and bylaws about several issues of medical ethics. • lack of efficient system for monitoring and surveillance of medical ethics. • absence of an institutional mechanism for ethical appraisal of policies, rules, and regulations in the health system. • absence of nationwide structures and national, provincial, and organizational ethics committees in areas other than research, e.g., the absence of national committees of clinical ethics and ethics in medical education. • weaknesses in the management of medical ethics research to direct them towards solving ethical problems of the healthcare system. o pportunities • emphasis of the supreme leader on theorizing in the field of humanities, knowledge-producing, and discourse based on ethical-spiritual values. • numerous areas for research in the field of medical ethics. • islamic-iranian noble resources of knowledge related to medical ethics. • growing demand for the ethical improvement of education and research among the scientific and medical community as well as the stakeholders. • support of the high-level national documents, including the constitution, development plans, and national comprehensive scientific map, for ethical development. • researchers interested in medical ethics. • religious beliefs, inner conscious, unconscious ethical, and common cultural, ethical, or moral beliefs among the society. • active related intellectual fields such as jurisprudence, philosophy, sociology, etc. • potential stakeholders' desire to enter this field. • research and educational institutes in medical universities that are active in the field of medical ethics. t hreats • the negative influence of the public ethics issues on professional medical ethics. • reduced public trust in the medical community. • reduced motivation of healthcare community to work effectively due to the socio-economic conditions. • insufficient justification of the stakeholders of medical ethics discourse and lack of common language among the clergy, doctors, lawyers, philosophers, and other stakeholders. • governance of technical-empirical paradigm (worldview) over the humanities worldview in the country. • growing tendency to use the medical methods and devices for non-medical purposes • lack of sufficient sensitivity to vulnerable groups including migrants, refugees, and slumdogs. • lack of public awareness and misunderstanding of medical ethics debates. • wrong and restrictive perception of laws and regulations affecting the implementation of medical ethics. • lack of the explanation of the consistency between the islamic and iranian medical ethics with the predominant secular discourse of medical ethics. • uncontrolled and unmannered use of the social networks by students. • giving the power to enhance commercial, technological, and industrial aspects of medical professions. the second strategic plan of medical ethics: a national report 6 j med ethics hist med. 2021(december); 14:17. journal of m edical ethics and h istory of m edicine table 3the main goals of the national strategic plan for medical ethics in iran. goal 1 to attain the basic islamic-iranian framework based on the heritage of medical ethics regarding the related contemporary knowledge. goal 2 to assemble a national collection of documents stating the approved standards of medical ethics. goal 3 to achieve and implement policies, structures, and specific resources in the field of medical ethics. goal 4 to obtain the support and involvement of the key stakeholders of medical ethics. goal 5 development of research in the field of medical ethics. goal 6 development of education in medical ethics. goal 7 developing effective national and international communications in the field of medical ethics. goal 8 establishment of a comprehensive system of action plans in the field of medical ethics the first goal emphasizes shifting the medical professionals’ attention towards the great heritage of islamic-iranian knowledge. four objectives were defined in this regard, as follows: • assembling, translating, classifying, and publishing the islamic texts related to medical ethics. • collecting, translating, and critical evaluation of the contemporary knowledge of medical ethics. • strengthening the conceptualization and interdisciplinary dialogue in the field of medical ethics. • compiling the textbooks related to medical ethics. to pursue the goal and its related objectives, the 19 defined activities included compiling comprehensive textbooks for the students of different fields of study (general medicine, nursing, dentistry, pharmacy, etc.) and at various education levels. development of the “islamic medical ethics encyclopedia” and other reference books are also among these activities. the second goal aims to provide necessary national documents, codes, guidelines, and regulations related to medical ethics as indicated in table 3. this is to be fulfilled through the following objectives: • development of an appropriate mechanism for the required assessment of ethical standards (laws, regulations, and guidelines related to medical ethics). • supporting the development of ethical standards (laws, regulations, and guidelines related to medical ethics). • design and implementation of appropriate mechanisms for the approval and legitimization of ethical standards (laws, regulations, and guidelines related to medical ethics). to achieve these objectives, 35 activities were designed in a detailed and complete way. these activities included the “establishment of a committee to identify the gaps in legislation and required ethical guidelines in healthcare and drafting the suggested regulations and ethical guidelines”. compiling ethical codes and guidelines for the dentistry, pharmacy, reproductive health, assisted technologies, organ transplantation, end of life care, parsapour a., et al. 7 j med ethics hist med. 2021(december); 14: 17. journal of m edical ethics and h istory of m edicine emergency medicine, the care of vulnerable groups, the care of patients with mental illness, healthcare in disasters, the use of biobanks, collected health data, the transmission of biologic samples to foreign countries, etc. goal 3 focuses on achieving and implementing policies, organizational structures, and resources in the field of medical ethics through the following five objectives: • creating the necessary organizational and administrative structures for healthcare institutions. • providing required financial and human resources for the healthcare institutions. • considering ethical enclosures in all policies, laws, and regulations related to healthcare. • ethical surveillance and monitoring of all the healthcare-related policies and regulations. • revising the health system regulations and laws based on ethical approaches and concepts. the establishment of the national committee for clinical ethics and related secretariat office in the mohme are among 18 activities set to achieve this goal and its associated objectives. forming the departments of medical ethics in the major organizations such as the “iranian medical council” and the “nursing organization of the islamic republic of iran” and providing the checklists and regulations for ethical appraisal of the pharmacies, the drug companies, medical professionals, faculties, fellows, residents, and students in the field of healthcare are among these activities. likewise, the allocation of specific funds to support the educational, research, and executive affairs of medical ethics by the mohme is one of the activities related to the third goal. involvement of the main stakeholders in the field of medical ethics and attracting their support and contribution have been following through the objectives of the fourth goal as outlined below: • developing appropriate strategies for disseminating information to the key stakeholders including the general public and patients. • creating appropriate mechanisms for surveillance and obtaining feedback from key stakeholders including the public and patients. • providing a supportive environment for the stakeholders’ engagement and their support. • to support founding non-governmental organizations (ngos) in the field of medical ethics and encourage the existing healthrelated ngos to focus on the issues of medical ethics and patient rights. activities defined for materializing the goal include teaching general concepts of bioethics, patients’ rights in high schools and compiling age-appropriate books for the children and adolescents to familiarize them with the ethics-related issues. six objectives are defined for the fifth goal that targets expanding research in the field of medical ethics. the objectives include: the second strategic plan of medical ethics: a national report 8 j med ethics hist med. 2021(december); 14:17. journal of m edical ethics and h istory of m edicine • development of necessary strategies for the needs assessment and priority-setting for research in the field of medical ethics. • supporting research in the field of medical ethics in all related healthcare sciences. • backing the production of evidence-based science in the field of medical ethics. • supporting the publication of the scientific literature and improving the quality of the existing journals. • provision of the infrastructure needed by medical ethics researchers to access international resources. • providing required funds for essential research projects and national initiatives in the field of medical ethics. moreover, the foundation of the medical ethics research centers in the leading universities of the country, integrating medical ethics departments within the structure of specialized medical research centers, creating and supporting related journals, holding medical ethics conferences, post-doctorate, sabbatical courses, and providing comprehensive databases of medical ethics studies and researchers are among 11 activities defined for fulfilling the fifth goal. goal 6 focuses on education emphasizing the following objectives: • qualitative and quantitative improvement in the relevant academic courses on medical ethics as well as expanding the interdisciplinary postgraduate programs. • forging regional, and international, scientific, and educational collaborations with prominent universities by supporting the student and faculty exchange programs. • improving the quality of medical ethics education provided to the learners in different disciplines at various levels. • integration of medical ethics education into the curriculum of all medical and healthrelated disciplines. • providing and offering medical ethics and professional ethics education in the form of in-service programs and continuing medical education (cme) courses for the healthcare system personnel. the change of the pedagogical methods in medical ethics from the traditional lectures to the interactive methods such as small group discussion, workshops, case reports, launching dual degree doctorates (md/ph.d.), md/mph programs, fellowships, and short-term courses in clinical ethics and research ethics are among 13 activities listed under the sixth goal. the seventh goal aims to promote collaborative activities in the country or around the globe and consists of four objectives, as follows: • to establish a national medical ethics network with the participation of all main stakeholders. • to support organizing national, regional, and international conferences on medical ethics. • to provide iranian researchers with the opportunity to participate in regional and international conferences. • to develop international collaborations and partnerships with the universities and institutions scientifically active in the field parsapour a., et al. 9 j med ethics hist med. 2021(december); 14: 17. journal of m edical ethics and h istory of m edicine of medical ethics. to achieve these objectives, twelve activities including the establishment of a regional medical ethics forum in the eastern mediterranean region, founding the islamic medical ethics forum within the islamic countries, facilitating membership in regional and international organizations related to medical ethics, and signing agreements for scientific cooperation with national and international universities have been considered. four objectives shed more light on the operational planning of medical ethics as the 8th goal: • establishing future studies and a surveillance system for medical ethics in the fields of education, research, and service delivery. • establishing a system for monitoring, evaluation, and providing feedback for medical ethics in the fields of education, research, and service delivery. • integrating the descriptive and analytical data and findings in the field of medical ethics. • establishing a rating, accreditation system, and encouraging ethical features in the healthcare system. the main related activities are consisted of developing a framework for the national reports in the field of medical ethics, compiling annual reports of “medical ethics strategic planning program”, “ethics in medical sciences research”, “monitoring of medical ethics education”, “observing patients’ rights and the status of the medical professionals' rights”, “evaluating justice in health care”, “analysis of complaints received by the mohme, the iranian legal medicine organization (lmo), and the medical council of the islamic republic of iran” discussion the historical documents confirm the iranian physicians’ interests in ethical conduct in their practice for centuries (9, 10), under the influence of the rich culture and the religious principles of zoroastrianism and islam (11). despite facing various difficulties in the recent decades (12), substantial scientific progress has been made in the field of medical ethics in the country (13). after the compilation of the first national strategic plan of medical ethics in 2002 (4), policymakers, related organizations, faculties, and researchers were responsible for its implementation. key stakeholders approved the vision and mission of the plan and were committed to achieving its goals. it is worth mentioning that in the current strategic plan, the specified stakeholders consisted of seven groups as follows: 1. international stakeholders (such as un agencies, regional scientific organizations, associations, universities, and research centers, especially in the islamic world). 2. decision-making and policy-making bodies including the parliament, high council of the cultural revolution, the guardian council, and the mohme. the second strategic plan of medical ethics: a national report 10 j med ethics hist med. 2021(december); 14:17. journal of m edical ethics and h istory of m edicine 3. governing and executive bodies including the mohme, several related ministries, iranian legal medicine organization, red crescent society, regulatory authorities, and medical universities. 4. clients (patients, their relatives, and the whole community). 5. unions and professional organizations (the medical council and the nursing council of the islamic republic of iran). 6. service providers (including hospitals, clinics, health care providers, insurance companies, and pharmaceutical or medical equipment companies). 7. professional stakeholders (educational departments and instructors in the field of medical ethics at the universities and the religious seminaries, research centers related to the field of medical ethics, postgraduate students, and faculties). the process of design and development of the current strategic plan was led by the ams, a high-level independent scientific authority in the country. this is considered as an advantage and opportunity to generate the plan through the consensus of several stakeholders and reinforce their responsibilities for achieving future goals. it is so important that the ams set timelines and monitor the progress of the plan towards the goals. moreover, reviewing the plan would be carried out regularly. all the key stakeholders are expected to be fully engaged in the implementation of the plan, commit time and efforts to venture out and accomplish the objectives. despite the consensus on the defined goals and activities, there may be controversies on the priority rankings of the action plan and surveillance strategies. the world medical association (wma) adopted a 5-year (2020-2025) strategic plan3 in 2019, the main purpose of which was to promote international standards in medical ethics. “medical ethics”, “universal health coverage”, “human rights and health”, and “organizational capacity” are four main strategic priorities. promoting the international code of medical ethics along with global discussion to provide a new revision of the international code of ethics in 2022, governance development, member integration, and staff development are among the priorities and deliverables. the emory center for ethics (atlanta, georgia, us) has been a leader in several fields of ethics since 1990, creating the first 5-year strategic plan in 2011. the “vision” of the second strategic plan (2016-2021) is “to inspire and advance scholarship and education in ethics, to ignite the moral imagination of leaders in all walks of life, and to foster lives of moral meaning and ethical engagement”.4 key strategic priority areas of the center consist of: ethical engagement through scholarship ethical engagement in health and science ethical engagement through corporate partnerships ethical engagement through citizenship and the public good ethical engagement in education 3. www.wma.net/wp-content/uploads/2020/02/20202025-strategic-plan-1.pdf 4. https://ethics.emory.edu/who-we-are/about/index.html https://ethics.emory.edu/who-we-are/about/index.html parsapour a., et al. 11 j med ethics hist med. 2021(december); 14: 17. journal of m edical ethics and h istory of m edicine ethical engagement in arts ethical engagement through financial stability for each strategic priority, some initiatives and their metrics are determined. for example, academic books and peer-reviewed journal articles are two initiatives of “ethical engagement through scholarship”. as for “ethical engagement in education”, some initiatives such as developing ethics curriculum and courses (undergraduate, graduate, doctoral) and non-degree educational offerings are defined. defining metrics for each initiative plays an encouraging role in engaging the faculties and the members in related studies. kirigia et al have reviewed and discussed the current status as the way forward to the establishment of the national health research systems in 47 countries of the world health organization (who) african region (14). although “research for health” was the subject of their study, their strategies and recommendations are used in other fields as well as for strengthening medical ethics discourse. several key contributing factors emphasized by kirigia et al include (14): an official national health policy and strategic plan related legislation components appropriate coordination mechanisms regulation mechanisms for scientific and ethical review committees at national and institutional levels and in hospitals and clinics developed collaborative agreements creating and sustaining resources financing and health budgetary planning securing funding by the private sector and local and international ngos promotion and implementation of research facilitating the production of human resources and strengthening their competencies through design and implementation of master and ph.d. courses, bursaries, and training grants building or reinforcing necessary infrastructures, such as well-equipped offices and laboratories all identified factors that enable national health research systems are critical for the establishment and reinforcement of the national medical ethics plans. fortunately, it seems that the eight goals of our strategic plan cover all emphasized factors stated by kirigia et al (14). the national strategic plan working group has approved 60 activities including compiling books and educational resources, ethical guidelines, related codes, and regulations. it has also endorsed 60 recommendations to mohme to provide the required infrastructure and empower the healthcare professionals. table 4 summarizes the key activities carried out in recent years, before and after compiling the second strategic plan. the second strategic plan of medical ethics: a national report 12 j med ethics hist med. 2021(december); 14:17. journal of m edical ethics and h istory of m edicine table 4summary of some key activities in recent years title/type timeline in accordance with responsible organization(s) general guideline for professional codes of ethics 2017 goal 2 the medical council of islamic republic of iran revising national guidelines for publication ethics 2017 goal 2,4,5 mohme compiling a textbook as an educational resource for medical residents 2015-2020 / in press goals 1,6 mehrc, the medical ethics group of emri of tums evolution and innovations packages in medical education: 6th package: promotion of professional ethics 2015-2016 goal 6 mohme herbal medicine research protocol 2015 goal 2 mohme hidden curriculums as longitudinal themes for “medical ethics and law” and “professionalism” ongoing goal 6 tums, and a few other designated universities the charter of rights for clients in medical diagnostics laboratories 2012 goal 2 high council of medical ethics of mohme the code of ethics for national pharmaceutical system 2012 goal 2 mehrc, high council of medical ethics of mohme the national code of ethics for nurses 2009-2011 goal 2 the medical ethics group of emri of tums, mehrc, mohme enhancing specific publications such as journals in the field of medical ethics; including the journal of medical ethics and history of medicine ongoing goal 1 mohme, ethics research centers and universities of medical sciences annual medical ethics congress/ and training workshops and courses 2013up to now / ongoing goals 3,4,6,7 mohme, mehrc, ams, tums and other universities of medical sciences, etc. defining an educational package to promote medical ethics and professionalism 2016now/ongoing goal 6 mohme evaluating teaching medical ethics in all medical universities 2018-2019 goal 6 mohme to plan and execute the proposed activities to achieve the goals, several tasks are in progress. as an example, the development of the iranian code of medical ethics (icom) to determine the ethical codes of mutual behaviors in the provision of medical services are being pursued by the mehrc at the tehran university of medical sciences in collaboration with the ams. the icom has been on the agenda with approximately 150 headings; 24 topics of which have already been completed in the public consultation phase. after summarizing and incorporating the feedback from the workshop participants, the codes were published in farsi (persian language) to parsapour a., et al. 13 j med ethics hist med. 2021(december); 14: 17. journal of m edical ethics and h istory of m edicine seek the input of the healthcare academics and practitioners. the final results are reported in a recent report of ams.5 moreover, the promotion of ethical standards and the development of related guidelines have been high on the agenda during recent years. for example, specific national guidelines for palliative care in terminal patients have been compiled by the medical ethics department of the “endocrinology and metabolism research center of endocrinology and metabolism institute (emri)” of tehran university of medical sciences (tums) in 2017 due to the ever-increasing attention to palliative care in the country. this was supported by a grant from the who office in the mohme. the results of the project were submitted to the high council of medical ethics of mohme and after approval (february 2019) was conveyed to the medical sciences universities for being implemented in clinical practice. education is an integral part of the current strategic plan and has been the focus of accrediting bodies. although working in the field of medical ethics requires lifelong learning, the educational mission of ethics is never accomplished. this is based on the henk ten have stating (15) that the empowerment of medical ethics education has always been one of the main initiatives around the globe. accordingly, more than twenty projects including the development of textbooks for different graduate and 5.http://www.ams.ac.ir/sites/default/files/book%20akhlag h%201400--02-18-021.pdf undergraduate programs, ethical guidelines for medical education, and ethical checklists for health professionals have been proposed. to achieve the educational goal of the new strategic plan, we designed a national descriptive survey to evaluate the medical ethics education in medical sciences, which is an ongoing project. providing higher academic education in the field of medical ethics is also considered an educational achievement in our country (5). the bioethics graduates are now helping to empower medical ethics discourse in the research centers, clinics, and hospitals, to provide specific education, ethics consultations, and to lead ethics ground rounds, and even to contribute to health policymaking. conclusion academic knowledge and practice of medical and research ethics have developed enormously in recent decades. compared with the first strategic plan (4), we have made great progress in strengthening and flourishing medical ethics throughout the country. however, considering the ethical challenges ahead, it is evident that there is no room for complacency. the development of the medical ethics strategic plan was an attempt to improve the capacity of the health system to be more proactive in client advocacy. today, the main challenges facing our healthcare system include increasing moral sensitivity, enhancing adherence to ethical principles amongst medical professionals and promoting a positive ethical climate in the http://www.ams.ac.ir/sites/default/files/book%20akhlagh%201400--02-18-021.pdf http://www.ams.ac.ir/sites/default/files/book%20akhlagh%201400--02-18-021.pdf the second strategic plan of medical ethics: a national report 14 j med ethics hist med. 2021(december); 14:17. journal of m edical ethics and h istory of m edicine system. it is also known that an acceptable level of accountability of health professionals is necessary to provide decent standards of care in an ethical atmosphere. we hope that achieving the goals and objectives of the recent strategic plan would play an essential role in the promotion of professionalism among healthcare practitioners in iran. the strategic plan presented in this article can also be adapted for other contexts and environments, taking into account the national priorities, challenges, and shortcomings. acknowledgements we would like to convey our sincere thanks to workshop participants (in alphabetical order): dr. forozan akrami, dr. khalil alizadeh, dr. masoud asadi, dr. omid asemani, dr. amin asgharian, dr. morteza ashrafi, dr. hamidreza ayatolahi, dr. sajad azmand, dr. fattanehsadat bathaie, dr. shabnam bazmi, dr. hasan behboodi, dr. saeed beiroodian, dr. kourosh delpasand, dr. zeynnab derakhshan, dr. sedighe ebrahimi, dr. seyedali enjoo, dr. mohsen fadavi, prof. dariyoosh farhhod, dr. mina foroozandeh, dr. nazafarin ghasemzadeh, dr. sadat hosseini, dr. nikzad isazadeh, dr maliheh kadivar, dr. ali khaji, dr. mehrzad kiani, dr. mansoureh madani, dr. alireza milanifar, dr mina mobasher, dr. seyedhasan moghadamnia, dr. maryam montazeri, dr. fatemehsadat nayeri, dr. nasrin nejadsarvari, dr. davood nezameslami, dr. mahshad nouroozi, prof. mohammad pajoohi, dr. mojtaba parsa, dr. roya rashidpouraie, dr. mohamadreza razaghi, dr. mohsen rezaie-adriani, dr. mahbobeh saber, dr. mehran seyf, dr. behzad shams, dr. mohammadnader sharifi, prof. seyedmahmood tabatabaie, dr. ladannaz zahedi.. the special thanks go to dr. pooneh salari, dr. amir keshavarzian, and dr. leila afshar for their valuable input and contribution in compiling this national plan. the authors also would like to thank dr. reza baradar jalili and dr. ali tooti for the english editing of the paper’s first draft. we have furthermore to thank ms. firoozeh hajipour for her sincere cooperation. parsapour a., et al. 15 j med ethics hist med. 2021(december); 14: 17. journal of m edical ethics and h istory of m edicine references 1. dastgerdi mv. islamic republic of iran's health system: achievements and prospective. iran j public health. 2013; 42(supple1): i-ii. 2. lankarani kb, alavian sm, peymani p. health in the islamic republic of iran, challenges and progresses. med j islam repub iran. 2013; 27(1): 42-9. 3. larijani b, zahedi f. contemporary medical ethics: an overview from iran. dev world bioeth. 2008; 8(3): 192-6. 4. larijani b, malek-afzali h, zahedi f, motevaseli e. strengthening medical ethics by strategic planning in the islamic republic of iran. dev world bioeth. 2006; 6(2): 106-10. 5. zahedi f, emami-razavi sh, larijani b. a two-decade review of medical ethics in iran. iranian journal of public health. 2009; 38(supple 1): 40-6. 6. mansoori p. evolution of iran's health research system over the past 50 years: a narrative review. j glob health. 2018; 8(2): 020703. 7. health ethics committee toolkit – part one: getting started [internet]. manitoba provincial health ethics network (mb‐phen). 2015. available from: https://pdfslide.tips/documents/health-ethics-committee-toolkit-mb-information-about-thisresource-and-others.html 8. macrae s, chidwick p, berry s, et al. clinical bioethics integration, sustainability, and accountability: the hub and spokes strategy. j med ethics. 2005; 31(5): 256-1. 9. larijani b, zahedi f. an introductory on medical ethics history in different era in iran. daru journal of pharmaceutical sciences. 2006; 0(suppl.1): 10-6. 10. loewy eh. textbook of medical ethics. new york: plenum medical book company; 1989. 11. larijani b, anaraki fz. islamic principles and decision making in bioethics. nature genetics. 2008; 40: 123. 12. larijani b, zahedi f. global bioethics and scientific sanction. am j bioeth. 2017; 17(10): 24-6. 13. larijani b, zahedi f. health promotion, islamic ethics and law in iran. daru journal of pharmaceutical sciences. 2006; 0(suppl.1): 7-9. 14. kirigia jm, ota mo, motari m, bataringaya je, mouhouelo p. national health research systems in the who african region: current status and the way forward. health res policy syst. 2015;13: 61. 15. ten have hamj. globalization of bioethics education. netherlands: springer; 2015. p. 1-19. https://pdfslide.tips/documents/health-ethics-committee-toolkit-mb-information-about-this-resource-and-others.html https://pdfslide.tips/documents/health-ethics-committee-toolkit-mb-information-about-this-resource-and-others.html abstract introduction references examination of crime and similar concepts in the medical law journal of medical ethics and history of medicine review article examination of crime and similar concepts in the medical law mohammad javad fathi1 1 associate professor, farabi school, university of tehran, tehran, iran corresponding author: mohammad javad fathi address: university blvd., (old tehran road), college of farabi, university of tehran, qom, iran. email: mjavadfathi@yahoo.com tel/fax: 982166419661 received: 03 sep 2014 accepted: 16 feb 2016 published: 1 may 2016 j med ethics hist med, 2016, 9:4 © 2015 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract crime is a human behavior that has captivated the thoughts of scholars of various disciplines throughout history. philosophers, sociologists, psychologists and others have investigated and analyzed the concept of crime from different aspects. crime is the main topic of criminal law, and in its legal meaning is a well-known term with a certain conceptual load that should not be confused with similar concepts such as guilt, civil crime (quasi tort), and particularly, the disciplinary transgression. although crime has common points with all the above, it is an independent concept with unique effects, features, and descriptions that distinguish it from similar acts. this article aims to determine the difference between the concepts of crime, guilt, civil crime and disciplinary transgression through enumeration of the related issues as well as examples of medical disciplinary crimes and transgressions. identifying and distinguishing these concepts can improve the procedure of prosecuting crimes and disciplinary transgression, bring punishment to criminals and transgressors, and facilitate compensation of pecuniary and non-pecuniary losses due to committers’ fault or failure. thus we may avoid taking a wrong route that can lead to infringement of individuals’ rights. keywords: criminal conduct, civil crime, disciplinary transgression, guilt, criminal responsibility, civil responsibility mailto:mjavadfathi@yahoo.com j med ethics hist med 9:4 may, 2016 jmehm.tums.ac.ir mohammad javad fathi page 2 of 8 introduction criminal law is a branch of public law that attempts to prevent crime by defining the acts or omissions that lead to public disorders and by specifying legal reactions for each of those acts. moreover, if a crime is committed, public law will specify the committer’s extent of liability and the manner of selecting and prosecuting these reactions in the light of the real personality of the committers. finally, public law will determine the appropriate means of correction for the committers (1). all branches of law including criminal law are used as means of social control, and their goal is to organize the behaviors and activities of citizens. nevertheless, the fundamental difference between criminal law and the other branches of law is that the former uses suppressing punishments against those who breach its commands. criminal law tries to reflect the principal values that demonstrate the human way of social life, and subsequently uses punishment as a means of consolidating these values and assuring their observance. accordingly, criminal law not only intends to support individuals, but also seeks to support the social structure (2). as a rule, criminal law uses coarse means and suppressing punishments. therefore, human societies employ this branch of law as the last resort to maintain social control and public order, but since “easier comes first”, they try to avoid criminalization and punishment when other methods are available (3). it is thus essential to identify crime and its features and attributes, and distinguish it from other concepts such as civil crime, guilt, and disciplinary transgression. additionally, recognizing the common and differentiating features of the above-mentioned concepts will help prevent confusion of the term “crime” with other similar terms. in medicine, examination of crime and concepts such as civil crime and disciplinary transgression will certainly yield important results. examples of medical crimes include abortion and violation of professional secrecy, which can be subject to public prosecution in criminal courts. some instances of medical disciplinary transgressions would be deeds contrary to medical codes of conduct and imposition of unnecessary costs on clients, and are prosecutable only in medical prosecutors’ offices and courts. the latter are syndicate institutions and have been established to maintain the dignity and vocational respect of medical communities. one of the objectives of the present article is to clarify the concept and conditions of civil responsibility and the mode of making restitution, which should be claimed in the criminal and otherwise the legal court following the criminal conduct. clearly, different authorities address crimes, disciplinary transgressions and restitution claims, and therefore lack of differentiation between the foregoing legal authorities will lead to initiation of claims to an incompetent authority. the obvious outcome will be prolongation of proceedings, loss of evidence, and finally, infringement of the beneficiaries' rights. part one: definition of crime crime1 has been defined in different social and humanistic sciences as "behavior against order", "behavior against public feelings and emotions", and "behavior incongruent with social conscience and common sense". crime is a human behavior and a social phenomenon that can be studied through different viewpoints. philosophers, speculative theologians, anthropologists, sociologists, psychologists, biologists, statistics scholars, etc. have investigated crime from various stances. from the sociological viewpoint, crime (criminal conduct) is human behavior that is incongruent with the common norms and values of a society. according to emile durkheim, a certain conduct is considered a crime when it hurts the strong and obvious feelings of the public conscience. this means that it is the judgment made by the society that criminalizes a conduct, not its tangible features. consequently, a conduct might (not) be considered a crime according to time and place. based on this viewpoint, a crime is quite dangerous, that is, it is so "intolerable" that it can hurt "the strong and obvious feelings of the collective conscience", and the disruption that this conduct brings about in life is such that the need for its stoppage is felt. the reason for the intolerability of a crime is that it hurts a social group's values and norms, which have been ordered according to their beliefs (4). it should be noted that "social values" are among the main topics of sociology. the term is attributed to those facts and issues that satisfy the society members' physical and mental needs, including values such as power, knowledge, wealth, respect, health, skills, affection, piety, etc. accordingly, behaviors that are against these values are considered abnormal and unacceptable (5). in law, crime is a phenomenon that can be studied both in its concrete and validity dimensions. a concrete study of crime is performed to discover the causes, conditions, and underlying factors of its occurrence. this is a practice of criminology. in criminology, the term “crime” is basically attributed to all antisocial conducts and tensions that hurt the society, and are caused by either psychological or social factors. in this domain, it is not very important if such conducts are subject to criminal law or are covered by the legal definition of crime. here, the 1 words that have been considered as equivalents and synonyms of the word jorm in farsi and arabic include bezeh, gonah, ethm, ma'siat, khalaf, khata, taqsir, and takhallof. in english, terms such as violation, fault, wrong, sin, delinquency, and misdemeanor have been adopted. j med ethics hist med 9:4 may, 2016 jmehm.tums.ac.ir mohammad javad fathi page 3 of 8 dangerous state of an individual is deemed as a sign of antisocial behavior and an illness, and so a treatment through protective measures is suggested (6). in criminal law, the validity and mental dimensions of crime are studied, which is important because the negative aspects of law breaking behaviors are assessed in the light of the principles, rules, and values prevalent in the society. for each behavior, a certain legal sanction is specified which is proportionate to the danger that threatens individuals' and the society's rights. in the 19th century, german and french schools attempted to offer a definition for crime. von listz and other proponents of the german school defined crime as merely "conduct that is against criminal law" and disregarded the mental element. therefore, according to the german school, presence of the physical element of committing an unlawful act or omission, as well as the legal element (being contrary to the criminal regulations) are enough for realization of a crime. the french school, however, added the mental element to the constituents of crime, and consequently defined crime as “the wrongful manifestation of one’s will for which a punishment, in its specific meaning, has been determined according to the law” (7). article 2 of the islamic penal code, enacted in 2013, defines crime by its two constituting elements and stipulates, “any behavior, either an unlawful act or omission, for which a punishment has been specified by the law, is considered a crime”. it is clear that the legislator has considered both physical and legal elements necessary for realization of a crime, and has not addressed the mental element. articles 144 and 145, however, state that the mental element is essential for realization of both intentional and unintentional crimes: “for realization of intentional crimes, not only should the committer be aware of the crime, but also his/her intention of committing the criminal act should be ascertained. in cases where realization of a crime is legally dependent upon its outcome, the committer’s intention of generating that particular result or awareness of its fulfillment should also be ascertained” (article 144). “realization of unintentional crimes is dependent upon ascertaining the committer’s fault … including imprudence and inadvertency” (article 145). in consideration of articles 144 and 145, the legislator should have included the mental element in the definition of crime in article 2, and accordingly, he should have defined crime as “any behavior, either an unlawful act or omission, for which a punishment has been specified by the law and is attributable to its committer”. in medicine crimes include intentional abortion (articles 622, 623, and 624 of the islamic penal code, enacted in 1996); disclosure of clients’ confidential information (article 648 of the islamic penal code, enacted in 1996); issuance of false certificates (article 539 of the islamic penal code, enacted in 1996, and article 5 of the law on providing a physician’s certificate before marriage, enacted in 1938); deceiving the clients (article 5 of the law on medical, medicinal, and food and drink regulations, enacted in 1955, and article 4 of the law on prevention of sexual and infectious diseases, enacted in 1941); and refusal to help the injured (the single article on the punishment of refusal to help the injured and abatement of imminent dangers, enacted in 1975). part two: features and attributes of crime in order to identify crime, one needs to recognize its features, which are listed below: 1. crime is always the outer conduct of a person, which is realized either through an act or an omission. therefore, having criminal intent is not considered a crime, and the mere intention to commit a crime is not punishable. moreover, holding beliefs is not criminating, but spreading certain beliefs may be in some cases (8). article 23 of the constitution of the islamic republic of iran stipulates, “inquisition is prohibited, and no one can be persecuted or reprimanded merely due to their beliefs”. 2. mere prohibition of an act does not denote it is a crime, while presence of punishment does. from a legal viewpoint, a prohibited act for which no punishment has been provided is not considered a crime even if it is evidently against public ethics and order of the society (9). 3. committing a prohibited act for which the legislator has assigned punishment is a crime only if the committer has perpetrated it without an enabling cause and in a way contrary to what is his right. therefore, committing an act that is legally banned in order to exercise one’s rights or to enforce legal regulations is not considered a crime. for example, if abortion is done with legal authorization, or if a person defends himself, his honor, his property, or his or another’s body, in the presence of all the stipulated conditions of article 156 of the islamic penal law1, the foregoing act is not considered a crime (10). 1 article 156 of the foregoing law stipulates, “if a person commits a legally criminal behavior while observing the proper stages to defend himself, his honor, his female family members, his property, or his or another’s body against any present or imminent danger or aggression, in case the following conditions are met, he will not be punished: a. the committed behavior is necessary to avert aggression or danger. b. the defense is based on logical indications or logical fear. c. the danger and aggression were not caused by the intentional conduct or aggression of the committer himself and the defense of the other person. d. immediate use of state forces is not possible or their intervention is not effective on the abatement of the aggression and danger. j med ethics hist med 9:4 may, 2016 jmehm.tums.ac.ir mohammad javad fathi page 4 of 8 4. providing instruments of crime or conducts and operations that are only criminal attempts and are not directly related to the criminal act, are not considered crimes unless in specific cases where the legislator has explicitly criminalized them (11). in article 664 of the islamic penal code, the legislator has considered the attempt to make or change a key to be used in a crime as a crime by itself, and has specified 3 months to one year imprisonment and up to 74 whip strokes for the committer. 5. the criminal act should be recognized as a crime by legally competent authorities and the legal formalities should be performed and enacted. according to the principle of the legality of punishments, no conduct is a crime unless it has been recognized by the law as such, and no punishment is executable and applicable unless it has been equalized to a criminal act by the law (7). part three: distinguishing crime from other prohibited acts with regard to the fact that after the islamic revolution of iran, the legislator has tended to follow the islamic penal law and apply its regulations, three sets of prohibited behaviors are identifiable in the iranian legal system that need to be distinguished from crime. these behaviors include sin and guilt, civil crime or quasi tort, and disciplinary and administrative transgression, and are explicated in some detail below. a. sin and guilt scholars of the islamic penal law have defined sin as an act that breaches the orders and prohibitions of quran and sunnah, or conduct that leads to the corruption of individuals or the society (12). therefore, there is a certain punishment for anyone who disobeys the divine orders and prohibitions that will afflict the committer in this world and must be executed by imam or the ruler and the judge appointed by him. punishment may be in the form of a religious obligation (an atonement for sin) that the committer performs to cover and make his sin disappear, or a torment that will affect the committer in the hereafter, unless he shows sincere repentance and compensates the victim(s) for their loss and infringed rights (13). according to islamic law, if punishing the wrongdoer is beneficial for the wellbeing of the public, that is, if it is necessary for the abatement of corruption or preservation of people’s health, it is a divine right that cannot be disregarded. based on the type of the infringed right, crimes may involve violation of either god’s right or man’s right, and are categorized accordingly. moreover, based on considerations related to public interests, crimes are divided into crimes against religion (e.g. apostasy), crimes against someone’s life (e.g. murder), crimes against wisdom (e.g. drinking), crimes against property (e.g. theft), crimes against progeny (e.g. adultery and sodomy), crimes against honor and dignity (e.g. imputation of unchaste individuals), and crimes against public security and comfort (e.g. muharabah) (14). therefore, crime differs from sin, which is an issue of predetermined and discretionary punishment. the relationship between these two concepts is that of generality and peculiarity in some way, that is, sin includes any form of immorality, even if it is personal and the outcome affects the committer himself, for instance drinking, lying, and failure to perform one’s religious duties. crime, however, is an issue of conventional criminal law and does not include sins in the above-mentioned sense (12). on the other hand, crimes such as violations of registration laws and customs regulations are not regarded as sin unless they infringe the rights of people (3). moreover, crime and sin are different with regard to their origins. islamic criminal law is based on divine revelation and follows quran and sunnah. the origin of criminal law, however, is conventional and substantive, and is developed in each country according to the opinions of a group of its scholars and is enacted by the legislative body of that country (13). b. civil crime in european law, civil crime refers to conduct leading to social liability and includes any act that harms others, and a person who commits civil crime is legally bound to recompense the inflicted damage. indeed, social liability is a kind of tortuous liability and is a form of legal responsibility not conditional to contract, such as usurpation, destruction, causation, and vindication (15). the present discussion only applies to destruction and causation. according to article 328 of the social law of the islamic republic of iran, “anyone who destructs other’s property is responsible for it and should return its equivalent or price, regardless of whether he has destructed it intentionally or unintentionally, and whether it is corpus or benefit …”. in addition, according to article 331 of social law, “anyone who causes the destruction of a property should return its equivalent or price …”. although punishable offence and civil crime are similar in some aspects, they are different in others, as can be seen below: 1. punishable crime is a violation of a part of the law. for example, without a certain law, suicide cannot be considered a crime and the suicide accomplice cannot be punished. nonetheless, civil crime can be inferred from any tort or imprudence that causes damage, needless of any certain law (10). 2. punishable crime is realizable independently and without infliction of any damage (e.g. vagrancy or abortion), while civil crime is realizable only due to the damage caused to j med ethics hist med 9:4 may, 2016 jmehm.tums.ac.ir mohammad javad fathi page 5 of 8 someone. therefore, civil crime is inconceivable without damage infliction (8). 3. in punishable crime, the mental element and presence of evil and criminal intent is the realization condition, while civil crime is based on a tort (16). 4. the sanction for punishable crime is penalty, while for civil crime it is restitution and compensation for the damage in the form of returning the destructed property to its previous state or paying its equivalent or price (17). 5. criminalization of punishable crime seeks to maintain public order, while civil crime is banned so as to support individuals’ personal interests and benefits. 6. any person might commit civil crimes, even the minor or the insane, but such individuals will not be held legally responsible if they do. it should be noted that the logical relationship between civil crime and punishable crime is generality and peculiarity in some way. therefore, an act might be a punishable crime and yet, it may entail civil responsibility. for example, inadvertence in surgery that leads to amputation will entail criminal charges, while the perpetrator will have to recompense the damage inflicted on the injured party as well. on the other hand, there are some punishable crimes that do not lead to civil responsibility, such as beggary, vagrancy and abortion. moreover, in some cases, an act might lead to civil responsibility but not be punishable by law, such as refraining from accomplishing an undertaking, usurpation, destruction, and causation. at any rate, if a certain conduct is the source of both criminal and civil responsibility, then the public action initiator will be the prosecutor, and the private action initiator will be the injured party or his inheritors. additionally, the public action adjudicating body will exclusively be the criminal court of law, while in private actions, the adjudicating body can be the criminal or legal court of law based on the injured plaintiff’s request. in the latter case, if the private action is initiated in a legal court, then the court should wait for the outcome of the public action in the criminal court of law (18). c. disciplinary transgression there are different syndicates and factions in every society for professionals and laborers of the same occupation. these entities receive certain regulations so that they can do their job in a healthy and honorable way and preserve their existence and professional dignity. therefore, if members of a syndicate commit a prohibited act related to their professional and administrative status, they will be sentenced to disciplinary punishment by the very syndicate (19). the iranian medical community is an entity that applies disciplinary measures against those members who neglect their dignity and professional integrity. the disciplinary bylaw of addressing the syndicate and professional transgressions of medical and related practitioners enacted by the state expediency council on november 6th, 2004, has enumerated the syndicate and professional transgressions of the following practitioners in various articles: physicians, dentists, pharmacists; specialists and doctors of laboratory sciences, medical diagnostics, gynecology; practitioners of laboratory sciences, optometry, eudiometry, speech therapy, immunology, medical biotechnology, radiology, bioradiology, radiation therapy, nursing, operating room, anesthesia, medicinal sciences, nutrition, disease control and prevention, oral and dental health care, health, rehabilitation, physiotherapy, medical biochemistry, social services and social care, clinical psychology, clinical psychology and gifted children, basic medical sciences, chiropractic, medical genetics, and other related branches of medical sciences. the respective disciplinary transgressions include: inadvertence in performing legal duties (subject of article 3); disclosure of clients’ confidential information and type of disease (subject of article 4); deeds contrary to medical codes of conduct (subject of article 6); imposition of unnecessary costs on clients (subject of article 7); alarming the client through unreal explanations of disease seriousness (subject of article 8); prescription of addictive and psychotropic substances in unnecessary situations (subject of article 9); non-observance of medical services tariffs (subject of article 10); receiving illegal monies (subject of article 11); seeking and directing clients from public institutes to private doctors’ offices (subject of article 13); absorbing clients through deceiving advertisements (subject of articles 14 and 15); using untrue titles (subject of article 16); prescribing medicine without scientific justification (subject of article 17); refusal to continue the treatment process (subject of article 18); selling medicine, makeup, hygienic products and medical equipment in the doctor’s office without a license from the ministry of health (subject of article 20); issuing prescriptions that are not based on scientific principles (subject of articles 21 and 22); nonobservance of size and other features of prescription forms and signs (subject of article 24); employing incompetent individuals in the medical practice (subject of article 25); failure to inform the medical council about the address of the medical practice (subject of article 26); failure to extend the professional license after expiration (subject of article 29); employing individuals who are not licensed to work in the doctor’s office (subject of article 30); embarking upon treatments out of one’s field of expertise (subject of article 31); embarking upon complementary medicine not consistent with previous treatments (subject of article 33); failure to obtain the necessary licenses by overseas graduates before starting medical practice (subject of article j med ethics hist med 9:4 may, 2016 jmehm.tums.ac.ir mohammad javad fathi page 6 of 8 32); therapeutic practice by medical professionals who have psychological, mental, or physical problems, out of the limits of their legal license (subject of article 34); any form of advertisement without written permission from the medical council (subject of article 35). punishable crime is different from disciplinary transgression in some ways, as can be seen below: 1. coverage: in the case of crime, the coverage extends to all members of the society, and sometimes the punishment even passes geographical borders and considers lawbreakers abroad liable to the internal law, even if they are not citizens of that particular country (articles 3, 4,5, 6, and 8 of the islamic penal law have clarified the ambit of criminal law). therefore, punishable crime applies to all citizens of a country, while disciplinary transgression is limited to a certain syndicate or community such as judges, physicists, lawyers, etc. (20). 2. legislation: punishable crime is determined, and has been prudently and transparently enumerated, by the legislator. punishable crimes are equal for all people, while disciplinary transgressions are determined by organizational, administrative and syndicate regulations. the type and nature of disciplinary transgressions are different from syndicate to syndicate, and any conduct that violates the dignity of a syndicate or organization can be examined and punished according to disciplinary principles, even if it has not been specified in the respective bylaws or regulations (16). article 6 of the disciplinary bylaw on addressing the syndicate and professional transgressions of the practitioners of the medical and related professions stipulates, “performing procedures contrary to medical codes of conduct by practitioners of the medical and related professions is prohibited, and these individuals should refrain from committing deeds that dishonor the medical community. instances of such conduct are determined by medical ethics committees”. moreover, clause 1, article 28 of the medical council establishment law enacted on november 6th, 2004 by state expediency council stipulates, “non-observance of religious and legal principles or syndicate and professional regulations, and inadvertence in performing legal duties by practitioners of medical and related professions is considered as transgression, and transgressors will be sentenced to the following punishments in a case-bycase manner based on the intensity of the committed conduct and its plurality and repetition …”. as can be seen, syndicate transgressions have not been specified explicitly and are legislated by broad and general regulations. 3. goals: the goal of criminology is to maintain public order and support the totality of the society. in disciplinary transgression, however, communities and syndicates attempt to preserve administrative and organizational order as well as the professional dignity of their members. 4. evidence of guilt: in criminal courts, confession, clear signs, judge’s knowledge, and similar forms of substantiation are considered evidence of guilt, and some crimes are provable through a specific number of such evidence. disciplinary courts, however, are not limited to legal evidence and can use proof and presumptions that may not have probative value in punishable crimes in order to support their decisions. 5. competent court: punishable crimes are investigated by competent judicial authorities such as criminal courts and prosecutors’ offices. disciplinary transgressions, on the other hand, are addressed by disciplinary courts and offices that are run by members of the same syndicate. article 28 of the medical council establishment law stipulates, “in order to investigate syndicate and professional transgressions of practitioners of the medical and related professions, the medical council will investigate cases of major medical disciplinary offense in the capital city, lower and court of appeals disciplinary transgressions in the capital cities of provinces, and minor medical disciplinary transgressions in the cities …”. article 29 of this law discusses members of the prosecutor’s office, article 35 specifies lower disciplinary transgressions, and article 36 determines court of appeals disciplinary transgressions. 6. sanctions: sanctions against crime are punishments, which in the case of punishable crimes are provided by the law. in disciplinary transgressions, however, sanctions are disciplinary and administrative, for instance reprimand, deduction of wages, demotion, dismissal, etc. therefore, disciplinary sanctions only affect the professional status of the committer and are lighter compared to criminal punishments, which can affect the criminal’s life (e.g. death penalty), body (e.g. whipping), freedom (e.g. imprisonment), property (e.g. fines and forfeiture), and dignity (e.g. public announcement of the decision) (21). clause 1, article 28 of the medical council establishment law has enumerated the following disciplinary punishments: a. oral warning or reprimand in the presence of the executive board of the respective medical council. b. written warning or reprimand, to be filed in the respective medical council records. c. written reprimand filed in the respective j med ethics hist med 9:4 may, 2016 jmehm.tums.ac.ir mohammad javad fathi page 7 of 8 medical council records and published in the council press or installed on the respective medical council signboard. d. deprivation from practicing medical and related professions in the location of transgression for duration of 3 months to one year. e. deprivation from practicing medical professions for duration of 3 months to one year throughout the country. f. deprivation from practicing medical professions for more than one year to five years throughout the country. g. permanent deprivation from practicing medical and related professions throughout the country. the logical relationship between crime and disciplinary transgression is also that of generality and peculiarity. for example, crimes such as embezzlement, bribery, abortion, issuance of false certificates, and disclosure of clients’ confidential information are considered disciplinary transgressions as well, while crimes such as theft or breach of trust are not considered disciplinary transgression. moreover, disciplinary transgressions such as committing deeds contrary to medical codes of conduct, non-observance of the size and other features of the prescription form and sign, and failure to inform the medical council about the address of the medical practice do not have criminal aspects. it should be noted that a sentence issued in a disciplinary action does not affect criminal or civil action. nevertheless, it is possible that a conduct is simultaneously the origin of disciplinary, criminal, and civil actions, such as a physician’s inadvertence in performing the legal duties leading to infliction of damages on the client, or prescription of medicine without scientific justification. in such cases, if the client suffers damages, in addition to disciplinary action, the physician will have criminal and civil liabilities as well. conclusion crime is the outer behavior of a person, which is sometimes realized as an unlawful act and sometimes as an omission, and the presence of punishment is a condition for its realization. the principle of the legality of punishments emphasizes criminalization of prohibited conduct and specification of punishments for transgressors and offenders by the legislator. this principle is used as the main criteria to distinguish crime from other similar concepts such as guilt, civil crime, and disciplinary transgression. sin and guilt are noncompliance with divine laws and consequently have a divine origin based on revelation, and are inferred from quran and sunnah. crimes, on the other hand, are conventional and substantive and are specified by the legislative body of each country. moreover, civil crime is any conduct that inflicts damage on another person, and the committer is legally bound to recompense the inflicted damage. therefore, civil crime might refer to any mistake or imprudence that causes damage, regardless of presence of a certain law. in addition, disciplinary transgression is a prohibited act that is related to the committer’s professional and administrative status and results in disciplinary action and punishment. contrary to punishable crimes, which are specified by the legislator, disciplinary transgressions are determined through organizational and administrative bylaws and syndicate regulations. furthermore, any conduct that jeopardizes the dignity of a syndicate or organization can result in disciplinary sentence and punishment, even if it has not been mentioned in the respective bylaws or regulations. j med ethics hist med 9:4 may, 2016 jmehm.tums.ac.ir mohammad javad fathi page 8 of 8 references 1. mohseni m. [hoghoogh-ejaza-eomoomi].tehran: ganj danesh publications; 2003, vol.1, p.12. [in persian] 2. clarkson cmv. understanding criminal law. tehran: mizan publications; fontana press; 1992, p. 15 & 160. 3. husak d. the criminal law as last resort. oxford j legal stud 2004; 24(2): 207-35. 4. picca g. criminology. translated by najafi abrandabadi ah. tehran: shahid beheshti university; 1991, p. 17. [in persian] 5. sane’i p. [hoghoogh-ejaza-eomoomei]. tehran: iranian national university publications; 1975, vol.1, p. 42. [in persian] 6. nurbaha r. [zameineh-ehoghoogh-ejaza-eomoomei]. tehran: ganj danesh publicaitons; 2012, p. 130. [in persian]. 7. stephanie g, lvasseur g, bouloc b, et al. public penal law. translated by dadban h. tehran: allameh tabatabaee university publications; 1978, vol.1, p. 308-351. [in persian] 8. baheri m. [hoghoogh-ejaza-eomoomei]. tehran: matbua’t corporation; 1954, p. 70, p.122. [in persian]. 9. ardebili m. [hoghoogh-ejaza-eomoomei]. tehran: mizan publications; 1998, vol. 2, p. 143. [in persian]. 10. golduzian a. [hoghoogh-ejaza-eomoomei]. tehran: university of tehran; 1993, vol.1, p. 147, p.144. [in persian]. 11. farhudinia h. [aemal-emoghadamatei dar hoghoogh-ekeyfarei-eiran]. tehran: samt publications; 2004, p. 67-82. [in persian]. 12. gorji a. [maghalat-ehoghoogei]. tehran: university of tehran publications; 1993, vol.1, p. 58, p.286. [in persian] 13. feiz a. [moghareneh va tatbigh dar hoghoogh-ejaza-eomoomei-eislam]. tehran: the ministry of culture and islamic guidance; 2002, p. 65. [in persian] 14. shatebi. [al-muwafaqat fi usulal-shari'a]. dar al-matba’ al-tejaryyah; vol.2, p.10. [in arabic] 15. sedarat a. [hoghoogh-ejaza va jorm shenasei]. tehran: kanunma’refat; 1966, p. 86. [in persian] 16. aliabadi a. [hoghoogh-ejenaei]. tehran: melli bank publications; 1968, vol.1, p. 72,p.74. [in persian] 17. aghaee jannat makan h. [hoghoogh-ejaza-eomoomei]. tehran: jungle publications; 2012, vol.1, p. 92. [in persian] 18. akhundi m. [aein-edadresei-ekeyfarei]. tehran: the ministry of culture and islamic guidance; 2007, vol.1, p. 265. [in persian] 19. ardebili m. [hoghoogh-ejaza-eomoomei]. tehran: mizan publications; 2000, vol.1, p. 123. [in persian] 20. aghaee jannat makan h. [hoghoogh-ekeyfarei-eomoomei]. tehran: jungle publications; 2012, vol.1, p. 123. [in persian] 21. kordnaeech k. [takhallofat-eedari-ekarkonan-edowlat va nahveye residegi be aan]. tehran: arvan publications; 2005. [in persian]. microsoft word jmehm-7-7 journal of medical ethics and history of medicine a comparison between conflict of interest in western and islamic literatures in the realm of medicine mojtaba parsa1, kiarash aramesh2, and bagher larijani3* 1medical ethics phd candidate, medical ethics and history of medicine research center, and department of medical ethics, tehran university of medical sciences, tehran, iran; 2 associate professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran; 3 professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. corresponding author: bagher larijani address: medical ethics and history of medicine research center, #23, shanzdah azar st.tehran, iran email: emrc@tums.ac.ir tel: 98 21 66 41 96 61 fax: 98 21 66 41 96 61 received: 18 aug 2013 accepted: 21 jan 2014 published: 17 mar 2014 j med ethics hist med, 2014, 7:7 © 2014 mojtaba parsa et al.; licensee tehran univ. med. sci. abstract in western literatures, “conflict” is a general term that refers to discord between two or more entities. in islamic jurisprudence, however, in addition to the term “conflict” (taāruz), there is another term which is called tazāhum. the two terms, however, have different definitions. conflict between two concepts, for instance, indicates that one is right and the other is wrong, while tazāhum does not necessarily have to be between right and wrong, and may appear between two equally right concepts. moreover, conflict exists on a legislative level, while tazāhum is a matter of obedience and adherence, meaning that in practice, both sides cannot continue to coexist. conflict of interest is a known term in western literatures, and according to d.f. thompson, it refers to a situation where professional judgment regarding a primary interest is improperly and unjustifiably influenced by a secondary interest. taking into account thompson’s definition and the distinction between “conflict” (taāruz) and “tazāhum”, the english term “conflict of interest” translates to “tazāhum of interest” in islamic jurisprudence as it refers to a person’s action without reflecting right or wrong, and simply concerns priority of one interest over another. the resolution to tazāhum in islamic jurisprudence lies in two principles: the principle of significance and the principle of choice. for instance, in case of conflict (the western term) or tazāhum (the islamic term) between the interests of patient and physician, the patient’s interest should be the main concern based on the principle of significance. although western literatures propose methods such as disclosure or prohibition in order to resolve conflict of interest, the foundation for these solutions seems to have been the principle of significance. keywords: conflict, conflict of interest, taāruz, tazāhum j med ethics hist med 7:7 mar, 2014 jmehm.tums.ac.ir mojtaba parsa et al. page 2 of 7 (page number not for citation purposes) introduction conflict has always been an important topic of discussion in ethics, so much so that plato maintained that morality developed as a solution to conflict (1). ralph barton perry, a 20th century philosopher, also suggested that morality was the solution to problems caused by conflict (1). conflict can be classified according to the field in which it arises. in management, for instance, it can be divided into intrapersonal, interpersonal, intragroup, and intergroup conflict (2). in another classification, conflict can be right-based, interestbased, or value-based (3), and where conflict exists between individuals or groups, it may be referred to as either conflict of interest or conflict of values (or beliefs) (4). obviously, conflict of interest is a form of conflict, and while conditions leading to it may be traced back to the times when human interactions commenced, the term itself has been specifically recognized in ethics in the past 60 years. conflict of interest was originally used as an ethical or legal term in law, commerce, and management, but gradually extended into medicine as a common problem (5). in this paper, since the concept of “conflict” in islamic and western literatures are not the same, firstly we compare the definition and distinctive features of this term in both doctrines. secondly, we discuss conflict of interest in the field of medical ethics through comparing this concept in both western and islamic literatures, and later through an evaluation of the solutions offered by both doctrines. it should be mentioned that throughout this paper, where reference is made to islam, it is based on shi’a rather than sunni fiqh (jurisprudence), not because the two differ greatly on the subjects discussed, but because this study has been based on shi’a sources. we will need to begin by introducing usūl al-fiqh (principles of jurisprudence) and explicating the terms taāruz and tazāhum and their differences, and the solutions to problems associated with each. since readers may not be acquainted with the terminology used in this paper, a glossary has been provided at the end. definition of fiqh and usūl al-fiqh in islam in islam the term “fiqh” or jurisprudence literally means “understanding”, whereas generally speaking, it refers to understanding the “hukms’’ (or sentences) of shari’ah (islamic law) on matters of people and other entities. usūl al-fiqh, therefore, is the science that investigates the “dalils” (or evidence) applied in fiqh and how they should be utilized, and surrounding topics. in other words, usūl al-fiqh is the set of rules required to comprehend the hukms of shari’ah (6). the arabic terms taāruz and tazāhum are also rather common in usūl al-fiqh, but are used in persian as well; the english equivalent of the former is “conflict”, while there is no exact translation for the tazāhum in the english language, as will be discussed later. definition of taāruz and tazāhum in islam and their distinctions taāruz: moeen persian dictionary defines taāruz as “disputing or disagreeing with one another” (7). in usūl al-fiqh, however, taāruz refers to an encounter between two or more dalils (evidence) that cannot coexist (8). in islamic literatures such as the holy qur’an and sunna (written islamic tradition) the islamic jurisprudent or faqīh may encounter issues that appear in conflict with one another, and he will need to resolve them based on the guidelines suggested by usūl al-fiqh. that is why usūl al-fiqh has a topic, namely taāruz-e adelleh, dedicated to this matter, which is of great significance (9). a case in point is the saying in islamic literatures “respect scholars” while another saying is “do not honor libertines”. the first saying means all scholars should be respected, while the second means no libertine should be honored. should a scholar happen to be a libertine as well, a case of taāruz will occur; i.e. the first dalil (respect) and the second dalil (do not honor) negate each other, and this is an example of taāruz (9). tazāhum: moeen persian dictionary defines tazāhum as “giving each other trouble and crowding one another out” (10). in usūl al-fiqh, tazāhum is used when two hukms conflict to the point that they cannot both occur at the same time (8). distinction between taāruz and tazāhum there are certain distinctions between these two terms among which the following are relevant to the subject of this study: taāruz describes the correlation between two dalils, while tazāhum refers to the confrontation of two hukms. -taāruz between two dalils arises on the legislative level, but tazāhum between two hukms is on the executive level. in other words, taāruz occurs because the legislator is unable to issue a certain order, while tazāhum between two hukms occurs because they are equally correct, but one cannot execute both of them (6). when two dalils are in taāruz, one is right (or legitimate) and the other is wrong (or illegitimate), while tazāhum may arise between two equally right hukms that cannot both be executed. either case entails discord, but in the former, it exists between right and wrong, while in the latter, it is a matter of obedience and adherence (11). j med ethics hist med 7:7 mar, 2014 jmehm.tums.ac.ir mojtaba parsa et al. page 3 of 7 (page number not for citation purposes) a case of taāruz: if someone says prophet muhammad passed away in the month of safar1 and another insists that he passed away in the month of rabī al-awwal2, we have a case of taāruz, since the prophet cannot have passed away in both months (12). a case of tazāhum: saving two drowning people when it is physically possible to only save one. the question here is not whether it is right or wrong to save them both, but that they cannot both be saved, and the only solution here is to save one and let the other drown (8). another case of tazāhum: according to shari’ah, among the duties of a person is providing financial support for one’s parents. from the legislative point of view, there is no conflict between providing for both parents, but since one may not be financially able to support both one’s mother and father, one will face a case of tazāhum, and may therefore have to choose between the two (6). tazāhum can be resolved by resorting to reason, while taāruz can be worked out through shari’ah. in the example above regarding the two drowning persons, if one’s father is one of the drowning people and they cannot both be saved, it is rational to save one’s father, but if there is no rational preference, one has the choice to save either (8). conflict in english (western) literatures in oxford online dictionary the word “conflict” has been defined as “a serious incompatibility between two or more opinions, principles, or interests” (13). in everyday usage, however, the term can refer to fighting or struggling, as well as a clash between opposing principles (14). in other words, conflict is a situation in which people believe they have incompatible goals, interests, principles, or sentiments (15). a comparison between the definition of conflict in western and islamic literatures in western literatures the word “conflict” has a broad usage and generally refers to a disagreement between two or more things. in islamic jurisprudence or fiqh, however, there are two terms for these disagreements, taāruz and tazāhum, the distinctions between which have been expounded above. consequently, the equivalent of the english term “conflict” is oftentimes “tazāhum” in islamic fiqh. in fact, the correct term for “conflict of interest” in islamic fiqh is “tazāhum of interest” which will be explicated in this study. solutions for tazāhum there are two solutions for tazāhum: the principle of al-aham fi al-aham (the principle of signifi 1 the second month in the islamic calendar 2 the third month in the islamic calendar cance) and the principle of takheer (principle of choice), explanations of which will follow below. it should be mentioned, however, that some solutions exist to taāruz, but they are not related to the topic of the present study. the principle of al-aham fi al-aham: this principle applies to cases where two hukms are involved and one is of greater significance, and therefore the more important hukm will rule. for instance, if one drowning person is one’s father and the other a stranger, and they cannot both be saved, one will naturally save one’s father (16). the principle of takheer: “takheer” is the freedom to choose one option over others and to act accordingly. in case of tazāhum between two hukms that cannot both be executed, if neither is preferable to the other, scholars of usūl al-fiqh state that individuals are free to select either hukm. for instance if both drowning people in the example above are strangers, one can make the choice to save either (16). definition of conflict of interest in western literatures many definitions have been suggested for this term. according to one, conflict of interest occurs when an individual’s obligations toward another person, or group of people, conflict with their personal interests (17). another source defines conflict of interest as a situation in which an individual is (or a group of individuals are) affected by circumstances that can potentially drive him (or them) toward actions that are in conflict with his (their) professional or ethical duties. an example of such a situation is when in a patient’s course of treatment the physician replaces known and effective medications with new ones only for financial gain from a pharmaceutical company (18). thompson describes conflict of interest as a situation where professional judgment regarding a primary interest (such as a patient’s welfare or validity of a research) is affected by a secondary interest (such as financial gain) in an improper and unjustifiable manner (19). thompson’s definition contains three elements: 1) primary interest: these include factors that have high priority in professional decision making. one such example is patient welfare, since physicians have agreed that patient welfare has priority over their own interests. 2) secondary interest: these come second to primary interests, and may or may not be financial. secondary interests are not necessarily illegitimate and can be desirable or even essential, but their priority in the hierarchy of professional decisions needs to be determined appropriately. therefore financial or other secondary considerations (such as preferential treatment of one’s family and friends, prestige seeking, and so on) do not j med ethics hist med 7:7 mar, 2014 jmehm.tums.ac.ir mojtaba parsa et al. page 4 of 7 (page number not for citation purposes) need to be minimized or eliminated as long as they do not overshadow or obliterate primary interests. 3) conflict: the term does not necessarily imply endangerment of primary interests, but it may refer to situations where secondary interests are prioritized to the point that primary interests are overlooked. conflict of interest is characteristically unavoidable in many cases, but a person can choose to not be overly affected by secondary interests. in other words, conflict of interest is similar to how smoking can increase the chance of lung cancer; it can increase the incidence of unethical decisions or judgments in certain situations, and while it does not always bring about unethical decisions, it prepares an environment where unethical decisions and judgments are more likely to occur. generally speaking, one can say that conflict of interest is the result of relationships with specifically defined responsibilities, particularly responsibilities that generate certain expectations of behavior due to moral or legal considerations, such as doctorpatient, attorney-client, professor-student and parent-child relationships. conflict of interest is the outcome of an opposition between interests and responsibilities that leads to behavior other than those expectations (5, 20, 21). other types of conflict in western literatures and how they differ from conflict of interest conflict of obligation: this form of conflict occurs when a person has at least two ethical or legal responsibilities at the same time that interfere with one another. an example case would be a member of congress who needs to vote on a bill that is beneficial to his country but may have disadvantages for his district. it can therefore be said that conflict of obligation is a difficult choice between two options neither of which has priority over the other but only one of which can be acted upon under the circumstances, and this is essentially a dilemma. one obvious dilemma in medical ethics is cases of contagious diseases where patient confidentiality is in conflict with other people’s safety. there is no conflict of interest in such cases as the conflict is between two legitimate primary interests, and therefore one can say that a dilemma is a conflict between two different primary interests. conflict of commitment: this form is closer to conflict of interest since it occurs when a person’s main responsibility within an institution is in conflict with their commitments elsewhere. it is similar to conflict of obligation in that the conflict exists between two legitimate activities, but it is also like conflict of interest since one has priority over the other. for instance, if a professor is active in a charitable organization, he may not always be able to perform his duties toward his students as his activities in the charity may conflict with his teaching responsibilities. conflict of bias: this form of conflict has a psychological factor of which the involved people may be unaware, even though it affects their decision making process and can injure anyone they are accountable for. examples are prejudices (ethnic, racial, religious, sexual, etc) or social and cultural issues (values acquired throughout childhood or adulthood) that can affect decision making, such as when a physician denies treatment to a patient who belongs to a different ethnic or racial group, especially one he feels hostile to (20, 21). a comparison of abovementioned types of conflict: in a quick look, we can say that conflict of interest exists between two clearly different conflicting interests one of which is distinctly superior and the other may not even be categorized as a value. in conflict of obligation, the two interests are equally legitimate and neither has priority over the other. in conflict of commitment, the conflicting interests are of different values but not as different or as obvious as in conflict of interest. as for conflict of bias, it appears to fall into the category of conflict of interest, although it has been considered a separate form of conflict. solutions to conflict of interest in western literatures 1) recusal or substitution (22): these solutions signify that people in conflict avoid making decisions under the circumstances and someone else be appointed to do so. if a judge, for instance, has interests in a case, he should recuse himself from that case so that another judge can take over (23). 2) disclosure: this is the golden rule in conflict of interest. in medicine, for instance, the test of whether or not one is in a conflict of interest is to ask themselves if they would feel comfortable in case the patient or others learned about their interest in the matter; if they worry that others might find out about their interests, disclosure is the solution. it seems obvious that if patients find out their physicians are keeping their interests from them, they will lose their trust in doctors (24). 3) prohibition: conflict of interest can at times have harmful effects on patients’ and the public’s trust in the medical profession, or at least have no particular benefit for patients, and therefore, activities leading to it need to be prohibited (24). 4) avoidance: this means to avoid conflict of interest situations. for instance if a researcher offers a physician payment for study subjects, the physician should decline (25). j med ethics hist med 7:7 mar, 2014 jmehm.tums.ac.ir mojtaba parsa et al. page 5 of 7 (page number not for citation purposes) a comparison between conflict of interest in western and islamic literatures based on the viewpoints expressed above, in order to draw a comparison between conflict of interest in western manuscripts and islamic jurisprudence, the matter can be approached from two different positions: a) the concept position: due to the reasons that follow, the equivalent for “conflict of interest” in islamic jurisprudence is “tazāhum-e manāfe”: 1. as stated previously, taāruz between two dalils arises on the legislative level, but tazāhum between two hukms is on the executive level and owing to a person’s inability to act on both. based on the definition of “conflict of interest” in western literatures, it appears that it pertains to two hukms rather than dalils, and in fact taāruz occurs because these hukms conflict. according to western literatures, if a doctor prescribes unnecessary lab tests so they can receive commission from the medical laboratory, they are in a conflict of interest, as their interest and that of the patient conflict. in islamic jurisprudence, however, this is regarded a matter of conflict between two interests and pertains to obedience and adherence, so it is viewed as a case of tazāhum; in other words, the physician’s interest (financial gain) and the patient’s interest cannot exist at the same time and therefore are in tazāhum. 2. based on thompson’s definition of conflict of interest, there are two kinds of interest: primary and secondary, which do not disagree from a legislative point of view. for example there is no conflict between the physician’s and patient’s interests on the legislative level, but on the executive level, they can conflict as they may not both be attainable, and therefore, in shi’a fiqh, conflict of interest is actually tazāhum of interest. 3. in islamic jurisprudence, taāruz occurs between two dalils that are not both legitimate as one of them is right and the other wrong, while tazāhum may happen between two equally legitimate hukms that cannot be acted upon simultaneously. as stated before, in conflict of interest, western literatures are not concerned with right or wrong, as neither side may be wrong. in the example of the doctor who prescribes unnecessary lab tests, one cannot claim that the doctor’s interest is illegitimate, it is merely not as important as the patient’s welfare, and this is the same case as in tazāhum. 4. based on the arguments above, conflict of obligation (dilemma), bias, and commitment, that are named as different types of conflict in western literatures, all fall into the category of tazāhum, although they may be different kinds of tazāhum. b) the problem solving position 1. according to thompson’s definition of conflict of interest, one of the two conflicting sides is more important. for instance, a doctor’s financial gain is secondary to a patient's welfare and health, and therefore western literatures seek to resolve conflict of interest through avoidance, disclosure and so on. in other words, physicians must avoid actions that are not in the best interest of their patients and at the same time, disclose their interests in the matter to the patients or the public. if for any reason avoidance, disclosure or other solutions are not possible, such as when doctors’ compliance cannot be relied on, other rules such as prohibition apply. many such rules are expressed in the form of guidelines and procedures, which may require disclosure of interests or prohibit certain actions. since in islamic jurisprudence tazāhum-e manāfe indicates that one interest has priority over the other, based on the principle of al-aham fi al-aham (the principle of significance) the primary interest (e.g. patient’s health) should be valued over the secondary interest (e.g. doctor’s financial gain). 2. as stated about conflict of commitment, both activities are legitimate and therefore we face a form of tazāhum, but one commitment has priority over the other. a professor’s primary responsibility is toward his students, so in the case of the professor who is also active in a charitable organization, the principle of alaham fi al-aham holds that his teaching commitments should take priority if his charitable activities interfere with his role as a professor,. 3. conflict of obligation is in fact another form of tazāhum, where neither side has priority over the other. the solution proposed by islamic fiqh is the principle of takheer (principle of choice), meaning a person is free to choose either side. it should be noted that western literatures state that in conflict of obligation or dilemma, neither interest has priority over the other. this is illustrated through examples such as an incurable patient who insists on knowing the diagnosis while his or her family is against it. in this case, the doctor is facj med ethics hist med 7:7 mar, 2014 jmehm.tums.ac.ir mojtaba parsa et al. page 6 of 7 (page number not for citation purposes) ing a moral dilemma (26). another moral dilemma is in the case of hivpositive patients who insist their partners not be informed by medical staff; this gives rise to conflict between patient confidentiality and the safety of their partners (27). although conflict of obligation is supposedly the result of a conflict between two interests of the same weight, in practice, one interest receives more weight and the whole situation ends up as a conflict of commitment. in the dilemmas presented above, patients are eventually told about their diagnosis, and hiv-positive partners are informed so they can be protected. it appears that solutions presented by islamic fiqh can resolve all of the above-mentioned types of conflict of interest mentioned in western literatures, at least on an individual level. on a social level, however, this is obviously not the case, because islam gives priority to social welfare over individual interests, and therefore in cases where theses two conflict, the latter must be compromised (28). consequently, the principle of takheer (choice) should be used to develop the necessary guidelines and procedures. conclusion although there are differences between western and islamic standpoints on the usage of terminology and concepts as well as solutions to the issue of conflict of interest (the western term) or tazāhum of interest (the islamic term), the important issue is, especially in the medical field, how we approach it. one major drawback is that conflict of interest can be viewed in two lights: individual and social. from an individual point of view, physicians in conflict are trusted to put their patients’ interests first even if there is no executive power to force them to do so, and simply as an act of conscience. there is another point of view, however, and that is the social point of view, since individual factors may not always be depended on, and so the social mechanism is there for cases where doctors fail to give priority to their patients’ interests. this explains why some solutions proposed in western manuscripts (such as avoidance, disclosure and recusal) or in islamic manuscripts (principle of alaham fi al-aham, for instance) are not always applicable, as they mainly rely on individual factors. it is true that the same solutions have been used by legislative bodies or professional organizations in order to enact guidelines and procedures, but they do not appear to have been adequate, and in many countries this inadequacy is quite noticeable, and therefore there seems to be room for more effort in this respect. glossary arabic/persian english explanation fiqh islamic jurisprudence the science of shari’ah; the sacred law of islam faqīh islamic jurisprudent an expert in islamic law usūl al-fiqh principles of islamic jurisprudence principles that are used in understanding the hukms (or sentences) of shari’ah (islamic law) dalil proof, evidence evidence that can be used in order to attain another objective through deliberation hukm sentence, commandment commandments of shari’ah (islamic law) regarding a muslim’s acts tazāhum a high concentration of people in a small place; the act of crowding one another out shari’ah religious law, islamic law matters in religion that god has specified and clarified for people shi’a shi’a one of the two main branches of islam that regards ali as the true successor of prophet muhammad and recognizes him as the first imam sunni sunni one of the two main branches of islam takheer preference, selection, choice providing someone with choice or option sunna tradition in shi’a islam, sunna refers to the sayings, practices, or written statements by prophet muhammad, his daughter fatima, 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[in persian] hhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh copyright © 2022 tehran university of medical sciences. this work is licensed under a creative commons attribution-non commercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. original article abstract emergency medical technicians (emts) are very likely to leave the profession due to their obligation to work in critical situations such as the covid-19 pandemic. this study aimed to investigate the relationship between the ethical work climate and the intention to leave the service among emts. in this descriptive correlational study, 315 emts working in zanjan province were surveyed using the census method in 2021. the research tools included the ethical work climate and the intention to leave the service questionnaires. data were analyzed using spss software version 21. we found the mean (sd) score of the organization's ethical work climate to be 73.93 (±12.53), and the intention to leave the service 12.54 (±4.52), which are at a moderate level. a statistically significant positive correlation existed between these variables (r = 0.148, p = 0.017). also, there was a statistically significant relationship between age and employment status among *corresponding author mohsen kamali address: abhar school of nursing, next to alghadir hospital, parastar blvd., abhar, zanjan, iran. postal code: 4561688131 tel: (+98) 24 35 27 94 12 email: mkamali@zums.ac.ir received: 28 jun 2022 accepted: 23 oct 2022 published: 28 dec 2022 citation to this article: mousavi sk, kamali m, bahrami eyvanaki z. ethical work climate and the intention to leave the service in emergency medical technicians during the covid-19 pandemic. j med ethics hist med. 2022; 15: 9. the demographic variables, and the ethical work climate and the intention to leave (p < 0.05). our findings indicate that ethical work climate is one of the influential but less noticed factors that affect the performance of emts. therefore, it is suggested that managers implement measures to develop a positive ethical work climate to reduce the tendency to leave the service among emts. keywords: ethical work climate; intention to leave; emergency medical technicians; covid-19. ethical work climate and the intention to leave the service in emergency medical technicians during the covid-19 pandemic 1. researcher, department of nursing, abhar school of nursing, zanjan university of medical sciences, zanjan, iran. phd candidate of nursing, shahid beheshti school of nursing and midwifery, guilan university of medical sciences, rasht, iran. 2. researcher, department of nursing, abhar school of nursing, zanjan university of medical sciences, zanjan, iran. phd candidate of medical education, department of medical education, virtual school of medical education and management, shahid beheshti university of medical sciences, tehran, iran. 3. researcher, department of nursing, abhar school of nursing, zanjan university of medical sciences, zanjan, iran. seyed kazem mousavi1, mohsen kamali2*, zeinab bahrami eyvanaki 3 ethical work climate and the intention to leave the service in emergency medical … j. med. ethics. hist. med. 2022 (dec); 15: 9. 2 introduction leaving the service is defined as the loss of an organization's workforce over time (1), and the intention to do so is an essential and significant prediction of the actual leaving of service. in other words, there is a cognitive stage before the act and refers to the thought or mental decision about staying or leaving the job (2). job stress has been mentioned as the most important underlying factor for the tendency to leave in many jobs (3). severe levels of job stress have led to the phenomenon of burnout and leaving the service as one of the problems of employees in many countries. emts experience increased levels of stress due to time constraints in performing tasks and skills as well as the critical patient conditions (4). over the past two years, the covid-19 pandemic has also put severe stress on health-care providers, and among them, emts on the front lines experience unprecedented stress (5). stressors such as increased working hours, job insecurity, and fear of infecting and transmitting the virus to their families have caused about 40% of health-care providers to have anxiety symptoms (6). according to studies conducted in this field, emergency medical personnel have been the most likely to leave the service in the health system (7). prior to the covid-19, the number of employees leaving the service was approximately ten percent (7, 8), which in the current situation has almost tripled to about 30 percent (9). mirzaei et al. found that during the covid-19 outbreak, job stressors have led to an increase in nurses’ turnover intention (10). also, zandian et al. discovered that proactive psychological support is crucial to prevention of burnout and continuation of nursing services during the covid-19 pandemic (11). one of the main factors in preventing the creation of a stressful atmosphere in the workplace is the organization's ethical climate. today, attention to ethical climate is the primary organizational issue that should be at the top of managers' priorities (12). victor and cullen believe that ethical climate is one of the most fundamental factors in the tendency or lack thereof among employees to show different behaviors. an ethical atmosphere reflects people's perception of their organization, influences their attitudes and behaviors, and is used as a framework for employee referral (13). in other words, ethical atmosphere is the hallmark of an organization and is an organizational variable that can change or improve the working conditions. the mousavi sk., et al. 3 j. med. ethics. hist. med. 2022 (dec); 15: 9. existence of an ethics-oriented flow within the organization prevents many workplace tensions and promotes satisfaction, commitment, positive interactions and other variables that can improve performance and productivity (14, 15). since ethical climate is influenced by various factors such as culture, environment, laws, and regulations, it is beneficial and of practical value to study it in different societies, working conditions, organizations and cultures (12). emts are the most influential group in the crisis response and are at risk of the destructive effects of job stress. the impact of a stressful work environment on healthcare providers' performance is inevitable. furthermore, considering the sensitivity of prehospital emergency care, especially during crises such as natural disasters, fatal accidents and pandemics, the importance of investigating stressors in their work environment doubles. until now, researchers have studied the effects of several factors on their working environment, but ethical climate seems to have received less attention. the combination of these factors and lack of similar research led us to plan the present study to investigate the relationship between the ethical work climate and the intention to leave the service among emergency medical technicians during the covid-19 pandemic. methods the current research was a descriptivecorrelational study that investigated the relationship between the ethical work climate of the organization and the intention to leave the service among emergency medical technicians in zanjan province during the covid-19 pandemic. the research population included all emts of zanjan province, and the research environment was urban and road emergency medical bases. the data collection method was census, and inclusion criteria consisted of willingness to participate, being employed in urban and road emergency bases, having at least one year of work experience, and having a bachelor's or master's degree in nursing or associate or bachelor's degree in medical emergency. data collection tools included the ethical climate questionnaire developed by victor and cullen, and the intention to leave the service questionnaire designed by seashore (13-17). the ethical climate questionnaire was designed in 1988 and had 26 items in five dimensions: care and attention (1 7), law (8 11), rules (12 15), instrumental (16 22), and independence (23 26). the care dimension is related to the ethical standards of each person in the organization, but the law dimension shows the ethical standards of ethical work climate and the intention to leave the service in emergency medical … j. med. ethics. hist. med. 2022 (dec); 15: 9. 4 the organization. the rules dimension is indicative of individuals’ obedience to the ethical standards of the organization. instrumental represents the individual performance based on ethical principles, and independence shows the degree of independence of the employees with regard to ethical principles. the items are scored based on a five-point likert scale ranging between “strongly disagree” with a score of one, and “strongly agree” with a score of five. to calculate the scores for each dimension, the sum of the points of the questions related to that dimension are added together. the score range of this questionnaire is between 26 and 130, with a score of 26 to 52 indicating a weak organizational ethical work climate, 52 to 78 an average ethical work climate, and above 78 a stable ethical work climate (13). the validity of the tool was confirmed in a study by daneshfard et al., and its reliability score based on cronbach's alpha for the organization's ethical work climate was calculated at 0.89 (16). in the present study, we determined the reliability of the questionnaire using cronbach's alpha of 0.95. the 4-item questionnaire designed by seashore et al. in 1982 assesses the intention to leave the service (17). it uses a five-point likert scale (very low to very high), and scores vary between 1 and 5. the score range of the questionnaire is between 4 and 20, with a score of 4 to 6.5 indicating the intention to leave the service at a high level, 6.5 to 13 a moderate level, and above 13 a low level. in a study by alizadeh et al., researchers validated this questionnaire, and its reliability was estimated based on cronbach's alpha of 0.71 (18). in the present study, the reliability of this questionnaire was 93% using cronbach's alpha method. this research was conducted at the emergency medical departments in zanjan province. after obtaining permission from the department managers and an introduction, the researchers announced the study goals and invited the employees to participate in the research, ensuring them that their information would be kept confidential. next, written consent was obtained and the questionnaires were provided to participants. the researcher was present when the participants were completing the questionnaires to answer any possible questions. due to the high number of the questions and to prevent fatigue and increase accuracy of responses, each participant was given half an hour to complete the questionnaire. the officials in the emergency bases and the research participants were thanked and assured that the results would be confidential and could be announced to them upon request. after collecting the data and entering them into spss mousavi sk., et al. 5 j. med. ethics. hist. med. 2022 (dec); 15: 9. software version 26, the obtained data were analyzed using descriptive statistics (frequency, frequency percentage, mean and standard deviation) and inferential statistics (pearson’s correlation coefficient, independent t-test and anova). in addition to invoking the central limit theorem, we used the smirnov-kolmogorov test to check the normality of the collected data, which was proved based on a significance level above 0.05, confirming that it was reasonable to apply parametric tests to examine the relationship between the variables. ethical considerations prior to conducting this study, the researchers obtained permission from the research department and ethics committee of zanjan university of medical sciences (ir.zums.rec.1400.101). all the study participants were informed about the objectives of the study, the confidentiality of the information, and the voluntary nature of their participation. results out of the 347 emts who participated in the study, 315 completed the questionnaires. the findings revealed that all pre-hospital staff participating in the present study were male, and their mean age and standard deviation was 33.57 ± 5.98. also, most of them were married and had an associate degree. demographic characteristics include frequency and percentage, and the total scores of ethical climate and intention to leave the service are listed in table 1. table 1frequency and percentage of demographic characteristics variables and the total scores of ethical climate and intention to leave the service variable number (frequency) total ethical climate score (mean ± sd) total intention to leave the service score (mean ± sd) marital status single 72 (22.9%) 72.82 ± 12.03 12.33 ± 4.25 married 243 (77.1%) 73.13 ± 11.71 11.02 ± 4.11 childbearing yes 182 (57.8%) 74.32 ± 12.10 11.15 ± 4.56 no 133 (42.2%) 73.18 ± 11.75 10.94 ± 3.19 degree associate degree in emergency 186 (59%) 71. 39 ± 13.03 12.55 ± 3.07 bachelor’s degree in emergency 109 (34.6%) 72.28 ± 12.93 11.41 ± 4.02 bachelor’s degree in nursing 15 (4.8%) 73.41 ± 11.98 12.04 ± 4.58 master’s degree in nursing 5 (1.6%) 70.95 ± 12.23 11.23 ± 4.22 employment status official 134 (42.5%) 76.53 ± 12.73 11.16 ± 3.50 contractual 181 (57.5%) 72.01 ± 11.39 14.84 ± 4.01 work experience (years) < 5 82 (26%) 73.14 ± 12.43 13.04 ± 4.69 5 10 85 (27%) 74.97 ± 12.14 12.34 ± 3.92 10 15 107 (34%) 75.23 ± 11.03 11.97 ± 4.32 > 15 41 (13%) 75.07 ± 12.38 10.24 ± 3.82 service location urban 181 (57.5%) 73.40 ± 12.49 12.94 ± 4.54 road 134 (42.5) 74.74 ± 11.63 11.53 ± 4.12 ethical work climate and the intention to leave the service in emergency medical … j. med. ethics. hist. med. 2022 (dec); 15: 9. 6 before starting the analysis, we knew that a high score and a low score in the ethical climate variable and its dimensions means a robust and a weak moral atmosphere, in the organization, respectively. contrary to the scoring interpretation in the organization's ethical climate variable, there is an inverse relationship between the intention to leave the service score and participants' genuine intention to leave. in other words, a rising intention to leave the service score represents a low genuine intention to leave the service and vice versa. in the first step, we found that the participants' scores were at a moderate level in all dimensions of the ethical climate, except the rules and regulations dimension, which was at a low level. also, the total score of ethical climate was within the moderate range (73.93 ± 12.53). furthermore, the mean and standard deviation of intention to leave the service in pre-hospital emergency staff was 12.54 ± 4.52, which is also in the moderate range. mean, standard deviation, maximum and minimum scores, number of questions, score ranges, and score categorizations of the ethical climate and its dimensions are presented in table 2. we investigated the relationship between ethical climate and its dimensions, and the intention to leave scores. the results of the correlation assessment revealed a significant positive correlation between the total scores of ethical climate and intention to leave the service (r = 0.148, p = 0.017). it can be concluded that with an increase in the total score of ethical atmosphere of the organization, the intention to leave the service decreases. moreover, an evaluation of the relationship between the ethical climate dimensions and the intention to leave the service scores revealed that there is a significant positive correlation between the total intention to leave the service score and care & attention (r = 0.299, p = 0.000) and independence (r = 0.290, p = 0.000) dimensions of the ethical climate. these results show that as the care & attention and independence dimensions of ethical climate develop and improve, employees' intention to leave the service decrease. we found that there was a statistically negative correlation between the intention to leave the service score and the law dimension of the ethical climate in the organization (r = 0.138, p = 0.039). this finding indicates that increasing the law dimension of the ethical climate can increase the intention of the prehospital emergency staff to leave the service. mousavi sk., et al. 7 j. med. ethics. hist. med. 2022 (dec); 15: 9. table 2mean, standard deviation, maximum and minimum scores, number of questions, and score ranges of the ethical climate and the intention to leave the service variable mean ± sd max. min. number of questions score range categorization of scores ethical climate care and attention 24.71 ± 3.06 35 7 7 7 35 low: 7 16.33 moderate: 16.33 25. 66 high: 25.66 35 law 8.67 ± 3.03 20 4 4 4 20 low: 4 9.33 moderate: 9.34 14.67 high: 14.67 20 rules 12.04 ± 3.11 20 4 4 4 20 low: 4 9.33 moderate: 9.34 14.67 high: 14.67 20 instrumental 18.58 ± 3.97 29 9 7 7 35 low: 7 16.33 moderate: 16.33 25.66 high: 25.66 35 independence 9.93 ± 2.94 20 4 4 4 20 low: 4 9.33 moderate: 9.34 14.67 high: 14.67 20 total 73.93 ± 12.53 114 51 26 26 130 low: 26 60.6 moderate: 60.7 95.3 high: 95.3 130 intention to leave the service 12.54 ± 4.52 20 4 4 4 20 low: 4 9.33 moderate: 9.34 14.67 high: 14.67 20 there was, however, no statistically significant relationship between the rules and instrumental dimensions of the ethical climate and the intention to leave the service (p > 0.05). details of the correlation between the ethical climate and its dimensions and the intention to leave the service score can be seen in table 3. at the end of our analysis, we investigated the relationship between demographic variables and the main variables of the research. our findings showed a significant relationship between age and employment status of the participants, and the total scores of ethical climate and intention to leave the service. based on these results, there is a significant positive correlation between the participants’ age and their ethical climate scores (r = 0.149, p = 0.038). this means that the ethical atmosphere score increases with age. also, we discovered a significant negative correlation between the age of ethical work climate and the intention to leave the service in emergency medical … j. med. ethics. hist. med. 2022 (dec); 15: 9. 8 the participants and their intention to leave the service score (r = 0.144, p = 0.045). on the other hand, our findings showed a significant relationship between the scores of the ethical climate and the intention to leave the service, and the participants' employment status. thus, the ethical climate's mean and standard deviation score was 76.53 ± 12.73 in official staff, and 72.01 ± 11.39 in contractual employment staff, which indicates a statistically significant difference according to the obtained p-value (p < 0.05). this result means that the ethical climate score of official employees is higher than that of contractual employment staff. moreover, we found a significant negative correlation between the employment status of participants and their intention to leave the service. according to the data from tables 1 and 4, it can be concluded that the score of intention to leave the service is lower in official employees than contractual employment staff. the statistical relationship between demographic variables and the main variables of the research is presented in table 4. table 3. the correlation between the ethical climate and its dimensions, and the total intention to leave the service score variables intention to leave the service ethical climate care & attention pearson’s correlation coefficient 0.299 pvalue 0.000 law pearson’s correlation coefficient 0.138 pvalue 0.039 rules pearson’s correlation coefficient 0.004 pvalue 0.484 instrumental pearson’s correlation coefficient 0.139 pvalue 0.082 independence pearson’s correlation coefficient 0.290 pvalue 0.011 total pearson’s correlation coefficient 0.148 pvalue 0.017 according to our findings, the relationship between the intention to leave the service score and the law dimension of the ethical climate in the organization is a statistically negative correlation (r = 0.138, p mousavi sk., et al. 9 j. med. ethics. hist. med. 2022 (dec); 15: 9. = 0.039). this finding indicates that increasing the law dimension of the ethical climate can increase the intention of the pre-hospital emergency staff to leave the service. there was no statistically significant relationship between the rules and instrumental dimensions of the ethical climate, and the intention to leave the service score (p > 0.05). details of the correlation between the ethical climate and its dimensions, and the intention to leave the service score can be seen in table 3. at the final stage of our analysis we investigated the relationship between demographic variables and the main variables of the research. our findings showed a significant relationship between the age and employment status of the participants, and the total scores of ethical climate and intention to leave the service. based on these results, there is a significant positive correlation between the participants’ age and their ethical climate scores (r = 0.149, p = 0.038). this finding means that the ethical atmosphere score increases with employees’ age. also, we discovered a significant negative correlation between the age of participants and their intention to leave the service score (r = 0.144, p = 0.045). therefore, it can be concluded that there is an inverse relationship between age and the intention to leave the service. on the other hand, our findings showed a significant relationship between the scores of the ethical climate and the intention to leave the service, and the participants' employment status. the ethical climate's mean and standard deviation score was 76.53 ± 12.73 in official staff, and 72.01 ± 11.39 in contractual employment staff, which is a statistically significant difference according to the obtained p-value (p < 0.05). this means that the ethical climate score of official employees is higher than contractual employment staff. moreover, we found a significant negative correlation between the employment status of participants and their intention to leave the service. the results revealed that the difference between official employees and contractual employment staff is statistically significant in terms of the intention to leave the service scores. according to the data presented in tables 1 and 4, the intention to leave the service score of official employees is lower than that of contractual employment staff. the statistical relationship between demographic variables and the main variables of the research is presented in table 4. ethical work climate and the intention to leave the service in emergency medical … j. med. ethics. hist. med. 2022 (dec); 15: 9. 10 table 4. the relationship between demographic variables and the total score of ethical climate and intention to leave the service demographic characteristics variables test total ethical climate score intention to leave score age pearson’s correlation p 0.038 0.045 r 0.149 -0.144 marital status independent t-test 0.157 0.094 childbearing independent t-test 0.083 0.533 degree anova 0.743 0.867 employment status independent t-test 0.023 -0.011 work experience anova 0.054 0.062 service location independent t-test 0.133 0.541 discussion this study aimed to investigate the relationship between the ethical work climate of an organization and the intention to leave the service among emergency medical technicians during the covid-19 pandemic. based on our findings, the average score of the organization's ethical work climate was at a moderate level, which is consistent with the findings of studies such as donkers et al. (19) and jiang et al. (20). among the dimensions of the ethical work climate of the organization, only the dimension of law received a low score, and the average scores of the other dimensions were at a moderate level. in this regard, we can say that the law dimension is related to the acceptance and observance of legitimate behaviors by members of the organization, and during the covid-19 pandemic, the instructions for dealing with this disease have changed several times. it is possible that the emts did not have enough opportunities to comply with the regulations and were somehow confused, which in turn has harmed the overall score of the work ethics of the organization. like the ethical work climate score, the emts’ average score of the intention to leave the service was at a moderate level, similar to studies by mirzaei et al. (10) and zandian et al. (20), both conducted in the same period of time in iran. moreover, among the demographic variables, there was a significant relationship between emts’ age and employment status, and the ethical work climate and intention to leave the service scores. according to our findings, participants who were older and had a more stable mousavi sk., et al. 11 j. med. ethics. hist. med. 2022 (dec); 15: 9. employment status better assessed the ethical work climate of the organization and were less likely to leave the service. in line with these results, teresi et al. also found that participants with a higher level of experience and job stability could provide suitable working conditions in the organization. in other words, highly experienced individuals can play the role of good mediators and positive role models in an organization, which increases emts’ motivation to stay in service (21). the findings also showed a positive and significant relationship between the ethical work climate and the intention to leave the service. given that there is an inverse relationship between the intention to leave the service score and participants' genuine intention to leave, it can be claimed that the intention to leave the service decreases with improvement of the ethical work climate. consistent with these findings, hojati et al., stated that improving the ethical climate of the organization increases retention of nurses in clinical work (22). van den bulcke et al. also stated that better ethical conditions in the organization reduce the intention of doctors and nurses to leave the service (23). also, ghasempour ganji et al. found that adverse organizational ethical climate positively affects the intention of employees to leave the service (24). examining the dimensions of the ethical work climate and the intention to leave the service showed a positive and significant correlation between the care and attention and independence dimensions of the ethical work climate, and the intention to leave the service. this result means that providing adequate care and attention and independence by the organization reduces the intention of emergency medical technicians to leave. in this regard, rubel et al. mentioned that receiving support and attention from the organization's managers reduces the intention of employees to leave the service (25). findings from a study by simha et al. also showed that the organization's trust in employees (by allowing them more independence and helping them to improve their performance) reduces their intention to leave the service (26). furthermore, we found a significant negative correlation between the law dimension of the ethical work climate and the intention to leave the service. this means that a higher score of ethical work climate in this dimension would increase the intention of the staff to leave the service. this finding indicates that the exact implementation of rules and regulations in an organization is always challenging and causes a conflict between personal and organizational interests. this issue is prominent among emts, because many of them inevitably have a second job ethical work climate and the intention to leave the service in emergency medical … j. med. ethics. hist. med. 2022 (dec); 15: 9. 12 due to low pay and job instability. on the other hand, most of these technicians work in road stations and travel long distances from home to work every day. therefore, they may not fully comply with all organizational rules and regulations, and the organization's insistence on strict adherence to regulations can provide the grounds for their desire to leave the service. with regard to the limitations of this study, it is possible that the participants did not complete the questionnaires accurately due to their unique job conditions. another significant limitation is the dependence of both main research variables on the environment of the study, which challenges the generalizability of the findings. therefore, we suggest that similar studies be conducted on similar groups of emts in different locations with different social, cultural and economic conditions. conclusion based on the findings obtained from this study, it seems that managers should take the necessary measures to improve the ethical work climate, increase job satisfaction and reduce the intention to leave the service among emergency medical technicians. in other words, in addition to paying attention to the economic situation and the facilities and equipment of the workplace, managers should plan measures to develop a positive ethical work climate. it is crucial to continue to retain the services of emts, especially in critical conditions such as the covid-19 pandemic. creating a lively work environment, paying attention to employees' mental and psychological conditions, and improving their interpersonal relationships are among the measures that can improve an organization's ethical environment. considering that few studies have been conducted on the effect of the ethical work climate on medical emergency technicians, we suggest that future studies examine this issue in the light of other aspects of their work, such as stress, job satisfaction and burnout. funding zanjan university of medical sciences financially supported our study. acknowledgements the researchers would like to thank the participants in this study and the emergency bases for their cooperation despite the restrictions caused by the covid-19 pandemic. conflict of interests the authors report no conflict of interest. mousavi sk., et al. 13 j. med. ethics. hist. med. 2022 (dec); 15: 9. references 1. neves t, parreira p, rodrigues v, graveto j. organizational commitment and intention to leave of nurses in portuguese hospitals. int j environ res public health. 2022; 19(4): 2470. 2. sasso l, bagnasco a, catania g, et al. push and pull factors of nurses' intention to leave. j nurs manag. 2019: 27(5): 946-54. 3. haji j, mohammadimehr m, khosravi m, 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management review. 2011; 3(830): 1-9. 17. seashore se, lawler ee, mirvis ph, cammann c, eds. assessing organizational change. a guide to methods, measures, and practices. new york: john wiley & sons inc; 1983, p. 563. 18. mondalizadeh z, javaheri s. the effect of job stress and job insecurity on the intention of job leaving the lifeguard due to the job satisfaction. organizational behavior management in sport studies. 2019; 6(22): 117-129. 19. donkers ma, gilissen vjhs, candel mjjm, et al. moral distress and ethical climate in intensive care medicine during covid-19: a nationwide study. bmc med ethics. 2021; 22(1): 73. 20. jiang w, zhao x, jiang j, zhang h, sun s, li x. the association between perceived hospital ethical climate and self-evaluated care quality for covid-19 patients: the mediating role of ethical sensitivity among chinese anti-pandemic nurses. bmc med ethics. 2021; 22(1): 144. 21. teresi m, pietroni dd, barattucci m, amata giannella v, pagliaros. ethical climate(s), organizational identification, and employees’ behavior. front psychol. 2019; 10: 1356. 22. hojati h, azma f. relationship between ethical climate and the intention to remain in clinical nurses. quarterly journal of nursing management. 2014; 3(1): 19-26. mousavi sk., et al. 15 j. med. ethics. hist. med. 2022 (dec); 15: 9. 23. van den bulcke b, metaxa v, reyners ak, et al. ethical climate and intention to leave among critical care clinicians: an observational study in 68 intensive care units across europe and the united states. intensive care medicine. 2020; 46: 46-56. 24. ghasempour ganji sf, johnson lw, babazadeh sorkhan v, banejad b. the effect of employee empowerment, organizational support, and ethical climate on turnover intention: the mediating role of job satisfaction. iranian journal of management studies. 2021; 14(2): 311-29. 25. rubel mrb, kee dmh, quah chh, rimi n. ethical climate and employee turnover intention in the ready-made garment industry of bangladesh. global business and organizational excellence. 2016; 36(2): 61-73. 26. simha a, pandey j. trust, ethical climate and nurses' turnover intention. nurs ethics. 2021; 28(5): 714-22. hhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh copyright © 2022 tehran university of medical sciences. this work is licensed under a creative commons attribution-non commercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. original article abstract the present study aimed to compile and develop a professional guideline for health-care providers in iran regarding cyberspace usage. this was a mixed-methods study, conducted in three phases. in the first phase, the principles of ethics in cyberspace were collected through a review of the literature and available documents, and were then subjected to content analysis. in the second phase, the views of experts on medical ethics, virtual education, information technology and medical education, as well as clinical sciences experts and representatives of medical students and graduates were evaluated using the focus group method. in the third phase, the draft was evaluated by various stakeholders. finally, after receiving the comments, the necessary modifications were applied to the guideline. the professional guideline for the use of cyberspace by health-care professionals comprised 30 codes in 5 domains, including the general regulations domain, care and treatment, research, education, and personal development. *corresponding author maliheh kadivar address: no.62, gharib st., division of neonatology, department of pediatrics, children's medical center, tehran, iran. postal code: 1419733151 tel: (+98) 21 66 91 76 48 email: kadivarm@tums.ac.ir received: 20 feb 2022 accepted: 1 nov 2022 published: 28 dec 2022 citation to this article: khabaz mafinejad m, kadivar m, asghari f, jannat z, hadizadeh n. developing a professional guideline for the use of cyberspace by health-care professionals in iran: a mixed methods study. j med ethics hist med. 2022; 15: 10. this guideline presents the various ways professionalism can be maintained in cyberspace interactions. adherence to the principles of professionalism in cyberspace is required to protect and preserve the public trust in health-care professionals. keywords: medical ethics; medical education; health-care guideline; professionalism; cyberethics. developing a professional guideline for the use of cyberspace by health-care professionals in iran: a mixed methods study 1. associate professor, health professions education research center, department of medical education, education development center, tehran university of medical sciences, tehran, iran. 2. professor, division of neonatology, department of pediatrics, children's medical center, tehran university of medical sciences, tehran, iran. 3. professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. 4. researcher, msc of neonatal intensive care nursing, children's medical center, tehran university of medical sciences, tehran, iran. 5. researcher, department of pharmacy, tehran university of medical sciences, tehran, iran. mahboobeh khabaz mafinejad1, maliheh kadivar2, fariba asghari3, zeinab jannat4, nastaran hadizadeh5 developing a professional guideline for the use of cyberspace by health-care professionals in iran: a mixed methods study j. med. ethics. hist. med. 2022 (dec); 15: 10. 2 introduction in recent years, there has been an ever-growing trend of using cyberspace in medicine (1). cyberspace is characterised by the ability for the virtual presence of, and interaction between, people through ‘icons, waypoints and artificial realities’ in the virtual world (2). the process of teaching, learning, patient education and therapeutic care through online communities has become rather common, and therefore cannot be separated from cyberspace (3). health-care professionals (hcps) can use online social media to engage the public in health activities, involve them in decision-making, and facilitate their access to medical information and services (4). the results of recent studies suggest that hcps are using digital media and social networking all the time more, for instance in virtual triage or assessments, therapeutic care via online platforms, and building online learning communities. despite the growing interest in cyberspace and the virtual world, various concerns regarding the principles of professional conduct remain unsolved, even as they may result in unexpected ethical dilemmas (5, 6). studies have found that professional misconduct in cyberspace may have detrimental effects on the relationship of hcps with patients and colleagues, threaten the future of their careers (7), and also damage the general public’s trust in the medical profession and staff (8). in order to address such concerns, ethical standards need to be developed for different professions (9 11). teaching professionalism has been one of the most important priorities of the health sector in recent decades (12); nevertheless, unethical and unprofessional behaviors such as blurring the boundaries between professional and personal spheres on user profiles, publishing selfie images with cadavers in cyberspace, and nonanonymous distribution of patients’ photos on social media have dramatically damaged the reputation of hcps (13, 14) and decreased the public’s trust in health-care professionals (15, 16). attention to medical commitments in this vast online space with diverse virtual capabilities underlines the necessity of developing a guideline to direct health-care professionals and learners toward observing professionalism in cyberspace. various guidelines have been developed about the professionalism of hcps in iran in recent years (17 20), but information regarding ethical codes within the cyberspace remain rather limited. furthemore, even though there are a few clear-cut khabaz mafinejad m., et al. 3 j. med. ethics. hist. med. 2022 (dec); 15:10. lapses in professionalism that have been published online by hcps, many more circumstances currently fall into a grey zone and further discussion among different stakeholders is required before reaching a specific consensus. to ensure stakeholders’ commitment to implementation of the professional guideline in practice, it is important to involve them them in the development of the the guideline (17). moreover, since affected professionals may aspire to design an institutional guideline for improving the professional development of hcps, this paper could be of interest to international readers and stakeholders to gain insight and draw conclusions regarding how such guidelines can be designed, modified, and applied within their own institutional context. this study aimed to compile and develop a cyberethics guideline for health-care professionals in iran. methods the aim of this study was to compile and develop a professional guideline for the use of cyberspace by health-care professionals in iran. this study was conducted in three phases, including a review of the literature, exploring the perspectives of experts, and assessing the views of stakeholders. the details of these methods are presented in table 1. table 1. details of the phases of developing a professional guideline for the use of cyberspace by hcps phase 1: reviewing the literature reviewing the literature using content analysis categorizing concepts and converting concepts to professional codes phase 2: exploring the perspectives of experts determining the inclusion criteria for experts inviting experts from different fields of medical ethics, virtual education, information technology, clinician and medical education, as well as representatives of medical students and graduates focus group sessions analyzing and modifying the draft according to the views of experts phase 3: assessing the views of stakeholders issuing a formal announcement for receiving stakeholders’ comments and modifying the draft approval and dissemination of the guideline phase 1: literature review in this phase, a review of the literature was conducted, comprising of two steps. a narrative review of the literature was conducted using the following keywords in eric, pubmed, sid and google scholar between 2005 and 2017: (cyberethics) or (cyber ethical behavior) and (health-care professional*) or (medical sciences professional*) and (guideline) or (guide). the purpose of this search was to find out whether there are existing guidelines that could help to develop or validate professional behaviors in cyberspace for developing a professional guideline for the use of cyberspace by health-care professionals in iran: a mixed methods study j. med. ethics. hist. med. 2022 (dec); 15: 10. 4 health-care professions. languages were limited to english and persian (figure 1). gray literature was identified for conference abstracts, and by searching other databases of information retrieval research accrued over the years, including material such as guidelines set out by the american medical association (ama), canadian federation of medical students (cfms), canadian medical association (cma), flurida state university (fus), australian and new zealand medical associations (ama and nzma), indiana university, etc. the search strategy was initially developed by one author (m.k.), while review and analysis were carried out by two other authors (m.km. & z.j.). data extraction was performed by one reviewer (z.j.) and verified by two reviewers (m.km. & m.k.). thematic content analysis was applied to assess the retrieved documents and continued until data saturation was achieved and no new data emerged. figure 1: an overview of the literature searches and retrieving articles sc re en in g database de-duplication records removed (n = 46) records excluded by title (n = 514) e lig ib ili ty records screened (n = 578) abstract of articles assessed for eligibility (n = 64) studies included in qualitative synthesis (n = 36) records identified through database search: 624 pubmed: 4 eric: 19 id en tif ic at io n in cl ud ed khabaz mafinejad m., et al. 5 j. med. ethics. hist. med. 2022 (dec); 15:10. the emerged meaning units of literatures were coded based on the concepts of professional ethics in cyberspace inductively. then, the extracted codes were analyzed primarily grounded in the data by a task force that consisted of three experts (a medical ethics expert, a medical education expert, and a clinician) (22). members of the task force were selected based on their experiences in the field of cyberethics. this process created a total of 146 initial codes. after summarizing relevant concepts, 43 extracted codes were obtained, which were classified into five categories: general regulations, care and treatment, research, education, and personal development. phase 2: exploring the perspectives of experts in this phase, the experts’ perspectives were evaluated through focus group sessions. nine experts, who were from different fields of medical ethics, e-learning, information technology and medical education, as well as a clinician participated in the sessions. in addition, one student who had spent more than 4 semesters in university and one early graduate were also invited to join the focus group. the experts had a minimum of fiveyears’ experience in research or educational activities in the mentioned fields. the experts’ views were evaluated in four focus groups, and an experienced moderator led the group discussions. during these sessions, the participants discussed the clarity, validity, importance and applicability of each comment. all focus groups were taperecorded and transcribed. analysis of the focus group data was conducted by a member of the research team (m.km) using directed content analysis based on five domains of the prior phase. to verify the extracted codes, they were sent to the experts who had attended the focus groups. several reminder emails were sent for one month to prevent attrition. after receiving the comments of ten experts, the task force revised the codes accordingly. phase 3: assessing the views of stakeholders based on reviews of the literature and focus group results, the task force generated 30 ethical codes in five main domains that hcps should consider prior to using the cyberspace. to receive the views of a variety of stakeholders including faculty members, managers, educational planners, etc., several announcements were posted on the official website of the university. thirty-six stakeholders returned a survey form in which they provided their comments qualitatively via an academic email. the stakeholders were asked to present the reason as to why they thought an item was not acceptable or developing a professional guideline for the use of cyberspace by health-care professionals in iran: a mixed methods study j. med. ethics. hist. med. 2022 (dec); 15: 10. 6 applicable. the comments were summarized by the task force to revise the final draft of the guideline. the final draft of the “professional guideline for the use of cyberspace by health-care professionals” was presented and approved at tehran university of medical sciences (tums). after approval, the guide was disseminated via the tums website and emailed to all faculty members. ethical considerations participation in the project was voluntary, but encouraged through incentives such as certifications and gifts. each participant provided consent to take part in the project, and confidentiality of the responses was mentioned at the beginning of each meeting. the project was approved by the research ethics committee of tehran university of medical sciences under license number 94-03-74-29906. results the guideline was formulated in 5 domains including general regulations of professional conduct in cyberspace (10 codes), care and treatment (11 codes), research (3 codes), education (3 codes), and personal development (3 codes). table 2 presents a summary of the professional guideline for the use of cyberspace by health-care professionals that can be used as a framework. table 2. a professional guideline for the use of cyberspace by hcps category codes general regulations of professional conduct in cyberspace 1 commit to upholding the dignity of the medical profession and preserving and protecting public trust in medical professionals: • never publish personal images in violation of medical values on professional medical websites, including personal images indicating involvement in unlawful activities. • maintain an appearance and attire in line with the values of the medical profession. • prevent spreading rumors, slandering, and propagating any untruthful information in cyberspace causing damage to public trust in medical professionals, and consider honesty and truthfulness in presenting information. 2 refrain from using unethical and aggressive words and propagating any discriminatory or insulting expressions against different ethnicities, genders, cultural and religious beliefs, etc. in cyberspace. 3 avoid making judgments and decisions about different topics raised in online environments before making sure of the accuracy of the published information. 4 respect copyright laws in online environments, avoid any kind of deceitful act or plagiarism in cyberspace, and assume responsibility for the materials published in the cyber world. 5 keep the information updated and ensure it's security in cyberspace and act responsibly in this regard. 6 confirm the identity of users before making contact with them and avoid baseless trust. 7 avoid invading the privacy of others, including their mailbox, user interface of digital media software, etc. khabaz mafinejad m., et al. 7 j. med. ethics. hist. med. 2022 (dec); 15:10. 8 treat colleagues with patience, respect and sobriety according to ethical principles and cultural values and norms and commit to keeping the secrets of colleagues and organization in cyberspace. 9 take responsibility for informing colleagues, students and other people of the negative consequences of inaccurate or improper content uploaded on the internet and warn them in private to protect their dignity. 10 try to use valid medical professional websites to present information, interact with colleagues, and exchange medical information. care and treatment 11 consider confidentiality in one’s attempts to upload patient information or group discussions in digital medical networking and other online public media and remove any information revealing the identity of patients. 12 prevent profit-making advertisements for medical and pharmaceutical companies known as service providers in cyber environments. 13 answer people’s questions frankly and promptly upon participation and activity in virtual counseling programs. 14 consider patients’ interest as top priority when providing counseling, and refrain from using patients’ information to pursue one’s interests. 15 take responsibility for health-care recommendations and activities in the online environment and accept the consequences. 16 introduce oneself by one’s name, role and professional position and avoid magnifying one’s capabilities in cyberspace such as public digital media. 17 seek the permission of patients or their families before establishing an electronic contact with them in cyberspace. 18 prepare a confidential backup file of the correspondence with patients in cyberspace in accordance with the terms and conditions of the university. 19 when interacting with patients or their families in cyberspace, pay attention to cultural and online social norms and values and consider the limits of professional relationships. 20 when establishing online social relationships with children or vulnerable individuals, beware the possibility of misinterpretation of the relationship or the presented information and act cautiously. 21 try to improve and enhance the quality and accuracy of the information presented on the websites of health-care centers in keeping with one’s duties. research 22 do not use the results of articles and materials published on the internet before assessing their reliability and level of evidence. 23 avoid virtual collaboration and cooperation with unfamiliar organizations to prevent information theft from research centers. 24 before entering patients’ information into patient data banks in cyberspace, make sure of the safety of the environment and users’ access level. education 25 share knowledge and information with colleagues and students in cyberspace (under the constraints indicated elsewhere in this guideline). 26 try to make the best use of cyberspace to promote the interaction of teachers and learners, and educational and specialized institutions. 27 accept responsibility and try to compensate if an error occurs in publishing educational materials on the internet. personal development 28 consider time management in the use of cyberspace and establish a balance between virtual and real life. 29 have a purposeful plan for checking educational material in cyberspace and pay attention to its possible effects on individuals mental, psychological and physical health. 30 pay attention to the management of emotional relationships when establishing professional interactions in cyberspace. before starting the analysis, we knew that a high score and a low score in the ethical climate variable and its dimensions means a robust and a weak moral atmosphere, in the organization, respectively. contrary to the scoring interpretation in the organization's ethical climate variable, there developing a professional guideline for the use of cyberspace by health-care professionals in iran: a mixed methods study j. med. ethics. hist. med. 2022 (dec); 15: 10. 8 is an inverse relationship between the intention to leave the service score and participants' genuine intention to leave. in other words, a rising intention to leave the service score represents a low genuine intention to leave the service and vice versa. in the first step, we found that the participants' scores were at a moderate level in all dimensions of the ethical climate, except the rules and regulations dimension, which was at a low level. also, the total score of ethical climate was within the moderate range (73.93 ± 12.53). furthermore, the mean and standard deviation of intention to leave the service in pre-hospital emergency staff was 12.54 ± 4.52, which is also in the moderate range. mean, standard deviation, maximum and minimum scores, number of questions, score ranges, and score categorizations of the ethical climate and its dimensions are presented in table 2. we investigated the relationship between ethical climate and its dimensions, and the intention to leave scores. the results of the correlation assessment revealed a significant positive correlation between the total scores of ethical climate and intention to leave the service (r = 0.148, p = 0.017). it can be concluded that with an increase in the total score of ethical atmosphere of the organization, the intention to leave the service decreases. moreover, an evaluation of the relationship between the ethical climate dimensions and the intention to leave the service scores revealed that there is a significant positive correlation between the total intention to leave the service score and care & attention (r = 0.299, p = 0.000) and independence (r = 0.290, p = 0.000) dimensions of the ethical climate. these results show that as the care & attention and independence dimensions of ethical climate develop and improve, employees' intention to leave the service decrease. we found that there was a statistically negative correlation between the intention to leave the service score and the law dimension of the ethical climate in the organization (r = 0.138, p = 0.039). this finding indicates that increasing the law dimension of the ethical climate can increase the intention of the pre-hospital emergency staff to leave the service. discussion the ever-increasing concerns about hcps' activity in cyberspace highlight the need for ethical guidelines on their appropriate presence in online environments (23). many researchers have pointed the necessity of developing a guideline for professional conduct in cyberspace (24, 25). khabaz mafinejad m., et al. 9 j. med. ethics. hist. med. 2022 (dec); 15:10. therefore, this study was conducted to develop a guideline for health-care professionals in cyberspace in iran. the development of such a guideline does not signify total adherence to its provisions; however, as the first step toward achieving professionalism in cyberspace, it is necessary to agree on the accepted rules and standards in order to maintain public trust in the medical profession. furthermore, without a standard of conduct in cyberspace, the application and presentation of the principles of professional conduct in the curriculum may be considered arbitrary (26). in the present study, the professional guideline for the use of cyberspace by hcps encompassed five domains, including general regulations, care and treatment, research, education, and personal development codes. these domains were suggested based on the challenges and concerns regarding the use of cyberspace by hcps (7, 27). one of the major concerns pertaining to the decline of professionalism in cyberspace is the dissemination of patients’ pictures and private information on social media, which may indicate an invasion of privacy as well as a breach of the principle of confidentiality in the online world. publishing selfie images with cadavers or patients, distributing patient information on social media, and uploading group discussions of health-care team members in digital medical networking without maintaining anonymity are examples of unprofessional behaviors in cyberspace. as a rule, disclosure of trivial information may not seem to violate the principle of confidentiality or lead to the disclosure of patient information, but a combination of these details may be enough to reveal the identity of patients or their family members and relatives. moreover, many people underestimate the identifiability of individuals in putatively anonymized data, especially when information is combined with other databases. therefore, this guideline includes several codes related to confidentiality. a review of similar studies also shows that the criteria of professionalism in cyberspace require that the hcps maintain patients’ confidentiality in online environments and refrain from publishing any incorrect or scientifically invalid material threatening the dignity of the medical profession (6, 28). dike et al. reported that in communication with patients, utmost caution must be exercised to protect the patients’ confidentiality as much as possible (23). moreover, the use of publically available digital media for interactions with patients or others may lead to the violation of developing a professional guideline for the use of cyberspace by health-care professionals in iran: a mixed methods study j. med. ethics. hist. med. 2022 (dec); 15: 10. 10 confidentiality and damage the hcps’ professional dignity and reputation (29). health-care professionals are required to respect other individuals’ rights in all digital and online relationships and should conduct themselves professionally in their interactions (30). according to the results of our study, some of the critical principles in cyberethics include: maintaining a respectful relationship with one’s colleagues in line with professional norms and values, keeping the secrets of colleagues and the organization in cyberspace, refraining from use of unethical and aggressive words, and avoiding propagation of any discriminatory or insulting expressions against different ethnicities and genders, as well as the cultural and religious beliefs of patients. von muhlen and ohno-machado’s survey showed that the use of negative language describing patients was evident in 57% of clinical cases (31). this finding demonstrates the necessity of better preparation of health-care professionals to communicate respect through appropriate interactions in cyberspace. as shown by one study, unprofessional relationships in cyberspace can be irrevocably severed because of a breach of trust and respect (32). therefore, respect for appropriate communication can be viewed as a component of professional practice in cyberspace. ease of information exchange and lack of tangible control in online social media may keep hcps from adhering to ethical principles when sharing and publishing individual patient information, which may cause problems for patients, their relatives, or even the health-care team (33). applications of the cyberspace may vary from educational purposes to information and experience exchange or even research, and it is therefore essential to use valid medical professional websites to present information, interact with colleagues, and exchange medical information. work interaction groups are being commonly used in social networking by health-care professionals to communicate availability for consultation or teaching. there are, however, challenges associated with some of these platforms because they may not be secure and messages may get sent to the wrong recipients, thus compromising privacy. the use of uncontrolled and open-access social networking to share patient information may expose professionals to violation of ethical standards and the law (34). based on our findings, checking the safety of the environment and users’ access level to information is a key point to the observance of cyberethics. this is important not only in sharing patients' information, but also with regard to the information, images and professional khabaz mafinejad m., et al. 11 j. med. ethics. hist. med. 2022 (dec); 15:10. identities of health-care professionals. employers may use this information to screen potential employees, and this may affect the health-care staff's professional future. based on grobler and dhai’s study, inappropriate content can affect one’s professional standing (35). it is also notable to mention that other guidelines have been developed and proposed by different organizations and institutions. however, in 2010, only 13 out of 132 american medical schools had specific social media guidelines (36). in 2009, a guideline was proposed by guseh et al., suggesting four main principles regarding patient-physician interactions on facebook: “avoid accepting patient friend requests”; “avoid adding private information gathered online to a patient’s medical record”; “restrain from disclosing personal information online”; and “understand privacy settings to ensure that content meant for private access does not become public” (37). the american medical association (ama) has also designed a social media-related guideline that addresses the importance of professionalism in cyberspace while discussing the potential benefits and drawbacks. similar to the guideline proposed in the present study, ama emphasizes the importance of patient privacy and maintaining appropriate boundaries that separate personal and professional interactions (36, 38). moreover, the council on ethical and judicial affarirs recommend the addition of several principles to those articulated by the ama. for instance, some of the principles outlined in that guideline are: “when using the internet for social networking, physicians should use privacy settings to safeguard personal information and content to the extent possible, but should realize that privacy settings are not absolute and that once on the internet, content is likely there permanently”, and “when physicians see content posted by colleagues that appears unprofessional, they have a responsibility to bring that content to the attention of the individual, so that he or she can remove it and/or take other appropriate actions. if the behavior significantly violates professional norms and the individual does not take appropriate action to resolve the situation, the physician should report the matter to appropriate authorities” (39). the american psychological association has also published a study that assists medical doctors to adhere to professionalism in online spaces by setting proper physician-patient boundaries as a core element in order to ensure the public’s trust in this profession (40). one strong point of the present study was the presence of representatives of students and developing a professional guideline for the use of cyberspace by health-care professionals in iran: a mixed methods study j. med. ethics. hist. med. 2022 (dec); 15: 10. 12 graduates in the focus groups that helped receive their views and perspectives. the researchers believe that, considering the serious disagreements on some examples of unprofessional behavior in cyberspace, the method used for compiling this guide can benefit readers of other countries to reach an agreement on the minimum necessary to maintain public trust. in other words, more than the content of this guide, the way it has been compiled is useful for international readers. the guideline can be used by hcps for self-assessment of their practice and in striving for excellence in terms of their presence in cyberspace. moreover, this guideline has paved the way for designing a tool to assess professional behaviors in cyberspace. one of the major limitations of this study was that public views were not reflected in the guideline. furthermore, there was no survey following implementation of this guideline and assessing the reactions of stakeholders, and the survey data were based on a single-center design. it is emphasized that discussion on the content of this guideline should be included in faculty development programs and also in the formal curriculum of health-care learners to transfer the attitude and insight into professional commitment in cyberspace to them. conclusion adherence to the principles of medical professionalism in cyberspace, just like the real space, is essential for maintaining public trust in the profession. after reviewing the existing literature and exploring the views of experts, a framework was suggested in five domains of cyberethics conduct, including general regulations, care and treatment, research, education, and personal development. this framework characterizes the various ways in which professionalism can be applied in interactions between hcps and other individuals in cyberspace. funding part of this study has been funded by the policy research and development center of tehran university of medical sciences with the code 29906 and the title of compiling a guide to ethics and professionalism in the use of cyberspace. acknowledgements we would like to thank the study participants and experts for their frank and honest contribution.the authors would like to thank dr. alireza parsapour, dr azim mirzazadeh, dr. hesam-e-din riahi, dr. ali labaf, dr. saeed mehrpour, dr. sina rezaie, and dr. bardia khosravi for their cooperation. we khabaz mafinejad m., et al. 13 j. med. ethics. hist. med. 2022 (dec); 15:10. also appreciate dr. hoomayoon amini for his great support. conflict of interests the authors report there are no competing interests to declare. references 1. giordano c, giordano c. health professions students' use of social media. j allied health. 2011; 40(2): 78-81. 2. fourkas v. what is cyberspace. 2004; [cited october 2022]; available from: https://www.academia.edu/5067012/what_is_cyberspace 3. yoo sh, joo ys, lee sh. graduate and postgraduate medical ethics education. journal of the korean medical association. 2017; 60(1): 24-31. 4. smith kp, christakis na. social networks and health. annual review of sociology. 2008; 34: 405-29. 5. lengelle r, 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media. j clin ethics. 2011; 22(2):165-72. 39. busl km, rubin ma, tolchin bd, et al. use of social media in health care-opportunities, challenges, and ethical considerations: a position statement of the american academy of neurology. neurology. 2021; 97(12): 585-94. developing a professional guideline for the use of cyberspace by health-care professionals in iran: a mixed methods study j. med. ethics. hist. med. 2022 (dec); 15: 10. 16 40. kolmes k, taube do. seeking and finding our clients on the internet: boundary considerations in cyberspace. professional psychology: research and practice. 2014; 45(1): 3-10. journal of medical ethics and history of medicine original article consanguineous marriages in the genetic counseling centers of isfahan and the ethical issues of clinical consultations narges nouri1, nayereh nouri2, samane tirgar3, elham soleimani4, vida yazdani4, farzaneh zahedi5*, bagher larijani6 1tohid genetic counseling center, isfahan, iran. 2 genetic laboratory of alzahra hospital, isfahan university of medical sciences, isfahan, iran. 3endocrinology and metabolism research center, endocrinology and metabolism clinical sciences institute, tehran university of medical sciences, tehran, iran; faculty of sciences, isfahan university, isfahan, iran. 4medical genetics laboratory of genome, isfahan, iran. 5endocrinology and metabolism research center, endocrinology and metabolism clinical sciences institute, tehran university of medical sciences, tehran, iran. 6professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. corresponding author: farzaneh zahedi address: no. 10, jalal al-ahmad st., next to shariati hospital, chamran hwy, tehran, iran. email: fzahedi@sina.tums.ac.ir tel: (+9821) 88631295 received: 25 may 2017 accepted: 4 nov 2017 published: 10 dec 2017 j med ethics hist med, 2017, 10:12 © 2017 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract consanguineous marriage, which is common in many regions in the world, has absorbed much attention as a causative factor in raising the incidence of genetic diseases. the adverse effects may be attributed to the expression of the genes received from common ancestors and mortality and morbidity of the offspring. iran has a high rate of consanguineous marriages. in recent years genetic counseling has come to be considered in health care services. this cross-sectional study was conducted in order to determine the prevalence and types of consanguineous marriages in the genetic clinics in isfahan. we aimed to define the different types of marriages, specific categories of genetic disorders associated with consanguineous marriages, and mode of inheritance in the family tree. we also narratively reviewed the ethical aspects of the issue. the data were collected using a simple questionnaire. a total number of 1535 couples from urban and rural areas formed the study population. the marriages were classified according to the degree of the relationship between couples, including: double cousin, first cousin, first cousin once removed, second cousin and beyond second cousin. the spss software version 16 was used for data analysis. data obtained through genetic counseling offered during a 5-year period revealed that 74.3% had consanguineous relationships, 62.3% were first cousins, 1% were double cousins and 7.8% were second cousins. in addition, 76% of the couples had at least one genetic disease in their family tree. related ethical issues were also considered in this study, including autonomy and informed decision making, benefit and harm assessment, confidentiality, ethics in research, justice in access to counseling services, financial problems ethics, and the intellectual property of scientific success. keywords: genetic counseling, genetics, consanguineous marriage, medical ethics, iran mailto:fzahedi@sina.tums.ac.ir j med ethics hist med 10: 12, december, 2017 jmehm.tums.ac.ir narges nouri et al introduction nowadays, the infant mortality rate has significantly declined due to the improvement in health and nutrition care and also the control of infectious diseases. however, one handicapped child is born every 8 minutes, of which 90% are in the developing countries (1-3). consanguineous marriage has been recognized as one of the important causes of these disorders (1, 4-7). these facts point out the necessity of training and preventive counseling with regard to consanguineous marriages. consanguineous marriages take place between blood relatives, that is, the husband and wife should have at least one common ancestor (1, 6). these individuals are first cousins (e.g. daughter of paternal uncle, daughter of maternal aunt, daughter of maternal uncle, etc.); second cousins (e.g. grandchild of paternal uncle, grandchild of maternal aunt, grandchild of paternal aunt, etc.); third cousins (e.g. great grandchild of maternal aunt, grandchild of half aunt, grandchild of maternal aunt, etc.); and double cousins (e.g. bilateral parallel cousins). the risk of having babies with congenital diseases in consanguineous marriages is 2 3 times higher than non-consanguineous ones (8-12). the frequency of consanguineous marriages varies between less than 1% in north america, europe, russia, and australia, and more than 50% in some arab countries, turkey, iran, pakistan, and south india (9, 13). previous studies have shown that this type of marriage is more common in islamic and arab countries, having a heterogeneous prevalence depending on custom, culture, religion, and the geographical zones within these countries (9, 13-16). one-fifth of the world’s population, namely about 1.1 billion people, lives in countries where one in every three marriages on average is a consanguineous marriage (1-3, 9, 11, 14, 17). in islam, there is a great emphasis on marriage and child support, and sufficient advice is given concerning marriage, choosing a spouse, the relationship between couples and their duties and rights, as well as protection of children and their rights (18, 19). consanguineous marriage has not been recommended, but rather criticized by islam. the hadiths of the infallibles advise against consanguineous marriage; as a case in point, prophet muhammad (pbuh) has been quoted to say, “marry strangers to have no weak children”1. there is also a quote by imam sadegh (pbuh), the 6th leader (emam) of shia muslims, saying, “do not marry blood relatives, because weak babies will be born”2. 1 alnahaye, ebn-e-asir, vol. 3, p. 106; almojazatalnabawi, sharif razi, p. 92. 2 masalek alafham, shahid thani, vol. 2, p. 38; almhjh al-bayda, feiz kashani, vol. 3, p. 94. historical evidence shows that only two of the fourteen infallible shia leaders have had consanguineous marriages (18, 19). by the end of the twentieth century, many researchers believed that the prevalence of consanguineous marriage would decline due to the industrialization and the increasing educational achievements of women. however, in most geographical areas, consanguineous marriage has increased or remained unchanged (9, 13, 17, 20). in iran, the statistics available on some parts of the country have shown different results concerning the frequency of consanguineous marriages. according to a study conducted on 300,000 iranian couples from different ethnic groups in iran, more than 38% of the marriages were consanguineous, of which 70% were between first cousins (21). in another study in tehran, marriages in three successive generations were studied and the results showed that consanguineous marriages in the third generation had significantly increased in comparison to the first and second generations (22). billions of dollars are spent every year to treat and control the congenital diseases resulting from consanguineous marriages. in arab countries, the treatment of 4 hereditary diseases including thalassemia, sickle-cell anemia, cystic fibrosis and hemophilia costs more than 13 billion dollars annually (23). in iran, 30-40 thousands disabled children are born every year (24) and excessive amounts of money are spent on the medical treatment and care of these children. considering the suffering nature and psychological damages caused by such diseases, it is highly recommended to seek a logical solution to this problem. genetic counseling can be very helpful in this matter. counseling can be done either before or after genetic testing, the aim of which is to empower individuals to deal with different situations and help them to make appropriate decisions. numerous ethical issues have been raised in the field of genetic counseling. in this regard, counselors should observe the general principles of medical ethics including respect for autonomy, beneficence, non-maleficence and justice. considering the importance of ethics in genetic counseling, a survey of the ethical issues associated with clinical consultation in consanguineous marriage was a major part of this study. obviously, genetic counseling without observance of ethical principles may be more harmful than beneficial. in the present study, ethical issues were investigated by presenting 3 clinical cases. in addition, to evaluate the clinical dimensions of the subject, the frequency of consanguineous marriages in clients of genetic counseling centers in isfahan was studied. method this study was conducted in two distinct parts page 2 of 10 j med ethics hist med 10: 12, december, 2017 jmehm.tums.ac.ir narges nouri et al including a cross-sectional descriptive design and a library research. data collection tool was form number 1 prepared by the deputy of cultural affairs and prevention of the state welfare organization entitled “the plan for the prevention of disabilities originating from genetic disorders”. the questionnaire included demographic data, type of couples’ relationship, and history of family disorders in the family tree. the forms were completed by two genetic counselors (first and second authors of the present study) over the course of 5 years in the genetic centers of isfahan, a large province in the center of iran. the sample population consisted of all the couples who referred to genetic counseling centers in isfahan during the years 1387 1392 (persian solar year corresponding to 2008 2013 a.d.). the total sample size was 3,200 individuals. the data were analyzed by a statistician using the spss software version 16. the second part of the study was a library research using available references and books and examined the ethical challenges in the field of genetic counseling of consanguineous marriages. we searched the sources of google as well as pubmed and scientific information databases (sid) and iran medex using keywords such as “genetic counseling” and “consanguineous marriage” in combination with the word “ethic*” (in farsi as well as english). subsequently, related articles were selected on the basis of the abstract and sometimes the main text. the available books were also searched manually in the medical ethics department and library of the endocrinology and metabolism research institute of tehran university of medical sciences. the overall content achieved by studying and analyzing these resources is presented in the results section. ethical considerations: the present study was approved by the research ethics committee of the endocrinology and metabolism research center of endocrinology and metabolism clinical sciences institute of tehran university of medical sciences under the code ec00327. the data resulting from this cross-sectional descriptive study were collected in genetic centers in isfahan. clients voluntarily referred to these centers for medical consultations about hereditary diseases. their information was recorded in the questionnaire with their consent and used anonymously in the study. in the library research, we used the resources with honesty and integrity, and carefully observed the “national ethical guideline of scholarly publications in medical sciences”. results as mentioned above, this study consisted of two separate parts, and the results of each part will be presented below separately. part one: determining the frequency of consanguineous marriages in the records of genetic counseling centers in isfahan in this part, the medical documents of all couples who had referred to genetic counseling centers in isfahan during the years 2008-2013 were reviewed. the total sample was 3,200 medical documents, of which approximately 130 samples were removed due to being incomplete. therefore, the number of study samples reached 3070 people (1535 couples). there were non-consanguineous marriages in only 25.7% of the cases. among the consanguineous marriages, 62.3% of the cases pertained to thirddegree relatives (first cousins)1, 9.1% to fourthdegree relatives (second cousins) 2, and 1.9 % to fifth-degree relatives (third cousins) 3. in addition, 1% of the participants were double cousins4 (table 1). in total, 74.3% of the clients had consanguineous marriages, and a minimum of one hereditary disease was observed in the families of 75.3% of these individuals. table 1the types of family relationships in the consanguineous marriages in this study type of family relationship no. percent (%) non-consanguineous marriage 788 25.7 consangu ineous marriage first cousins 1913 62.3 second cousins 279 7.8 third cousins 59 1.9 double cousins 31 1 total 2282 74.3 total 3070 100 1 first cousins marriages: the marriage between the son and daughter of the maternal aunts, the son and daughter of parental uncles, maternal uncle's daughter and maternal aunt's son, parental aunt's daughter and maternal uncle's son. 2 second cousins marriages: the marriage between uncle's grandchildren, maternal aunt and parental uncle's grandchildren, and grandchildren of maternal aunts. 3 third cousins marriages: the marriage between great grandchildren as non-consanguineous marriage has low genetic risk; but when some genetic disorders exist in the family, this distant relationship may lead to diseases in children. 4 double cousins marriages: the marriage in which there are two common ancestors, and the male and the female from both paternal and maternal families are close has the greatest risk. page 3 of 10 j med ethics hist med 10: 12, december, 2017 jmehm.tums.ac.ir narges nouri et al diagram 1clients’ inbreeding coefficient for the times of referral for counseling as shown in diagram 1, the inbreeding coefficient1 was various according to the time of referral for a broad range of counseling, including genetic counseling, pre-marriage counseling (pmc), preconception counseling (pcc), during pregnancy counseling (dpc) and diagnostic counseling (dc) of couples accompanied by their disabled children. part two: library research on the ethical issues of clinical consultation in consanguineous marriages in recent years, pre-marriage counseling has been increasingly popular among couples who have records of certain genetic diseases in their families, or those who are planning consanguineous marriages. this is mainly due to the progress made in medical sciences and technologies on one hand, and the development of some methods of public education on the other. in fact, providing counseling services is mainly considered as a preventive approach to reduce defects and hereditary diseases. pre-marriage genetic counseling is, however, complicated by numerous ethical issues originating from the strong emotions associated with marriage, and the critical decision-making related to spouse and fertility. the most important ethical challenges in this regard are mentioned below: 1. respect for autonomy and the couples’ informed decision making the importance of pre-marriage genetic counseling 1inbreeding coefficient is defined as a measure to gauge the possibility to inherit two identical copies of a gene locus from parents. in other words, due to the fact that in consanguineous marriages the ancestors are common, the possibility of the symmetry of genes is higher than in nonconsanguineous marriages. the possibility of this symmetry depends on the degree of couples’ kinship and history of consanguineous marriage between their parents, which is called the inbreeding coefficient. (adapted from the book entitled: a review of clinical genetics, compiled and written by dr. pune nikoii, publications of the state welfare organization of iran, 1393, p. 52). is undeniable, and if couples fail to have consultation, they may face adverse consequences that are sometimes costly. nevertheless, according to the ethical principle of “autonomy”, any pressure by the government, community or physicians on couples and families to make them seek genetic counseling is impermissible (25). autonomy is defined as respect for human beings’ inherent rights and their capacity for thinking, and the idea that they can make their own decisions and act on the basis of their values and beliefs (26). therefore, it is recommended to encourage couples to attend consultations voluntarily through strategies such as public education, establishing conventional or distance workshops, and facilitating the process of counseling. during consultations, the necessity, goals, steps, benefits and even possible consequences of genetic counseling (such as overturning the decision to marry because of increased risk of developing genetic diseases in the offspring) should be clearly explained (27). moreover, individual autonomy should be fully respected at all stages of consultation, including providing the information, screening, announcing the results, ensuring confidentiality, offering possible treatments, and the use of couples’ data in future studies. respect for individuals’ autonomy means that they should receive the necessary information about the tools and available choices, and also be supported in making decisions based upon their personal authority while their questions and concerns are addressed (26). sometimes the results of the tests and genetic screenings are inconclusive. in such cases, ethical appraisal should be carefully carried out in order to weigh correctly the couples’ autonomy in decisionmaking against the possible consequences (28). in other words, clinicians should not feel burdened with responsibility to force the couples to overturn their decision to be married. the issue of informed consent is critical in genetic counseling, as in many other fields of medical practice, and therefore it is necessary to consider the related principles and rules. clients should also receive information about the page 4 of 10 j med ethics hist med 10: 12, december, 2017 jmehm.tums.ac.ir narges nouri et al possible benefits and harms of consanguineous marriage, which will enable them to make decisions voluntarily (26). 2. benefit and harm assessment of consanguineous marriage considering couples and the entire community providing pre-marriage counseling has undeniable effects not only on the couples, but also on their families, the society, and even the future generations (29). there are potential personal, social, professional and financial harms associated with genetic testing. personal harms include anxiety, feelings of inefficiency and depression, changes in the goals and plans of life, and refusing treatment and medical care resulting from uncertainty in the genetic testing results (30). some social harms consist of stigmatization, or manifestations of the privacy violation resulting from the propagation of the news of having a genetic disorder. while one example of professional harm is difficulty in employment (31), financial harms comprise high costs of genetic testing and sometimes long-term medical follow-ups (30). considering all the issues mentioned above, effective measures should be taken to minimize the harms. 3. preserving confidentiality of families in pre-marriage counseling and its limits some of the genetic testing results may impact the health of other family members, so confidentiality is rather important (32). it is necessary to provide couples with detailed information about the potential problems prior to performing diagnostic tests, and they should be well informed in case the identified genes may affect the health of other relatives. as ethical principles necessitate, the couple should be the first to learn about the results, and only with their consent may others be notified. in these cases, the couples’ confidentiality should be protected and only the most essential information may be disclosed (33). any attempt to inform other individuals who are at the risk of genetic harm against the couples’ wish is an ethical challenge that must be addressed prudently (34-36). in the meantime, willingness and autonomy of those individuals that are at high risk in case they do not receive genetic incompatibility information is an important factor that should be taken into account (37). 4. professional ethics in the manner of disclosing information to couples and their families professionals who conduct counseling sessions must consider several issues including (but not limited to) age and level of education, since these factors are crucial to determining the quantity and quality of information transfer (38). culture and ethnicity also play an important role (39). the counselor should be well informed about the strategies, amount of information, and the audience to whom he/she wants to disclose genetic information (35). other professional ethical principles to be observed by genetic counselors are truth telling and honesty, and avoiding paternalistic leadership. in fact, it is extremely important to provide information and counseling without any sort of judgment (28). specific skills are required in order to best manage clients’ psychological and emotional reactions (35, 40). some ethical conflicts that consultants may face include: marriage counseling for only research and scientific purposes without any results for the clients, diagnostic failures and their consequences, conflicts and disagreements arising from value differences among consultants, clients, and their relatives (35), and also confronting clients under legal age (41). in each of these cases, the consultant has an ethical obligation in the manner of providing information to clients. some genetic test results may necessitate the couples’ follow-up till they decide to have babies. in such cases, other ethical issues arise, for instance respect for confidentiality, relationship limits between consultants and clients, and conflicts of interest. therefore, consultants should inform and assure couples that counseling facilities are always accessible for them and their families (42). 5. ethical principles regarding the use of clients’ data in research due to the fast advances in genetic sciences and its effective role in many scientific fields such as medicine on one hand, and the costly nature of genetic testing on the other, data are utilized by researchers to ameliorate research projects. thus, clients should be informed and receive a written informed consent. the fundamental point is that data owners should be well informed about the importance of genetic information. in addition, information preservation entails important considerations concerning the protection of confidentiality, for example why, when, how, by whom or in what electronic system the information will be stored (30), and who will have access to the data? on the same bases, biological and genetic databases generally include specific rules about issues such as identifiable or non-identifiable samples, long-term or short-term data storage, and performing numerous studies (43). another challenge arises in terms of using the data for future study purposes, bringing up questions such as in what conditions the owner of the samples should be informed about the new results of the studies (in order to gain profits and reject harms), and several other questions. in this regard, announcements and ethical guidelines have also been developed at national and international levels. following the approval of the “universal declaration on the human genome and human rights” (44) by unesco in 1997, the “international declaration on human genetic data” (45) was also approved in 2003. in iran, the “national ethical guidelines for genetic research” was developed in 2004 along the same line (46). it is page 5 of 10 j med ethics hist med 10: 12, december, 2017 jmehm.tums.ac.ir narges nouri et al obvious that application of these guidelines will make a significant contribution to the ethical process of research in genetics. 6. justice in couples’ access to necessary counseling services in one sense, justice means that services need to be equally divided among individuals (30). as a matter of fact, in our country, all couples who want to have consanguineous marriage, or have a history of hereditary diseases in family, should have access to genetic counseling services in a fair and low-cost manner. some developed countries provide free genetic counseling services and genetic testing, while in developing countries these services are expensive and are not widely available. in this regard, the principle of equality and dignity of all human beings should be respected. therefore, all people should have fair access to counseling services (47). in this vein, counseling services should be perfectly and fairly applied through creating suitable infrastructures and removing obstacles. the barriers to access genetic counseling services include: lack of adequate education and training of medical genetic professionals, lack of genetic counseling centers in the government sector, and lack of adequate insurance coverage (25). there are important financial restrictions such as the costs imposed by diagnostic genetic laboratory tests, which can be a preventive factor in the couples’ decision to receive genetic counseling (48). in this regard, counselors should consider the necessity and priority of diagnostic tests, and should provide them with the best recommendations. moreover, the issue of conflict of interests (i.e., directing individuals towards laboratories that bring financial profit for the consultants) is highly challenging and unethical at times (49). 7. the intellectual property of innovative scientific results sometimes investigating a rare disease leads to the discovery of a new gene or new mutation. the intellectual property of results and probably commercial profits arising from it may or may not belong to couples who have been tested. the issue should therefore be considered and determined before doing research, and the rights of each member of the research team must be respected by the principal investigator. clinical cases before proceeding with the discussion, we contemplate some clinical cases in order to pay more attention to the ethical challenges faced by practitioners in this field. the first case: a 23-years-old woman and a 29years-old man with the kinship of uncle’s grandson (fifth-degree) were advised to seek genetic counseling before marriage. before the counseling session, the young man’s mother declared in a face to face and private contact that the family had not approved the marriage and failed to prevent him from it because of their son’s persistence. she then went on to insist that the practitioner prohibit the marriage regardless of the results of the genetic counseling and tests. the second case: a young couple with distant kinship or relationship (above fifth-degree) referred to a genetic clinic before marriage. there were no signs of hereditary diseases in their family tree. after a few months of marriage, the woman’s mother visited the counselor alone and stated that three uncles of the bride were paralyzed! she requested from the genetic counselor a letter stating that the condition could be transferred to the couple’s future children and that they would definitely be affected. the third case: a 25-years-old woman was planning a consanguineous marriage with her 28-year-old cousin (her uncle’s son). there were no records of genetic diseases in the family tree, but a genetic counselor had requested genetic tests in the previous session. the couple had not done the tests yet, and since they had been referred to a private center (where the previous counselor happened to be a stakeholder), they would have to bear enormous costs! discussion consanguineous marriage is a complex and multifaceted issue, and no major, successful action has been taken to control it so far, mainly due to a lack of consideration for cultural, social and geographical variables. a review of the texts reveal that in societies where consanguineous marriage is common and fostered by the existing customs and traditions, people’s awareness of the harms is very low. couples, especially those who are married at a younger age, do not have the necessary knowledge in this field, and mass communication has seemingly failed to educate the public on the issue. therefore, encouraging couples to perform genetic counseling before marriage, raising their level of knowledge during the sessions, and answering their questions can be helpful in carrying out a scientific and rational decision. in the present study, which was performed on couples who had referred to genetic counseling centers in isfahan, about 75% of the marriages were consanguineous, and more than 62% of the clients were close relatives. it should be mentioned that the study was conducted on clients of counseling centers, not all the couples who had been married in that period of time. the current study results cannot be generalized to the entire community, but can indicate the importance of the issue in the country. in a similar study conducted on 2686 couples who had referred to genetic counseling centers in shiraz during a four-year period, 85% had consanguineous marriages, 23% of whom were first cousins (50). furthermore, in a study that was conducted in tabriz over a period of 4 years, 20.12% of the marriages page 6 of 10 j med ethics hist med 10: 12, december, 2017 jmehm.tums.ac.ir narges nouri et al were consanguineous, more than 50% of which were between first cousins (51). in another study on the various ethnic groups from different regions of iran, 38% had consanguineous marriages, 70% of whom were first cousins (52). one limitation of the study was that we could not provide exact statistics on the prevalence of consanguineous marriage, because the clients referring to genetic counseling centers in isfahan are not representative of all the couples in the community. while considering the issues mentioned in the results section facilitates the ethical process of genetic counseling, it seems that studying the psycho-social consequences of consultations is also necessary. such investigations will help to determine the method of counseling by clarifying the social and psychological effects and can reduce the undesirable consequences. in addition, genetic counseling training programs can make genetic specialists aware of how effective the ethical principles will be. conscience may also serve as a moral gauge for decision-making in difficult situations. medical geneticists’ collaboration with medical ethics experts and referring specific and controversial cases to them may also play an effective role in resolving challenges. during genetic counseling, the autonomy of families should be respected, and it must be noted that the unconscious choice will lead to regret. genetic counseling before marriage should be done in the presence of couples’ parents, because consanguineous marriage is usually proposed by one of the parents, and if the genetic counselor can convince the elders, couples will be able to make a better decision in a more relaxed atmosphere far from family coercion. respect for elders and their beliefs and customs and providing them with related scientific research results and past experiences can always be helpful. in pre-marriage counseling sessions, couples state their problems privately and genetic counselors should ensure confidentiality. preserving the ethical commitment towards clients can reduce family conflicts. in some cases, there are dangerous inherited diseases among the family members of a client that he/she may not wish to reveal in the genetic counseling session. in such cases, ethical responsibility forces the counselor to persuade the client to provide the necessary and true information to his/her future spouse and then consult the genetic counselor about strategies to prevent those diseases from being transferred to the offspring. discussion of clinical cases the first case (a real case): considering the principle of confidentiality and the potential profits and harms, the genetic counselor drew the family tree in full honesty and explained the inbreeding coefficient to the couple. they had a fifth-degree consanguineous marriage and an inbreeding coefficient of 4% was determined as the incidence risk of disease in their children. the counselor explained that even if the couple’s kinship is distant, the incidence risk of diseases in children will still be higher in consanguineous marriages than nonconsanguineous ones. the counselor also emphasized that no genetic testing and paraclinical measures could give full confidence to the couple that their child would be born healthy. finally, according to the principle of respect for individual autonomy, decision-making was left to the couple and their families. the second case (a real case): in pre-marriage genetic counseling, families are provided with comprehensive information, and therefore in the case of consanguineous marriages, a full explanation is provided based on the risk of certain diseases in children. the situation is different in genetic counseling after marriage, since the family cannot be disintegrated on the pretext of disease risk in children. in this case, the couple had a distant relationship and the disease was recognized only after the marriage. therefore, the genetic counselor advised members of the family who suffered from the disease to have genetic testing so that in the case of a definite diagnosis of gene mutation, carrier testing could be done for the couple. in the case of carrier couples, fetal sampling during pregnancy and prenatal diagnosis should be provided, and in the case of diseases that lead to severe disabilities in children, after obtaining the family’s consent and the approval of forensic medicine authorities, an abortion permit can be issued. thus, being honest with couples and their families is beneficial in such cases. in diagnostic genetic counseling, it should be notified that sometimes a disease is transferred by one of the parents to the child. the facts cannot be stated unless the couple requests investigation of the cause of the disease, and any suspicion and nonscientific speculation in this regard should be avoided. only after genetic testing and establishment of a definitive reason can the issue be shared with the couple. in these cases, even informing their families of the existence of the disease should be done only by the couple or with their consent. the third case (a real case): financial problems can greatly impact the relationship between the counselor and clients. considering the patients’ benefits and harms and avoiding the imposition of unnecessary costs are moral imperatives. to avoid conflict of interests, counselors must not refer their clients to facilities that they own, since that would be an unethical practice, and in some countries could even result in heavy punishment. there is a misconception that by having genetic testing a couple can be assured of their child’s health despite consanguineous marriage. there are ethical concerns in this regard that are considerably page 7 of 10 j med ethics hist med 10: 12, december, 2017 jmehm.tums.ac.ir narges nouri et al important. it is unethical to encourage families to do unnecessary tests and then assure them of the test results. the genetic counselor should clearly notify couples about the high incidence of consanguineous diseases and the limited predictive value of the tests. sometimes families pay enormous sums on genetic testing and think that favorable results mean that the risks associated with consanguineous marriage have been removed completely! unfortunately, such an assurance is given to couples in some counseling centers for reasons such as financial gain and commercial arrangements. professionalism in the field of genetic counseling necessitates that testing be done only in helpful situations. conclusion genetic counseling is known as one important way to prevent congenital diseases. providing genetic counseling plays a special role in decision making capacity building for important issues such as choosing a spouse and fertility. genetic counseling also presents many ethical challenges for professionals. therefore, it is necessary for experts in this field to be familiar with the related ethical issues and the principles of ethical decision-making. one basic principle in the health system is the priority of prevention to treatment, and the authorities need to provide practical and effective ways to reduce costs and provide equitable access to genetic counseling facilities. indeed, the ethical process of these consultations will have a significant impact on couples’ decision-making. considering the statistics obtained in this study and the important ethical issues discussed throughout the paper, the following key points and recommendations can be offered: • applying comprehensive programs to prevent the birth of children with disabilities is a professional commitment in line with the principle of justice in distribution of health resources. • consanguineous marriage is deeply rooted in the culture of some ethnic and social groups. as an initial step, the society must be perfectly informed of its disadvantages and consequences in order to be able to act consciously in this regard. • as a religion that pays attention to the worldly and spiritual matters of its followers, islam has never encouraged consanguineous marriage, and has even prohibited it in some cases. this point can be used and emphasized in counseling. finally, providing specific courses on ethical issues related to genetic counseling is a necessity in iran. two main goals of such a course should include enhancement of ethical sensitivity, and empowerment of counselors to help them act according to ethical codes and make appropriate decisions when encountering ethical conflicts. acknowledgements this study was part of a research conducted by the medical ethics group of the endocrinology and metabolism research center under code number 1392-02-106-1709 performed under the supervision of the endocrinology and metabolism clinical sciences institute of tehran university of medical sciences. page 8 of 10 j med ethics hist med 10: 12, december, 2017 jmehm.tums.ac.ir narges nouri et al references 1. bowirrat a, armaly z. consanguineous marriage in the middle east: nature versus nurture. the open complementary 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http://www.ncbi.nlm.nih.gov/pubmed/17394399 http://www.ncbi.nlm.nih.gov/pubmed?term=brierley%20kl%5bauthor%5d&cauthor=true&cauthor_uid=22846730 http://www.ncbi.nlm.nih.gov/pubmed?term=blouch%20e%5bauthor%5d&cauthor=true&cauthor_uid=22846730 http://www.ncbi.nlm.nih.gov/pubmed?term=cogswell%20w%5bauthor%5d&cauthor=true&cauthor_uid=22846730 journal of medical ethics and history of medicine respect for cultural diversity and the empirical turn in bioethics: a plea for caution karori mbugua university of nairobi, nairobi, kenya. *corresponding author: karori mbugua address: university of nairobi, nairobi, kenya. postal box: 30197-00100 email: karorim@yahoo.co.uk received: 23 nov 2011 accepted: 27 dec 2011 published: 07 feb 2012 j med ethics hist med. 2012; 5:1. http://journals.tums.ac.ir/abs/20181 © 2012 karori mbugua; licensee tehran univ. med. sci. abstract keywords: ethics, cultural sensitivity, empirical bioethics, ethical relativism, naturalistic fallacy. introduction over the last twenty years a number of scholars have been calling for a bioethics that is culturally sensitive. many have been critical of traditional bioethics, arguing that it is dominated by the principles and methods of anglo-american philosophy which are too abstract and insensitive to social and cultural realities (1). at the same time, there has been a trend to make bioethics more relevant to real life cases by incorporating the methods of the social sciences (2). this is what is popularly referred to as the empirical turn in bioethics. my argument is that although these trends in bioethics have their own merits, if overemphasized and not properly conceptualized, they can easily undermine the normativity of bioethics by reducing it to a social science. bioethicists must endeavor to provide judgments of how things ‘ought to be’ and not simply describe how things ‘are’. it is useful to note that the issues discussed in this paper are part of a wider contro versy concerning the universality of human rights. indeed, like in the field of bioethics, similar calls have been made for human rights to be culturally relevant and sensitive to context (3). the cultural turn in bioethics as i have already pointed out, over the past twenty years there have been incessant calls for bioethics to be more sensitive to culture and social context. what has motivated these calls is the realization that all individuals see the world through the filtered eyes of their own culture. consequently, any attempt to impose moral in the last two decades, there have been numerous calls for a culturally sensitive bioethics. at the same time, bioethicists have become increasingly involved in empirical research, which is a sign of dissatisfaction with the analytic methods of traditional bioethics. in this article, i will argue that although these developments have broadened and enriched the field of bioethics, they can easily be construed to be an endorsement of ethical relativism, especially by those not well grounded in academic moral philosophy. i maintain that bioethicists must resist the temptation of moving too quickly from cultural relativism to ethical relativism and from empirical findings to normative conclusions. indeed, anyone who reasons in this way is guilty of the naturalistic fallacy. i conclude by saying that properly conceptualized, empirical research and sensitivity to cultural diversity should give rise to objective rational discourse and criticism and not indiscriminate tolerance of every possible moral practice. bioethics must remain a normative discipline that is characterized by rigorous argumentation. j med ethics hist med 2012, 5:1 karori mbugua page 2 of 5 (page number not for citation purposes) principles based on anglo-american philosophy to people with different cultural perceptions is unjust and amounts to cultural imperialism. the main criticism leveled against traditional bioethics is that it ignores the role of social and cultural factors in the ethical-decision making process. a number of scholars, especially those from the developing countries, see the globalization of bioethics as a form of neocolonialism and an attempt by the developed world agencies to advance their biomedical agenda on resource poor nations. these critics have gone on to call for a truly global bioethics that acknowledges the existence of alternative ethical frameworks (4). one of the earliest advocates of a culturally sensitive bioethics was richard lieban. he coined the term ethnoethics to refer to the examination of ethical issues in biomedicine in non-western cultures. he described ethnoethics in the following way: “this would include moral norms and issues in health care as understood and responded to by members of these societies. ethnoethics should be informative not only about cross-cultural variation in ethical principles of medicine, but also about variations in issues which in different societies become defined as morally relevant or problematic. ethnoethical information should contribute to the discourse of medical ethics, not only by illuminat ing culturally distinctive moral views and prob lems, but also by helping to provide a more realistic and knowledgeable basis for the explora tion of cross-cultural ethical similarities (5).” murove (6) and ogundiran (7) have separately complained about the western domination of contemporary bioethics. they have gone on to call for the evolution of an authentic african bioethics, one that benefits from other cultural influences yet not overshadowed by them. expressing similar sentiments, tai and lin (8) have called for a truly asian bioethics, which is based on the traditions and culture of the asian people. taking the principle of informed consent as an example, the two authors have argued that applying this principle to research involving human subjects in the asian context without consulting the family would be inappropriate because of the high value that asians place on community shared decisions. but de castro (9) has cautioned that any attempt to assert asian bioethics must recognize that, even within asia, different bioethical perspec tives exist and it would therefore be wrong to lump all asian people together as if asia is a homogene ous society. an understanding of the cultural beliefs of oth ers and how they are influenced by them is especially important in clinical practice. learning how different cultures define and understand health, illness, pain and even death can go a long way in helping resolve the many ethical dilemmas that healthcare providers routinely encounter. such an understanding will also translate into improved clinical management (10, 11, 12). from the foregoing it is clear that there is an urgent need to recognize that different cultures have different practices and values and we should take this into account when evaluating them. however, as we shall see later, this does not mean that we cannot make important judgments about particular cultural practices. the empirical turn in bioethics calls for a culturally sensitive bioethics have coincided with what is now described as the ‘empirical turn’ in bioethics. as with the calls for a culturally sensitive bioethics, the empirical turn in bioethics has come about as a result the traditional bioethics’ preoccupation with conceptual analysis, which many critics claim has led to a disconnect between theory and practice.while this turn has its own merits, when accompanied by calls to take cross-cultural moral differences seriously, it can undermine our confidence in the normative analytic methods of bioethics. a quantitative analysis of peer reviewed medical ethics journals in the field of bioethics in the period 1990-2003 showed that the proportion of empirical research in bioethics rose in these journals from 5.4% in 1990 to 15.4% in 2003 (2). a more recent study carried out in turkey showed a sharp increase in empirical studies in turkish medical ethics literature during the period 1994-2009 (13). this turn in bioethics has come as a response to the social science critique of traditional bioethics, with some commentators dismissing it as too abstract and naïve. as john irves forcefully puts it ‘philosophers must get out of the platonic ivory tower, and acknowledge that ethics is about people, not just good arguments. it is about encounter with experience and using those encounters to inform one’s philosophy’ (14) the wellcome trust of the united kingdom has described this approach to bioethics as an ‘abstract exercise carried on over sherry in the tutorial rooms of ivory towers’ (15). it is noteworthy that this trust has been at the fore front of funding empirical studies in bioethics. the value of empirical research to bioethics is not in dispute. this turn has been well received because it has enriched the field of bioethics in a number of ways. mildred solomon has identified three different ways in which empirical research can be used in bioethics. firstly, empirical studies can help facilitate the move from ethical analysis to ethically justifiable behavior; secondly empirical data can be used to enhance ethical analysis and justification (this involves testing consequentialist claims), and thirdly it can be used to identify and document new moral dilemmas (16). however, it j med ethics hist med 2012, 5:1 karori mbugua page 3 of 5 (page number not for citation purposes) must be emphasized that empirical data per se does not determine what is right or wrong although it might be relevant in making such a determination. but it could be argued that this approach to bioethics is not entirely new. according to sociologist adam hedgecoe those who are interest ed in incorporating the empirical element into their work do not need to invent a new discipline. such a discipline already exists in the form of medical sociology. as he forcefully puts it: ‘if medical ethicists are interested in the lived experience of the social world of modern medicine, an obvious solution would be to read some medical sociology rather than look towards developing a new disci pline’ (17). hedgcoe is right. sociology and anthropology have a history of investigating bioethical subjects which are not always recognized by mainstream bioethics (see for example fox (18) and edel (19). however, the two disciplines i.e. sociology and anthropology do not have ethics as their primary focus. it is therefore still necessary to incorporate an empirical component into mainstream bioethics. the lure of ethical relativism although both cultural sensitivity and empirical research can enrich bioethical debate, they can be harmful to the extent that they can be used to shield certain harmful but well entrenched cultural practices from external criticism. indeed the greatest challenge facing bioethicists today is how to produce a bioethics that is both sensitive to culture and lived experience and yet critically normative. we should be worried about cultural relativism because in the past some people have equated it with ethical relativism, which is the claim that morality is relative to one’s culture. those who argue in this way are accused of deriving an “ought” from an “is” or deriving normative claims from factual claims.the naturalistic fallacy, as this error in reasoning is called, was first pointed out by david hume (20) in the 18 th century and elaborated by george edward moore (21) in the 20th century. moreover, ethical relativism and its prescription for tolerance conjure images of a world where any thing goes. just because cultures differ in their ethical judgments does not mean that they are justified in holding them or that we should tolerate those beliefs. the major advocates of ethical relativism were anthropologists who were heavily engaged in the study of indigenous cultures. however, one of the earliest defenders of moral relativism was the greek philosopher protagoras. protagoras is reputed to have said that man is the measure of all things. he went on to suggest that morality is a matter of social convention and in not found in nature. more recently, varied versions of ethical relativism have been defended. for example, brandt (22) defends the view that there are conflicting moral claims that are equally valid, while hartman (23) defends what he calls norma tive moral relativism, which is the claim that different people are subject to different moral demands. wong (24) rejects the notion that there is one true morality and defends the view that there is a plurality of true moralities. in the area of anthropology the main defenders of ethical relativism are benedict (25) and her skovits (26). after studying the cultural practices of different human communities they concluded that what is considered morally normal is culturally bound and historically defined and the western standards of morality should not be considered universal. they also called for toleration of cultural practices with which one may profoundly disagree. a major criticism of moral relativism is that even if different cultures practice different moral behaviors, they may nevertheless share the same underlying moral values. furthermore, even if we accept that different societies have different moral beliefs, this does not warrant the conclusion that all moral codes are equally valid (27). the field of bioethics cannot survive without the belief that there are moral universals. the truth of the matter is that despite the exist ence of significant cultural differences, there exist some core moral values that are shared by inhabit ants of most human communities. unfortunately, most people have tended to over-emphasize cultural differences at the expense of the similari ties. again consider the much debated concept of autonomy. many authors have claimed that this concept is absent in both african and asian cultures whose moral theories are communal in nature. but this view has been challenged by agulanna (28). according to him, the idea that africans value collective agreement over individual choice is grossly exaggerated. along the same lines metz (29, 30) has conclusively argued that just like utilitarianism and kantianism, african ethics entails a right to autonomy and informed consent. another argument against ethical relativism is the argument from moral progress. throughout history cultures have been known to change their beliefs about what is right and wrong. but if the later beliefs are better than the earlier ones, it must be because they are closer to what is objectively right. take the concept of autonomy again as an example. this concept, which is today very highly valued in western culture, came about as a counter response to the paternalistic hippocratic medicine, which had dominated western medicine since the time of hippocrates. the problem with ethical relativism is that it would make such moral progress impossible. today cultural relativism has come to mean nothing more than the idea of tolerance. on the j med ethics hist med 2012, 5:1 karori mbugua page 4 of 5 (page number not for citation purposes) face value this might be considered good but as nafisi rightly pointed out such an attitude neutral izes action instead of galvanizing it (31). indeed, it is possible to practice cultural relativism as a social scientist and the same time maintain a commitment to moral objectivity. by reasoning and argument we can discover the true moral beliefs. further more, as velasquez (32) has noted, moral disa greements may be an indication that some people are more morally enlightened than others and we should not assume that if ethical truth exists, then everyone must know it. empirical studies and bioethics’ normative mandate as they use empirical studies to enhance bioeth ical discourse, bioethicists must ensure that bioethics does not become a chapter of sociology or anthropology. it must remain a second order activity. this in essence means that the cross fertilization between ethics and the social sciences must be done with utmost care. the temptation to move from ‘is’ to ‘ought’ is very real. most bioethicists don’t have a very good grounding in academic moral philosophy. and as david benatar points out, ‘the field of bioethics today suffers from serious quality control prob lems’. the reason for this is that although strictly speaking bioethics is a sub-branch of ethics (as its name suggests) which is in turn a branch of philosophy, many of the practitioners in this field are either social scientist, lawyers, health econo mists, theologians and medical practitioners who are not well grounded in academic moral philoso phy. benatar’s further notes: “…there has been a proliferation of courses, diplomas and degrees in bioethics. as these courses are often aimed at those without philosophical training and lack the rigor and often duration of other courses of study, there are more and more people with formal and poor bioethics education. there is a whole enterprise of bioethics education that is creating “experts” if not instantly then certainly very quickly. in some cases, a brief course or a diploma is thought sufficient to transform a novice into a so called “ethicist”, “bioethicist” or, worse still, bioethics educator (33).” these kinds of bioethicists are vulnerable to the seductive lure of ethical relativism. given that they do not have a good grounding in academic moral philosophy, they can easily be tempted to move too quickly from empirical findings to normative conclusions. but this is not to suggest that bioethics should be the exclusive domain of professional philoso phers or that empirical research has no role to play in bioethics. on the contrary, non-philosophers and especially social scientists have a big role to play in bioethics because empirical findings are often used as premises in ethical arguments. indeed, good studies in bioethics must be grounded on good empirical data and the philosopher has no choice but to either collaborate with the social scientist or be acquainted with social science methodologies so that she can at least read and interpret empirical data if not carry out the empirical research herself. bioethicists will also need to know what counts as useful and relevant empirical data and where to find it. this is because the most useful and original empirical studies, as james dubois recently pointed out, are not published in traditional bioethics journals. bioethicists must therefore understand that ‘empirical data in bioethics are not data that determine what is right or wrong, but rather are relevant to that determination’ (34). some of these data is to be found in non-bioethical journals. but as i pointed out previously, in order to avoid the compartmentalization of the empirical and the ethical, collaboration between philosophers and social scientists should be encouraged. what i am calling for is a moderate form of naturalism that does not threaten to undermine the normativity of bioethics. eric racine prefers to call it pragmatic or moderate naturalism (35). the worries i have raised regarding the relation ship between facts and values; ethical theory and empirical data should not be viewed negatively by social scientists. as chris herrera has pointed out this tension should be viewed ‘as part of the normal inquiry in bioethics….’ (36). it is a reminder that bioethics is rooted in philosophy, which is a self reflective discipline that questions its own methods. indeed, the relationship between facts and values is a perennial problem of philosophy. conclusion in this paper i have argued that although both the cultural and empirical turns in bioethics have enriched the field of bioethics, if not properly conceptualized and integrated with ethical theory, they can easily undermine bioethics’ normative mandate. this concern cannot be wished away or dismissed with a wave of the hand as it touches on the very essence of bioethics as a philosophical discipline. as they use empirical data and acknowledge that different cultures have different moral codes, bioethicists must be guided by the belief that objective moral values that transcend culture exist. this is the only way that bioethics as a discursive discipline can grow and flourish. it is also the only way that we can have moral progress. bioethicists should debate and, if need be, reject those moral practices that defy rational justification. page 5 of 5 (page number not for citation purposes) j med ethics hist med 2012, 5:1 karori mbugua references 1. ryan ma. beyond a western bioethics. theol stud 2004; 65(1): 158-77. 2. borry p, schotsmans p, dierickx k. empirical research in bioethics journals: a quantitative analysis. j med ethics 2006; 32: 240-5. 3. james sa. reconciling international human rights and cultural relativism: the case of female circumcision. bioethics 1994; 8(1): 1-26. 4. mbugua k. is there an african bioethics? eubios j asian 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m. philosophy. new delhi: wardsworth; 2007. 33. benatar d. bioethics and health and human rights: a critical review. j med ethics 2006; 32: 17-20. 34. du bois j m. what counts as empirical research in bioethics and how do we find the stuff? am j bioethics 2009; 9(6): 70-72. 35. racine e. which naturalism for bioethics? a defense of moderate (pragmatic) naturalism, bioethics 2008; 22(2): 92-100. 36. herrera c. is it time for bioethics to go empirical? bioethics 2008; 22(3): 137-146. jmehm-9-11_r1_.docx journal of medical ethics and history of medicine review article medical futility and its challenges: a review study maryam aghabarary1, nahid dehghan nayeri2* 1phd student in nursing, nursing and midwifery care research center, faculty of nursing and midwifery, tehran university of medical sciences, tehran, iran; 2professor, nursing and midwifery care research center, faculty of nursing and midwifery, tehran university of medical sciences, tehran, iran. corresponding author: nahid dehghan nayeri address: nosrat st., tohid sq., faculty of nursing and midwifery, tehran, iran. email: nahid.nayeri@gmail.com tel: 98 21 66 42 16 85 fax: 98 21 66 42 16 85 received: 13 feb 2016 accepted: 28 aug 2016 published: 20 oct 2016 j med ethics hist med, 2016, 9: 11 © 2016 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract concerns over limited medical equipment and resources, particularly in intensive care units (icus), have raised the issue of medical futility. medical futility draws a contrast between physician’s authority and patients’ autonomy and it is one of the major issues of end-of-life ethical decision-making. the aim of this study was to review medical futility and its challenges. in this systematized review study, a comprehensive search of the existing literature was performed using an internet search with broad keywords to access related articles in both persian and english databases. finally, 89 articles were selected and surveyed. medical futility is a complex, ambiguous, subjective, situation-specific, value-laden, and goal-dependent concept which is almost always surrounded by some degrees of uncertainty; hence, there is no objective and valid criterion for its determination. this concept is affected by many different factors such as physicians’ and patients’ value systems, medical goals, and sociocultural and religious context, and individuals’ emotions and personal characteristics. it is difficult to achieve a clear consensus over the concept of medical futility; hence, it should be defined and determined at an individual level and based on the unique condition of each patient. keywords: medical futility, physiologic futility, qualitative futility, decision-making, withholding of treatments mailto:nahid.nayeri@gmail.com j med ethics hist med 9: 11 october, 2016 jmehm.tums.ac.ir maryam aghabarary et al. page 2 of 13 introduction concerns over limited medical equipment and resources, particularly in intensive care units (icus), have raised the issue of medical futility (1-4). advances in medical technology, increased healthcare costs, and the aging of the population have added to the importance of medical futility in recent years, so much so that the issue of medical futility has become an increasing concern (3, 5-9). technological advances have enabled medical experts to prolong the lives of terminally-ill patients even when there is no hope for successful treatment of their underlying pathology. in addition to generating debates on heavy healthcare costs, such practices have increased the demand for intensive care services and icu equipment particularly by elderly people suffering from chronic conditions (5, 8). this increase in demand for intensive care services may become greater than the supplies in the near future and cause different problems (1-3). for instance, the need for icu beds is estimated to increase by 80–93% in the subsequent 20 years. consequently, the impending shortage of icu beds highlights the necessity for paying greater attention to the debates over futile treatments, particularly in icus (2). most people believe that futile treatments should not be provided; however, there are different viewpoints about what can be defined as a futile treatment (8). differences in people’s perceptions of futile treatment have created many challenges between patients’ family members and healthcare professionals regarding continuing or discontinuing treatments (3). contrast between physician’s authority and patients’ autonomy is another important issue which has made clinical decisionmaking difficult. some individuals believe that judgment about futility of treatments is a privilege of medicine and is more valuable than patients’ autonomy (10). however, there might be instances in which patients’ family members insist on continuing treatments, while patients are reluctant to receive them and healthcare professionals believe that they are futile (2, 8, 11). although a physician can ethically reduce the delivery of treatments which are inappropriate or futile (3), the questions ‘is the treatment really futile?’ and ‘who has the right to determine futility (physician, patient, or family members)? (12) are raised. consequently, deciding on the futility of a certain treatment is among the most sensitive health care issues which can even result in making decisions that are unethical. the sensitivity of this issue originates from the fact that the term ‘futile treatment’ is widely used in clinical reasoning as a strong reason for avoiding treatment of a patient. accordingly, a cause of concern here is that valuable treatments are discontinued for patients who are unable to make decisions because treatments are considered to be futile (13). similarly, treatments with small gain may be eliminated out of their presumed futility. this may finally result in patients’ premature death. another concern in the area of futility is that essential treatments may be labeled as futile in order to cut healthcare costs (14). accordingly, the major futility-related concerns are: ’what is futility?’ ‘how can it be defined?’ ‘what are its attributes and instances?’ ‘what factors affect people’s perceptions of it?’ ‘who has the authority to decide upon continuation or discontinuation of futile treatments?’ ‘what factors result in the delivery of futile treatments?’ and ‘what are the consequences of futile treatments?’ this review study aims to answer these questions. the findings of this study can enhance healthcare professionals’ understanding and knowledge regarding the nature, definitions, attributes, reasons, and consequences of the concept of medical futility. method this systematized review was conducted from december 2013 to april 2014. a comprehensive search was conducted via pubmed, proquest, ovid, wiley online library, science direct, and google scholar databases. the time interval determined in the search protocol was 1980–2014. the search keywords were futility, medical futility, medically futile care, futile care, futile treatment, ineffective care, inappropriate care, and non-beneficial care. the equivalents of these keywords in farsi were searched in persian databases such as sicentific information database (sid), iranmedex, magiran, and medlib. by using these broad terms, initially, more than 10000 documents (including articles, books, and theses) were found. after excluding books, theses, duplicate articles, commentaries and letters to the editor, the titles of the articles were assessed and the irrelevant articles were excluded. the abstracts of the remaining articles were studied. thereafter, the full text of 284 articles which met the inclusion criteria were retrieved and studied. moreover, the reference lists of the retrieved articles were assessed. finally, 89 articles which met the inclusion criteria were included in the final analysis. figure 1 shows the inclusion criteria, and the process of searching, retrieving, and selecting the documents. j med ethics hist med 9: 11 october, 2016 jmehm.tums.ac.ir maryam aghabarary et al. page 3 of 13 date of searches: 1980-2014 search terms: futility، medical futility،medically futile care، futile care، futile treatment،ineffective care ، inappropriate care search field tag: the search terms were used in different combinations in title, abstract, keywords or text. search result: 243153 documents were included at this stage. pubmed (n = 15467) proquest (n = 2705) google scholar (n = 223500) sciencedirect (n = 121) wiley online library (n = 241) ovid (n = 1108) magiran (n = 3) sid (n = 5) iranmedex (n = 0) medlib (n = 0) 11253 duplicated documents excluded the full text of 384 articles were retrieved (after reading abstracts) + 15 articles were included by checking the reference lists of key studies a total of 89 articles were included in the analysis (after reading the whole document) persian article english article theoretical empirical theoretical empirical 3 qualitative quantitative 45 qualitative quantitative 3 1 11 26 figure 1. the process of searching, retrieving, and selecting the documents results the history and emergence of the concept of medical futility futility in medicine is a concept with a long history. the hippocratic oath includes a part which requires physicians to avoid over-treating a patient, at any cost, whose body has been swamped with diseases. hippocrates clearly noted that medicine is unable to treat such patients (3, 15-17). consequently, avoidance of futile treatment became an ethical obligation for physicians since the time of hippocrates (12, 18). on the other hand, rapid advances in medical sciences and technology made it possible to manage and treat many life-threatening conditions, increased human longevity, and led to an increase in the population of elderly people. medical technology helped physicians prolong the lives of many terminally-ill patients without having any hope for successful treatment of their underlying pathologies (8, 19). in other words, medical science reached a state in which it was able neither to prevent patients’ inevitable death nor to ignore patients whose death was imminent. some professionals have equated such practices with prolonging the process of patients’ death, pain, and agony, and reducing their quality of life (qol). moreover, given the scarcity of medical equipment and the heavy burden of healthcare costs, it was 3670 articles met the inclusion criteria (after reading title of abstracts) inclusion criteria: document type: article article type: the and empirical language: english, and persian study design: qualitative, quantitative, and mixed methods species: humans subject: health, medicine, and nursing articles about: history, meaning, definition, attribute, and scope of medical futility, and reasons and consequences of providing futile medical treatments j med ethics hist med 9: 11 october, 2016 jmehm.tums.ac.ir maryam aghabarary et al. page 4 of 13 considered as an ineffective, worthless, and futile practice (8, 19, 20). therefore, the concept of medical futility was introduced in the late 1980s (19, 21, 22) in order to discontinue life-sustaining treatments for terminally-ill patients (3, 21, 23). an important question which was raised then was: ‘does one-sided labeling of a treatment procedure as futile by a physician provide the permission for discontinuing that procedure or avoiding its administration (24)?’ the ethical challenge of such a practice was that human life cannot be decided on only by physicians, but that patients and their families also have the right to participate in the decision-making process. therefore, the history of scientific debates about futility in medicine and medical ethics go back to the 1990s (3). other experts considered the contrast between physicians’ authority and patients’ autonomy as the reason behind the emergence of this concept (25-27). the physician-patient paternalistic relationship in the past sometimes required patients to receive treatments which they did not like. patients’ reluctance to and dissatisfaction with receiving such unwanted treatments caused the medical society to base clinical decisions and prescriptions on patient’s right to have autonomy (28). therefore, the paternalistic physician-patient relationship was changed into a participatory relationship. however, patient’s autonomy was limited only to accepting or rejecting diagnostic and therapeutic procedures and it did not include patient’s right to ask to receive treatments (29). thereafter, rapid advances in medical sciences created realistic and unrealistic expectations from medical technology and enhanced patient’s autonomy and authority, so much so that physicians gradually received requests from patients and their families for treatments which were considered professionally as futile, ineffective, worthless, or impossible. consequently, some experts believe that the concept of medical futility was introduced by the medical society in order to regain its earlier paternalistic authority and position and to use it as permission for rejecting patient’s requests (16, 30). however, after some time, it was found that improper use of this concept can cause many ethical challenges. the lexical meaning and the definition of medical futility the root of the word ‘futile’ is the latin word ‘futtilis’ which means worthless. the ordinary meanings of futile include ineffective, useless, unsuccessful, and meritless (9). webster’s dictionary defines futility as ‘serving no useful purpose; completely ineffective or producing no valuable effect’ (31). the definition of this word in the oxford english dictionary is ‘leaky, vain, failing of the desired end through intrinsic defect’ (32). simply, medical futility occurs when: 1. there is a goal 2. there is an action or activity for achieving that goal 3. there is a virtual certainty that the action or the activity fails to achieve the goal consequently, the simplest definition of medical futility would be: ‘a clinical action which is not performed for achieving a clear goal, and hence, is not useful for the intended patient’ (15). many scholars considered this simple definition as inadequate, criticized it, and thus, provided different definitions for the concept and used different expressions and terms for explaining it, all of which added to the ambiguity of the concept (33). table 1 shows that there are numerous definitions and terms for medical futility. nonetheless, the most cited definition of medical futility is the definition which was provided by schneiderman et al. (34). table 1. the definitions of the concept of medical futility in the literature no keyword definition author(s) 1 medical futility quantitative medical futility: “when physicians conclude (either through personal experience, experiences shared with colleagues, or consideration of published empiric data) that in the last 100 cases a medical treatment has been useless, they should regard that treatment as futile” (p.437). qualitative medical futility: “physicians should distinguish between an effect which is limited to some part of the patient's body, and benefit which the patient has the capacity to appreciate and which improves the patient as a whole” (p.950). “if a treatment merely preserves permanent unconsciousness or cannot end dependence on intensive medical care, the treatment should be considered futile” (p.437). schneiderman et al. (17, 34, 35) 2 medical futility medical futility “is when treatment cannot, within a reasonable probability, cure, ameliorate, improve or restore a quality of life that would be satisfactory to the patient” (p.36). quinn (41) 3 medical futility quantitative medical futility is related to the success of a treatment in achieving its intended goals. qualitative medical futility is related to the value of a treatment to a patient’s qol. schneiderman et al. (27) j med ethics hist med 9: 11 october, 2016 jmehm.tums.ac.ir maryam aghabarary et al. page 5 of 13 4 medical futility futile treatment “an action, intervention or procedure that might be physiologically effective in a given case but cannot benefit the patient, no matter how often it is repeated. a futile treatment is not necessarily ineffective, but it is worthless either because the medical action itself is futile, (no matter what the patient s condition) or the condition of the patient makes it futile” (p.69). clark (38) 5 medical futility the concept needs to be defined individually and based on the unique condition of each patient and the desires of the patient and family members: 1. continuing treatments while death is certain and survival is impossible 2. continuing treatments while post-survival qol is low (because of permanent physical or cognitive damage) 3. continuing treatments for a patient with brain death heland (40) 6 medical futility the concept needs to be defined individually and based on the unique condition of each patient: medical futility is a state in which an intervention (either diagnostic, therapeutic, preventive, or rehabilitative) provides no benefit to the intended patient. aramesh (37) 7 medical futility medical futility at the end of life includes the following instances: 1. failure to achieve goals such as saving life, prolonging life, and improving qol 2. disproportionate harm-benefit ratio: imposing heavy costs or inflicting harm 3. the concept needs to be defined individually and based on the unique condition of each patient jox et al. (30) 8 medical futility the concept needs to be defined individually and based on the unique condition of each patient: a state in which a certain intervention produces no benefit to a certain patient. the intervention may include a surgery, intravenous or oral medications, or laboratory or imaging studies. saettele and kras (8) 9 futile treatment in the context of medicine, futile treatment is a type of care which does not fulfill the intended goals and includes: 1. a treatment which does not provide a reasonable chance of survival 2. a treatment which is useless or ineffective 3. a treatment which is unsuccessful at enhancing qol or medical utility 4. a treatment which can never fulfill the patient’s goals the definitions 1 and 2 are the definitions of quantitative or physiologic futility and relate to alterations in the functions of organs. perceiving and using these two definitions are associated with few problems and debates for physicians. definitions 3 and 4 pertain to qualitative futility, are mostly holistic, and seek patient’s benefits. jecker et al. (36) 10 futility/futile care treatment is medically futile or non-beneficial because it offers no reasonable hope of recovery or improvement, or because the patient is permanently unable to experience any benefit. jones and hunter (39) 11 futile treatment “treatments that offer no physiological benefits to the patient are futile” (p.888). danis et al. (24) 12 futility/futile care futility is a complex concept which relates to achieving and fulfilling the intended goals. an action is considered futile once it cannot achieve its intended goals or its success is empirically improbable. futile care is a state in which providing life-sustaining treatments produces no medical benefit for the intended patient, cannot terminate patient’s dependence on intensive medical treatments, and results in an unacceptable level of qol. meltzer and huckabay (11) 13 futile care “medically futile care to mean the use of considerable resources without a reasonable hope that the patient would recover to a state sibbald et al. (2) j med ethics hist med 9: 11 october, 2016 jmehm.tums.ac.ir maryam aghabarary et al. page 6 of 13 of relative independence or be interactive with his or her environment” (p.1201). 14 futile care futile care “consists giving clinical cares irrelevant to a nurse’s job and giving cares through which the return of patient would be impossible both physiologically and qualitatively” (p.301). bahramnezhad et al. (54) 15 futile care futile care “is useless, ineffective care giving with wastage of resources and torment of both patients and nurses having nursing and medical aspects” (p. 235). yekefallah et al. (55) in their definition, they highlighted the difference between effect and utility in that effect is limited to a certain part of a patient’s body while utility or benefit encompasses all the aspects of a patient as a whole. according to them, a treatment which has an effect, but has no utility for a patient is considered as futile (17, 34, 35). based on the difference between effect and utility, futility can be classified as physiologic, quantitative and normative, or qualitative futility (table 2). table 2. the types and the examples of medical futility medical futility definition examples strict physiologic futility (focuses on achieving the physiological effects of treatments.) treatments do not produce the intended physiological effect treatments do not help achieve the intended physiological goals ø ineffectiveness of an antibiotic against viral infection ø ineffectiveness of aspirin in managing cancer ø the treatment is not effective in reversing a physiologic deterioration which will finally cause death. the medical diagnosis shows an inevitable death and the treatment will have no useful physiologic effect. for instance, ineffectiveness of defibrillation on asystole or conventional cardiopulmonary resuscitation for a patient with myocardial rupture. quantitative futility (focuses on the success rate of a treatment.) the chance of producing the desired effects is low or poor (less than 1%). ø the low success rate of saving the life of an elderly patient who suffers from end-stage hepatic cirrhosis and severe organ failure qualitative futility (focuses on the value of treatments in terms of qol.) treatments which have the desired physiological effects, but the effects are useless or worthless to the intended patient the effect is producible, but there are value-laden controversies on its justifiability given the disproportionate harmbenefit ratio, the treatment has no value to patient’s qol. ø a successful resuscitation which finally results in a vegetative state for the patient ø poor qol after a successful resuscitation on a patient with end-stage cancer whose survival had been estimated to be 0%–10% ø prolonging survival for only two months by using costly and potentially harmful chemotherapy agents ø sustaining the life of a terminally-ill patient using life-sustaining treatments (such as ventilator and vasopressors) a brief review of the existing definitions of the concept of medical futility (tables 1, 2, and 3) reveals that these definitions have been based on the following six foundations: 1. the probability of achieving the physiological effects which have been supposed for a medical treatment (only physicians can determine it) (12, 17, 24, 34) 2. the probability of achieving the defined goals of a treatment (physicians, patients, and family members can have roles in determining it) (11, 23, 30, 36) 3. the amount of benefit and utility which the intended treatment has for the intended patient (this is completely individual and is affected by values) (8, 11, 36-39) 4. the survival rate of the intended treatment (30, 36, 40) 5. post-treatment quality of life (qol) (8, 11, 17, 30, 34, 36, 40, 41) 6. the cost-effectiveness of the treatment (2, 8, 30) j med ethics hist med 9: 11 october, 2016 jmehm.tums.ac.ir maryam aghabarary et al. page 7 of 13 the abovementioned data reveals that the probability of the success of a treatment and the value of the treatment in terms of qol are two main themes which can be extracted from the existing definitions. however, the diversity of perceptions of acceptable probability of success and acceptable qol has made it difficult to provide a clear and comprehensive definition of the concept (42). the main problem occurs when we decide to determine an objective border beyond which medical treatments can be considered as futile. in other words, how much should the probability of success for a treatment or qol be in order to consider the treatment futile (12)? most importantly, who has the authority or the competence to define and establish such borders? we could not find any clear answer to these questions in the literature; however, in the majority, it was indicated that judgment on futility is an individual concept and based on the unique conditions of each patient (8, 30, 37, 40). the main components in the definitions of the concept of medical futility the data presented in tables 1, 2, and 3 reveal that the main components of medical futility debates are goal, effect, utility, and value. goals of medicine: the most fundamental component of medical futility is the goal of medicine. determining whether a treatment is ineffective, useless, or worthless necessitates weighing it against the intended goals (11, 12, 15, 23, 30). in other words, we can talk about the effect, utility, or value of a certain treatment only when we know the goals of that treatment. in the next step, the probability of achieving the goals and the effect, utility, and value of achieving the goals are assessed (23, 42). consequently, improbability or low probability of achieving the intended goals is among the most essential characteristics of the concept of medical futility (17, 34). the goals may include • successful treatment, complete recovery, returning to normal life, and gaining autonomy and the ability to interact with the surrounding environment; • achieving the physiological outcomes of the treatments irrespective of the quality of their effects (for instance, successful removal of excess fluids and waste products by a dialysis machine irrespective of the effect of dialysis on the survival of a dying patient); • saving life and preventing death; • improving survival and prolonging life (without inflicting pain or agony and not at any cost); • alleviating pain and other physical symptoms and providing comfort; • psychological palliation (giving hope, sympathizing, and bringing satisfaction to patients); • improving qol through alleviating physical and psychological symptoms; • preparing the patient for a peaceful death. the goals may change during the course of the disease and in line with the patient’s condition, medical treatments, access to equipment and facilities, and etcetera. any change in the goals may be associated with changes in individuals’ perceptions of the utility and their judgment about the futility of a certain treatment (23). effect: effect is the result of achieving the physiological goals which have been set for a treatment while utility or outcome implies the quality of the effect. a futile treatment may exert significant effects on patients’ physiology or anatomy; however, the important point here is that the effects are not useful to the patient. therefore, ‘utility’ is a key term in medical futility debates (37). utility: utility can be objective or subjective and physical or psychological (13). although the meaning of utility in the area of medical futility is the direct and indirect benefits of treatments for patients, decision upon the futility or non-futility of a certain treatment is sometimes made based on the benefits of that treatment for other people (such as family members or other patients). the most prominent example in this area is hospitalizing and caring for a patient with brain death in the icu. given the current inabilities of medical sciences, providing life-sustaining medical treatments to such a patient is among the clearest instances of medical futility (10, 18, 40). the reason is that none of the abovementioned goals for the patient are achievable, and thus, continuing life-sustaining treatments is completely useless to the patient. on the other hand, such treatments are not futile if they are provided for the purpose of organ donation to other patients or in order to help the patient’s family members cope with and accept their patient’s death. the reason is that such practices can be beneficial to other people (including family members and other patients). value: for assessing the value of a treatment, not only the probability of achieving the goals, but also the amount of benefit should be taken into account. the benefit can be measured using the benefit-harm ratio (23, 30). in other words, if achieving the intended goals inflicts heavy costs, undue pain, agony, or damage, the value of the benefit resulted from treatments is dubious. of course, judgments about value should also be made individually and based on patients’ and their family members’ values and preferences (2, 22, 23, 40). for instance, prolonging the survival of a patient with end-stage ovarian cancer for only two months by administrating costly and potentially harmful chemotherapy agents may be considered futile and worthless by many physicians, nurses, hospital managers, and insurance companies. they may not consider a two-month increase in survival as an j med ethics hist med 9: 11 october, 2016 jmehm.tums.ac.ir maryam aghabarary et al. page 8 of 13 optimum goal and may also not consider the benefits of achieving the goal proportional to the harms of the treatment. on the other hand, the patient, who is waiting for the birth of her first grandchild in the next two months, may consider such short-term increase in survival as a desirable goal which is worth achieving. factors affecting perceptions of medical futility factors which can affect individuals’ perceptions of the concept of medical futility are the conditions of patient/disease, medical goals (therapeutic or palliative), and the value system of patients, family members, and healthcare professionals. these factors are discussed in what follows. the conditions of patient/disease: patient-related and disease-related factors can contribute to the perceptions of futility or non-futility of medical treatments (table 4). table 3. comparing quantitative and qualitative futility qualitative futility quantitative futility ø normative futility ø value futility ø value dependent ø physiologic futility ø goal futility ø value free points to the value of achieving a certain goal points to the probability of producing physiological effects points to the success rate of a treatment requires knowing patients’ and their family members’ values and beliefs to decide upon continuation or discontinuation of treatments requires medical knowledge to decide upon continuation or discontinuation of treatments table 4. patient-related/disease-related conditions which affect perceptions of medical futility impossibility of survival low quality survival brain death imminent death lethal condition low quality of life • total brain death (cortex, medulla, and cerebellum). • partial brain death (cortex, medulla, or cerebellum). • the patient will die in the near future (within several hours or days) irrespective of treatments. • a terminally-ill patient • a dying patient • premature babies with fatal congenital defects (will die within several hours after birth). • the patient is suffering from an underlying condition which will cause a premature death despite receiving treatments • a patient with poor prognosis • a patient with end-stage disease • a patient with metastatic cancer • patients with stable vegetative state • very old patients suffering from multiple conditions and organ failure • very old patients suffering from advanced dementia • permanent unconsciousness • patient’s dependence on lifesustaining equipment, devices, and medications given the ever-changing conditions of patients due to known or unknown causes (43) as well as patients’ unique personal values and preferences, there is no consensus over these factors. according to some authors, prediction of a patient’s death based on disease severity, poor prognosis, and low qol is not a good criterion for determining futility of treatment procedures (3, 20, 24, 43). uncertainties of human sciences, unpredictability of the future, the possibility of committing errors while establishing medical diagnoses and determining prognoses (44, 45), and differences in people’s perceptions of optimum qol can affect judgments about futility of treatments (42). medical goals (therapeutic or palliative): medical futility is inherently correlated with the goals of medical treatments. in fact, goals play a central role in defining medical futility, particularly qualitative futility (12). the main problems here are: ‘what is the goal?’ and ‘who determines the goal and the time for and ways to achieve the goal?’ in other words, the goal and the right to decision-making are the two important criteria for defining and determining medical futility. therefore, there are many debates between healthcare teams and family members in terms of determining futile treatments and deciding upon continuation or discontinuation of treatments (3, 12, 21). goals can widely range from completely objective (i.e., physiologic) to completely subjective (qualitative and value-dependent). moreover, they can be either short-term or long-term. physiological goals can be determined and established solely by physicians. in other words, determining the instances of physiologic and quantitative futility and deciding upon continuation or discontinuation of treatments j med ethics hist med 9: 11 october, 2016 jmehm.tums.ac.ir maryam aghabarary et al. page 9 of 13 are among the responsibilities of physicians. for instance, only physicians can decide not to resuscitate a patient with a myocardial rupture. however, qualitative goals need to be established based on patients’ and their family members’ desires and values. in other words, goals may be completely subjective and even in contrast with physicians’ and other healthcare professionals’ values. in this view, determining the instances of futility and deciding upon continuation or discontinuation of treatments are not done solely by physicians, rather patients’ personal values and preferences need to be also taken into account for decision-making (23). for instance, continuing treatments for a patient with end-stage lung cancer may not result in the longterm goals of recovery or hospital discharge. however, it can help the patient and his/her family members achieve their short-term goals such as having an opportunity for being together in the new year celebration which is going to be held in the next two days (12). thus, we cannot achieve desirable outcomes if the goal is not established accurately or the means for achieving the goal are not selected carefully. subsequently, failure to achieve a certain goal may be erroneously interpreted as futility or worthlessness (15). the value system of patients and their family members, and healthcare professionals: the goals and the benefits as well as the value of achieving them are always affected by patients’ and their family members’, and healthcare professionals’ personal, cultural, socioeconomic, and religious values (3, 7, 8, 12, 22, 26, 46-49). moreover, patients’ conditions, personal preferences, priorities, and values can affect judgments about the futility of a treatment. given the importance of the benefits of medical treatments to patients, considering patients’ values may result in decisions which are based on unrealistic or even subjective benefits. for instance, the family members of a patient with brain death may ask for the administration of a completely ineffective traditional medication. despite the known ineffectiveness of the medication, its administration helps the patient’s family members feel that they did all their best in order to save their patient’s life (37). another patient may ask for an in vitro fertilization despite knowing its ineffectiveness. similarly, such a request gives her the lifelong feeling that she has not disregarded any endeavor to have a baby (13). therefore, preferring a benefit over another is an arbitrary value judgment (22). the scope of medical futility our literature review revealed that medical futility debates revolve around two main areas including futility in terminal situations and futility in nonterminal situations (50). although, futility is a major challenge in icus and focuses on end-of-life care (6, 22, 30, 40, 44, 46), it is not unique to terminally-ill patients. rather, many diagnostic and therapeutic procedures which are performed in non-terminal situations may relate in some ways to futility (50). two instances of futility in non-terminal situations may include prescribing a non-indicated computed tomography scan for a trauma patient whose chest x-ray shows no pulmonary problem or performing a thyroidectomy on a patient whose hyperthyroidism had been successfully managed by medication therapy and had no manifestation of malignancy. on the other hand, although medical futility can be related to different preventive, diagnostic, therapeutic, and rehabilitative factors (8, 37), our literature review indicated that it mainly deals with life-sustaining treatments (such as cardiopulmonary resuscitation/the use of ventilator) in end-of-life situations (6, 19, 22, 30, 40, 44, 46, 50, 51), particularly, performing cardiopulmonary resuscitation on patients suffering from terminal cancers (10, 12, 18, 52). reasons behind providing futile medical treatments the most important reasons behind providing futile medical treatments which had been referred to either implicitly or explicitly in the literature were as follows: • patients’/family members’ request and persistence (2, 6-8, 30, 40, 44, 53) • healthcare professionals’ personal emotions, beliefs, and attitudes (6-8, 30, 40, 53) • organizational factors and fear over getting involved in medical litigation (2, 6-8, 30, 40, 44, 53) • social, cultural, and religious factors (2, 68, 30, 40, 44, 53, 54) the consequences of providing futile medical treatments the most important consequences of providing futile medical treatments which had been mentioned in the literature either implicitly or explicitly were • suffering for the patient (2, 54-56); • suffering, moral distress, job burnout, job dissatisfaction, and increased turnover among nurses and physicians, and hence, decreased quality of care (2, 9, 11, 40, 49, 54-58); • heavy financial burdens on families, healthcare systems, and societies (2, 8, 11, 22, 55, 56, 59); • putting other patients at risk (5, 8, 54, 55). challenges related to medical futility the overlap of medical futility and rationing: when expensive diagnostic or therapeutic procedures are prescribed for patients, particularly in icus, the two concepts of futility and rationing are usually mistaken for each other. accordingly, differentiating these two concepts seems essential. in medical j med ethics hist med 9: 11 october, 2016 jmehm.tums.ac.ir maryam aghabarary et al. page 10 of 13 futility, prescribing a certain procedure for a certain patient is useless irrespective of the costs of that procedure or the necessity for fair distribution of resources. on the other hand, in rationing, the procedure would be useful to that certain patient; however, it is neither appropriate nor reasonable to implement the procedure for that patient once its costs or other patients’ need for that procedure are taken into account (17, 60). the important point here is that futile treatments should be avoided not because they are expensive, but because they are not useful to the intended patient and are not effective in achieving the intended goals. moreover, treatments which are useful, but are expensive should also be avoided occasionally because their benefits are not proportionate to their costs (21). another difference between futility and rationing is that decisions about futility are made at the bedside of a specific patient while rationing-related decisions are made at a community level, based on the needs of different patient populations, and in order to ensure fair distribution of resources in the community. it is noteworthy that futility-related policies should not be considered as a means for managing costs (17, 21, 60), because one of the most important concerns in the area of futility is that some treatments may be labeled as futile in order to cut healthcare costs (14). lack of objective and valid criteria for determining futility: there is no laboratory test or clinical criteria for accurately identifying patients receiving futile treatments (44). in addition, due to the subjectivity (19, 49, 61), complexity (8, 40, 61, 62), and ambiguity of the concept of medical futility, it is perceived and defined differently by individuals (2, 44, 49, 61, 63). consequently, assessing the concept solely from the perspectives of healthcare professionals would not be valuable, because their perspectives toward utility and outcome may be different from that of patients and their family members. the type, the amount of the benefit, and the outcomes of medical treatments should be assessed based on the values, preferences, priorities, and desires of patients and family members (2, 26, 40). a major ethical dilemma is: ‘who has the competence to determine the usefulness and the fruitfulness of treatments and care services?’ this dilemma has remained unresolved because personal, cultural, and religious values and beliefs as well as socioeconomic factors severely affect its perception and interpretation (3, 7, 8, 22, 26, 46-48). the failure of the icu scoring system to determine the instances of futility: some researchers introduced poor prognosis, minimal survival chance, and high probability of death as the predictors for futility and recommended the icu scoring system for determining instances of futility (64). in other words, they attempted to correlate the scores of the icu scoring system with the instances of futility in order to have permission for withholding and withdrawing of treatments in icus. instruments such as the icu scoring system are usually used for assessing patients during the first 24 hours after icu admission, determining the severity of their conditions, determining the type of treatments needed, determining prognosis for patients, and estimating the probability of death based on a series of physiological parameters. however, some other researchers believe that, as these instruments are based solely on physiological parameters, they cannot be used for determining the futility of diagnostic and therapeutic procedures (24). therefore, using these instruments for determining futility was criticized severely, because the studies showed that • first, models and systems which determine the severity of illnesses are instruments for estimating hospital death among critically-ill patients. moreover, their validity has been evaluated in large samples and in certain confidence intervals. consequently, on an individual level, they should be used cautiously. once the concepts of probability and confidence interval are accurately explained by physicians and understood by patients and family members, the data obtained from such scoring systems can provide only useful, but not authoritative, information for deciding upon continuation or discontinuation of treatments. the reason is that survival rate (which is determined by these instruments) is only one of the factors in the determination of the appropriateness of treatments for a patient in the icu. moreover, these instruments cannot provide information about other factors which are important to clinical decision-making (such as patients’ post-icu conditions as well as their and their family members’ preferences and goals) (24, 44). studies showed that patients’ and their family members’ evaluation of treatment options vary with progressive deterioration of patient’s health. in other words, compared with healthy people (such as physicians and nurses), a patient with a critical illness is more likely to choose sophisticated treatments which have low potential benefits. for patients and their family members, a chance of one percent is much better than no chance, and hence, their viewpoints need to be taken into account by healthcare professional while deciding upon the futility or non-futility of treatments (3, 23). • second, disease severity, poor prognosis, and probability of death cannot be strong and valid predictors of futility (3, 20, 24, 43). continuous alterations in patients’ conditions due to either known or unknown causes (43) as well as the inability of illness severity scoring models and j med ethics hist med 9: 11 october, 2016 jmehm.tums.ac.ir maryam aghabarary et al. page 11 of 13 systems to provide information about post-icu morbidity are among the limitations of such instruments in determining the instances of futility. therefore, decisions upon discontinuing treatments based on the findings of these instruments would be unwise and questionable. on the other hand, the concept of futility is based on value judgments made by different parties, such as patients, family members, and healthcare professionals (2, 22, 23). hence, it cannot be determined and directly measured based solely on physiological parameters. to conclude, although these systems are helpful for deciding upon the most effective treatments, they cannot be used independently for determining futility and making decisions about continuation or discontinuation (or withholding and withdrawing) of treatments in icus (24). • third, any attempt to determine futile treatments is associated with the possibility of self-fulfilling prophecy. this problem can affect any situation in which there is a high probability of death and can result in decisions about restricting life-sustaining medical treatments. the risk of self-fulfilling prophecy is that restricting life-sustaining treatments due to a high probability of death abnormally increases mortality rate (3). in other words, the information obtained from icu scoring systems which show a high severity of illness and a high probability of death can enhance the possibility of healthcare professionals’ selffulfilling prophecy. once the death of a patient is highly probable, she/he would receive limited intensive care services, and hence, would have greater probability of death (43, 49). according to wilkinson and savulescu (2011), self-fulfilling prophecy is associated with higher mortality rate among patients suffering from hemorrhagic stroke and hypoxic brain injuries, critically-ill patients, and even patients with brain death (3). conclusion medical futility is an extremely complex, ambiguous, subjective, situation-specific, valueladen, and goal-dependent concept which is almost always surrounded by some degrees of uncertainty. thus, there is no objective and valid criteria for determination of medical futility. determining the futility of a certain treatment for a certain patient and deciding upon its continuation or discontinuation have always been difficult and challenging. this concept is affected by many different factors such as physicians’ and patients’ value systems, medical goals, sociocultural and religious context, and individuals’ emotions and personal characteristics. such characteristics have made it difficult to achieve a clear consensus over the concept of medical futility. accordingly, medical futility should be defined and determined at individual level and based on each unique case. the most important reasons behind providing futile medical treatments are patients’/family members’ request and persistence, healthcare professionals’ personal motives, and social, cultural, religious, and organizational factors predominating the immediate community. on the other hand, the most important deleterious consequences of providing futile treatments are suffering for patients, and heavy financial burdens on families, healthcare systems, and societies, and moral distress, job burnout, job dissatisfaction, and increased turnover among healthcare professionals, and hence, decreased care quality. it is essential to study the nature and 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medical sciences, tehran, iran; 2phd candidate, department of health management and economics, school of public health, tehran university of medical sciences, tehran, iran; 3phd candidate, health management and economics research center, iran university of medical sciences, tehran, iran; 4department of health services management, school of health, qazvin university of medical sciences, qazvin, iran; 5assistant professor, research center for social determinants in health promotion, hormozgan university of medical sciences, bandar abbas, iran. corresponding author: jalal arabloo address: department of health management and economics, school of public health, tehran university of medical sciences, tehran, iran; email: arabloo_j@razi.tums.ac.ir tel: 98 21 88 98 91 29 received: 10 dec 2013 accepted: 07 sept 2014 published: 13 sept 2014 j med ethics hist med, 2014, 7:15 © 2014 nader khalesi et al.; licensee tehran univ. med. sci. abstract in order to improve the ethical climate in health care organizations, it is important to apply a valid measure. this study aimed to investigate the psychometric properties of the persian version of the hospital ethical climate survey (hecs) and to assess nurses' perceptions of the ethical climate in teaching hospitals of iran. a cross-sectional study of randomly selected nurses (n = 187) was conducted in three teaching general hospitals of tehran, capital of iran. olson’s hospital ethical climate survey (hecs), a self-administered questionnaire, was used to assess the nurses' perceptions of the hospital ethical climate. descriptive statistics, confirmatory factor analysis (cfa), internal consistency, and correlation were used to analyze the data. cfa showed acceptable model fit: an standardized root mean square residual (srmr) of 0.064, an non-normalized fit index (nnfi) of 0.96, a comparative fit index (cfi) of 0.96, and an root mean square error of approximation (rmsea) of 0.075. the cronbach´s alpha values were acceptable and ranging from 0.69 to 0.85. the overall cronbach´s alpha coefficient was 0.94. the factor loadings for all ethical climate items were between 0.50 and 0.80, which revealed good structure of the persian version of the hecs. survey findings showed that the "managers" subscale had the highest score and the subscale of “doctors” had the lowest score. this study shows that the persian version of the hecs is a valid and reliable instrument for measuring nurses' perceptions of the ethical climate in hospitals of iran keywords: ethics, ethical climate, organizational ethics mailto:arabloo_j@razi.tums.ac.ir j med ethics hist med 7:15 sep, 2014 jmehm.tums.ac.ir nader khalesi et al. page 2 of 7 (page number not for citation purposes) introduction ethical climate is part of the overall organizational climate and refers to "shared perceptions of what ethically correct behavior is and how ethical issues should be handled" (1). olson describes ethical climate as the “individual perceptions of the organization that influences attitudes and behavior and serves as a reference for employee behavior”. attention to nursing and health care ethics has arisen as a result of an increased awareness about the complexity of ethical problems in health care environments. ethical climate can influence the behavior and beliefs of staff when difficult patient care problems are discussed and resolved in work settings (2). various studies have shown the influence of hospital ethical climates on ethics stress, job satisfaction, and turnover intentions (3 5). therefore, it seems important to apply a valid measure in order to improve the ethical climate in health care organizations. a number of selfassessment questionnaires have been developed to measure the ethical climate in health care settings. one of the most widely used surveys is the hospital ethical climate survey (hecs) developed by olson in the united states. hecs has good psychometric properties and identifies five subscales of the ethical climate in health care organizations (2). it has been used in different countries and cultures including the united states, turkey, jordan, sweden and south korea (2, 6 10). although research on ethical climate is abundant in business, limited studies have been done on the subject in health care organizations (11). several iranian studies have used hecs to assess the ethical climate in hospitals throughout the country, but they have provided limited data on the psychometric properties and suitability of the questionnaire for use in iran. for this reason, the present study aimed to investigate the psychometric properties of the persian version of the hospital ethical climate survey (hecs) and to assess nurses' perceptions of the ethical climate in three teaching hospitals in iran. the findings of this study may provide a better understanding of the ethical climate in teaching hospitals in the country . method study design and sampling a cross-sectional study was conducted on the nurses working in three teaching hospitals affiliated with tehran university of medical sciences, located in tehran, the capital of iran, during 2013. one way to determine the sample size for conducting a confirmative factor analysis (cfa) is to use the number of parameters, and assign at least five cases per parameter (12). considering the fact that the questionnaire has 26 parameters, we estimated 260 samples (ten cases per parameter) to be appropriate. samples were then proportionally allocated to each hospital. finally the questionnaires were distributed randomly to 260 nurses in 3 hospitals. systematic random sampling was used to select the nurses in each hospital. the participants filled out the survey voluntarily, and a total of 187 questionnaires were completed . the hospital ethical climate survey the hospital ethical climate survey (hecs) was originally developed by olson in the united states to assess hospital nurses' perceptions of the ethical climate in their work place (2). hecs is a 26-item self-administered questionnaire consisting of five subscales including relationship with peers (4 items), patients (4 items), managers (6 items), hospital (6 items), and physicians (6 items). a fivepoint likert scale was employed for the responses. the scales ranged from 0 (almost never true) to 4 (almost always true). preparing the persian version of the hecs the hecs items were translated into persian by one of the researchers. the draft was then reviewed by other members of the research group. based on their comments and suggestions, the questionnaire was revised for further comprehensibility . the comprehensibility of the hecs was tested on five nurses who had not been included in the study group and their opinions were used to prepare the final version of the hecs. the resulting questionnaire was then translated back into english by an independent translator in order to compare and contrast the back translation with the original questionnaire. all discrepancies were discussed and resolved until a satisfactory version was achieved. statistical analyses a confirmative factor analysis (cfa) was performed to investigate whether the factor structure of the hecs could be used with iranian data. cfa using linear structural relations (lisrel) offers 15 goodness of fit indices, and at least three measures are needed for assessments (13). kline proposes to report the chi-squared test, the root mean square error of approximation (rmsea), the standardized root mean square residual (srmr), and the comparative fit index (cfi) (14). the fit indices that were used for cfa in this study were: chi-squared test, comparative fit index [cfi > 0.90 acceptable or > 0.95 good fit], non-normalized fit index (nnfi), also known as tucker-lewis index [nnfi > 0.90 acceptable or > 0.95 good fit], root mean square error of approximation [rmsea<0.08 acceptable or ≤ 0.05 good fit] and the standardized root mean square residual [srmr < 0.08 good fit] (15). j med ethics hist med 7:15 sep, 2014 jmehm.tums.ac.ir nader khalesi et al. page 3 of 7 (page number not for citation purposes) to investigate construct validity, a correlation analysis was carried out among the hecs factors. the internal consistency of the factors was calculated by means of cronbach’s alpha [criterion: ≥ 0.7 for each subscale] (16). all statistical analyses were performed using spss 20 and lisrel 8.8. the level of significance was set to p < 0.05. the survey data were summarized as percentage, mean, and standard deviation (sd) values . the researchers obtained the approval of the ethics committee of tehran university of medical sciences and attained institutional permits. the selected nurses were informed that participation is voluntary. completing the survey was considered as consent for participation. results of the 260 distributed questionnaires, 187 valid questionnaires were returned (response rate 72%). most of the respondents (91%) were female. fiftyone percent (51%) of the participants had six years or more professional experience and 56% were aged 31 years or younger (table 1). table 1. characteristics of the samples (n = 187 nurses) characteristic category n % gender (n = 184) female male 168 16 (91) (9) age (n = 163) ≤ 31 years 32 40 years 41 49 years ≥ 50 years 91 51 17 4 (56) (31) (10) (3) hospitals (n= 155) a b c 93 27 35 (60) (17) (23) work experience (n =173) ≤ 1 year 2-5 years 6 10 years ≥ 11 years 22 63 34 54 (13) (36) (20) (31) cfa was performed on the original five-factor questionnaire with 26 items. the data of the 187 participants were used, and the cfa results showed acceptable model fitness between the hypothetical model of ethical climate and the data in this study (x2 (df) = 589 (289), p<0.001; x2/df = 1.99; srmr = 0.064; nnfi = 0.96; cfi = 0.96; rmsea=0.075). the factor loadings for all ethical climate items were between 0.50 and 0.80, which revealed good structure of the persian version of the hecs (table 2). table 2. factor loadings for ethical climate items item factor peers patients managers hospital physicians q 1: my peers listen to my concerns about patient care. 0.69 q 10: my peers help me with difficult patient care issues/problems. 0.63 q 18: i work with competent colleagues. 0.55 q 23: safe patient care is given on my unit. 0.69 q 2: patients know what to expect from their care. 0.51 q 6: nurses have access to the information necessary to solve a patient care issue/problem. 0. 50 q 11: nurses use the information necessary to solve a patient care issue/problem. 0.60 q 19: patients' wishes are respected. 0.55 q 3: when i'm unable to decide what's right or wrong in a patient care situation, my manager helps me. 0.60 q 7: my manager supports me in my decisions about 0.78 j med ethics hist med 7:15 sep, 2014 jmehm.tums.ac.ir nader khalesi et al. page 4 of 7 (page number not for citation purposes) patient care. q 12: my manager listens to me talk about patient care issues/problems. 0.77 q 15: my manager is someone i can trust. 0.80 q 20: when my peers are unable to decide what's right or wrong in a particular patient care situation, i have observed that my manager helps them. 0.80 q 24: my manager is someone i respect. 0.64 q 4: hospital policies help me with difficult patient care issues/problems. 0.71 q 8: a clear sense of the hospital's mission is shared with nurses. 0.70 q 25: i am able to practice nursing on my unit as i believe it should be practiced. 0.60 q 13: the feelings and values of all parties involved in a patient care issue/problem are taken into account when choosing a course of action. 0.56 q 16: conflict is openly dealt with, not avoided. 0.60 q 21: there is a sense of questioning, learning, and seeking creative responses to patient care problems. 0.52 q 5: nurses and physicians trust one another. 0.55 q 9: physicians ask nurses for their opinions about treatment decisions. 0.69 q 14: i participate in treatment decisions for my patients. 0.56 q 17: nurses and physicians here respect each other's opinions even when they disagree about what is best for the patient 0.74 q 22: nurses and physicians respect each other. 0.66 q 26: nurses are supported and respected in this hospital. 0.79 internal consistency was measured by calculating cronbach’s alpha reliability coefficients for each of the five factors. the cronbach’s alphas for the five factors or subscales were between 0.69 and 0.85. the overall cronbach’s alpha coefficient was 0.94. table 3 shows the reliability level of the persian translation as compared to the original english hecs. table 3. cronbach’s alphas of the hecs/ persian version as compared to the hecs factor no of items cronbach’s alpha (α) hecs/ persian version cronbach’s alpha (α) hecs * peers 4 0.74 0.73 patients 4 0.69 0.68 managers 6 0.73 0.81 hospital 6 0.85 0.92 physicians 6 0.81 0.77 total 26 0.94 0.91 *olson’s study (2) the interrelation of the ethical climate subscales was investigated. the correlations ranged from 0.507 to 0.752. the highest correlation was found between “hospital” and “physicians” (r = 0.752) while “hospital” and “managers” showed the lowest correlation (r = 0.507) (table 4). the overall ethical climate score was 2.75. the score means varied between 2.46 and 3.04 across the 5 factors. the highest scored subscale was “managers” (3.04) followed by “peers” (2.90), “patients” (2.80), “hospital” (2.61) and “physicians” (2.46). table 4. inter-correlations of the 5 factors factor 1 2 3 4 5 j med ethics hist med 7:15 sep, 2014 jmehm.tums.ac.ir nader khalesi et al. page 6 of 7 (page number not for citation purposes) peers 1 patients 0.740* 1 managers 0.636* 0.619* 1 hospital 0.672* 0.644* 0.507* 1 physicians 0.696* 0.721* 0.700* 0.752* 1 *correlation is significant at the 0.05 level. the items with the lowest mean scores were "hospital policies help me with difficult patient care issues/problems" with a mean of 2.39, "physicians ask nurses for their opinions about treatment decisions" with a mean of 1.97, and "nurses are supported and respected in this hospital" with a mean of 1.91. the items with the highest mean scores were "my manager is someone i respect" with a mean of 3.36, "when i'm unable to decide what's right or wrong in a patient care situation, my manager helps me" with a mean of 3.14, and "my manager listens to me talk about patient care issues/problems" with a mean of 3.05 (table 5). table 5. descriptive statistics of the survey on ethical climate five subscales and survey items mean std. deviation peers 2.90 0.65 q 1: my peers listen to my concerns about patient care. 2.91 .868 q 10: my peers help me with difficult patient care issues/problems. 2.91 .876 q 18: i work with competent colleagues. 2.84 .820 q 23: safe patient care is given on my unit. 2.94 .888 patients 2.80 0.64 q 2: patients know what to expect from their care. 2.42 .990 q 6: nurses have access to the information necessary to solve a patient care issue/problem. 2.83 .867 q 11: nurses use the information necessary to solve a patient care issue/problem. 3.00 .870 q 19: patients' wishes are respected. 2.93 .823 managers 3.04 0.66 q 3: when i'm unable to decide what's right or wrong in a patient care situation, my manager helps me. 3.14 .826 q 7: my manager supports me in my decisions about patient care. 2.93 .881 q 12: my manager listens to me talk about patient care issues/problems. 3.05 .843 q 15: my manager is someone i can trust. 3.03 .914 q 20: when my peers are unable to decide what's right or wrong in a particular patient care situation, i have observed that my manager helps them. 2.70 .934 q 24: my manager is someone i respect. 3.36 .829 hospital 2.61 0.72 q 4: hospital policies help me with difficult patient care issues/problems. 2.39 1.059 q 8: a clear sense of the hospital's mission is shared with nurses. 2.48 1.262 q 25: i am able to practice nursing on my unit as i believe it should be practiced. 2.91 .932 q 13: the feelings and values of all parties involved in a patient care issue/problem are taken into account when choosing a course of action. 2.52 .943 q 16: conflict is openly dealt with, not avoided. 2.70 .962 q 21: there is a sense of questioning, learning, and seeking creative responses to patient care problems. 2.65 .850 physicians 2.46 0.69 q 5: nurses and physicians trust one another. 2.79 .884 q 9: physicians ask nurses for their opinions about treatment decisions. 1.97 1.272 q 14: i participate in treatment decisions for my patients. 2.55 1.023 q 17: nurses and physicians here respect each other's opinions even when they disagree about what is best for the patient. 2.58 .943 q 22: nurses and physicians respect each other. 2.95 .922 q 26: nurses are supported and respected in this hospital. 1.91 1.246 overall 2.75 0.58 j med ethics hist med 7:15 sep, 2014 jmehm.tums.ac.ir nader khalesi et al. page 7 of 7 (page number not for citation purposes) discussion this study investigated the psychometric properties of the hecs, which demonstrated the validity and reliability of this instrument for measuring the ethical climate in hospitals in iran as perceived by nurses. validity of the original fivefactor structure with 26 items was confirmed by cfa. the reliability of the hecs was evaluated by cronbach’s alpha. the overall cronbach´s alpha in this study was 0.94 and was higher than those reported in studies by olson [cronbach’s alpha = 0.91] (2), bahcecik and oztürk (6), jalali et al. (17) and ghorbani et al. (18). the highest hecs scores were observed on the subscale “managers” and items 24, 12 and 3 had the highest average, which is in agreement with findings of other studies (6, 17-19). this indicates that the hospital managers in the present study have succeeded in developing a positive ethical climate (2). the role of managers in creating and maintaining a desirable ethical climate is extremely important. studies in the united states and finland have shown one main concern area for nurses to be lack of management support (20, 21). the lowest hecs scores were observed on the subscale ‘physicians’, which is consistent with the findings of other studies (18, 19). furthermore, items 26, 9 and 4 obtained the lowest average, which also confirms the findings of other studies (6, 18, 19, 22). all this indicates a lack of organizational support when dealing with problems, and suggests that low teamwork and inadequate interaction between physicians and nurses can have a negative impact on the ethical climate. considering the role of the ethical climate in providing safe and high quality care, certain strategies must be used to improve the communication between nurses and physicians. given the above findings, it seems that despite cultural differences, the relationship between nurses and their colleagues follows a relatively similar pattern in different countries (22). in general the survey showed that the level of collaboration and communication between nurses and physicians is rather low, and therefore it is necessary to develop plans to improve the situation. conclusion this study investigated the reliability and validity of the persian version of the hecs. the results indicate that the persian translation of the full version of hecs is easy to understand and can be self-administered. moreover, this instrument has good psychometric properties and its use can be recommended to measure the ethical climate in hospitals in iran. conflict of interests the authors declare that they have no conflict of interests. funding this study was funded and supported by tehran university of medical sciences (tums) under grant no 91-01-157-17133 . acknowledgements we would like to express our gratitude to all nurses of the teaching hospitals of tehran university of medical sciences for participation in this study and their sincere cooperation. references 1. elçi m, alpkan l. the impact of perceived organizational ethical climate on work satisfaction. j bus ethics 2009; 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[in persian] journal of medical ethics and history of medicine the challenge of truth telling across cultures: a case study farzaneh zahedi md, endocrinology and metabolism research centre, medical ethics and history of medicine research centre, tehran university of medical sciences, tehran, iran. *corresponding author: farzaneh zahedi address: 5th floor, shariati hospital, north kargar avenue, tehran, iran. postal box: 14114-13137 tel: (+98) 21 88 22 00 37-8 fax: (+98) 21 88 22 00 52 e-mail: fzahedi@sina.tums.ac.ir received: 09 feb 2011 accepted: 01 nov 2011 published: 27 dec 2011 j med ethics hist med, 2011; 4:11. http://journals.tums.ac.ir/abs/20244 © 2012 farzaneh zahedi; licensee tehran univ. med. sci. abstract keywords: truth telling, ethics consultation, autonomy, informed consent, culture, clinical ethics. introduction physician-patient communication has changed significantly in recent decades in most countries throughout the world. before the era of contempo rary bioethics, the key decision makers in medical practice were physicians. they visited patients, prescribed drugs and their main duty was to save life and avoid death. information about the disease and the treatment was often not shared with patients, and they were rarely included in the decision making as to how the treatment should proceed. sometimes physicians even concealed the diagnosis from patients. some people even died without knowing what their disease was. accompanied with various opinions across cultures, truth telling is a major debate in bioethics. many studies have focused on attitudes toward truth disclosure. we intend to review several relevant research studies, and discuss the issue through a clinical case consultation. it seems that while "the right to know" is emphasized in bioethics, in some cultural contexts, health professionals fear communicating bad news. the patients may not receive information directly, because it is believed that the truth may make the patient feel hopeless and unable to cope with the problem. nevertheless, some believe that sharing information may strengthen a trusting relationship between patients and medical professionals. extensive efforts are in process in some societies to make patient rights to know the truth as a natural part of medical practice. however, in some cases, the principles of respect for patient autonomy require us to accept patient's refusal to know the truth, with the provision that he assigns someone to receive information and make medical decisions on his behalf. in conclusion, it is suggested that healthcare professionals should not act on a unique presumption in all cases and they should explore what the real interest of patient is, in order to respect individual autonomy. j med ethics hist med 2011, 4:11 farzaneh zahedi page 2 | 11 (page number not for citation purposes) however, there has been a rapid change from a paternalistic approach to an individualistic one. telling the patient the truth is now a common practice in many western countries and is also more acceptable than in the last decades in the eastern cultures. different interpretations of respect for autonomy and a greater emphasis on the role of the family and the community in patient care have resulted in a different approach in caring for patients in the east. patient’s capacity is a main element of autonomy-based decision making which may be influenced by different internal (e.g. mental capacity, stress, and level of understanding of medical information) and external (e.g. culture, and socioeconomic class) factors (1). interpersonal relationships have also a significant effect on the sense of autonomy in various cultural contexts. although family request of “do not tell” the truth and their strong resistance to informing patients about their diseases may confuse healthcare professionals in some societies (2), it may also reflect divergence in patients’ interests in people. many research studies in recent years have focused on the attitude and practice of health care teams about whether and how to disclose diagnoses to patients with cancer or terminal illness. this has been the subject of many resear ches in recent years. in this paper, we intend to review the relevant studies and address the following questions: 1. is truth-telling acceptable in different cul tures? 2. is there objective evidence that patients, regardless of their country, want to know the truth about their diseases? 3. what is the moral force of the family or the physician claiming that telling the truth is harmful to the patient? 4. are there justifiable cases in which the physi cian is permitted not to tell the truth? the aim of this paper is to clarify these ques tions through a comprehensive assessment of one clinical case. the case mrs. b, 34 years old, comes to the emergency department for dressing a small ulcer on her forehead. previously in a good health, she has fallen on the ground after a sense of lightheadedness. it seems to you, as a physician, that the patient is pale. so you ask her to do some laboratory studies including cbc for evaluation of anemia. she agrees and does the work-ups. when you receive the results, you realize that the patient has leukemia. in each of the following situations, what is your ethical duty? 1. the patient herself does not come back to receive the lab results. instead, her husband comes to you to consult about the results. should the physician disclose this information to the husband? 2. in fact the information is disclosed to him and he asks you not to tell his wife the truth and to tell her only that she has anemia and needs hospitalization and treatment. he explains that informing her might cause her to lose hope. 3. in the course of events, mrs. b sees the results and asks you not to tell the diagnosis anyone, including her family. she thinks this news may put a strain on the family members and make them worried. they are going to go to a 10-day trip together and she promises you that she will begin her treatment as soon as they come back home. telling the truth physician paternalism is no longer acceptable to many people because of the dramatic shift toward individual autonomy in the recent decades. informed about their diseases and therapeutic approaches, many patients prefer to participate actively in the decision making process. the role of family and friends as spokespersons is reduced considerably in autonomy-centered systems if the patient has capacity to speak for herself. however, the attitudes of patients and doctors towards the disclosure of information can still vary from culture to culture. in some countries, family members make decisions for patients, and they sometimes fail to follow the patients' interests and priorities. since such patients are psychosocially dependent on the family, they permit their family members to decide on their behalf and seldom defy their decisions. table 1 summarizes data from some research studies in different countries (3-9). in western countries, overall approximately 80– 90% of patients are given the truth about their diagnosis, whereas in other cultures, figures can range from 0 to 50% (10). two surveys conducted in the usa shows that clinicians' practices have changed significantly over recent decades. in one study conducted in 1961, 88% of physicians did not routinely discuss a diagnosis of cancer with their patients, whereas almost 20 years later in 1979, 98% of those surveyed generally did discuss the diagnosis (10-12). however, as hanssen says 'disclosure of diagnosis and prognosis, and discussions of for instance termination of treatment reflect mainstream j med ethics hist med 2011, 4:11 farzaneh zahedi page 3 | 11 (page number not for citation purposes) liberal western cultural values, and are not even necessarily supported everywhere in europe. (13)'. hanssen discusses examples from italy, japan, asian arabs, and hispanics. italy is one european country where 'the opportunity not to reveal to the patient or to mitigate a serious or lethal prognosis' is evaluated by physicians (13, 14). in spite of persistent cultural resistance, truthtelling attitudes have evolved in italy in recent decades too (15). in contrast to western individualistic cultures, most traditional eastern cultures place more emphasis on the collective role of family in decision-making. in china, for instance, the longstanding influence of confucian philosophy has established “harmony” as an essential and im portant social value, as lai states (16). individual and family harmony is believed to be essential for both the prosperity of a family and a nation. the essential role of these values in chinese society is captured in a well-known chinese proverb: 'family harmony makes everything successful and prosperous' (16). lai also emphasizes that 'truth telling in taiwan may also be influenced by four major socialcultural and ethical factors: family as a key player in medical[ly]-related decision making, harmony as an essential value for both the individual and family, taboo about discussing death and related issues, and ethical concerns in truth telling: the predominant value of nonmaleficence (do no harm) leads to not telling the truth'. in the following we may find a definition of harm which may be accompanied with telling the truth. as a central point, death is a taboo subject in some traditional societies. chinese believe that discussing or thinking about death or death-related concepts or approaching a dead body will hasten death. for example, hospitals rarely have a floor numbered '4' since the pronunciation of '4' in both mandarin and taiwanese is similar to that of 'death' (16). a nationwide survey of 229 palliative care workers (72.5% nurses and 16.6% physicians) in taiwan suggested that several factors made family members reluctant to tell patients the truth; first, the family did not know how to tell the truth, second, the family did not think it was necessary to tell the truth to elderly patients, and three, patients would be better or happier if they didn't know the truth (16). however, the question remains that whether the truth about the diagnosis should be concealed from a patient or not. die trill and kovalcik argue that it is difficult to prevent a patient (a child) from being informed about her/his illness (17). they say that: 'his interactions with other patients in the hospital, his increased exposure to the media, where cancer is frequently discussed, and the responses of those around him to his disease will increase his awareness of the seriousness of his condition'. it means that many patients will know their diagnosis without direct disclosure by the physician or their family. a comparison between japanese and american physicians' and patients' attitudes towards telling the diagnosis of cancer to a child (6) is demonstrated in table 1. in japan, historically it was not common to tell patients their diagnosis of cancer as it was traditionally believed that knowledge of cancer would dash hope (6,18). this probably was related with the lack of treatment options and inevitable death in the past decades, which is not true anymore. most japanese believed that a doctor should inform the patient’s family of the diagnosis (not the patient) at first and should let them decide whether the patient should be told or not (5). ornek buken states that in the physician-patient relationships in turkey, the one who is primarily responsible for making decisions about the patient’s treatment is not the patient but the patient’s next of kin, and sometimes the diagnosis is known by everyone except the patient (19). data from a limited research study done on 58 physicians and 150 medical students at ankara university medical faculty ibn sına (avicenna) hospital showed that 52% of the physicians and medical students had a “protector, guardian” approach to the cancer patients (19). in iran, kazemiyan has carried out in-depth interviews with 20 specialists about terminal diseases (20). all of the physicians said that considering cultural issues and negative psycholog ical effects, they would tell the diagnosis to the family members first. although they believed the patient has a right to know the truth, the specialists preferred not to tell the diagnosis directly before consultation with the family members (20). this is a situation where culture strongly influences medical decisions. table 1 also shows the results of another study (7) in iran. also, in an investigation on 71 health professionals (physicians and nurses), most respondents (54%) said that they told the true diagnosis to less than 20% of their patients. when respondents were asked about the barriers or reasons, they mentioned families' request (18%) and time limitations (16%) as the reasons. seven percent said that they do not inform patients because of the patients' own reluctance to know (21). it is also plausible if we conclude that this could be as a result of a lack of confidence of the physicians in terms of talking about such issues. physicians in different cultural contexts may face this problem, and this could indicate their lack of skills in communicating bad news in a health care settings. as mentioned before, according to the major j med ethics hist med 2011, 4:11 farzaneh zahedi page 4 | 11 (page number not for citation purposes) studies in the us regarding the disclosure of terminal illness to cancer patients, there was a dramatic change from 1960 to 1979, from not disclosing the truth, to full disclosure. by the late 1970s only 2% of surveyed us physicians did not reveal the cancer diagnosis to their patients (22). nevertheless, the united states is becoming a multicultural society and physicians may encounter patients who have divergent ideas on this notion. for example, as glass and cluxton have written, in traditional latino families, it is considered the husband’s duty to hear the bad news and then to tell his wife what he thinks she would want to know (23). if the spouse is deceased, the adult children assume this role to honor their mother and to protect her from the unpleasantness of the bad news. and, because the patient may not be fully informed of the illness, the spouse or the children are expected to make decisions about the care that the patient would want to receive (23). there is still a main question here of 'do patients really want to know the truth?'. patients’ attitudes toward disclosure can vary from one cultural context to another. in the us, several studies indicate that people do want to know the truth about their illness and prognosis, even when the news is not good (23). surveys in western populations have found that 83–99% of those surveyed would like to be informed of their diagnosis, with a somewhat lower figure in nonwestern countries of 24–74% (10). many predictors of the desire for information have been identified, including age, level of education, ethnicity, a religious locus of control and in some studies, gender (10). a survey conducted by the us president's commission in 1982 indicated that 94% of patients wanted to know everything about their condition, 96% wanted to be informed of a diagnosis of cancer and 85% wanted to be given a realistic estimate of their time to live, even if this were less than 1 year (11). however, in one study a greater percentage of korean-born patients preferred to be given less information than did usborn patients (4,11). in taiwan, researchers in one study in 1982 found that more half (58.6%) of family caregivers opposed telling patients the truth, and only 39.7% agreed to tell the truth (16). the author states that 'major reasons for not telling the truth about cancer consisted of: worry that patients could not take the emotional impact, concern about not being able to manage the patients' emotional reaction after learning the truth, and protecting patients from harm' (16). however, there have been changes in truth telling in cancer diagnosis over the past 20 years. a self-report survey of 195 people admitted to a medical center in southern taiwan for a 3-day health examination showed that 92.3% of participants preferred being informed of the truth about their cancer diagnosis and 7.7% did not (16,24). case consultation the issues raised so far in the research studies can now be analyzed in regards with the presented case. some practical approaches for ethical decision making on case consultation process will be used (25,26). mrs. b's physician accidentally makes a diagno sis of leukemia in this relatively young patient. the ethical question is whether the physician has the right to reveal the diagnosis to her husband or anybody else before informing the patient. what is his ethical duty, as a physician, when the patient or her husband asks him to conceal the diagnosis? systematic description of the case 1. medical indications: considering the primary diagnosis, some complementary paraclinical evaluations are necessary. more specific blood examinations, bone marrow biopsy, and sometimes lumbar puncture are needed. whether it affects granulocytes, lymphocytes, or monocytes determines the type of leukemia and its prognosis. the physician's decision may be different based on the type of leukemia and the fact that it is acute or chronic, but his duty is the same: seeking the welfare and interest of the patient. the treatment then should be started promptly. the patient should be referred to an oncologist for scoring and staging of the disease. under supervision of an oncologist, a combination of chemotherapy and other approaches such as drug therapy and radiotherapy may be administered. the physician should also consider cell therapy. so, the patient and her family need to be prepared for complicated therapeutic approaches fairly quickly. 2. patient preferences: she is a legally competent woman, and she has the capacity to make decisions about the medical process. moreover, she has the right to clearly state if she wants her husband or other family members to be informed about her disease, but she is reluctant to let her family know about her disease. 3. quality of life: although she has had a good quality of life so far, her life will be complicated with physical and psychological problems as the result of the severe and painful side effects of therapeutic approaches. in addition, receiving a cancer diagnosis may be seen as a death sentence by her and perhaps by her family. unfortunately, without treatments, her life will be in danger, and delay will make a bad outcome more likely. the prognosis for j med ethics hist med 2011, 4:11 farzaneh zahedi page 5 | 11 (page number not for citation purposes) various forms of leukemia varies widely. the 5year survival may be less than 50% to more than 80% in different types of leukemia. in most cases the patient would have the best chance for survival if the leukemia is diagnosed and cured in early stages. 4. contextual features: her cultural context is an important issue. bad news such as a cancer diagnosis may be considered as a critical condition for her and the family. as mentioned before, in some cultures, the family members prefer to conceal the diagnosis to preserve the patient's hope and protect her from further distress. all previous discussions about characteristics of different cultures may be applicable in this case. in some cases difference in the attitudes might be important and should be considered and discussed by the health care team and the patient. for instance, the approaches would be completely different in a chinese couple and an american one. we may also consider a situation in which one spouse has an eastern culture and the other spouse is an american. expectations and interests are different, and conflicts may arise. physicians can play a distinguished role which may seem beyond their general duty. the physician should take into account this point that some decisions may be medically appropriate but not ethically sound. sometimes there are psychosocial adverse effects which limit the options. besides, other issues such as treatment cost, outcome, her personal values and goals influence on the decision. assessment it seems that she has good familial relationships and their trip is so important for her since she may think this will be the last opportunity for her to enjoy life. but, the patient is in a critical situation and she should receive medical treatment as soon as possible. the physician is faced with the conflict between how to respect her autonomy, preserving family unity and providing appropriate medical care for her serious condition. discussion any plausible solution in this case will need ethical justification based on wellestablished ethical principles and values. how to best respect for patient autonomy while acting in manner consistent with beneficence in medical practice, and their various interpretations under the influence of cultural variables, are the main issues to be discussed. patient autonomy could be a key notion in this argument. in western bioethics, the sick person has a right to self-governance (21), so she has a definite right to know the diagnosis. also, her information cannot be revealed to other people without prior consent, and she is the key decision maker about sharing information with the family or anybody else. however, as surbone says, autonomy is a complex concept, which refers both to the one's capacity to choose and the ability to implement one's choices (21). autonomy is a necessary attribute of rational human beings and it is universally valid. however, both internal and external factors and resources contribute to one's autonomy and from the beginning to the end of our lives, we are embedded in a context of social relations, which shape us and sustain us. thus, autonomy is always relational and situated, rather than simply a matter of individual choice (21). understanding “relational autonomy” helps framing the ethics of truth telling and understand ing those many unsolved aspects of truth telling that go beyond cultural differences (21). surbone adds to this interesting notion by suggesting that imposing the truth on an unprepared patient whose cultural expectation is to be shielded from painful medical truths is not necessarily an act of respect for autonomy. the notions of cultural sensitivity and of cultural competence are also essential to the discourse on truth telling (21). in some cases, the patient may not wish to receive information directly, and select someone as a surrogate decision maker. usually this means just to accept the family as the decision makers. in honoring a capable patient’s wish not be told healthcare information, the team respects the patient’s autonomy to determine what he or she wants to know. this approach is not only culturally sensitive; it is also legally sound as long as the patient’s wishes and chosen surrogate(s) are documented in the medical record (23). no doubt, quality of patientphysician communication is a pivotal point which helps physician to realize that s/he should communicate the information and the care plan with the family. beneficence and non-maleficence are also close ly linked to the notion of truth telling. some people may believe that the sick should be protected from harm by withholding the truth. as a case in point, as lai states, for many chinese, not telling a patient his/her cancer diagnosis is a way for the family to protect the patient from further hurt by the diagnosis and to preserve both individual and family harmony (16). also, the predominant values of non-maleficence and family harmony in taiwanese society determined truth-telling approach in cancer care (16). physicians in the past have voiced concerns that revealing a cancer diagnosis would result in the loss of j med ethics hist med 2011, 4:11 farzaneh zahedi page 6 | 11 (page number not for citation purposes) hope. families are still often fearful that knowledge of cancer will result in despair, depression or result in increased suffering. few studies have directly examined this question but it is likely that any increase in anxiety is transient. there is some evidence to support the notion that informing patients truthfully about a life-threatening disease does not result in a greater incidence of anxiety, despair, sadness, depression, insomnia or fear (10,27). it should be mentioned that ever-increasing knowledge and technological advancements have increased hope for all patients including cancer patients. so cancer diagnosis is no longer as scary as it was in the past decades. one study design based on the utrecht school of phenomenology in 9 cancer patients showed eight core themes describing the participants' lived experience: living with fears and uncertainty, loss of happiness, feeling of added responsibility, living in a state of emergency, sharing the pain, living the dilemma of truth telling, being disturbed by being pitied, and reliance on god (28). furthermore, one study on 142 iranian patients which has compared the quality of life between patients who were aware of cancer diagnosis and patients who were not, indicated that those who knew their diagnosis had a significantly lower degree of physical (p=0.001), emotional (p=0.01) and social functioning (p<0.001), but the global quality of life and other functional scales including role functioning and cognitive functioning did not show any significant differences (7). there were no statistically significant differences in symptoms scores between two groups, except for fatigue which scored more frequently in patients who knew their diagnosis. the financial difficulties were also significantly higher in patients who knew their cancer diagnosis (7). conversely, many believe that informed patients have better communication with relatives and with their treating staff as well as greater trust in the care provided (10), and not telling the truth can harm patients in many ways (11). many negative ramifications can result from not telling the truth to patients and families; for instance, it is predictably difficult to make treatment decisions that are consistent with personal goals in the absence of accurate and complete information. this may result in adverse physical and emotional suffering, as well as increased family expenses (23). patients who remain uninformed about their condition may fail to seek medical attention when they should. they may also make decisions affecting their lives that they would not make if they were aware of their condition (11). additionally, not telling patients the truth about their condition may entail deceiving them (11). many patients feel frustrated because they sense they are not being included in their treatment plan. this frustration is especially true when family members are given more information than the patient without the patient’s consent. finally, when bad news is withheld from patients, they are denied the opportunity to get their affairs in order and may miss the opportunity to live meaningfully before their death (23). lack of candor or outright deception, even when well intentioned, can undermine the public’s confidence in the medical profession (11). in addition, the benefits accompanying patients’ adapting to their illness are frequently spiritual and emotional. for example, many people focus on preparing themselves and their loved ones for the imminent death. for those with religious beliefs and spiritual sensitivities, making peace with god, others, and oneself is essential for achieving a sense of closure and integration (23). however, there can be a socio-cultural differ ence in the prioritizing and weighting of the principles. for example, as ornek buken states, the principles of “do no harm and beneficence” sometimes take priority for turkish patients over the principles of “respect for autonomy and justice” because of the structure of society, their customs and traditions and their sociocultural structure (19). the goal of the good physician, particularly in a cosmopolitan society, is to discern what the patient's preferences are and how s/he feels about the relationship between the triangle of patient, physician and the family. the third angle may not be acceptable in making decision in some societies, but it may be as important as other angels in some other cultures. the physicians' communication skills and the manner with which he or she gives bad news is an important issue. as glass and cluxton point out (23), most healthcare professionals would not intentionally do anything to harm a patient or family. however, if healthcare professionals fail to become skilled in giving bad news honestly and sensitively, they may severely impede patients’ and families’ ability to deal with serious illness and/or prepare for death. if we accept that the physician should tell the patient the truth, there are still some decisions to be made including determining to whom and to what extent the truth should be shared, and how the truth should be told. some elements would be important in dealing with this issue including: the person who discloses the information, the manner of telling news, available supports (such as family, spiritual and social support), and the methods of coping with difficulties and stress in different cultures (29). gold believes that the doctor alone should not make the decision about how much to tell an individual patient, even if j med ethics hist med 2011, 4:11 farzaneh zahedi page 7 | 11 (page number not for citation purposes) s/he is well informed about the likely cultural preferences of the person seeking care (11). the needs of each person must be evaluated individually because illness is, in the first instance, a subjective experience, influenced by cultural, personal and religious beliefs and traditions (11). the doctors do not have any right to lie to the patient but they are not obliged to tell the whole truth (30). gold states 'too much information can be overwhelming and most physiciansl will recall instances of patients abandoning a successful treatment after hearing of a rare potential adverse effect' (10). a sincere dialogue is required. cultural differences between patients and health care professionals are potentially inevitable. involvement of families in information and decision making processes is also a concern, even within western societies where individualism is prized. putting these points together, it is obvious that physician cannot act based on a fixed default in all patients and s/he should take cultural context into account to decide how to communicate the information to the patient, her husband, and her family. as a default in western culture, mrs. b has the right to be informed about the diagnosis of her disease unless she is incompatible and someone else is her spokesperson and decision maker. the physician is not permitted to share the information with other people without her permission, including her family members. she is a competent woman and is capable of deciding whether to share the information. however, in an eastern culture, family members have a caring role and they may be informed in order to help patient to cope with the problems of the diseases. she is going to travel with her family for 10 days, but the complementary work-ups and treatments should be started immediately. family members in cancer patients may play a very important supportive role. it seems that for an effective and timely treatment, it is necessary that her close family members know about her disease, but if she is clearly reluctant the physician is ethically obliged to hide the patient's secrets. it is the physician's duty to clearly explain the harms and benefits of different decisions, but mrs. b will make the final decision by her own. anyway, the physician should be respectful for all patients; those who insist on an absolute autonomy or those who refuse to know. recommendations mrs. b's desires and preferences should be respected and her confidentiality should be protected as far as possible. without treatments, her life would be in danger; but if she wants to take this potentially last trip with her family, the physician should not oblige her to stay and follow his recommendations. no doubt, it is better that the physician not to be neutral. he/she should evaluate the situation; consider the different aspects of the disease and what will happen in coming weeks and months. benefiting from psychosocial supports of family in patients struggling with the malignant disease may be of a key importance in many cases. the physician should evaluate the personality and psychological status of the patient and use appropriate language and skills to alleviate fear and possible hopelessness of the patient. speaking about the new generations of anti-cancer drugs with high efficacy would be useful. physician should also emphasize to her the importance of beginning the therapeutic process as soon as possible. in the case when the patient's husband requests information about her wife's disease, the principle of confidentiality and privacy require the physician not to tell him the information except when there is a presumed consent for disclosure as a cultural ruling. for making the best decision, there should be a discussion with the patient, the physician and health care team, and the close family. prior to any decision, the physician and the ethics consultant if he or she is involved, should get familiar with the patient's goals, values, religious and cultural beliefs. a clear and sincere conversation is necessary. it should be clarified whether the patient wants to be the key decision maker, and/or to what extent she wishes the family to play a role. conclusion physicians and nurses in some cultures fear communicating bad news because they may make the patient feel hopeless and unable to cope with the problem. words like 'cancer' may create a sense of death and despair in patients. sometimes a diagnosis of a malignant disease results in the deterioration of patient's quality of life. advocates of truth telling believe that sharing information strengthens a trusting relationship between patients and medical professionals and also permits patients to make informed decisions. many patients will know their diagnosis without direct disclosure by the physician or their family, so not telling the truth may ruin the trust between patient and physician. in addition, without disclosure of diagnosis and proper information about disease, the patient's choices would not be autonomous. patients may also deny their diseases or be j med ethics hist med 2011, 4:11 farzaneh zahedi page 8 | 11 (page number not for citation purposes) reluctant to receive full information. the patients' own reluctance to know should also be respected. it is obvious that many internal and external factors may have an influence on individual capacity and self-determination. however, it seems that interpersonal relationships have a significant effect on the sense of autonomy in various cultural contexts. excessive advocacy of autonomy is mostly based on the accepted interpersonal relationships in some western societies; while different familial connect edness may give various meanings to autonomy; bearing in mind the social nature of human being. finding a balance between appropriate medical decision and patient’s preference is the physician’s duty. in other words, deontological approach which considers truth-telling a moral duty in all situations is not in accordance with respect for autonomy in principlism. in a paternalistic interpretation of principles of autonomy and beneficence, all people from all various cultures may be treated equally. however, as an obligation, medical professionals ought to consider the variations in different cultural contexts and interpret these principles in any clinical cases according to their patients’ cultural backgrounds. the right approach should be discussed through interactive consultation sessions among healthcare professionals, patients and the relatives. in conclusion, a new perspective on the principle of autonomy is needed. it is so clear that respect for autonomy means that different people should be treated differently according to their ideas and beliefs. so, physicians should certainly have and use excellent skills in the areas of cultural sensitivity, and the decisions should be shaped by the patients' values and preferences. they should work to develop better skills in handling these difficult conversations, and consider various cultural differences as a key part of the essential skill set. acknowledgments this research has been supported by tehran university of medical sciences by the use of the research grant (contract no. 8938). i appreciate prof. wayne shelton for his invaluable comments and sincere support through the course of "online practicum in clinical ethicsambi 603". i also thank ms. christine simons for her kind assistance and dr. shellie asher for her valuable suggestion. i confirm that there is no conflict of interest relevant to this article. j med ethics hist med 2011, 4:11 farzaneh zahedi page 9 | 11 (page number not for citation purposes) table 1some research studies about truth telling in different countries. references research sample results mosconi et al. 1991 (3) 1171 italian breast cancer patients and their physicians only 47% of the patients reported having been told that they had cancer. 25% of their physicians stated they had not given accurate information. blackhall et al. 1995 (4) 800 people with different ethnicity, los angeles county, california korean americans (47%), mexican americans (65%), european americans (87%), and african americans (88%) believed that a patient should be told the diagnosis of metastatic cancer. korean americans (35%), mexican americans (48%), african americans (63%), and european americans (69%) believed that a patient should be told of a terminal prognosis. ruhnke et al. 2000 (5) 400 japanese physicians, 65 patients; and 120 us physicians, 60 patients few japanese physicians (17%), but 42% of patients agreed that a doctor should inform the patient of a cancer diagnosis. but at least 80% of us physicians and patients agreed. 80% of japanese physicians and 65% patients agreed that a doctor should inform the patient’s family of the diagnosis. a minority of us physicians (6%) and patients (22%) agreed. mayer et al. 2005 (6) 362 japanese and 350 us pediatric oncologists japanese physicians (61.8%) did not explicitly tell the child the diagnosis; only 9.5% always told. 65% of the us physicians always explicitly told the child the diagnosis. tavoli et al. 2007 (7) 142 iranian patients, tehran, iran only 48% of hospitalized patients with gastrointestinal cancers were aware that they had cancer and the rest did not know their diagnosis. (the researchers asked patients and their families in the separate sessions about the disease and the reason of hospitalization.) erer et al. 2008 (8) 104 cancer patients, medical oncology department of uludag˘university, turkey 86.5% positive response to the items that the patients have the right to be informed, 92.3% agreed that the physician should inform the patient on the diagnosis and the treatment, 76.9% believed that the physician is obliged to inform the patient kazemi et al. 2010 (9) 200 iranian clinical practitioners, tabriz university of medical sciences, iran twenty percent of physicians believed that a patient should be told the diagnosis of a serious terminal disease. but 8% stated that they won't tell the patient the truth. most respondents (72%) believed that the decision may be different in different conditions and various socio-cultural contexts. j med ethics hist med 2011, 4:11 farzaneh zahedi page 10 | 11 (page number not for citation purposes) references 1. surbone a. telling the truth to patients with cancer: what is truth? lancet oncol 2006; 7: 944-50. 2. shahidi j. not telling the truth: circumstances leading to concealment of diagnosis and prognosis from cancer patients. eur j cancer care 2010; 19: 589–93. 3. mosconi p, meyerowitz be, liberati mc, liberati a. disclosure of breast cancer diagnosis: patient and physician reports. ann oncol 1991; 2: 273-80. 4. blackhall lj, murphy s, frank g, michel v, azen s. ethnicity and attitudes toward patient autonomy. jama 1995; 274: 820–5. 5. ruhnke gw, wilson sr, akamatsu t, et al. ethical decision making and patient autonomy. chest 2000; 118; 117282. 6. mayer dk, parsons sk, terrin n, et al. school re-entry after a cancer diagnosis: physician attitudes about truth telling and information sharing. child care health dev 2005; 31: 355–63. 7. tavoli a, montazeri a, mohagheghi ma, roshan r, tavoli z, melyani m. knowledge of cancer diagnosis and quality of life in patients with gastrointestinal cancer. payesh 2007; 6: 257-64. 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(in persian) 22. surbone a. truth telling and ethical issues: an overview. proceeding of the uicc world cancer congress 2006: bridging the gap: transforming knowledge into action july 8-12, 2006, washington, dc, usa, 89-1. 23. glass e, cluxton d. truth-telling: ethical issues in clinical practice. j hosp palliat nurs 2004; 6, 232-42. 24. wang st, chen ch, chen yh, huang hl. the attitude toward truth telling of cancer in taiwan. j psychosom res 2004; 57: 53-8. 25. jonsen ar, siegler m, winslade wj. clinical ethics: a practical approach to ethical decisions in clinical medicine. new york, ny: mcgraw-hill, medical publishing devision; 2002. 26. orr rd, shelton w. a process and format for clinical ethics consultation. j clin ethics 2009; 20: 1-11. j med ethics hist med 2011, 4:11 farzaneh zahedi page 11 | 11 (page number not for citation purposes) 27. centeno-cortés c, núñez-olarte jm. questioning diagnosis disclosure in terminal cancer patients: a prospective study evaluating patients’ responses. palliat med 1994; 8: 39–44. 28. doumit m, huijer h, kelley j, nassar n. the lived experience of lebanese family caregivers of cancer patients. cancer nurs 2008; 31(4): e36-e42. 29. zahedi f, larijani b. common principles and multiculturalism. j med ethics hist med 2009; 2: 6 (online). available at: http://journals.tums.ac.ir/upload_files/pdf/13464.pdf (accessed in 2010) 30. zahedi f, larijani b. cancer ethics from the islamic point of view. iran j allergy asthma immunol 2007; 6: 17-24. hhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh copyright © 2022 tehran university of medical sciences. this work is licensed under a creative commons attribution-non commercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. original article abstract the professional quality of life of pre-hospital emergency technicians has been adversely affected during the covid-19 pandemic. the present study was performed to investigate the professional quality of life and resilience and their relationships in pre-hospital emergency technicians of kermanshah province, iran during the covid-19 pandemic. this cross-sectional, descriptive correlational study was conducted on 412 pre-hospital emergency technicians in kermanshah province in 2020 using the census method. data collection tools were the stamm professional quality of life questionnaire and the emergency medical services resilience scale. pre-hospital emergency technicians experienced moderate levels of the professional quality of life dimensions and high/acceptable levels of resilience. there was a significant correlation between resilience and the dimensions of the professional quality of life. *corresponding author maryam aghabarary address: school of nursing. golestan 1st, south eshteraki st., baghestan blvd, karaj, iran. postal code: 3146883811 tel: (+98) 26 34 30 16 66 email: m.aghabarary@abzums.ac.ir received: 28 aug 2022 accepted: 30 oct 2022 published: 28 dec 2022 citation to this article: fatahi y, norouzinia r, aghabarary m. professional quality of life and resilience in pre-hospital emergency technicians during covid-19 in iran: a cross-sectional study. j med ethics hist med. 2022; 15: 15. the results of the regression test showed that resilience had a significant effect on all three components of the professional quality of life. therefore, the use of resilience enhancement strategies is recommended to improve the professional quality of life of pre-hospital emergency technicians. keywords: professional quality of life; resilience; emergency medical services; iran; covid-19. professional quality of life and resilience in pre-hospital emergency technicians during covid-19 in iran: a cross-sectional study 1. msc student of emergency nursing, student research committee, alborz university of medical sciences, karaj, iran. 2. assistant professor, social determinants of health research center, alborz university of medical sciences, karaj, iran. yasser fatahi1, roohangiz norouzinia2, maryam aghabarary 2* professional quality of life and resilience in pre-hospital emergency technicians during covid-19 in iran j. med. ethics. hist. med. 2022 (dec); 15: 15. 2 introduction the most important component of the pre-hospital emergency system is efficient and operational technicians (1). pre-hospital emergency technicians are faced with problems such as tragic scenes, time constraints, patients’ critical conditions, expectations and requests from patients’ family and friends, fear of failure to rescue critical patients, and the pressure to make swift decisions in serious situations (2). it seems that the tension has escalated during the covid19 pandemic. the potential risk of the disease, fear of transmitting the infection to the family, lack of effective treatment strategies, doubts about the duration of the pandemic, and lack of personal protective equipment may result in or worsen psychological stress. all this can affect the professional quality of life of health-care workers, particularly the staff in the emergency departments, since they are at the forefront of treatment for patients with suspected or confirmed infections (3). according to stamm, professional quality of life is defined as a person's perception of his or her work (4). it includes the dimensions of “compassion satisfaction” and “compassion fatigue”. compassion satisfaction is a positive attitude toward care; in other words, it is a feeling of satisfaction that comes from being able to accomplish something properly and perfectly, and it makes one enjoy helping others, which is one of the most important determinants of the productivity of an organization (5). compassion fatigue is an occupational hazard for people experiencing psychological trauma (6) and occurs in medical staff that witness patients’ physical and psychological suffering but do not receive emotional support at work (7). compassion fatigue can make caregivers feel apathetic, indifferent and ruthless toward their patients (8). it includes the components of “secondary traumatic stress” and “burnout” (5). secondary traumatic stress, also known as stress secondary to an accident, includes negative emotions that emerge as a result of fear or occupational accidents that occur to others. this kind of stress is not the result of a person's direct confrontation with accidents. secondary stress may occur unexpectedly and without prior warning. its symptoms may include feelings of helplessness, confusion and being deprived of others’ support (9). burnout due to compassion fatigue causes emotional exhaustion, apathy, and low self-esteem; it also increases medical errors, personal and professional problems, and patient dissatisfaction, fatahi y., et al. 3 j. med. ethics. hist. med. 2022 (dec); 15:15. and leads to decreased health-care quality (10). ultimately, both secondary traumatic stress and burnout affect the quality of patient care and threaten the patient's safety (11). the results of a study on italian health-care workers during the covid-19 pandemic showed that health-care professionals at the forefront of treating covid19 patients tended to have a lower professional quality of life than those treating other patients (12). in another study in hong kong, emergency department health-care professionals reported moderate levels of compassion satisfaction, secondary traumatic stress and burnout during the covid-19 outbreak (13). furthermore, according to studies in spain (14) and singapore (15), emergency department health-care professionals reported moderate to high levels of secondary traumatic stress and burnout during the covid-19 pandemic. in such situations, resilience can certainly be helpful (13, 16). resilience is defined as the ability to overcome and master difficult life situations (17). connor and davidson defined resilience as the ability to endure harms or threatening conditions, and efficiently and actively participate in the event, leading to the realization of a psychobiological balance in stressful situations (18). resilience is described as the positive potential of humans to cope with stress and critical situations. in this way, resilience is viewed as a protective factor against future risks (19). the results of a study showed that the higher a person's resilience, the lower their physical symptoms, anxiety levels, social dysfunction, and depressive tendencies. it can therefore be concluded that resilience improves the psychological health of individuals (20). another study found that resilience skills training improved resilience in nurses and consequently reduced their job stress and increased their professional quality of life (21). based on the results of another study, psycho-education improves the resilience of emergency staff and enables them to control their anger (22). shojafard et al. evaluated the relationship between burnout and resilience in prehospital emergency technicians in tehran and found a significant inverse relationship between resilience and burnout (23). santarone et al. found that during the covid-19 pandemic, resilience has been an important characteristic that enables health-care professionals to overcome challenges (24). several studies have evaluated the professional quality of life, resilience, and their determinants in health-care professionals. nonetheless, they have not been clear with respect to pre-hospital emergency technicians, especially during the professional quality of life and resilience in pre-hospital emergency technicians during covid-19 in iran j. med. ethics. hist. med. 2022 (dec); 15: 15. 4 covid19 pandemic. therefore, it is important to evaluate the above-mentioned issues in prehospital emergency technicians during this critical period. the present study was conducted to assess the professional quality of life, resilience, and their relationship in pre-hospital emergency technicians in kermanshah province, iran, during the covid19 pandemic. methods a cross-sectional, descriptive, correlational study was conducted between august 2020 and january 2021. the study population included all prehospital emergency technicians in kermanshah province, northwest of iran. the total number of pre-hospital emergency operational personnel working in 63 urban, road and air bases of kermanshah province was 412 individuals who entered the study by census method. the inclusion criteria were as follows: at least six months of field experience and operation in the field, willingness and consent to participate in the study, and no history of family problems such as divorce or losing a family member or friends in the past three months. data collection tools included the stamm professional quality of life questionnaire, the emergency medical services resilience scale, and a demographic information form. the stamm professional quality of life questionnaire: this is a 30-item questionnaire including three dimensions of compassion satisfaction, burnout, and secondary traumatic stress, measured on a fivepoint likert scale (never = 1 to always = 5) as a self-report. this questionnaire was designed and psychometrically assessed by stamm (5). the modified persian version of the questionnaire with 25 valid and reliable items was psychometrically evaluated by ghorji et al. (25). in the modified version, five reverse scored items in the main questionnaire related to the burnout dimension were removed. the ultimate version included three dimensions: compassion satisfaction (10 items), burnout (5 items), and compassion fatigue or secondary traumatic stress (10 items). in the first dimension, a score higher than 45 indicated high compassion satisfaction, a score less than 32.6 low compassion satisfaction, and values between 32.6 and 45 showed moderate compassion satisfaction. regarding the second dimension, a score greater than 18.16 indicated high burnout, a score lower than 8.74 low burnout, and a score between 8.74 and 18.16 showed moderate burnout. fatahi y., et al. 5 j. med. ethics. hist. med. 2022 (dec); 15:15. as for the third dimension, a score higher than 32.72 revealed high secondary traumatic stress, a score lower than 21.52 low secondary traumatic stress, and scores between these two values showed moderate secondary traumatic stress. ghorji et al. calculated the reliability of the questionnaire using internal consistency (cronbach's alpha), and coefficients of 0.73, 0.87, 0.87, and 0.74 were obtained for the whole instrument, compassion satisfaction, burnout, and secondary traumatic stress, respectively. in the present study, a cronbach's alpha coefficient of 0.72 was obtained for the whole questionnaire indicating the acceptable reliability of the scale. the emergency medical services resilience scale: this scale consists of 31 items covering six dimensions, including job motivation (13 items), communication challenges (3 items), social support (2 items), remaining calm (5 items), selfmanagement (5 items), and consequence of stress (3 items). it was designed and psychometrically assessed by ebadi et al. (26), and is a self-report questionnaire completed on a five-point likert scale (strongly disagree = 1 to strongly agree = 5). the total score of the scale ranges from 31 to 155, with higher scores indicating higher resilience. ebadi et al. reported a cronbach's alpha coefficient and intraclass correlation coefficient of 0.91 and 0.85, respectively. in the present study, a cronbach's alpha coefficient of 0.89 was obtained for the whole questionnaire indicating the acceptable reliability of the scale. the demographic information form: this form included questions about age, work experience, education level and marital status. after obtaining approval and making the necessary appointments with the kermanshah medical emergency and accident center technicians, the researcher proceeded to data collection through distributing the questionnaires. for this purpose, the first author and co-authors visited different medical emergency bases in the cities of kermanshah province during their off-duty hours for questionnaire distribution and data collection. ethical considerations this study was part of a master’s thesis in nursing approved by the nursing faculty of alborz university of medical sciences, karaj, iran. ethical clearance was obtained from the ethics committee of alborz university of medical sciences (ir.abzums.rec.1399.087), and all ethical considerations were observed in this study. the research subjects (pre-hospital emergency field technicians) participated voluntarily in the study and were provided with the necessary information before completing the questionnaires. professional quality of life and resilience in pre-hospital emergency technicians during covid-19 in iran j. med. ethics. hist. med. 2022 (dec); 15: 15. 6 completion and return of the questionnaires were considered as informed consent to participate in the study. the questionnaires were completed anonymously, and the participants' information was confidential. statistical analysis after data collection, descriptive and inferential statistics were used for data analysis. first, the demographic characteristics of the research population were determined, and the main variables were examined using mean and standard deviation. the total resilience score and the scores of all three components of the professional quality of life, including compassion satisfaction, burnout, and secondary traumatic stress, had p-values lower than 0.001 according to kolmogorov-smirnov normality test, indicating that the research variables did not have a normal distribution (p < 0.001). since the variables in the study did not have a normal distribution, spearman’s correlation coefficient was used to examine the relationship between resilience and the professional quality of life dimensions. multiple and simple linear regression models were used to predict the professional quality of life factors. the regression test was performed using the concurrent method. data analysis was done using spss software version 22, and the significance level was set at p ≤ 0.05. results of the 412 questionnaires that were distributed to the whole research population, 370 were completed and returned (response rate: 89.80%). the mean ± standard deviation of the participants’ age was 32.19 ± 6.37 years (22 to 53 years). in addition, the mean ± standard deviation of the participants' work experience was 8.47 ± 5.90 years, ranging from 1 to 29 years. as for the other demographic factors, 229 participants (61.9%) were married, 164 (44.3%) had an associate degree, and 206 (55.7%) had a bachelor's degree. in accordance with the requirements of the pre-hospital emergency structure in iran, all field technicians must be male, and therefore there were no female participants in the study. the mean scores of compassion satisfaction, burnout, secondary traumatic stress, and resilience were 39.37 ± 8.06, 10.82 ± 4.39, 22.85 ± 6.06, and 126.53 ± 12.89, respectively (table 1). fatahi y., et al. 7 j. med. ethics. hist. med. 2022 (dec); 15:15. table 1. resilience and professional quality of life (n = 370) dimensions of resilience mean (sd) job motivation 53.48 ± 6.35 self-management 20.67 ± 2.63 remaining calm 20.75 ± 2.87 communication challenges 12.34 ± 1.62 social support 7.88 ± 1.51 consequence of stress 11.38 ± 2.61 total 126.53 ± 2.61 dimensions of professional quality of life mean (sd) compassion satisfaction 39.37±8.06 burnout 10.82±4.39 secondary traumatic stress 22.85±6.06 sd: standard deviation there was a significant correlation between resilience and all three dimensions of the professional quality of life (p < 0.001) (table 2). table 2. correlation between the six components of resilience and the three components of professional quality of life details job motivation selfmanagement remaining calm communication challenges social support consequence of stress resilience compassion satisfaction r = 0.59* r = 0.44* r = 0.46* r = 0.35* r = 0.37* r = 0.33* r = 0.63* burnout r = 0.43* r = 0.25* r = 0.23* r = 0.28* r = 0.25* r = 0.43* r = 0.47* secondary traumatic stress r = 0.31* r = 0.21* r = 0.19* r = 0.27* r = 0.23* r = 0.45* r = 0.40* r: spearman’s correlation coefficient *p < 0.001 according to the findings, resilience had a positive correlation with compassion satisfaction, but a negative correlation with burnout and secondary traumatic stress. the correlation coefficient of the relationship between resilience and compassion satisfaction, burnout, and secondary traumatic stress was 0.63, 0.47, and 0.40, respectively. the results also showed that all dimensions of resilience were correlated with the professional quality of life dimensions. the relationship between resilience components and compassion satisfaction was positive, but it was negative for burnout and secondary traumatic stress. table 3 presents the results of the regression analysis to predict the three components of the professional quality of life (compassion satisfaction, burnout, and secondary traumatic stress) based on the six components of resilience (job motivation, communication challenges, social support, remaining calm, self-management, and consequence of stress). the coefficient of determination for compassion satisfaction, professional quality of life and resilience in pre-hospital emergency technicians during covid-19 in iran j. med. ethics. hist. med. 2022 (dec); 15: 15. 8 burnout, and secondary traumatic stress indicated that the resilience components could predict 32% of compassion satisfaction changes, 24% of burnout changes, and 22% of secondary traumatic stress changes. table 3. predicting the components of professional quality of life based on the six components of resilience d ep en de nt v ar ia bl e in de pe nd en t v ar ia bl e u ns ta nd ar di ze d c oe ff ic ie nt s st an da rd iz ed e rr or st an da rd iz ed c oe ff ic ie nt s p -v al ue alignment indices r 2 c oe ff ic ie nt o f d et er m in at io n variance inflation factor tolerance 0.32 compassion satisfaction job motivation 0.451 0.085 0.356 < 0.001 2.41 0.414 communication challenges 0.093 0.186 0.030 0.619 2.01 0.499 social support 0.249 0.163 0.089 0.128 1.83 0.545 remaining calm 0.334 0.272 0.067 0.221 1.62 0.617 selfmanagement 0.882 0.276 0.165 0.002 1.45 0.690 consequence of stress 0.557 0.141 0.181 < 0.001 1.12 0.891 burnout job motivation 0.241 0.049 0.348 < 0.001 2.41 0.414 0.24 communication challenges 0.020 0.107 0.012 0.848 2.01 0.499 social support 0.142 0.094 0.093 0.131 1.83 0.545 remaining calm 0.009 0.156 0.003 0.954 1.62 0.617 selfmanagement 0.307 0.158 0.106 0.053 1.45 0.690 consequence of stress 0.500 0.081 0.298 < 0.001 1.12 0.891 secondary traumatic stress job motivation 0.181 0.068 0.190 0.008 2.41 0.414 0.22 communication challenges 0.062 0.150 0.027 0.678 2.01 0.499 social support 0.150 0.132 0.071 0.255 1.83 0.545 remaining calm 0.208 0.219 0.056 0.342 1.62 0.617 selfmanagement 0.351 0.222 0.088 0.115 1.45 0.690 consequence of stress 0.869 0.113 0.375 < 0.001 1.12 0.891 multiple linear regression model (simultaneous method) three components of resilience, including job motivation, self-management, and consequence of stress, were also found to be effective in improving compassion satisfaction (p < 0.05) and could significantly predict compassion satisfaction. all three components of job motivation, self fatahi y., et al. 9 j. med. ethics. hist. med. 2022 (dec); 15:15. management, and consequence of stress had positive effects on compassion satisfaction. comparison of standard coefficients showed that job motivation had the largest influence on compassion satisfaction with a coefficient of 0.356. job motivation and consequence of stress as two components of resilience had a considerable impact on burnout (p < 0.05) and were able to significantly predict it. job motivation and consequence of stress had negative effects on burnout. comparison of standard coefficients showed that job motivation had the strongest impact on burnout with a coefficient of 0.348. findings also showed that two components of resilience including job motivation and consequence of stress had a strong negative effect on secondary traumatic stress (p < 0.05) and significantly predicted it. comparison of standard coefficient showed that consequence of stress had the highest impact on secondary traumatic stress with a coefficient of 0.375. table 4 presents the results of the regression test with the aim of predicting compassion satisfaction, burnout, and secondary traumatic stress based on the total resilience score. table 4. predicting the components of professional quality of life based on the total resilience score dependent variable independent variable unstandardized coefficients standardized error standardized coefficients p-value r2 coefficient of determination compassion satisfaction resilience 0.335 0.026 0.552 < 0.001 0.30 burnout resilience 0.143 0.016 0.434 0.19 secondary traumatic stress resilience 0.164 0.022 0.359 0.13 simple regression model (simultaneous) the results showed that resilience had a considerable impact on all three components of the professional quality of life (p < 0.001). accordingly, resilience could significantly predict the three components of compassion satisfaction, burnout, and secondary traumatic stress. resilience had a positive effect on compassion satisfaction, while it had a negative effect on burnout and secondary traumatic stress. the comparison of standard regression coefficients showed that resilience had the strongest impact on compassion satisfaction with a standard coefficient of 0.552, professional quality of life and resilience in pre-hospital emergency technicians during covid-19 in iran j. med. ethics. hist. med. 2022 (dec); 15: 15. 10 while burnout was the second most affected variable with a standard coefficient of 0.434. discussion this study investigated the professional quality of life, resilience, and their relationship in prehospital emergency technicians in kermanshah province, iran during the covid-19 pandemic for the first time. in general, the subjects experienced overall moderate levels of all dimensions of the professional quality of life (compassion satisfaction, burnout, and secondary traumatic stress), which was consistent with the results of a study by wong et al. in hong kong. health-care professionals working in emergency departments in hong kong also experienced overall moderate levels of compassion satisfaction, burnout, and secondary traumatic stress during the covid-19 pandemic (13). before the covid-19 pandemic, norouzinia et al. found that the pre-hospital field staff of alborz province, iran had moderate levels of compassion satisfaction (27). smart et al. reported similar findings in the united states (28). ducar et al. also found moderate levels of the professional quality of life components including compassion satisfaction, burnout, and secondary traumatic stress in pre-hospital emergency technicians before mindful intervention (29). people working in occupations such as pre-hospital emergency are more prone to acute and chronic stress (30) as well as consequences such as burnout, depression, anxiety, sleep disorders, heart disease, substance abuse and suicide due to frequent exposure to scenes of death, pain, torment and sufferings of others (31). burnout and secondary traumatic stress are effective factors in reducing efficiency, loss of ability, and physical and psychological complications among pre-hospital emergency technicians, which can adversely affect professional performance, safety and care standards provided to patients (32). during the covid-19 pandemic, there were several factors that could cause psychological stress, for instance the potential risk of infection, fear of transmitting the infection to the family, lack of personal protective equipment, lack of effective treatment strategies, and doubts about the duration of the pandemic (12, 14). efforts to enhance the employees' professional quality of life reduce complaints, absenteeism and disciplinary procedures, and increase positive attitudes and engagement (33). thus, there is an urgent need for efforts aiming at improving the professional quality of life of health-care professionals working in emergency departments as well as pre-hospital fatahi y., et al. 11 j. med. ethics. hist. med. 2022 (dec); 15:15. emergency technicians during this critical time (13). the results revealed high/acceptable levels of resilience in the study participants. before the covid-19 pandemic, norouzinia et al. found acceptable levels of resilience in the pre-hospital staff of alborz province (27). froutan et al. measured the pre-hospital emergency workers’ resilience in khorasan razavi province, iran, and found high/very high levels of resilience (21). although the results of the present study are consistent with other studies in this field, differences in management practices, facilities, equipment and infrastructure in other regions and countries may affect the resilience of staff. studies have shown that supportive facilities and structures such as family, social and organizational support, available resources, and balance between life and work are among the external factors affecting resilience in personnel. these factors help individuals adapt better to stressful work conditions (34), which has been especially important during the covid-19 pandemic (13, 16). the findings revealed significant relationships between compassion satisfaction, burnout, and secondary traumatic stress among pre-hospital emergency technicians in kermanshah province, iran during the covid-19 pandemic. higher levels of compassion satisfaction were associated with lower levels of burnout and secondary traumatic stress, suggesting that compassion satisfaction can serve as a protective factor against poor psychological health in pre-hospital emergency technicians. studies investigating health-care professionals working in various settings have found similar results (13, 14, 35). however, o’callaghan et al. found no relationship between the dimensions of the professional quality of life (36). in the present study, there was a significant correlation between resilience and the different dimensions of the professional quality of life. the relationship between resilience and compassion satisfaction was positive, while it was negative for burnout and secondary traumatic stress. in other words, an increase in resilience increased compassion satisfaction and reduced burnout and secondary traumatic stress. the results also showed that resilience had a significant effect on all three components of the professional quality of life. the effect of resilience was positive on compassion satisfaction, and negative on burnout and secondary traumatic stress. when standard regression coefficients were compared, it was found that resilience had the greatest impact on compassion satisfaction, followed by burnout. studies investigating medical staff and emergency professional quality of life and resilience in pre-hospital emergency technicians during covid-19 in iran j. med. ethics. hist. med. 2022 (dec); 15: 15. 12 workers in italy (37) and health-care professionals in emergency departments in hong kong (13) during the covid-19 pandemic reported similar results. before the covid-19 pandemic, norouzinia et al. and miller et al. found a significant positive relationship between resilience and compassion satisfaction, indicating that resilience was associated with higher compassion satisfaction (27, 38). according to miller et al., resilience was inversely related to burnout and secondary traumatic stress (38). shojafard et al. found a significant inverse relationship between resilience and burnout (23). studies on nurses in australia (39) and saudi arabia (40) also showed similar results. a review of the literature suggests that personnel with higher resilience and those who use more resilient behaviors and actions through resilience enhancement techniques when faced with occupational issues are less prone to emotional fatigue and burnout (13, 37). the results of a study by abrishamkesh et al. showed that the higher a person's resilience, the lower their physical symptoms, anxiety levels, social dysfunction, and depressive tendencies (20). higher levels of resilience consequently improve the psychological health of individuals. dyer and mcguinness found that resilience, indefatigability, self-awareness and altruism were among the characteristics of resilient individuals. according to these two researchers, proficiency and coping skills are among the major predictors of resilience (41). thus, in stressful situations such as pre-hospital emergency care, resilience can be one of the most important and effective factors in increasing compassion satisfaction and reducing burnout and secondary traumatic stress. findings regarding the relationship between resilience and the professional quality of life showed that three components of resilience, i.e., job motivation, self-management, and consequence of stress, affected and significantly predicted compassion satisfaction and burnout. the effect of all three components of job motivation, selfmanagement, and consequence of stress on compassion satisfaction was positive, while it was negative for burnout. the strongest impact on compassion satisfaction and burnout was related to job motivation. the data also revealed that two components of resilience, i.e., job motivation and consequence of stress, influenced and strongly predicted subsequent traumatic stress. job motivation and consequence of stress negatively affected secondary traumatic stress, and the strongest impact on secondary traumatic stress was related to the consequence of stress. these findings are consistent with the results of a study by fatahi y., et al. 13 j. med. ethics. hist. med. 2022 (dec); 15:15. norouzinia et al. (27). thus, priority should be given to improving resilience in medical staff, emergency workers and pre-hospital emergency technicians in order to prepare them for the difficult situations rising due to the covid-19 pandemic (13, 42). previous studies revealed that resilience could be acquired and improved. for instance, according to a study by ahmadi et al., resilience skills training promotes resilience in nurses and consequently reduces job stress and improves their professional quality of life (43). in addition, mohamadi sadegh et al. found that psychoeducation improved emergency workers’ resilience and enabled them to control their anger by enhancing resilience (22). it has been proposed that pre-hospital emergency staff should receive inservice training programs including psychoeducation to improve resilience and anger control in those exposed to high stress levels. thus, it is important to employ training programs to enhance resilience and improve the professional quality of life of pre-hospital emergency technicians. this also improves the general situation and preparedness for dealing with and managing future pandemics. this study had some limitations. first, it was performed only on pre-hospital emergency technicians of kermanshah province located in the northwest of iran. thus, it is recommended to design and implement larger, multi-center, descriptive-analytical studies to compare the data and measure the relationship between the main variables of the study (resilience and professional quality of life) in other iranian cities and other countries, taking into account the cultural and social factors prevailing in different societies. second, the self-reporting nature of the surveys and the psychological condition of the participants at the time of completing the questionnaires might have affected the results, which was beyond the control of the researcher. third, this study had a cross-sectional design and data collection was performed within a period of six months. longitudinal studies during and after the covid19 pandemic are recommended for a better and more comprehensive understanding of the relationship between the professional quality of life and resilience of pre-hospital emergency technicians. conclusion pre-hospital emergency technicians of kermanshah province in iran experienced moderate levels of the professional quality of life dimensions (compassion satisfaction, burnout, and secondary traumatic stress) during the covid-19 professional quality of life and resilience in pre-hospital emergency technicians during covid-19 in iran j. med. ethics. hist. med. 2022 (dec); 15: 15. 14 pandemic. they also had acceptable/high levels of resilience. there was a significant correlation between resilience and the professional quality of life, that is, resilience had a strong impact on all three dimensions of the professional quality of life. due to the significant relationship between resilience and the professional quality of life dimensions, resilience enhancement strategies should be adopted to improve the professional quality of life of pre-hospital emergency technicians. this study investigated the professional quality of life, resilience, and their relationship in prehospital emergency technicians in kermanshah province, iran during the covid-19 pandemic for the first time; while the pre-hospital emergency technicians around the world have been affected by this pandemic, and therefore the results of the present study may be useful for similar international professional groups. funding none declared. acknowledgements the authors are grateful to all the participants in this study. the authors also thank the student research committee and the vice-chancellor for research and technology of alborz university of medical sciences. conflict of interests the authors declare there is no conflict of interests. references 1. shakeri k, fallahi khoshknab m, khankeh h, hosseini m, hosseinzadeh s, haghi monie n. evaluation of clinical skills of medical emergency personnel in tehran emergency center confronting the trauma. journal of health promotion management 2012; 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6: 1613. 40. alharbi j, jackson d and usher k. personal characteristics, coping strategies, and resilience impact on compassion fatigue in critical care nurses: a cross-sectional study. nurs health sci 2020; 22: 20–27 41. dyer jg, mcguinness tm. resilience: analysis of the concept. arch psychiatr nurs 1996; 10: 276-282. 42. giorgi g, lecca li, alessio f, et al. covid-19-related mental health effects in the workplace: a narrative review. int j environ res public health 2020; 17: 7857. 43. ahmadi b, mosadeghrad am, karami b. effectiveness of resilience education on quality of working life among nursing personnel: a randomized controlled study. payesh. 2019; 18: 279289. hhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh original article copyright © 2023 tehran university of medical sciences. this work is licensed under a creative commons attribution-non commercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. abstract the concept of common morality is fundamental in medical ethics, and lack of universal content and characteristics of common morality is a product of its multifaceted nature. this study aimed to identify the ideas and experiences of academic faculties regarding common morality in a pluralistic setting to promote conceptual knowledge and strengthen moral reasoning and ethical decision-making. the study was conducted using a qualitative method, employing semi-structured in-depth interviews with thirteen faculty members who were selected purposively. in order to assess their ideas and experiences, the transcripts of the interviews were analyzed using the content analysis method through directed and conventional approaches. the interviews were coded manually. two themes were reflected in the interviews: ontology and epistemology of common morality. the study indicates that the debate about the subjective or objective dependence of common morality questions the coherence of beauchamp and childress' common morality (cm) theory, as common morality is the result of various individual and social factor that influence moral and *corresponding author bagher larijani address: shariati hospital, north kargar ave., jalal-e-al-e-ahmad hwy., tehran, iran. postal code: 1411713135 tel: (+98) 21 88 63 12 97 email: larijanib@tums.ac.ir received: 10 aug 2022 accepted: 1 may 2023 published: 19 jun 2023 citation to this article: zahedi l, larijani b, javadi m, aawani s, jafari sa, joodaki k, et al. a dialog on common morality in medical ethics in a pluralist setting in iran: a qualitative content analysis. j med ethics hist med. 20232; 16: 3. decision -making in pluralistic environments. additional studies are needed in order to investigate the effect of cultural, social, theoretical, ideological and individual factors on promoting clinical ethical reasoning and decision-making skills. keywords: principle-based ethics; common morality; clinical reasoning; cultural diversity; qualitative research. a dialog on common morality in medical ethics in a pluralist setting in iran: a qualitative content analysis 1. phd candidate in medical ethics, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran; faculty member of iranian academy of medical sciences, tehran, iran. 2. professor, endocrinology and metabolism research center, endocrinology and metabolism clinical sciences institute, tehran university of medical sciences, tehran, iran. 3. professor, ethics department, university of qom, qom, iran. 4. associate professor, iranian research institute of philosophy (irip), tehran, iran. 5. associate professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. 6. phd in medical ethics, member of national association of iranian obstetricians and gynecologists (naigo), tehran, iran. 7. phd in medical ethics, head of medical error committee, shahriar medical council, tehran, iran. 8. assistant professor, ethics department, iran university of medical sciences, tehran, iran. ladannaz zahedi1, bagher larijani2*, mohsen javadi3, shahin aawani4, seyed abdosaleh jafari5, kobra joodaki6, roya rashidpouraie7, saeedeh saeedi tehrani8 a dialog on common morality in medical ethics in a pluralist setting in iran j. med. ethics. hist. med. 2023 (jun); 16: 3. 2 introduction common morality (cm) is a concept claiming that there exists a set of universal norms shared by all morally committed individuals. this basic concept plays a prominent role in medical ethics and ethical decision-making, and is the fundamental justification for beauchamp and childress' cm theory, which includes moral judgments in the medical arena. this theory implies that cm has realistic content; however, the existence and subjective independence of cm is disputed (1, 2). as moral universalists, beauchamp and childress attribute mind-independent properties to cm and consider morality as a reality detached from human knowledge (3). they claim that cm is not relativistic to cultures or peoples. in contrast, other researchers believe that cultural, social and psychological foundations argue for the nonuniversal conceptualization of morality (4 6). as moral relativists, the second group relies on the empirical doctrine that reality exists only within human knowledge and that reality is an object of knowledge relative to the conscious subject (7). relativists relate the fallibility and provisional nature of solutions to ethical dilemmas to the hermeneutic aspect of moral reasoning (8). beauchamp and childress state that coherence and practicality should be part of the criteria for evaluating ethical theories. theories should not contain conceptual inconsistencies or contradictory propositions. their practical requirements are unacceptable if they are too high to be met (9). beauchamp and childress base their cm theory on rawls’ reflective equilibrium to achieve coherence. they ground cm on four principles of autonomy, beneficence, nonmaleficence and justice to achieve harmonious solutions to moral dilemmas while maintaining practicality (10). these principles are essential in the decision-making process when dealing with complex ethical dilemmas. for the decision-making process to be coherent and coordinated, well-considered judgments are required in moral reasoning. when conflicting arguments arise, balancing and specification help achieve the primary goal of coherence. the wide reflective equilibrium approach facilitates the examination of the solutions to ethical problems by integrating basic ethical principles with the ethical paradigm of the context in which they arise; the role and competence of the moral agent are also effective in this approach. zahedi l., et al. 3 j. med. ethics. hist. med. 2023 (jun); 16: 3. some scholars claim that the neutrality of moral agents and freedom from bias are unrealistic ideals that may make the cm theory less practical (11). when the cm theory is introduced to normative issues, problems with coherence and practicality arise because the cm theory ignores the role of the moral agent who interprets and applies the principles. therefore, it appears that the cm theory may not be a suitable guide for practitioners because it does not provide a practical tool for analyzing ethical issues (12, 13). the reason for this is that the cognitive mechanism of the moral agent, which is affected by his/her values, desires, motivations, and social and interpersonal relationships, is the central pillar of medical decision-making approaches (14). the pluralistic process of cm decision-making highlights the shortcomings of the cm theory in the realistic realm. to date, few studies have been conducted on the perspectives and experiences of pluralistic academic faculties regarding cm. a detailed explanation of the multiple aspects of the cm theory will help resolve the debate about the subjective and objective dependence of cm and enhance the reasoning and ethical decisionmaking skills of medical ethicists. therefore, this research was designed to investigate the opinions and experiences of faculty members about cm in pluralistic settings. methods qualitative approach and research paradigm this exploratory study was conducted from april 2018 to september 2019 through separate face-toface interviews with faculty members of six academic faculties and research centers in tehran. the naturalistic paradigm in which the subjects are observed in their natural environment was chosen because it helped the interviewers to better understand the content and meaning of the interviewees’ responses. the research team agreed to use directed and conventional approaches and not to use the summative method in order to avoid over-reliance on the quantification of the manifest content (pure lexical meaning cannot reveal latent meanings). similarly, counting the frequency of codes increases the risk of overlooking content because the same word may be repeated for various reasons. directed content analysis analyzes participants' perspectives and begins with a theory or relevant research findings as a guide for initial codes. this study started with the directed approach, and the questionnaire guide was created based on a narrative review. however, conventional content a dialog on common morality in medical ethics in a pluralist setting in iran j. med. ethics. hist. med. 2023 (jun); 16: 3. 4 analysis analyzes participants’ experiences, and therefore coding categories are extracted directly from the transcribed textual data (15 17). researcher characteristics and reflexivity five of the eight members of the research team were women. during the study, lz was an m.d. and a ph.d. candidate in medical ethics. bl, mj, sa, saj and sst were faculty members of local universities and research centers. kj was a member of the national association of iranian gynecologists and obstetricians (naigo), and rr was a member of the local medical council. lz conducted the interviews, and all researchers carried out each stage of the study. this research sought faculty members' perspectives on cm content and cm-based experiences in decisionmaking when faced with ethical dilemmas, and the findings may expand relevant literature. context and sampling strategy the study population consisted of 13 faculty members from five fields (medicine, medical ethics, philosophy, theology and sociology) in six academic faculties and research centers in tehran. this ensured the diversity of the informants using a purposeful snowball sampling method. eligible participants met the following criteria: 1) being faculty members of universities, research centers and institutes, scientific associations, and medical councils; 2) being interested in medical ethics, and 3) having deep opinions and experiences regarding the subject under study. data collection continued until saturation, which was achieved after the initial ten interviews. nevertheless, three additional interviews were performed for confirmation. ethical issues pertaining to human subjects the participants were told about the interviewer and the purpose of the study, and were assured that they could cease participation at any time. the recording of the interviews started after obtaining their consent. data confidentiality was ensured by restricting data access to the principal researcher and the study supervisor, and written informed consent was obtained from all participants. ethical approval was obtained from the research ethics committee of tehran university of medical sciences (code number: ir.tums.rec.1395.2627). data collection semi-structured in-depth interviews were used to collect data. the interviews lasted an average of 75 minutes and were held at the time and location chosen by each participant. when most of the quotes or initial codes became increasingly repetitive, data collection and analysis were stopped. zahedi l., et al. 5 j. med. ethics. hist. med. 2023 (jun); 16: 3. triangulation was achieved through: 1) interviewing participants from different disciplines and multiple sites (data source triangulation); 2) involving several researchers in data coding (researcher triangulation); 3) repeating the analysis with the same researcher six months later (data triangulation); and 4) peer debriefing on the entire process of the emerging categories and final themes with independent experts. data collection instruments scientific articles addressing cm were examined through a narrative review to guide the directed approach. the narrative review included articles on the philosophical aspects of the cm theory found in google scholar containing the keywords “common morality” and “medical ethics”. at the time, google scholar listed 146 articles on the theory of “common morality” in medical ethics. thirty-three of those, which extensively discussed the philosophical aspects of the theory, were included in this study. the three themes that emerged from the extracted codes and categories were: 1) the existence of cm; 2) the universality of cm; and 3) cm as an a priori or a posteriori concept. finally, the findings were transcribed as a questionnaire guide. the principal investigator (lz) interviewed each participant. the interview guide was designed to explore the participants' opinions and experiences with cm, notably how they understood and applied the cm concept. based on the responses, exploratory questions were asked to discover any deeper perspectives. for example, interviewees were asked to discuss various ethical topics and how they would resolve hypothetical medical ethics dilemmas, such as a mother's request for a non-medical abortion. does the interviewee defend the mother's autonomy by following western bioethics, or does he/she respect the life of the fetus to comply with jurisprudence? finally, the remaining subjects were searched, if any. the interviews were audio recorded, listened to several times, and then transcribed by the interviewer (the principal researcher). the tone of the interviewee (including surprise, anger and protest) was noted in the transcription if it affected the understanding of the concepts. units of the study thirteen faculty members with an average age of 46 and an average of 14 years of work experience were interviewed. the meaning unit of analysis consisted of any part of the cm-related transcript that could be coded under a category to represent a dialog on common morality in medical ethics in a pluralist setting in iran j. med. ethics. hist. med. 2023 (jun); 16: 3. 6 a single theme. table 1 shows the demographic data of the participants. data processing the principal interviewer (lz) transcribed all of the data. participants were anonymized using numbers. the data coding process was verified in two ways: a) the main researcher did the coding twice at an interval of six months, and b) two coresearchers did the coding separately. comparison of the results showed that these two methods did not produce significantly different results. the initial coding was accomplished manually by the principal researcher. the initial codes (tags) were grouped into categories in order to determine whether a coherent and meaningful pattern existed. this step was performed several times to avoid double selection, overlapping, or missing data and to ensure the re-coding or new coding of previously coded data. data analysis to interpret the data obtained from the interviews, the directed and conventional approaches of the content analysis technique were used sequentially. the directed approach analyzed the opinions and conceptualizations of the participants. the interview questionnaire guide was prepared based on the findings of the narrative review, as mentioned earlier. the theme of cm ontology was extracted from 4 categories: the existence of cm, the universality of cm, the relationship between cm and experience, and the relationship between cm and human sensory perception. in order to explore the interviewees' experiences with the concept, new categories were created inductively through the conventional approach, starting directly with the transcribed data to describe them. this coding approach led to the theme of cm epistemology based on the three categories of participants' moral intuition, moral reasoning, and moral decision-making. techniques to enhance trustworthiness in order to ensure trustworthiness, lincoln & guba's criteria (1985) were used (18). trustworthiness was maintained through: 1) the proper purposive snowball data sampling, prolonged interaction with data, appropriate meaning units, good data coverage of categories and themes, the consensus in researchers' codings, and peer debriefing by three faculty members (credibility of findings); 2) repeating the entire analysis process within six months with no significant change in the results (dependability of findings); and 3) interviews with experts in several fields from different academic centers who had diverse views and academic levels (transferability of findings). zahedi l., et al. 7 j. med. ethics. hist. med. 2023 (jun); 16: 3. this study is reported according to the “standards for reporting qualitative research (srqr) guideline (19). results thirteen faculty members from five disciplines (medicine, medical ethics, moral philosophy, islamic theology, and sociology) were interviewed. the male-to-female ratio was 1:6. the average age of the participants was 46 years and they had an average of 14 years of work experience. academic levels included: full professors, associate professors, assistant professors, and doctoral students. table 1 shows the demographic data of participants. table 1. demographic data of participants variable n (%) gender male famale 8 (61.5) 5 (38.5) expertise medical ethics medicine philosophy of ethics islamic theology social sciences 8 (61.5) 9 (69.2) 3 (23) 2 (15.3) 2 (15.3) academic level full professors associate professors assistant professors doctoral students 1 (7.7) 7 (53.9) 3 (23) 2 (15.3) work experience < 10 years 10 17 years more than 17 years 2 (15.3) 10 (76.9) 1 (7.7) in this study, a total of 374 initial codes were extracted from the interviews. after collapsing and clustering, two themes of cm ontology and cm epistemology were identified in seven categories. theme 1: cm ontology at first, a directed approach was adopted. the authors formulated questions from semi-structured interviews based on the narrative review findings. cm ontology was derived from participants' perspectives on cm in four categories: cm existence, cm universality, the relationship between cm and experience, and the relationship between cm and human sensory perception. the categories, subcategories and initial codes of the cm ontology are shown in table 2. a dialog on common morality in medical ethics in a pluralist setting in iran j. med. ethics. hist. med. 2023 (jun); 16: 3. 8 table 2. categories, subcategories and initial codes of cm ontology categories subcategories initial codes cm existence 1.cm as a reality 1. a reality dependent on an inner sense such as intuition 2. a reality dependent on an inner sense such as conscience 3. a reality dependent on an inner sense such as an innate virtuous nature 4. a reality dependent on an inner sense such as a common nature (fitrah) 5. a reality dependent on an inner sense such as reasoning 6. a reality dependent on an inner sense such as will 7. a reality dependent on external elements such as social moral norms 8. a reality dependent on external elements such as social health determinant s 2.cm as a fantasy 9. a fantasy due to its indetermina cy 10. a fantasy due to the zahedi l., et al. 9 j. med. ethics. hist. med. 2023 (jun); 16: 3. pluralist characteristi cs of the individual’s values 11. a fantasy due to dependence on the agent, the observer and their goals cm universality 1.cm as a generalizable concept 1. shared by all because it is intuitionoriented 2.cm as an un-generalizable concept 2. not shared by all because of the individual’s intentions and benefits that influence behavior more than morality 3. an unshared, individual, diverse and divergent concept because people create morality through their thoughts the relationship between cm and experience 1.cm as an a priori concept 1. self-evident and requiring no argument 2.cm as an a posteriori concept 2. influenced by cultures and subcultures 3. influenced by individual preferences the relationship between cm and human sensory perception 1.related to human sensory perception 1. related to rationality 2.outside of human sensory perception 2. related to fitrah 3. neither related to a dialog on common morality in medical ethics in a pluralist setting in iran j. med. ethics. hist. med. 2023 (jun); 16: 3. 10 rationality nor fitrah 1-1 cm existence in the literature, there are debates about whether cm exists as a pillar of human interactions or a variable non-real entity. participants approached this concept in the subcategories of "cm as a reality" and "cm as a fantasy". the first considered cm as a reality dependent on an internal sense (such as intuition, conscience, innate virtue, fitrah or common nature, reason and will), or dependent on external realities (such as moral norms or determinants of social health). other faculty members believed that cm was a fantasy because of its indeterminacy, the pluralistic nature of people's values, or its dependence on the moral agent, the observer, and their goals. in this regard, the participants stated: “human creation is based on the common nature (fitrah) that god placed in humans. therefore, cm is rooted in human nature.” [participant no. 3] “anything that conforms to the moral norms of the society is compatible with cm.” [participant no. 7] “cm depends on what the values mean to the person and what image of the values they have formulated in their mind.” [participant no. 10] 1-2 cm universality this category questions whether or how the cm concept can be generalized and discusses whether the principles of cm are applicable. uniformity, stability and completeness are other characteristics that express the generalizability of cm. two subcategories of "generalizable concept" and "non-generalizable concept" emerged from the participants' input. according to many participants, cm is a self-evident concept shared by all morally committed individuals. other participants conceived cm to be an ungeneralizable concept because it is influenced by many factors. in this regard, some of the participants’ comments were as follows: “cm is a universal concept because it involves philanthropy or the feeling of empathy that people feel for each other to increase human capacity, alleviate the suffering of others and create a sense of solidarity.” [participant no. 12] “commonality is merely an abstraction. in the real world, we have to constantly develop specifications about principles to reach an agreement across cultures." [participant no. 8] zahedi l., et al. 11 j. med. ethics. hist. med. 2023 (jun); 16: 3. "common values are equivalent to universal values. however, values are pluralistic because they are subjective.” [participant no. 9] 1-3 the relationship between cm and experience if an entity is related to experience, it is a posteriori concept, a relationship that an a priori concept lacks. thus, if the participants believed that cm was not influenced by experience, they considered it a pre-theoretical and a priori concept. if, however, they believed cm to be influenced by an individual's lived experiences and culture, they would consider it as posteriori. most of the participants thought that cm was an a priori concept. in this regard, some of the participants stated: “cm is a pre-cultural, pre-religious, pre-ritual, pre-geographical and pre-historical ethos that is common to all people.” [participant no. 13] “cm is self-evident and requires no argument; however, the weight of moral principles depends on the culture.” [participant no. 1] “moral propositions are not abstract because they have analytical presuppositions and are not independent. therefore, morality implies a social contract.” [participant no. 9] 1-4 the relationship between cm and human sensory perception while rationality and intuition are natural human sensory perceptions, religious beliefs are related to supernatural issues. compared to the narrative review, this category was uniquely identified from the two subcategories of cm's relationship with metaphysical and natural subjects. fitrah, which means the purity and innocence that muslims believe all human beings are born with, represents the relationship between cm and a supernatural entity; rationality, as human sensory perception, establishes this relationship with a natural subject. some of the participants associated cm with fitrah, while most connected it to rationality. in this regard, two of the participants stated: “human dignity is one of the important and comprehensive principles in all religions, especially islam. it is in accordance with rationality and is close to divine fitrah.” [participant no. 12] “cm is closely related to rationality, but religious stereotypes prevent the generalizability of its principles.” [participant no. 4] theme 2: cm epistemology at this point we conducted a conventional content analysis and inductively extracted new categories from the participants’ experiences with the concept. the theme of cm epistemology was derived and developed from the three categories a dialog on common morality in medical ethics in a pluralist setting in iran j. med. ethics. hist. med. 2023 (jun); 16: 3. 12 of moral intuition, moral reasoning and moral decision-making, resulting from the initial codes (table 3). table 3. categories, subcategories and initial codes of cm epistemology categories subcategories initial codes moral intuition moral foundations: 1. not inflicting harm 2. equity 3. loyalty 4. authority 5. purity 1. deciding according to justice, altruism and honesty 2. truthfulness, keeping promises, tolerance, recognizing others, giving dignity to man and humanity, sanctity of life, respect for nature, and attention to god affect decisions moral reasoning 1. respect for autonomy 1. avoiding religious stereotypes and following rationality 2. respect for religious instructions 2. not harming anybody because religious instructions prohibit it 3. respect for life 3. respecting personal choices to the extent that they do not harm others moral decisionmaking 1. pro-choice 1. acting according to the parents' will because they have the right to choose to have an abortion 2. pro-life 2. acting according to religious teachings, which consider abortion acceptable before the fourth month of gestation but forbidden thereafter 2-1 moral intuition thinking may either be a rapid, non-thinking process that is automatic and emotional, or a slow and deliberate one. the former emphasizes the importance of social and cultural influences, and the latter reflects the role of education. in this study, participants' impulsive, quick and unconsidered statements about moral principles expressed during the interviews were perceived as their moral intuitions and the equivalent of their cognitive moral foundations. based on haidt's social intuitionist theory of moral foundation (20), statements were classified into five subcategories: not inflicting harm, equity, loyalty, authority and purity. in this regard, one of the participants stated: “i make my decisions based on justice, altruism and honesty” [participant no. 2]. from this statement, the modules of “fairness” (for justice and honesty) and “loyalty” (for altruism) were extracted. “truthfulness, keeping promises, tolerance, recognizing others, giving dignity to man and humanity, the sanctity of life, respect for nature and attention to god are among the most influential principles in my decisions.” [participant no. 13]. zahedi l., et al. 13 j. med. ethics. hist. med. 2023 (jun); 16: 3. from this statement, the modules of “fairness” (for truthfulness), “loyalty” (for keeping promises, tolerance, recognizing others, and giving dignity to human beings and humanity), and “purity” (for the sanctity of life, respect for nature, and attention to god) were extracted. 2-2 moral reasoning moral reasoning establishes a relationship between the participant's moral intuition and moral action. in this research, three subcategories of respect for autonomy, respect for religious instructions, and respect for life were induced from the initial codes. in this regard, some of the participants stated: “in this type of decision, i consider many factors, including the mother's mental background, goals, and social circumstances.” [participant no. 9] “i do not accept at all the right to abortion based on the autonomy of the mother. this request is against the islamic philosophy.” [participant no. 10] “i respect personal choices as long as they don't hurt others.” [participant no. 5] 2-3 moral decision-making decision-making is a cognitive process that leads to a choice. therefore, the participant's reaction to a pregnant woman's request for a non-medical abortion is considered their decision. in this research, two subcategories of pro-life and prochoice were identified. below are the statements of two of the participants in this regard: “i follow the wishes of the parents because it is up to them whether to choose abortion or not.” [participant no. 4] “i make a decision from a jurisprudential point of view: haq al-nas says that we are obliged not to violate the rights (of the fetus).” [participant no. 2] discussion this qualitative study explored the main aspects of cm from a pluralist academic perspective in order to enhance insights into the concept of cm and its characteristics. in this study, the authors generated the two themes of ontology and epistemology of cm. the first was extracted from the participants' opinions, and the second from their experiences with cm. in an interdisciplinary manner, cm ontology was extracted from the participants’ comments, reflecting their philosophical viewpoints and the way they conceptualized cm. cm epistemology, on the other hand, was identified in their experiences with cm. experiences are related to social influences and are therefore explored in the field of social psychology. a dialog on common morality in medical ethics in a pluralist setting in iran j. med. ethics. hist. med. 2023 (jun); 16: 3. 14 cm is conceptualized as a set of universal norms shared by all morally committed individuals and is applicable to all people in all places (9). the integration of rawls' reflective equilibrium theory with the concept of human rights is one of the distinctive features of beauchamp and childress' theory (21). however, balancing and specification in reflective equilibrium ignite debates about the existence of cm and the validity of universal moral principles in terms of their independence. a debate about cm ontology ontology is the science of the existence of moral concepts and their general characteristics, a debate that shapes most of the history of philosophy (22 25). in this study, most cm proponents saw it as a universal reality, while most critics of cm saw it as a non-universal and non-fundamental illusion without reality. the former believed cm to be a reality dependent on an internal sense, such as intuition and conscience, or external elements, such as social health determinants (relative to their expertise). the latter regarded it as a fantasy because of its indeterminacy and dependence on the moral agent, observer, and their goals. in terms of the universality of cm, for some participants, cm was a universal concept because it is intuition-oriented. others called it a nonuniversal, individual and divergent concept because it is created by people’s thoughts, intentions and interests. as realists, beauchamp and childress defend the existence and universality of cm (26, 27). the two dimensions of existence and independence constitute the cornerstone of realism. however, non-realists typically reject realism by discarding one of these dimensions (28). moral relativists believe that the moral system has no unified definition due to the influence of interconnected sets of values, virtues, norms, procedures, identities, institutions, technologies and evolved psychological mechanisms that are formed through individual and cultural tendencies. (29). in contrast, universalists such as beauchamp and childress believe that some shared characteristics or qualities are mind-independent. their universalistic view has been criticized from various aspects. universal principles do not take into account cultural differences, the diversity of concepts associated with moral principles, and value judgments dependent on culture (30 34). attention is directed toward culturally-defined moral meaning systems. in this way, the generalizability of moral principles is denied due zahedi l., et al. 15 j. med. ethics. hist. med. 2023 (jun); 16: 3. to individual rights and individualistic views (35, 36). the variety of interpretations of principles highlights the role of the moral agent, an important aspect that is overlooked in beauchamp and childress’ cm theory (37). critics of this theory argue that even emotions influence moral judgments. beauchamp and childress' cm theory ignores the characteristics of a particular situation, for instance psychological considerations (38). the existence of implicit meta-ethical individual commitments that are not verbally discussed affects moral judgments (39). according to moral relativism, moral judgments and beliefs vary significantly across time and contexts, and their validity depends on the individual or culture. this view undermines universally agreed moral norms or values. moral relativists believe in the relativity of knowledge because all knowledge is dependent on the knowing mind (40). here, the presuppositions that lead to different processes of knowledge, namely experiences, become crucial. however, the logic of understanding remains the same (41). some experts believe that we know moral propositions in advance; they are called apriorists and discuss morality as an entity independent of experience, which is true only through thinking and reasoning (42). others think morality is a perception that comes from experience and empirical observations. in other words, the issue is whether morality is discovered or created. in this study, the participants discussed the relationship between cm and experience: some believed that cm is self-evident and does not require reasoning, while others thought that culture and individual preferences influence cm. researchers have recognized the same basic cognitive processes, the existence of limited universal values that are not linked to cultural preferences, and significant similarities in moral phenomena across various cultures (43 45). these findings contribute to the acknowledgment of cm as an a priori concept. however, many opponents of cm consider it an a posteriori concept due to individual and cultural factors influencing it. some say that genetics contributes to cultural learning in moral development (46). others have focused on the influence of psychological antecedents of behavior and emotional experiences, and the influence of emotions, situational variations and social perceptions in shaping moral judgment (47, 48). some have evaluated the role of attitudinal goals in behavioral responses and the relationship between moral reasoning or pro-social behaviors a dialog on common morality in medical ethics in a pluralist setting in iran j. med. ethics. hist. med. 2023 (jun); 16: 3. 16 and the underlying mechanism of protecting reputation or avoiding offending others (49, 50). from a cultural perspective, some who see cm as an a posteriori concept believe that moral traits are value-laden cultural entities (51), and others emphasize social factors such as the influence of intergroup attitudes and prior social beliefs that shape moral foundations (52). according to darwinian theory, the universal and common foundation of cm represents different stages of moral evolution and is related to rationality as a product of evolution by natural selection (53). however, some researchers suggest reconceptualizing beliefs such as "natural" or "intuitive" because they have have been unable to establish a relationship between intuitive or analytical thinking and supernatural beliefs. they believe that factors other than cognitive style help shape and maintain supernatural beliefs (54). in this study, some participants pointed to the relationship between cm and human sensory perception. they linked cm either to rationality as human sensory perception or to fitrah as a supernatural entity beyond human sensory perception. a debate about cm epistemology epistemology focuses on the nature of knowledge and evidence, the logic of knowledge justification, and types of inferences (55). in short, it deals with how we can learn about the outside world through inference (56), and connects the mind with reality. in this study, the interconnected set of moral intuition, moral reasoning and decision-making was identified and thematized as cm epistemology since justification is a fundamental concept of epistemology. the thinking process can either be a rapid, nonanalytical involuntary emotional process, or a slower, more deliberate and analytical one; the former highlights social and cultural influences, and the latter is a reflection of acquired knowledge and education. haidt believes that moral judgments are primarily driven by automatic emotional responses. they are spontaneous, intuitive, effortless and rapid. his social intuitionist model emphasizes the importance of social and cultural influences. (57). however, there is a slower and more deliberate, rule-based and effortful thinking process. (58). there are debates as to which one is more important or which one takes precedence over the other. haidt’s model presents five cognitive foundations: not inflicting harm, equity, loyalty, authority and purity, all of which guide moral intuition and emotional response (59). not inflicting harm and zahedi l., et al. 17 j. med. ethics. hist. med. 2023 (jun); 16: 3. equity are considered individualistic moral foundations because they highlight the rights of autonomous individuals; loyalty, authority and purity constitute binding moral foundations that focus on values related to sociality and spirituality and emphasize a collective focus on group cohesion (60, 61). as shown in table 4, these five foundations refer to a wide range of actions and virtues. table 4. actions and virtues attributed to the modules of the moral foundations theory (62) modules of moral foundation theory attributed actions and virtues not inflicting harm disliking pain, virtues of kindness, gentleness, nurturance, caring, empathy, synergy, peace, tranquility, security equity not cheating, virtues of fairness, altruism, justice, respecting rights, autonomy, human dignity loyalty avoiding betrayal, virtues of loyalty, patriotism, self-sacrifice for the group authority avoiding subversion, virtues of leadership and followership, deference to legitimate authority, respect for traditions, respect for religious values, tolerance purity avoiding degradation, virtues of disgust over depravity, striving to live, avoiding immoral activities, sacredness of life, being faithful to god conclusion cm theory is a cornerstone of medical ethics, but in practice, its role in medical decision-making is controversial. this study highlighted the relationship between the philosophical and sociopsychological dimensions of cm. two themes of cm ontology and cm epistemology were extracted from the interviews. these findings strengthen our insight into cm content in a pluralistic setting. the results showed that the basic concept of cm has multidisciplinary aspects that are pivotal in promoting cm understanding among consultants and decision-makers of medical ethics in pluralistic settings. more studies are needed to investigate the influence of cultural, social, theoretical, ideological and individual factors on the conceptualization of cm in medical ethics in iran. funding this study was part of ladannaz zahedi’s ph.d. dissertation in medical ethics entitled “common morality and intercultural issues” and was financially supported by the school of medicine, tehran university of medical sciences, tehran, iran. acknowledgements the authors gratefully acknowledge the participants in this study. conflict of interests a dialog on common morality in medical ethics in a pluralist setting in iran j. med. ethics. hist. med. 2023 (jun); 16: 3. 18 the authors declare that they have no known competing financial interests or personal relationships that could have influenced the work reported in this paper. references 1. annonymose. moral anti-realism. 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105: 105056. 70. ricou m, marina s. decision making and ethical reasoning in psychology. psychology in russia: state of the art 2020; 13(1): 2-10. ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________________________________________________________ contributors copyright © 2021 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e journal of medical ethics and history of medicine chairman and editor-in-chief: b. larijani professor, medical ethics and history of medicine research center, and endocrinology and metabolism research center, endocrinology and metabolism clinical sciences institute, tehran university of medical sciences, tehran, iran. email: larijanib@tums.ac.ir managing editor: p. salari associate professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. email: salari@tums.ac.ir associate editor: f. zahedi md, endocrinology and metabolism research center, endocrinology and metabolism clinical sciences institute, tehran university of medical sciences, tehran, iran. email: fzahedi@tums.ac.ir https://emri.tums.ac.ir/merg/item/16387 section editor: h. namazi assistant professor, medical ethics and history of medicine research center, and department of medical ethics, school of medicine, and department of history of medicine, school of persian medicine, tehran university of medical sciences, tehran, iran. email: hrnamazi@sina.tums.ac.ir chairman and editor-in-chief, managing editor, associate editor, section editor ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________________________________________________________ journal of medical ethics and history of medicine 2 contributors j med ethics hist med. 2021(december); 14: contributors. l. afshar associate professor, department of medical ethics, shahid beheshti university of medical sciences, tehran, iran. email: leilaafshar@sbmu.ac.ir n. bahrami associate professor, department of tissue engineering and applied cell sciences, school of advanced technologies in medicine, tehran university of medical sciences, tehran, iran. email:n-bahrami@sina.tums.ac.ir m. aghabarary assistant professor of nursing (by research), social determinants of health research center, alborz university of medical sciences, karaj, iran; department of nursing, school of nursing, alborz university of medical sciences, karaj, iran. email:m.aghabarary@abzums.ac.ir s. bazmi associate professor, forensic medicine specialist, medical ethics fellowship, medical ethics department, shahid beheshti university of medical sciences, tehran, iran. email: sh.bazmi@sbmu.ac.ir f. akrami post-doc researcher, medical ethics and law research center, shahid beheshti university of medical sciences, tehran, iran; expert of deputy of public health, ministry of health & medical education, tehran, iran. email:f.akrami@sbmu.ac.ir; email:akrami@health.gov.ir m.behshid assistant professor, phd in nursing education, medical education research center; academic member of medical surgical nursing department, school of nursing and midwifery; academic member of medical ethics department, academic member of medical education department, tabriz university of medical sciences, tabriz, iran. email:behshidm@tbzmed.ac.ir f. asghari professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. email: fasghari@tums.ac.ir f. borhani professor, shahid beheshti university of medical sciences, tehran, iran. email: faribaborhani@sbmu.ac.ir reviewers ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________________________________________________________ journal of medical ethics and history of medicine 3 j med ethics hist med. 2021(december); 14: contributors. contributors a. ebadi behavioral sciences research center, life style institute, nursing faculty, baqiyatallah university of medical sciences, tehran, iran. email: ebadi1347@bmsu.ac.ir m. kadivar professor, division of neonatology, department of pediatrics, children’s medical center, tehran university of medical sciences, tehran, iran. email: kadivarm@tums.ac.ir m. forouzandeh assistant professor, department of medical ethics, medical school, iran university of medical sciences, tehran, iran. email: foruzandeh.m@iums.ac.ir m. kasiri assistant professor, department of history, faculty of literature and humanities, university of isfahan, isfahan, iran. email: masoodkasiri@ltr.ui.ac.ir a. hashemi assistant professor of medical education, medical ethics department, school of medicine, iran university of medical sciences, tehran, iran. email: hashemi.a@iums.ac.ir m. khabaz mafinejad health professions education research center, education development center, department of medical education, tehran university of medical sciences, tehran, iran. email: m-mafinejad@tums.ac.ir s. joolaee ph.d. rn. msc. research ethics & regulatory specialist, department of evaluation and research services, fraser health authority, bc; researcher, ubc centre for health evaluation & outcome sciences (chéos), vancouver, bc; professor nursing care research center, iran university of medical sciences. tehran, iran. a. khorshidian dental research center, dentistry research institute, tehran university of medical sciences, tehran, iran. email: jddrc1@sina.tums.ac.ir email: jddrc1@sina.tums.ac.ir ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________________________________________________________ journal of medical ethics and history of medicine 4 contributors j med ethics hist med. 2021(december); 14: contributors. a. manookian associate professor, school of nursing and midwifery, and usern care (tums) office, school of nursing and midwifery, tehran university of medical sciences, tehran, iran. email: ar-manookian@sina.tums.ac.ir n. momeni dentist, phd candidate, department of medical ethics, school of medicine, tehran university of medical sciences, tehran, iran. email: n-momeni@farabi.tums.ac.ir m. mardani hamooleh nursing care research center, iran university of medical sciences, tehran, iran. email: mardanihamoole.m@iums.ac.ir a. monajemi mdphd, associate professor, department of philosophy of science and technology, institute for humanities and cultural studies, tehran, iran. email: monajemi@ihcs.ac.ir n. mehrdad msc, rn, phd, professor, endocrinology and metabolism research institute, tehran university of medical sciences, tehran, iran. email: nmehrdad@tums.ac.it s. nikfar department of pharmacoeconomics and pharmaceutical administration, school of pharmacy and evidence-based evaluation of cost-effectiveness and clinical outcomes group, pharmaceutical sciences research center (psrc), pharmaceutical management and economics research center (pmerc), the institute of pharmaceutical sciences (tips) and personalized medicine research center, endocrinology and metabolism clinical sciences institute, tehran university of medical sciences, tehran, iran. email: nikfar_sh@tums.ac.ir m. mobasher assistant professor, department of medical ethics and history of medicine, school of traditional medicine, kerman university of medical sciences, kerman, iran. n. nikpeyma phd, assistant professor, department of community health and geriatric nursing, school of nursing and midwifery, tehran university of medical sciences, tehran, iran. email: nnikpeyma@sina.tums.ac.ir email: m.mobasher@kmu.ac.ir ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________________________________________________________ journal of medical ethics and history of medicine 5 j med ethics hist med. 2021(december); 14: contributors. contributors m. noroozi assistant professor, department of medical ethics, school of medicine, iran university of medical sciences, tehran, iran. email: noroozi.mahshad@iums.ac.ir a. sadooghiasl phd assistant professor, nursing department, faculty of medical sciences, tarbiat modares university, tehran, iran. email: a.sadooghi@modares.ac.ir a. parsapour assistant professor, medical ethics and history of medicine research center, and department of medical ethics, school of medicine, tehran university of medical sciences, tehran, iran. email: aliparsa@tums.ac.ir s. saeidi tehrani assistant professor of medical ethics, department of medical ethics, school of medicine, iran university of medical sciences, tehran, iran. email: saeeditehrani.s@iums.ac.ir m. parsa assistant professor, medical ethics and history of medicine research center, and department of medical ethics, school of medicine, tehran university of medical sciences, tehran, iran. email: mparsa @sina.tums.ac.ir m. salehian nursing and midwifery care research center, mashhad university of medical sciences, mashhad, iran. department of operating room and anesthesiology, school of nursing and midwifery, mashhad university medical of medical sciences, mashhad, iran. email: salehianmr@mums.ac.ir s. poortaghi associate professor, nursing and midwifery school, tehran university of medical sciences, tehran, iran. email: spoortaghi@gmail.com e. shamsi gooshki associate professor, medical ethics and history of medicine research center, and department of medical ethics, school of medicine, tehran university of medical sciences, tehran, iran. email: shamsi@tums.ac.ir ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________________________________________________________ journal of medical ethics and history of medicine 6 contributors j med ethics hist med. 2021(december); 14: contributors. sm tabatabaei md. professor of psychiatry, roozbeh hospital and medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. email: smtabataba_md@yahoo.com s. tajalli nursing care research center, school of nursing and midwifery, iran university of medical science, tehran, iran. email: tajalli.s@iums.ac.ir n. yavari department of ethics in health sciences, school of medicine, isfahan university of medical sciences, isfahan, iran. email: ne.yavari@med.mui.ac.ir ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________________________________________________________ journal of medical ethics and history of medicine 7 j med ethics hist med. 2021(december); 14: contributors. contributors technical editor & reference editing & publication: s. khashaie msc. in medical genetics, department of medical ethics, school of medicine, tehran university of medical sciences, tehran, iran. email: jmehm@tums.ac.ir; j.med.ethics.hist.med@gmail.com english editor: s. esfahani email: shadiesfahani@gmail.com english editor: p. khashayar md. center for microsystems technology, imec and ghent university, gent-zwijnaarde 9052, belgium. email: patricia.kh@gmail.com english editor: elham safi phd. editor-in-chief of english academic publications; ph.d. in computer hardware engineering, university of toronto, canada. faculty of engineering, university of tehran alumni, tehran, iran. email: elham.safi@gmail.com article designer: zeinab karimi ma of linguistic, payame noor university, south-tehran; medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. email: zeinabkarimi@yahoo.com technical editor & reference editing & publication, english editors, article design jmehm-7-5 journal of medical ethics and history of medicine teaching endotracheal intubation on the recently deceased: opinion of patients and families azim mirzazadeh1, nima ostadrahimi2, seyedeh mojgan ghalandarpoorattar3, fariba asghari4* 1associate professor, department of internal medicine, imam khomeini hospital complex, tehran university of medical sciences, tehran, iran; 2resident, department of neurosurgery, imam khomeini hospital complex, tehran university of medical sciences, tehran, iran; 3resident, department of obstetrics & gynecology, tehran university of medical sciences, tehran, iran; 4associate professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. corresponding author: fariba asghari address: medical ethics and history of medicine research center, #23, shanzdah azar st.tehran, iran email: fasghari@tums.ac.ir tel: 98 21 66 41 96 61 fax: 98 21 66 41 96 61 received: 04 sep 2013 accepted: 16 feb 2014 published: 10 mar 2014 j med ethics hist med, 2014, 7:5 © 2014 azim mirzazadeh et al.; licensee tehran univ. med. sci. abstract this study was done to explore the views of patients and their companions concerning endotracheal intubation training on newly deceased patients and the necessity of obtaining their consent in this regard. in this cross-sectional descriptive analytical study, we used a questionnaire to collect data through structured interviews conducted by the researcher on patient discharge day. a convenient sample of over 18 year old patients hospitalized at a teaching hospital were enrolled, and after receiving patient consent, one of each patient’s companions was enrolled in the study as well. in this study, 150 of the approached patients agreed to participate (response rate = 85.0%); of those, 92 (61.3%) allowed their companions to be enrolled as well. eighty-three persons (55.3%) in the patient group and 68 persons (73.9%) in the companion group agreed to have endotracheal intubation training on their own bodies after death. among these consenting patients and companions, 75.9% (n = 63) and 91.2% (n = 62) believed it was necessary to acquire patient consent for this procedure. obtaining relatives’ consent was thought to be necessary by 69.9% (n = 72) of the patients and 72.1% (n = 49) of the companions, even when there was patient prior consent. therefore it seems that asking the patient’s consent for doing educational procedures on their dead body is crucial. keywords: endotracheal intubation, clinical education, informed consent, medical skills mailto:fasghari@tums.ac.ir j med ethics hist med 7:5 mar, 2014 jmehm.tums.ac.ir azim mirzazadeh et al. page 2 of 6 (page number not for citation purposes) introduction endotracheal intubation is a life saving medical skill that requires training and practice. one way to teach this skill is through performing it on intubation models. however, despite the significant advances in the design of models, they have limitations in improving the skills of medical students and residents. in one study, physicians who were trained using intubation models were shown to have lower success rates when compared to those who had practiced on animals and patients (1). endotracheal intubation training on newly deceased patients (eit/ndp) is practiced commonly (2-5), and studies have shown the success of this method in improving physicians’ skills and self confidence (6, 7); however, in terms of patient autonomy and dignity, the method comes with serious ethical issues that have been raised and discussed by bioethicists (811). respect for the beliefs and autonomy of patients and their families and considering their wishes are important to maintaining public trust in the medical profession. to date, several studies have examined the issue of consent for teaching intubation on one’s own or relatives’ bodies after death under supervision of a skilled trainer; in most of these studies, the majority of respondents have approved of the procedure provided that a formal consent is obtained from the deceased or their relatives (1215). at present, eit/ndp is practiced at teaching hospitals in iran without patient consent or informing their relatives, and there are no rules or guidelines for conducting such procedures on patients’ dead bodies. teaching medicine in inhumane ways is of little worth. practicing procedures on newly dead patients without their consent is a kind of deception and will reduce medical trainers’ moral sensitivity to respecting patients’ rights and putting patients’ best interest first. in iran paternalistic medicine is practiced. faculty members believe that talking to patients or their families about eit/ndp would worry them and very few of them would give consent. on the other hand, practicing intubation on newly dead bodies is helpful for providing safer care for patients who need to be intubated, and therefore some believe that it is better to train students in intubation using newly dead patients without obtaining patients’ or their families’ consent. it is worth mentioning that the human body is highly respected in the iranian-islamic culture, and practicing invasive procedures on the patient’s body even for educational purposes might be considered a sin. the lack of field studies around this issue in iran, as well as the importance of the matter and considerable cultural and religious differences between iran and western countries prompted us to explore the opinions of patients and their companions about teaching intubation on the recently deceased. methods study design and population: we conducted a cross-sectional study. the studied population was selected from over 18 year old hospitalized patients at the internal ward of a teaching hospital affiliated with tehran university of medical sciences and their companions from spring 2008 to summer 2010. survey content and administration: our data collection tool was a questionnaire designed based on the standardized one by hergenroeder et al. (13). their questionnaire contains questions to find out if patients and their families would permit endotracheal intubation training on themselves, if respondents would permit endotracheal intubation training on their family members, and if respondents felt permission should be obtained from the family of the deceased patient prior to performing endotracheal intubation training. we replaced the permission of the family with that of the patient and added a question regarding their attitude about the necessity of obtaining their family’s consent as well. the questionnaire consisted of 18 questions. in order to evaluate the validity of the questionnaire we back-translated the translated questionnaire into english and compared it with the original. as it was difficult to get access to patients for retesting the questionnaire, we could not test the reliability of our survey tool. to assess patients’ perception of the questionnaire and remove possible ambiguities, we ran a pilot of the first version with 10 patients. considering the high proportion of illiteracy among the patients admitted in this hospital, we gathered the data by structured interview. for every one of the participants the same interviewer read out the questions of the questionnaire and filled in the questionnaire based on their response. the interviewer was present on site two random days a week and approached all patients who were discharged that day. the companion was defined as one of the patient’s family members most informed of the disease process of the patient and the most involved in the patient’s decision making about treatment. since companions were asked about teaching intubation on the patient in case of death, we sought patients’ consent to enroll their companions. we excluded end stage cases with an expected survival of less than 6 months (according to their physician) and patients with reduced levels of consciousness (at the discretion of the interviewer). j med ethics hist med 7:5 mar, 2014 jmehm.tums.ac.ir azim mirzazadeh et al. page 3 of 6 (page number not for citation purposes) after obtaining patients’ and companions’ oral consent to participate in the study, first the interviewer thoroughly explained intubation and its importance in training students, the constant supervision of a skilled physician during the practice, and that this educational goal would not cause negligence of the medical team to save a patient’s life. the study protocol was approved by the research ethics committee of the tehran university of medical sciences. data analysis: to present results, we summarized our findings in mean and frequency percentage to describe data and used chi-square and correlation tests to assess the effect of different variables on the independent variables. results of the 176 approached patients, 85.0% (n = 150) agreed to participate, and 92 of them allowed their companion to be enrolled as well. all companions consented to participate in the study. in six cases, we had to interrupt the interview because the patient felt uncomfortable answering the questions. a summary of the respondents’ demographics are presented in table 1. table 1. demographics of the patients and companions participating in this study patients companions total number 150 92 mean age (standard deviation) 56.4 (16.9) 39.9 (11.9) sex n (%) men 64 (42.7%) 57 (62.0%) women 86 (57.3%) 35 (38.0%) education level n (%) illiterate 51 (34.0%) 0 (0.0%) primary school 54 (36.0%) 22 (23.9%) middle school 12 (8.0%) 30 (32.6%) high school 23 (15.3%) 21 (22.8%) college 10 (6.7%) 19 (20.7%) relation of companion to patient n (%) father 2 (2.2%) mother 3 (3.3%) child 67 (72.8%) brother 5 (5.4%) spouse 15 (16.3%) eighty-three (55.3%) of the patients and 68 (73.9%) of the companions agreed to eit on their own bodies under supervision of a skilled physician. however, when the bodies of their loved ones were concerned, 45.1% (n = 65) of the patients and 55.4% (n = 51) of the companions agreed to the procedure (table 2). half of the patients who were against eit/ndp on their relatives would consent to the procedure if they were aware of their beloved ones’ prior consent; this increased the percentage of agreeing people to two thirds of the total (71.5%). table 2. the opinions of patients and companions about endotracheal intubation training on newly deceased patients (eit/ndp) patients’ response companions’ response question yes no total yes no total agree to eit on own body under supervision of a skilled physician. 83 (55.3%) 67 (44.7%) 150 (100%) 68 (73.9%) 24 (26.1%) 92 (100%) agree to eit on a relative’s body under supervision of a skilled physician1. 65 (45.1%) 79 (54.9%) 144 (100%) 51 (55.4%) 41 (44.6%) 92 (100%) agree to eit on a relative’s body under supervision of a skilled physician, knowing that the deceased had consented to the procedure before death2. 38 (48.1%) 41 (51.9%) 79 (100%) 17 (41.5%) 24 (58.5%) 41 (100%) 1. companions were asked if they would agree to eit on patient’s dead body; 2. this question was asked if the response to the previous question was negative. in terms of allowing their companions to participate, the distribution of responses significantly differed between patients in favor of intubation and those against it. of the 83 patients who agreed to j med ethics hist med 7:5 mar, 2014 jmehm.tums.ac.ir azim mirzazadeh et al. page 4 of 6 (page number not for citation purposes) have eit on their own body, 72 patients (86.7%) allowed their companions to be interviewed, while only 32.8% (20/61) of those against it approved of their companions’ participation (p < 0.001). to examine the patient-companion response agreement in terms of intubating the patient in case of death, 70.8% (n = 51) of the companions of the 72 agreeing patients consented to the procedure, and if they knew the patient would consent, the rate increased to 78.5% (n = 63). we found no relationship between agreeing to eit on one’s own body and the age and gender of the patients or companions, but the rate significantly increased with higher education (p < 0.001) (table 3). table 3. association between patient and companion education and their approval of endotracheal intubation training (eit) on one’s own body. education response illiterate primary school middle school high school college total eit on one’s own body in case of death yes 28 (54.9%) 39 (51.3%) 25 (59.5%) 35 (79.5%) 24 (82.8%) 151 (%62.4) no 23 (45.1%) 37 (48.7%) 17 (40.5%) 9 (20.5%) 5 (17.2%) 91 (%37.6) total 51 (100%) 76 (100%) 42 (100%) 44 (100%) 29 (100%) 242 (%100) in terms of the necessity of obtaining patient prior consent for eit on their bodies after death, 42.4% of the patients and 26.1% of the companions found eit/ndp absolutely impermissible. among participants who thought eit/ndp was acceptable, 75.9% (n = 63) of the patients and 91.2% (n = 62) of the companions believed it should be done with prior consent from the patient. obtaining relatives’ consent was thought to be necessary by 69.9% (n = 72) of the patients and 72.1% (n = 49) of the companions, even when there was patient prior consent (table 4). table 4. the opinions of patients and companions about the necessity of obtaining informed consent from the patient or a relative for endotracheal intubation training (eit) on a newly deceased patient. patients’ response companions’ response all participants questions yes (%) no (%) eit should not be done (%) total (%) yes (%) no (%) eit should not be done (%) total (%) yes (%) no (%) eit should not be done (%) total (%) necessity of obtaining informed consent from the patient before death 63 (43.7) 20 (13.9) 61 (42.4) 144 (100) 62 (67.4) 6 (6.5) 24 (26.1) 92 (100) 125 (53.0) 26 (11.0) 85 (36.0) 236 (100) necessity of obtaining informed consent from patient's relatives if the patient had given consent 72 (50.0) 31 (21.5) 41 (28.5) 144 (100) 49 (53.3) 19 (20.7) 24 (26.0) 92 (100) 121 (51.3) 50 (21.2) 65 (27.5) 236 (100) discussion about half of the patients and two thirds of the companions agreed to have eit on their own bodies after death under the supervision of a skilled physician. more than eighty percent of the participants believed patient prior consent was necessary for teaching intubation on their own bodies after death, and two thirds of the participants believed relatives needed to consent to the procedure as well. our findings were very similar to those reported in similar studies such as the one by oman ks et al. conducted in colorado, usa in 2002 in which only 54% had agreed to eit on their own bodies (15); however, there are considerable differences in some other studies as well. for example, the study by hergenroeder et al. at the department of neurosurgery of texas university in 2007 included 108 patients and their families; 85% of them agreed to eit on their own bodies, and 76% agreed to the procedure being done on their relatives’ bodies (13). in the study by manifold et al. that was conducted in the united states in 1999, 280 patients and their families were included; 75% of them agreed to have the procedure on their own bodies, and 70% agreed to have it on their recently deceased relatives (14). compared to western countries, the rates of agreement to have eit on one’s own body and their relatives’ bodies are much lower among iranian patients and their relatives. we did not inquire after reasons for disapproval of the procej med ethics hist med 7:5 mar, 2014 jmehm.tums.ac.ir azim mirzazadeh et al. page 5 of 6 (page number not for citation purposes) dure; however, possible explanations could be cultural and religious views, differences in satisfaction with hospital service provision, lack of understanding of the importance of eit in improving physicians’ skills, or misconceptions of the procedure, thinking it might harm the corpse. in terms of the necessity of obtaining patient consent, more than one third of the participants believed eit was impermissible, and this is a considerably high rate. that is a major difference between our study and the one by hergenroeder et al. in their study, for the questions regarding the necessity of obtaining consent, participants had to choose yes or no while we added a third option to find out whether participants rejected eit/ndp regardless of obtaining permission. it seems some participants believe this procedure is dishonoring a muslim body and do not think that even patient’s consent could make it acceptable to perform eit/ndp. a direct relationship was observed between education and participants’ approval of eit/ndp, and this supports the role of education for proper understanding of the procedure and its effect on the corpse. similar to other studies, we found that the approval rate for eit on one’s relative’s body was lower than the approval rate for performing the same procedure on one’s own body. this difference could be due to the sense of ownership of one’s own body and more freedom to make decisions about it. in addition, emotional attachments do not allow people to approve of eit/ndp on their loved ones. thus, measures to obtain patients’ consent while they are capable of decision-making can increase their availability for this procedure rather than leaving the decision to their companions after their death. among those who found the procedure acceptable, more than eighty percent thought prior patient consent was necessary. if people witness physicians teaching procedures on the deceased without their prior consent, their trust in the medical profession would be at stake. in addition, relatives’ awareness of patients’ prior consent can increase the chances of their approval of the procedure and reduce the number of people who are strictly against it. we also observed that two thirds of those who approved of eit/ndp thought it was necessary to obtain both companion consent and patient consent. certain measures can be taken to increase cooperation in this regard, and make decision making easier for companions when the patient has already consented. one important measure is public education, which can improve patients’ knowledge of the nature of endotracheal intubation as a procedure that does not harm the corpse, and demonstrate the importance of teaching it to medical students. there should also be a means for official declaration of consent for teaching intubation on one’s own body similar to organ donor cards. in this study, most patients who were against intubation on their own bodies did not allow their companions to participate. this can explain why most companions agreed to teaching intubation on their own bodies, and thus, our results concerning companions are less generalizable. their favorable response could also be due to their better health status. we had to limit our study to one department only, because directors of other departments were concerned about the fear and anxiety that the study might cause in their patients. although the hospital was a referral one, generalizing results requires larger studies in other types of patients. reasons of disapproval were not investigated in this study. in addition, patients’ fear of medical procedures and the tangibility of the meaning of intubation can all affect patients’ responses, and it is necessary to study these variables in future investigations. larger studies on the reasons for disapproval of this procedure are recommended. conclusion based on the findings of the present study, the majority of patients and companions allow eit/ndp on their body, although they feel permission of both patient and companion should be obtained for this procedure. in order to respect patients’ autonomy, obtaining their consent is essential; however, it will not be easy if they do not have a correct concept of teaching procedures on their dead body. educational campaigns could help to improve their perception and persuade them to have an altruistic role in medical education. through establishing this public discourse, it would be much easier for health care workers to ask patients’ consent for eit/ndp. acknowledgments the authors wish to thank dr. shiva mehravaran for translation of the manuscript into english language. competing interests all authors declare having no conflict of interest. references 1. iserson kv. requiring consent to practice and teach using the recently dead. j emerg med 1991; 9: 509-10. 2. 2. stewart rd, paris pm, pelton gh, garretson d. effect of varied training techniques on field endotracheal intubation j med ethics hist med 7:5 mar, 2014 jmehm.tums.ac.ir azim mirzazadeh et al. page 6 of 6 (page number not for citation purposes) success rates. ann emerg med 1984; 13: 1032-6. 3. 3. denny cj, kollek d. practicing procedures on the recently dead. j emerg med 1999; 17: 949-52. 4. 4. fourre mw. the performance of procedures on the recently deceased. acad emerg med 2002; 9: 595-8. 5. 5. hudson ts. is it ethical to practice intubations on the deceased? jonas healthc law ethics regul 2000; 2: 22-8. 6. 6. benfield dg, flaksman rj, lin th, kantak ad, kokomoor fw, vollman jh. teaching intubation skills using newly deceased infants. jama 1991; 265: 2360-3. 7. 7. hatton kw, price s, craig l, grider js. educating anesthesiology residents to perform percutaneous cricothyrotomy, retrograde intubation, and fiberoptic bronchoscopy using preserved cadavers. anesth analg 2006; 103: 1205-8. 8. 8. burns jp, reardon fe, truog rd. using newly deceased patients to teach resuscitation procedures. n engl j med 1994; 331: 1652-5. 9. 9. goldblatt ad. don't ask, don't tell: practicing minimally invasive resuscitation techniques on the newly dead. ann emerg med 1995; 25: 86-90. 10. 10. iserson kv. law versus life: the ethical imperative to practice and teach using the newly dead emergency department patient. ann emerg med 1995; 25: 91-4. 11. 11. mcnamara rm, monti s, kelly jj. requesting consent for an invasive procedure in newly deceased adults. jama 1995; 273: 310-2. 12. 12. garnes mk, vassbo k, forde r. [intubation training on the deceased newborn--parents' opinion?]. tidsskr nor laegeforen 1999; 119: 39-41. [article in norwegian] 13. 13. hergenroeder gw, prator bc, chow af, powner dj. postmortem intubation training: patient and family opinion. med educ 2007; 41: 1210-6. 14. 14. manifold ca, storrow a, rodgers k. patient and family attitudes regarding the practice of procedures on the newly deceased. acad emerg med 1999; 6: 110-5. 15. 15. oman ks, armstrong jd, stoner m. perspectives on practicing procedures on the newly dead. acad emerg med 2002; 9:786-90. ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ original article copyright © 2021 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. journal of m edical ethics and h istory of m edicine applying ethical theories to the iranian health system governance: a critical empirical assessment *corresponding author amirhossein takian address: school of public health, pour sina st., qods st., keshavarz blvd., tehran, iran. tel: (+98) 21 42 93 32 25 email: takian@tums.ac.ir received: 13 sep 2021 accepted: 20 nov 2021 published: 8 dec 2021 citation to this article: bahmanziari n, mohammadi sm, takian a, arab m, harirchi i. applying ethical theories to the iranian health system governance: a critical empirical assessment. j med ethics hist med. 2021; 14: 23. najmeh bahmanziari1, seyed-mehrdad mohammadi2, amirhossein takian3,4*, mohammad arab4, iraj harirchi5 1.phd candidate in health policy, department of health management and economics, school of public health, tehran university of medical sciences, tehran, iran. 2.affiliated lecturer, department of health management and economics, school of public health, tehran university of medical sciences, tehran, iran; chair of public health law group, the institute for legal innovations, tehran, iran. 3.chair, department of global health & public policy, school of public health, tehran university of medical sciences, tehran, iran; chief research officer, health equity research center (herc), tehran university of medical sciences, tehran, iran. 4.professor, department of health management and economics, school of public health, tehran university of medical sciences, tehran, iran. 5.professor, department of general surgery, school of medicine, tehran university of medical sciences, tehran, iran. abstract the policies of health systems are inspired by ethical priorities. a critical review of policies can reveal the ethical theories/justice schools behind them. this study aimed to identify the ethical theory(ies) underpinning the iranian health system governance over the past 50 years. this was a qualitative study conducted in two stages during 2019. first, we identified and constructed the key concepts and distinctive notions of prominent ethical theories/justice schools. then, we spotted and selected 24 strategic laws and policy documents in the iranian health system governance during the past 50 years and analyzed their content to surmise their underlying ethical theory. the results showed that the dominant theory affecting the policies of the iranian health system governance over the past 50 years was egalitarian liberalism and then objective utilitarianism and relativist communitarianism. retrospective empirical application of ethical theories to health system governance is methodologically doable, and this application reveals the mood or priorities of the politics. also, highlighting the underpinning ethical theories of health system governance as well as the gap between ambitions versus realization are insightful and may prospectively empower and strengthen egalitarianism keywords: ethical theories; justice; health. applying ethical theories to the iranian health system governance … 2 j med ethics hist med. 2021(december); 14:23. journal of m edical ethics and h istory of m edicine introduction policymaking and governance of health systems are always influenced by ethical considerations and entail tensions and dilemmas. although issues such as justice, efficiency, social customs, human rights, and personal choice are taken into account in the adoption of health policies, these issues are rarely systematically analyzed. taken as an ethical endeavor, policy-making – be it health legislations, programs, or reforms – is inspired by, and maybe evaluated and based on, justice schools (1, 2). government officials always consider these ethical theories in their decisions, even if they are not explicitly aware of the concepts or do not clearly express them (3). the major justice schools or ethical theories behind health systems governance are utilitarianism, libertarianism, and communitarianism. while utilitarianism states that a certain policy should be judged based on its consequences, liberalism focuses on the people’s rights and opportunities for enjoying services. communitarianism, on the other hand, emphasizes the links between individuals and society and states that the judgment of general policies is influenced by the type of society and people that the government desires (4 6). we found no empirical study on this subject in international or iranian literature. in most studies, justice schools are presented theoretically and are illustrated by anecdotal examples of health systems' programs or policies. empirical studies that come closest to the subject are those on health system values, e.g., equity, efficiency, patient satisfaction, nondiscrimination, responsiveness, etc. (7 15). one study analyzed the “mega policies for health” and reported that egalitarianism was the dominant theory (16). another survey titled “maximization of health benefits vs. egalitarianism: an australian study of health issues” reported that policies of maximizing health benefits received little support when they led to unequal access of the elderly and vulnerable groups to healthcare services (17). events or developments such as “heath for all by 2000” of alma ata declaration”; the recent commitments to “universal health coverage (uhc)” in a 2018 united nations general assembly; the “national health service (nhs)” in the united kingdom; “medicare” in australia; and the “medicaid” and the “medicare” in the united states indicate a deep inclination towards egalitarianism in the health services of different countries and cultures over the past 70 years or so. the primary hypothesis of this study was that the ethical theory inspiring the iranian health system governance over the past 50 years has also been an intensified orientation towards egalitarian liberalism1. we aimed to analyze the content of the nation’s strategic laws and health policy documents to empirically identify the ethical theory/justice school governing the iranian health system. the study findings can augment and sharpen political analysis, steer the national 1 . the reader should be reminded that orientation and ambition may not mean actual realization. bahmanziari n., et al. 3 j med ethics hist med. 2021(december); 14: 23. journal of m edical ethics and h istory of m edicine conversations in the desired direction and enhance the accountability of policymakers. methods this qualitative study was conducted in 2019 based on a deductive approach to determine the ethical theory prevailing in the iranian health system governance. the method entailed four distinct tasks as follows. task 1: first, we shortlisted and chose a handful of main sources as our primary references on justice (2, 6, 18 24). reviewing these sources, we then established and standardized our concepts of the schools of justice as summarized in table 1. table 1 a summary of justice schools/ethical theories justice school/ethical theory description subjective utilitarianism this orientation compares and evaluates policies based on their total desirability level for all members of society. accordingly, the cost-benefit analysis (e.g., willingness to pay) is applied to determine the actions with the highest desirability level. the followers of this school are highly optimistic about personal choices and the compliance of social policies with public demands and decisions. objective utilitarianism according to this orientation, the decisions to improve public health should be taken objectively by a group of specialists. proponents of objective utilitarianism call for policies that bring the highest collective level of enjoyment of health services. they employ costeffectiveness analysis, e.g., dalys2, qalys3, and non-comprehensive measures such as infant mortality rate (imr) and survival rate as a result of interventions to investigate the options. libertarianism supporters of this orientation believe that only ‘negative’ rights4 need protection. these rights guarantee individual freedom so people can do what they want and others are not entitled to violate their choices. proponents of libertarianism emphasize the role of a limited government in protecting property rights and individual freedoms. some of them seriously oppose taxation for resource redistribution (they sometimes accept limited taxation for the provision of basic government services such as defense and security issues). egalitarian liberalism egalitarians believe that individual freedom and human dignity cannot be realized without basic resources and facilities. therefore, everyone has a positive right5 to enjoy a minimum level of services and resources needed to ensure relative equality of opportunities, freedom, basic needs and demands, and access to basic amenities. these points inevitably refer to the issue of “redistribution”, which is to the benefit of people who are deprived of even the lowest level of welfare. proponents of this school state that the government should be responsible for providing the minimum quality and quantity of living and health-care services for all people. universalist communitarianism universalist communitarians argue that there is a unique universal model for having good individuals and a good society. religious and non-religious examples such as monotheistic religions and the feminist movement can be classified to, at least partly, correspond with this school. relativist communitarianism relativist communitarianism identifies a wide range of cultural behaviors around the world and the extent to which people are influenced by these cultures. followers of this view believe that any society should determine its norms and methods of social organization. this group views ethics as an inherently contextual issue and does not 2 .disability-adjusted life years 3 . quality-adjusted life years 4 . these rights usually require no action, either legally or morally, in order to be achieved. 5 . these rights require an action in order to be achieved. applying ethical theories to the iranian health system governance … 4 j med ethics hist med. 2021(december); 14:23. journal of m edical ethics and h istory of m edicine believe in a global position outside a society to judge cultural traditions. further, we identified and standardized a distinctive notion for each school as presented in table 2. in this regard, we sought comments from three healthcare ethicists to ensure the credibility and dependability of the findings. table 2distinctive notions of each justice school/ethical theory justice school/ethical theory distinctive notion subcategory distinctive notion utilitarianism efficiency subjective utilitarianism personal choice objective utilitarianism the planning and decision-making initiatives by health authorities libertarianism rights libertarianism fundamental freedoms egalitarian liberalism fundamental welfare benefits/ entitlements communitarianism culture universalist communitarianism universal equality and fraternity relativist communitarianism community values task 2: based on multiple and numerous national and international norms and practices mentioned before, we assumed egalitarian liberalism to have been a universal component of health system governance in the past 70 years or so in all nations. however, we further recognized the difference not in the egalitarian inclination itself but in the depth of countries’ embrace of egalitarianism. for illustrative and taxonomic purposes, we developed an "egalitarian grid" as presented in figure 1. levels arm’s length embrace moderate embrace full embrace examples the us medicare australian medicare the uk nhs figure 1. the egalitarian grid: exemplifying the depth of the embrace of egalitarianism in the health system of countries task 3: the study was conducted on the strategic policy documents and laws of the iranian health system. famous strategic health policy documents and laws, such as “the mega policies for health”, “the sixth economic, social and cultural development plan of the islamic republic of iran act” (2017-2021), and “the 20-year vision document of the islamic republic of iran”, were purposively selected by four of the research team members who have more than two decades of experience in the iranian health system. we also systematically searched the keywords “health”, “public health”, and “health care” on the legal databases of the iranian parliament and the bahmanziari n., et al. 5 j med ethics hist med. 2021(december); 14: 23. journal of m edical ethics and h istory of m edicine “ministry of health and medical education (mohme)” to spot the strategic policy documents and laws in the past 50 years (i.e., since 1968). the guiding criteria for selecting the strategic health policy documents and laws were health or therapeutics-related decisions or acts by the “parliament”, the mohme, and the “expediency discernment council” with a long-term nature and national scope. task 4: using the deductive framework established in task 1 above, one of the authors, n bahmanziari, meticulously explored the content of the identified strategic health documents and laws section by section to determine the ethical undertones and implicit or explicit references to notions of justice as structured in table 2. before embarking on this task, n bahmanziari underwent a deep and iterative orientation and training exercise on the recognition of justice schools in official texts under sm mohammadi; sm mohammadi is the recognized authority in the field of justice in health policy. also, as a pilot, a sample of content was analyzed by n bahmanziari and the results were validated by sm mohammadi. at the end, all the processes and results were double-checked and approved by sm mohammadi and a takian. this research was approved by the ethics committee of the school of public health and paramedical sciences of tehran university of medical sciences (ethics code: ir.tums.sph.rec.1398.017). result doing task 3 of the methods section above, we found 24 strategic health policy-related documents and laws established in the past 50 years as summarized in table 3. it should be noted that some key ministerial or director general-level documents were also included. table 3strategic health policy documents and laws (25, 26) title reference of approval year the provision of medical services to government employees act (pmsgea) parliament 1972 the establishment of the ministry of social welfare act (emswa) parliament 1974 the social security act (ssa) parliament 1975 the constitution of the islamic republic of iran (ciri) assembly of experts for constitution 1979 the establishment of the mohme act parliament 1985 the organizations and duties of the mohme act parliament 1988 the first economic, social and cultural development plan of the islamic republic of iran act (the chapter related to health) parliament 1989 the second five-year economic, social and cultural development plan of the islamic republic of iran act (the chapter related to health) parliament 1994 public health insurance act (phia) parliament 1994 the third economic, social and cultural development parliament 2000 applying ethical theories to the iranian health system governance … 6 j med ethics hist med. 2021(december); 14:23. journal of m edical ethics and h istory of m edicine title reference of approval year plan of the islamic republic of iran act (the chapter related to health) strategic policies of the mohme in the third development plan mohme 2001 organizing health-care services based on articles 3, 29, and 43 of the ciri act parliament 2002 the 20-year vision document of the islamic republic of iran (20-yvdiri) expediency discernment council 2003 the fourth economic, social and cultural development plan of the islamic republic of iran act (the chapter related to health) (fescdpiri) parliament 2004 the national document for the development of the health sector, the fescdpiri mohme 2004 the structure of the comprehensive system of welfare and social security act (lscswss) parliament 2004 the fifth economic, social and cultural development plan of the islamic republic of iran act (2011 2015) (the chapter related to health) parliament 2010 the comprehensive scientific health map (cshm) specialized committee of health and life sciences of the supreme council of the cultural revolution, mohme 2010 the health system transformation map based on the iranian-islamic progress model (hstmbiipm) policy council of the mohme 2011 mega policies for health (mph) supreme leader’s commands, expediency discernment council 2014 the health system transformation plan directive (hstpd) deputy for medical services, mohme 2014 the family physician and rural insurance program directive – version 18 (fpripd) deputy for health, mohme; iran health insurance organization 2016 the sixth economic, social and cultural development plan of the islamic republic of iran act (2017 2021) (the chapter related to health) (sescdpiri) parliament 2017 obligations of the health insurance organization of iran to cover and provide health insurance services cabinet 2017 we identified 73 distinct sections/articles/paragraphs/notes related to macro health policymaking in these 24 laws/documents that referred to justicerelated concepts either directly or indirectly (table 4). some referred to more than one orientation or theme (table 5). table 4analysis of the strategic health policy documents and laws title section/article /paragraph/note ethical theories/justice schools pmsgea article 1 note 3; article 10 libertarianism; egalitarian liberalism emswa article 1 paragraphs a and d egalitarian liberalism ssa article 1 egalitarian liberalism ciri chapter 1 article 3; chapter 3 article 29; chapter 4 article 43 egalitarian liberalism, relativist communitarianism; egalitarian liberalism; egalitarian liberalism, libertarianism, relativist communitarianism bahmanziari n., et al. 7 j med ethics hist med. 2021(december); 14: 23. journal of m edical ethics and h istory of m edicine title section/article /paragraph/note ethical theories/justice schools the establishment of the mohme act article 1; article 3 objective utilitarianism, egalitarian liberalism; relativist communitarianism the organizations and duties of the mohme act article 2; article 6; article 7 egalitarian liberalism; objective utilitarianism, egalitarian liberalism; egalitarian liberalism the first economic, social and cultural development plan of the islamic republic of iran act (the chapter related to health) section 1 part b – 6 egalitarian liberalism the second fiveyear economic, social and cultural development plan of the islamic republic of iran act (the chapter related to health) single article note 94; section 2 article 1 egalitarian liberalism phia articles 4, 5, 9, 11, 12, 14 egalitarian liberalism the third economic, social and cultural development plan of the islamic republic of iran act (the chapter related to health) chapter 5 article 36; chapter 25 article 192 egalitarian liberalism; objective utilitarianism, egalitarian liberalism strategic policies of the mohme in the third development plan article 4 egalitarian liberalism organizing health-care services based on articles 3, 29, and 43 of the ciri act single article egalitarian liberalism, objective utilitarianism 20-yvdiri vision paragraph; social, political, defense and security affairs paragraph article 12 egalitarian liberalism, libertarianism, relativist communitarianism fescdpiri section 3 article 89; article 90; article 91 egalitarian liberalism, objective utilitarianism the national document for the development of the health sector, the fescdpiri prevention and reduction of poverty and deprivation paragraph; promoting health and improving the quality of life and preserving the environment toward sustainable development paragraph egalitarian liberalism lscswss article 1; chapter 2 article 6 egalitarian liberalism the fifth economic, social and cultural development plan health article 32; health article 34; health insurance article 38 egalitarian liberalism, objective utilitarianism; egalitarian liberalism; egalitarian liberalism, objective utilitarianism applying ethical theories to the iranian health system governance … 8 j med ethics hist med. 2021(december); 14:23. journal of m edical ethics and h istory of m edicine title section/article /paragraph/note ethical theories/justice schools of the islamic republic of iran act (2011 2015) (the chapter related to health) cshm important messages and value principles paragraph; health system performance index paragraph egalitarian liberalism, relativist communitarianism; egalitarian liberalism hstmbiipm values paragraph; justice paragraph egalitarian liberalism, objective utilitarianism, relativist communitarianism mph article 7; article 8; article 9; article 10 objective utilitarianism; objective utilitarianism; egalitarian liberalism, subjective utilitarianism, objective utilitarianism; egalitarian liberalism, objective utilitarianism hstpd directive for the program to reduce the out of pocket payment of patients admitted to mohme-affiliated hospitals article 2; article 3; article 4; article 5; directive for the program to support the physicians’ retention in the underserved areas article 2; article 3; directive for the program of residence of the attending specialists in mohme-affiliated hospitals article 2; article 3; article 4; directive for improving the quality of patients' visit services in mohmeaffiliated hospitals article 2; article 3; directive for the program of hoteling quality improvement in mohmeaffiliated hospitals article 2; article 3; directive for the program of financial protection of patients with incurable or special diseases, and needy patients article 2; article 3; article 5; directive for the program of natural childbirth promotion article 2; article 3; article 4 egalitarian liberalism; egalitarian liberalism; egalitarian liberalism; egalitarian liberalism; egalitarian liberalism, objective utilitarianism; egalitarian liberalism, objective utilitarianism; egalitarian liberalism; egalitarian liberalism; egalitarian liberalism, objective utilitarianism; objective utilitarianism; objective utilitarianism; objective utilitarianism; objective utilitarianism; egalitarian liberalism; egalitarian liberalism; egalitarian liberalism; objective utilitarianism; egalitarian liberalism; egalitarian liberalism, objective utilitarianism fpripd introduction; article 1; article 45; article 46; article 61 egalitarian liberalism, objective utilitarianism; egalitarian liberalism, objective utilitarianism; egalitarian liberalism; egalitarian liberalism; egalitarian liberalism, objective utilitarianism sescdpiri section 14 article 70; section 14 article 72; section 14 article 74; section 4 article 25 objective utilitarianism; objective utilitarianism; egalitarian liberalism, objective utilitarianism; objective utilitarianism obligations of the health insurance organization of iran to provide and cover insurance services article 1 egalitarian liberalism bahmanziari n., et al. 9 j med ethics hist med. 2021(december); 14: 23. journal of m edical ethics and h istory of m edicine table 5analysis of the strategic health policy documents and laws: a selection title section/article /paragraph/note ethical theories/justice schools ciri chapter 3 nation’s rights, article 29 to enjoy social security and benefits for retirement, unemployment, old age, workers’ compensation, lack of guardianship, destitution, accidents, emergencies, and health and medical treatments through insurance, etc. is a universal right. in accordance with the law, the government is obligated to use the proceeds from the national income and public contributions to provide the abovementioned services and financial support for each and every one of the citizens. fundamental welfare benefits/entitlements the organizations and duties of the mohme act 6 planning for the equitable distribution of manpower and other facilities (medical education and health facilities) throughout the country with emphasis on fulfilling the priorities of health programs and meeting the needs of underserved areas. the planning and decision-making initiatives by health authorities; fundamental welfare benefits/entitlements 20-yvdiri social, political, defense and security affairs: 12 efforts should be made to achieve social justice, provide equal opportunities, and promote indices such as education, health, food supply, increased per capita income, and fight against corruption. fundamental welfare benefits/entitlements; fundamental freedoms; community values mph 9 quantitative and qualitative development of health insurances aiming at: 9-1providing universal basic health insurance. 9-2covering all basic treatment needs for all members of the community and reducing out-of-pocket payments so that patients will have no concern other than the suffering due to their disease. 9-3provision of services beyond basic insurance by supplementary insurance companies within the framework of transparent legal instructions to always maintain a desirable quality of basic medical services. 9-4determining a package of comprehensive health services covered by both the basic and supplementary insurances under the ministry of health and medical education, overseeing the purchase of these packages by the insurance system, and supervising the correct distribution of the packages by eliminating unnecessary measures and costs in the process of testing, diagnosis and treatment. 9-5strengthening the competitive market for health insurance services. 9-6developing evidence-based and value-added tariffs for healthcare services with the same real technical right for governmental and non-governmental sectors. fundamental welfare benefits/entitlements; the planning and decision-making initiatives by health authorities; personal choice the data presented in chart 1 indicates that the most dominant theories in policies of the iranian health system over the past 50 years were egalitarian liberalism and then objective utilitarianism and relativist communitarianism. among the reviewed documents, the “health system transformation plan directive” referred to applying ethical theories to the iranian health system governance … 10 j med ethics hist med. 2021(december); 14:23. journal of m edical ethics and h istory of m edicine egalitarian liberalism and objective utilitarianism 14 and nine times, respectively. in the next position was the “mega policies for health” document, which mentioned objective utilitarianism, egalitarian liberalism, and subjective utilitarianism four, two, and one times, respectively. lastly, the ciri, phia, the 20yvdiri, and the fourth, fifth, and sixth economic, social and cultural development plans referred to these concepts more than the other reviewed documents. phia referred to concepts of egalitarian liberalism six times, the ciri and the 20-yvdiri referred to concepts of egalitarian liberalism three times, relativist communitarianism two times, and libertarianism one and two times, respectively. the development plans of the islamic republic of iran also discussed concepts related to egalitarian liberalism and objective utilitarianism. chart 1frequency distribution and percentage of justice schools/ethical theories mentioned in the reviewed documents and laws discussion this study aimed to explore the ethical undertones of the iranian health system governance over the past 50 years and test the hypothesis that egalitarian liberalism has been the dominant undertone. although there have been previous attempts at characterizing the inclination of a health system’s justice schools, there has been neither a prior attempt at developing a robust measurement instrument for such characterization (as presented in tables 1 and 2 above), nor a comprehensive and systematic assessment of the main health policy documents. also, most similar studies have focused on social values and principles of medical ethics (7, 8, 10, 12, 16, 27). our findings confirmed that the most egalitarian liberalism, 62, 60% libertarianism, 4, 4% objective utilitarianism, 29, 28% subjective utilitarianism, 1, 1% relativist communitarianism , 7, 7% universalist communitarianism, 0, 0% egalitarian liberalism libertarianism objective utilitarianism subjective utilitarianism bahmanziari n., et al. 11 j med ethics hist med. 2021(december); 14: 23. journal of m edical ethics and h istory of m edicine dominant justice school/ethical theory in policies of the iranian health system over the past 50 years was indeed egalitarian liberalism, as 60% of the concepts mentioned in documents and laws were related to this justice school/ethical theory. objective utilitarianism and relativist communitarianism ranked second and third by capturing 28% and 7% of the concepts. one study reviewed the document of “mega policies for health” and identified egalitarianism as its dominant theory. they also stated that policy-making in the field of health and life sciences based on the islamic culture necessitates the existence of social justice in the light of divine morality (16). others also believe that the principles of the iranian health system are influenced by religious values (11). some experts emphasize the effects of political and cultural systems on health services, for instance, the profound impact of religion on reproductive and sexual health services in islamic states (e.g., iran, afghanistan, saudi arabia, and malaysia) (28). our findings demonstrated that islamic norms and values were also among the main concepts taken into account in the health legislation. by contrast, one study in singapore reported that the philosophy behind healthcare services in that context was a combination of free-market principles and strict governmental control, that is to say, the government usually avoids a completely egalitarian welfare orientation in favor of the free market, but recognizes the failure of the health free market to intervene in the health system whenever necessary (29). among the reviewed documents, the “health system transformation plan directive” mentioned egalitarian liberalism and objective utilitarianism 14 and nine times, respectively. in the next rank was the “mega policies for health” document, which referred to objective utilitarianism, egalitarian liberalism, and subjective utilitarianism more frequently than the other reviewed documents. finally, the ciri, phia, the 20-yvdiri, and the fourth, fifth, and sixth economic, social and cultural development plan of the islamic republic of iran (see table 3) referred to these concepts more than the other documents and laws. it is noteworthy that phia solely referred to concepts of egalitarian liberalism. a similar study in iran showed that policy documents emphasize or refer to some values either explicitly or implicitly. they found that “the health system transformation map” was the most comprehensive document emphasizing the values, and “justice” was the most common term repeated in the reviewed documents (10). the study of the nature and quality of the ethical framework in 24 canadian health strategy documents (from 1998 to 2005) reported that the ethical framework contained in the documents was generally restricted to a list of principles and values that only differed in justification, coherence, content and form, and played a decorative rather than a fundamental and developmental role (27). the study of schroder-back et al. also showed that the health strategy of the european union is barely documented in scientific literature, and no specific attention has been given to applying ethical theories to the iranian health system governance … 12 j med ethics hist med. 2021(december); 14:23. journal of m edical ethics and h istory of m edicine its value base. they concluded that a theory of well-being is needed on a more general level for effective policy-making (30). although we based our assessment of the inclination of the health system governance in the last 50 years on the mainstream legal and policy developments in this latter period, the existing policy context should not be ignored. laws such as “the medical, pharmaceuticals and foodstuff affairs act (1955)” and “the methods of prevention of contagious and sexually transmitted diseases act (1941)” would necessarily shift the national policies and programs of the latter 50-year period. as mentioned earlier, this research proved that the ethical theory governing the iranian health system over the past 50 years has been orientated towards egalitarian liberalism – as the perennial theme – mixed with objective utilitarianism and relative communitarianism – as the more recent trends. in spite of this very strong political consensus, there has been a big gap between ambition and real achievement in the past decades. only recently has the coverage been nearly attained, thanks to the hstp and “iran health insurance organization” (31, 32), but in terms of the out-of-pocket component of the uhc, we are dealing with a stubborner situation and have a long challenging way ahead (33 35). finally, it is worth noting that health system reforms such as the family physician program and the health services referral system have been frequent themes in a number of strategic documents in the past three decades without real actualization. the absence of specific laws and policy documents for some actual reforms and fundamental changes in the iranian health system was a major issue. for example, the iranian phc initially rolled out in the 1980s, although its enormous implications about the populations’ healthcare lacked a formal legislative or cabinet regulation source in its inception. for that reason, despite its enormous relevance to this research, it does not appear as an entry in table 3. also, a number of strategic health policy documents including the “social security act (1975)” – that now supports coverage of more than 44 million iranians – and “the health network system” – that now covers all iranians in some form or shape – constitute the most conspicuous forms and symbols of uhc in the iranian health system. however, such weighting or grading has not been adopted in this research method. conclusion the study results showed that the dominant ethical theory/justice school in the iranian health system governance over the past 50 years has been egalitarian liberalism. however, the undertones of objective utilitarianism and relativist communitarianism have also been present. data shows that despite the ambition, we are far from the realization of egalitarianism. highlighting the strong inclination of the health system towards egalitarianism should have an enabling role in its political realization too. this may enhance a political push for a higher gross domestic product (gdp) share of healthcare, other attempts at a single-payer national insurance plan, bahmanziari n., et al. 13 j med ethics hist med. 2021(december); 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[cited dec 2021]; available from: https://nih.tums.ac.ir/upfiles/documents/9cc6019b-5412-4dfb-a04a0ea752cd9e4c.pdf https://rc.majlis.ir/fa/law/search https://behdasht.gov.ir/ https://nih.tums.ac.ir/upfiles/documents/585cfa1d-0861-4bc3-9db9-21cb553bb826.pdf https://apps.who.int/gho/data/node.imr https://nih.tums.ac.ir/upfiles/documents/de465f9a-fb45-4af9-9119-f62b075290d8.pdf https://nih.tums.ac.ir/upfiles/documents/de465f9a-fb45-4af9-9119-f62b075290d8.pdf abstract introduction references occupational therapists 174minoo kalantari journal of medical ethics and history of medicine original article perception of professional ethics by iranian occupational therapists working with children minoo kalantari1, mohammad kamali2*, soodabeh joolaee3, mehdi rassafiani4, narges shafarodi5 1 phd candidate in occupational therapy, department of occupational therapy, school of rehabilitation sciences, iran university of medical sciences, tehran, iran; 2 associate professor, department of rehabilitation management, school of rehabilitation sciences, iran university of medical sciences, tehran, iran; 3 associate professor, center for nursing care research, school of nursing & midwifery, iran university of medical sciences, and iranian academy of medical sciences, tehran, iran; 4 associate professor, pediatric neuro-rehabilitation research center, department of occupational therapy, university of social welfare and rehabilitation sciences, tehran, iran; 5 assistant professor, school of rehabilitation sciences, department of occupational therapy, iran university of medical sciences, tehran, iran. corresponding author: mohammad kamali address: mirdamad blvd, madar sq, shahnazari st., nezam st., school of rehabilitation sciences, tehran, iran. email: kamali.mo@iums.ac.ir tel: 98 21 22221577 fax: 98 21 22220946 received: 01 sep 2014 accepted: 19 may 2015 published: 23 may 2015 j med ethics hist med, 2015, 8:8 © 2015 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract ethics are related to the structure and culture of the society. in addition to specialized ethics for every profession, individuals also hold their own personal beliefs and values. this study aimed to investigate iranian occupational therapists’ perception of ethical practice when working with children. for this purpose, qualitative content analysis was used and semi-structured interviews were conducted with ten occupational therapists in their convenient place and time. each interview was transcribed and double-checked by the research team. units of meaning were extracted from each transcription and then coded and categorized accordingly. the main categories of ethical practice when working with children included personal attributes, responsibility toward clients, and professional responsibility. personal attributes included four subcategories: veracity, altruism, empathy, and competence. responsibility toward clients consisted of six subcategories: equality, autonomy, respect for clients, confidentiality, beneficence, and non-maleficence. professional responsibility included three subcategories: fidelity, development of professional knowledge, and promotion and growth of the profession. findings of this study indicated that in iran, occupational therapists’ perception of autonomy, beneficence, non-maleficence, fidelity and competence is different from western countries, which may be due to a lower knowledge of ethics and other factors such as culture. the results of this study may be used to develop ethical codes for iranian occupational therapists both during training and on the job. keywords: occupational therapy, professional ethics, children mailto:kamali.mo@iums.ac.ir j med ethics hist med 8:8 may, 2015 jmehm.tums.ac.ir minoo kalantari et al. page 2 of 8 (page number not for citation purposes) introduction competence and sufficiency in a profession is a combination of knowledge, skill and conduct. knowledge and skill are formed through professional education, experience and continued learning, but these factors are not the sole requirements for creating a capable and reliable therapist. a therapist should behave in a way that would promote and maintain the welfare of the society and protect the reputation of employers and the profession (1). rapid scientific and technological advances in health sciences have influenced research related to occupational therapy. meanwhile, one important concern is the graduates’ ability to think critically and make decisions based on correct values and professional ethics (2). therefore, occupational therapy associations and boards in different countries have described core values and professional ethics according to their culture and needs (3-6). values are a set of beliefs to which an individual is committed, and form an important part of any profession. moreover, actions and attitudes are the reflections of individual values. attitudes are our tendencies in giving positive or negative responses to an object, individual, concept or situation. all professional actions and interactions, therefore, originate from values and beliefs (3). although there are specific professional values in every line of work, individuals also hold their own personal beliefs and values. ethics are related to the structure and culture of the society (7), and provision of occupational therapy services without a link to the values and needs of the community is detrimental to the clients in the long run (8). in order to develop appropriate ethical codes and professional behavior in the field of occupational therapy in iran, the elements of ethics and ethical practice must be identified from the points of view of iranian occupational therapists. occupational therapists work with different age groups that may suffer from physical, mental or social disabilities or limitations. children are very vulnerable due to their age and decision-making capacity (9). the present study aimed to describe iranian occupational therapists’ perception of professional ethics when working with children. method this study was conducted using a conventional qualitative content analysis. ethical issues and implications of ethical practice in pediatric occupational therapy were investigated based on the experiences of iranian occupational therapists. it should be added that qualitative content analysis is a method for subjective interpretation of written content through a process of systematic classification of codes and determination of themes and patterns (10). setting and participants participants in this study included ten (5 female and 5 male) iranian occupational therapists selected by purposeful sampling. two of the occupational therapists were phd students, three of them had master’s degrees, and the remaining five had bachelor’s degrees in occupational therapy. all participants had between 6 and 25 years of experience in working with children. in selecting the participants, we tried to consider maximum diversity in gender, work experience, academic degree and workplace. all participants took part in this study voluntarily. one of the participants worked in a hospital, one in a school for special education, two in centers of the state welfare organization, four in private clinics, and two in university clinics. four participants also provided home care services. the study was conducted between 2013 and 2014 in tehran, iran. data collection data were collected through a total of 11 semistructured interviews with ten participants at their workplaces. duration of interviews varied between 30 and 60 minutes. research goals were explained to the participants before the interviews, and their written informed consent was obtained. participants were encouraged to share their experiences of professional ethics in pediatric occupational therapy, and then exploratory questions were asked for more detailed information. interviews continued until data saturation, that is, until the data were repeated and no new information emerged. ethical considerations the present study was approved by the ethics committee of iran university of medical sciences. after providing the necessary information, written informed consent was obtained from all participants. consent was also obtained for recording the interviews. participants were assured that the data would be kept confidential, and the interviews were coded accordingly. the participants were told that they had the right to withdraw from the study at any time. data analysis recorded interviews were transcribed and then analyzed using a content analysis approach. each interview was double-checked by coauthors, and units of meaning were extracted and then coded and categorized. the analysis process was repeated upon addition of each interview and the codes and categories were modified (10). in this study, credibility, dependability and confirmability measures were used in order to determine accuracy. for this purpose, prolonged engagement was attained by dedicating approximately 6 months to performing interviews and obtaining codes. diversity in participants was another measure that was employed to enrich data, and therefore participants with j med ethics hist med 8:8 may, 2015 jmehm.tums.ac.ir minoo kalantari et al. page 3 of 8 (page number not for citation purposes) different academic degrees and job experiences were selected from various settings. the participants were allowed to review their transcribed interviews to help them maintain consistency. during several meetings our research team members modified and revised the extracted codes until reaching a consensus, and for external check, an expert occupational therapist, who was familiar with both qualitative research and working with children, reviewed the results in the context. results three categories were extracted in connection with ethical practice when working with children: personal attributes, responsibility toward clients, and professional responsibility. each category included some subcategories (12 subcategories in total), which described specific aspects of ethical practice when working with children (see table 1). table 1categories and subcategories extracted from the participants’ responses categories subcategories personal attributes veracity altruism empathy competence responsibility toward clients equality respect for clients confidentiality autonomy non-maleficence beneficence professional responsibility fidelity development of professional knowledge promotion and growth of the profession personal attributes the subcategories of personal attributes are as follows: 1) veracity our participants believed veracity to be of high importance in providing services. truthfulness with clients and their family members, providing realistic information, avoiding deception and creating unrealistic expectations were among the ideas mentioned by most participants. one occupational therapist said: “i realized that i should be honest if i want to be effective. this is the ethical rule of veracity.” [occupational therapist 6] some occupational therapists preferred veracity over their financial interests when expressing the prognosis. one participant said: “at times, i have had to explicitly tell the kid’s prognosis to the mother, even though i knew that she might not bring her kid to the clinic again.” [occupational therapist 2] 2) altruism the participants believed that it was one of the personal attributes of a good occupational therapist to do their job in any condition and provide appropriate services even when there is no supervision. one occupational therapist said: “sometimes i was not in a good mood, but i provided all services as if someone was supervising me. it was very important for me. i adhere to ethical principles.” [occupational therapist 2] 3) empathy the participants pointed out that understanding the family, considering their financial situation and helping them were among the personal attributes of an occupational therapist. one of our participants said: “i have tried to develop empathy with them and help them as far as i could, and to give a discount if they had financial problems. i have received nothing for some sessions.” [occupational therapist 5] 4) competence the participants believed that occupational therapists should keep their professional knowledge current, as this depicts their competence for providing therapeutic interventions. “sufficient knowledge of therapeutic interventions is very important because the negative consequences of mistakes in interventions may be much more irrecoverable in children than in adults. occupational therapists should have up-to-date information.” [occupational therapist 10] definition of competence, however, seemed to be different for each participant. on the subject of recruiting students in private clinics before their graduation, one occupational therapist said: “if supervised, students in their final semester can work because 8th semester students have enough experience to work.” [occupational therapist 9] responsibility toward clients this category mainly focuses on ethical practice by way of equality, respect for clients, confidentiality, autonomy, non-maleficence, and beneficence. 1) equality non-discrimination in provision of services was a fact indicated by most participants, who believed that the cultural, religious and social conditions of families should not lead to any discrimination among the patients. one occupational therapist said: “the cultural, religious and social conditions of a family have no effect on admission of patients. [factors like that] do not affect me. i had a patient coming from iraq, another one was very religious, another not. i try to carry out my duties.” [occupational therapist 9] in order to establish social equality, some occupational therapists tried to make use of public facilities for their patients so that financial problems would not prevent them from continuing treatment. one of the participants said: “… i have written letters for them to receive money j med ethics hist med 8:8 may, 2015 jmehm.tums.ac.ir minoo kalantari et al. page 4 of 8 (page number not for citation purposes) from charities so that they could continue their sessions and not miss any.” [occupational therapist 2] 2) respect for clients the participants believed that observing children’s rights and respecting their culture and religion were important issues that should be considered when providing services. one occupational therapist believed that observance of this ethical rule would attract clients because families also expect respect. “the most important part of communication is to respect the patients. both the patients and their families should feel respected. what attracts patients is observance of these ethical rules because their families understand that they are respected.” [occupational therapist 9] another occupational therapist saw inappropriate conditions in clinics as disrespectful to the clients and stated: “i cannot work in a humid and dark basement. it is not human. i want to provide human services, so the conditions should be suitable for humans.” [occupational therapist 6] 3) confidentiality according to the participants, professional ethics require that occupational therapists keep patients’ information confidential and respect their privacy. one participant believed: “rules of professional ethics should be observed and the patient’s information should be kept confidential. therapists should not take off the child’s clothes for examination in the presence of others. the child or the family, especially those with strong religious beliefs, may not approve of that.” [occupational therapist 6] 4) autonomy our participants believed that giving the family the right to decide about their responsibilities is among the rules that should be preserved for the patients. “before discharging a patient, i explain to the family that the sessions are enough in my opinion and the kid needs no further sessions, and tell them that further treatment is up to them.” [occupational therapist 1] moreover, most participants stated that in working with children, their consent is a must and they should not be forced to cooperate. one occupational therapist said: “i try to establish rapport with the kid for two or three sessions. they should accept me and adapt to the environment, so that i can work with them.” [occupational therapist 3] the participants believed that families should receive the necessary information about the techniques and therapeutic procedures. some occupational therapists emphasized the education of families and their presence during the sessions. “i work for 30 minutes, and train the mother for 15, and the family attends the treatment session.” [occupational therapist 7] another occupational therapist said: “i certainly involve the family in treatment. in my opinion, the role of families in the treatment process is close to 80%. but i do not ask their opinion in setting the goals because they may not have realistic expectations.” [occupational therapist 9] 5) non-maleficence the participants stated that they believed it was their duty to avoid behavior that may have potentially harmful consequences. one participant said: “occupational therapists should not practice excessive pressure, as aggression may cause the patient to suffer…. i can only ask them in all seriousness if they did what i said, and how they exercised.” [occupational therapist 6] in order to protect the patient, one occupational therapist said that if the mental health of the parents is not established, they should not be asked to do the exercises at home. “as for procedures that need excessive pressure, if the family is not mentally competent, techniques of violent nature should not be assigned to the mother.” [occupational therapist 6] “giving a colleague a hint when facing unethical behavior” was a matter reflected by another occupational therapist: “i warn my colleagues when i see unethical behavior, even if it influences my relationship with them.” [occupational therapist 2] another occupational therapists showed more flexibility in confronting with unethical behavior: “if i somehow feel that they do not misinterpret my words and do not act defensively, and if their characters are known to me, i will give them a hint that it is better not to do so. but at times i have had to remain silent.” [occupational therapist 3] another occupational therapist spoke about the steps to follow in this regard: “i have warned my colleague several times and i do not care if they feel uneasy. i don’t mind telling the supervisor, and i may even ask the patient to submit a complaint to the ward authorities.” [occupational therapist 10] 6) beneficence our participants all believed that the patient’s interests should be put in priority. one occupational therapist said: “the head of the clinic wanted me to increase group therapy sessions to add more cases to my list, but i refused. i said, ‘you are trying to make money, but i am thinking of my job. this kid does not fit in this group at all.’” [occupational therapist 3] regarding their responsibility toward patients, one occupational therapist mentioned evidence-based treatment: “we cannot apply all techniques to all patients. when it comes to evidence-based treatment, there should be scientific experience on the one hand, and the patient’s demand on the other. the patient should also accept the treatment.” [occupational j med ethics hist med 8:8 may, 2015 jmehm.tums.ac.ir minoo kalantari et al. page 5 of 8 (page number not for citation purposes) therapist 6] the participants believed that they had to inform the family of the child’s condition and ask for their cooperation: “instead of understanding the child’s condition and adapting her expectations to the kid’s ability, the mother regularly shouted at the child. i provided the mother with the necessary information without considering the time and expenses, and helped her to assist the child rather than struggle and make negative remarks.” [occupational therapist 1] professional responsibility this category focuses on professional responsibility and its subcategories, that is, fidelity, development of professional knowledge, and promotion and growth of the profession. 1) fidelity one occupational therapist believed that it is not ethical to interfere with another colleague’s job, and when necessary, we should support them rather than defame them: “in general, i do not consider it ethical to interfere in the affairs of any specialist. i never comment on my colleague’s performance… i tell the mother that i can’t comment on my colleague’s work when i have not even met them. i cannot make a judgment because i might choose the same course of action if i was in their shoes.” [occupational therapist 3] 2) development of professional knowledge the participants believed that occupational therapists should consult various resources to obtain the necessary information about the disease, and should always keep their knowledge updated. one occupational therapist said: “typically, i dedicate one session to assessment. if necessary, i search for information… and try to consult experienced specialists. for instance, i tell them ‘the kid has uncontrolled convulsion, do you think it advisable to do these exercises?’” [occupational therapist 9] one occupational therapist pointed out that we should develop professional knowledge by sharing our experiences: “i try to share what i have learned scientifically. i don’t keep things to myself. if i learn a new technique, i make sure to tell others about it.” [occupational therapist 9] 3) promotion and growth of the profession as viewed by our participants, it is necessary for the promotion and growth of the profession, to avoid inappropriate advertisement. thus, any action that casts doubts on the performance of occupational therapists should be prevented so that the position and dignity of the profession is maintained. one occupational therapist said: 1) “if someone is making questionable advertisments about the profession, they should be informed. we should preserve our unity. if someone works individualistically, we will be damaged [as members of a profession].” [occupational therapist 9] another occupational therapist said: “i believe we should not act when in doubt. it is better not to do that… why should we insist on doing something that may be criticized?” [occupational therapist 6] another point emphasized by the participants in relation to the growth of the profession was advertisement and introduction of the profession. one occupational therapist said: “enough information should be provided. ads will be helpful for public information. they are about introducing our profession [to the public] and the capabilities we have.” [occupational therapist 10] discussion findings of this study indicated that ethical practice in working with children could be divided into three categories: personal attributes, responsibility toward clients, and professional responsibility. the participants in this study believed that personal attributes included veracity, altruism, empathy, and competence. world federation of occupational therapists (wfot) has assigned a code to personal attributes, suggesting that occupational therapists should comply with principles of personal integrity, loyalty, open-mindedness, and reliability in their profession (11). the subcategories extracted in this study have also been mentioned in the ethical codes of different countries. for example, the american occupational therapy association has addressed truthfulness under the title of “veracity” and defined it as conveying “comprehensive, accurate and objective” information to the clients and promoting their comprehension of such information (5). this is necessary for establishing a good partnership between the therapist and the patient (6), and good practice has been found to decrease the possibility of misunderstanding and help occupational therapists avoid moral distress (12). in core values and attitudes of occupational therapy practice, kanny and kyler state that the values and attitudes in occupational therapy have been organized around seven main concepts: altruism, equality, freedom, justice, dignity, truth, and prudence (2). pleoquin identifies empathy as the origin and base of ethics. she believes that empathy is an ethical tendency, and ethical practice is possible through empathy (13). the capacity to empathize with another individuals is the art of practice in occupational therapy (14). in the code of ethics and professional conduct of the british occupational therapy association (3) and in the ethical codes of the australian association of occupational therapists, competence has been proposed as a professional standard (15). many mistakes in clinical practice are due to lack of skill, and this explains why competence is included in ethical codes of occupational therapy associations (16). nevertheless, further studies need to be conducted on the concept of competence among j med ethics hist med 8:8 may, 2015 jmehm.tums.ac.ir minoo kalantari et al. page 6 of 8 (page number not for citation purposes) iranian occupational therapists. although it is illegal to work before graduation due to lack of sufficient acquaintance with ethical codes and rules, some iranian occupational therapists recruit senior students in clinics. another finding of this study was responsibility toward clients. the participants believed that equality, respect for clients, confidentiality, autonomy, non-maleficence, and beneficence are necessary for ethical practice in working with children. wfot identifies respect, nondiscrimination, consideration of the client’s values and priorities, and confidentiality among the responsibilities of occupational therapists toward all service receivers (11). these concepts have also been included in ethical codes of the united states, australia and canada, although the implications are somehow different. for example, in the united kingdom, australia and the united states, autonomy means to give the client the right to choose and have active participation in therapeutic decisions and procedures, and the client’s consent is necessary before the treatment process (3, 5, 15). in this study, some participants saw autonomy as seeking the child’s consent and not forcing them to attend treatment sessions, or communicating the treatment plan to the family due to the client’s age. children are more dependent on others (their parents in particular) compared to adults. the important question here is, who is the actual client, the child or the family? children can have different views from their parents and should therefore be consulted about the treatment process as far as possible. in pediatrics, the family-centered approach is more common than the client-centered approach (17). although being family-centered is a core value in working with children, participation of the family in determining treatment goals and decisions is not fully enforced. some of our participants suggested that they could not follow the demands of the family because their expectations were not realistic. for most participants, autonomy meant asking about the family’s goals and informing and educating them about the treatment plan. the occupational therapists in this study stated that clients do not actively participate in the treatment process and mentioned the inappropriate expectations and low educational level of some families to be the reason. this may be partly due to a lack of moral education in occupational therapists, although some of the participants were phd students and had passed ethics courses. the study conducted by pettersen and svilaas in india showed that culture influenced client-centered treatment, and that indian occupational therapists tried to apply some elements of client-centered treatment (18). ludwick and silva suggested that in some cultures, health decisions were not made by an individual, but by a group, that is, the family or the society. it is therefore necessary to address the values prominent in such cultures in order to promote ethical thinking (19). as for beneficence, some iranian occupational therapists seem to go to extremes in their commitment to this rule. although some of our participants believed that the child should be at peace during the sessions, others thought that crying was inevitable and should be ignored to make the best use of the treatments. they stated that some parents preferred that their children be treated with higher intensity. it seems that participants in this study were so involved in beneficence that they overlooked the rule of nonmaleficence, which needs further research. another category of ethical practice in this study was found to be professional responsibility. the participants believed that professional responsibility included fidelity, development of professional knowledge, and promotion and growth of the profession. with respect to fidelity, rule 7 of the american occupational therapy code of ethics states: “occupational therapy personnel shall treat colleagues and other professionals with respect, fairness, discretion, and integrity” (5). this definition is consistent with the responses of iranian occupational therapists, although fidelity should not interfere with fulfillment of ethical commitments. if an occupational therapist is in doubt about his/her colleague’s behavior, he/she may submit a complaint to competent authorities (15). occupational therapists should assume their professional responsibility and deliver safe, ethical and effective treatments and report unethical or incompetent conduct (20). nevertheless, most participants in this study sidestepped confrontations and did not report unethical conduct to the authorities so as to maintain relationships with their colleagues or avoid isolation. some participants had passed ethics course and were familiar with ethical rules, but uncertainty was evident in their responses as well. it seems that such behavior stems from the culture rather than unawareness of ethical rules. as a rule, cultural factors influence people’s conduct to a great extent (21), and further studies on this issue are therefore suggested. the participants believed that development of professional knowledge and promotion and growth of the profession are among our duties in working with children. development of professional knowledge through continuing and post-professional education programs may provide occupational therapists with the knowledge, skills and attitudes that will help them perceive themselves as competent practitioners (22). brown (2010) suggested that continuing education may be required to ensure evidence-based treatment and research utilization among pediatric occupational therapists (23). guidelines on continuing education have been compiled due to the importance of developing professional knowledge (24). for instance in the united kingdom, occupational therapists are expected to assume responsibility for the education j med ethics hist med 8:8 may, 2015 jmehm.tums.ac.ir minoo kalantari et al. page 7 of 8 (page number not for citation purposes) of the public and the promotion of health and welfare in order to decrease the influence of disease and disability (3). conclusion based on our findings, the views of iranian occupational therapists on ethical practice in working with children were similar to those of occupational therapists of western countries in some aspects. nevertheless, their understanding of concepts such as autonomy, beneficence, nonmaleficence, competence and fidelity were different from those of western occupational therapists. it can be concluded that various people may develop different interpretations of the same concept. this may be due to lack of education, which should be considered in undergraduate curricula as well as ethical courses and workshops for iranian occupational therapists. in this regard, other possible factors such as culture should also be taken into account. acknowledgements the authors would like to kindly appreciate all occupational therapists who participated in this research. without their assistance, this study would not be possible. this article is part of a phd thesis by the first author submitted in iran university of medical sciences. j med ethics hist med 8:8 may, 2015 jmehm.tums.ac.ir minoo kalantari et al. page 8 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(accessed in 2014). https://www.cot.co.uk/sites/default/files/publications/public/code-of-ethics2010.pdf http://www.pacificu.edu/sites/default/files/documents/8-core%20values.pdf http://www.caot.ca/default.asp?pageid=35 https://www.aota.org/-/media/corporate/files/aboutaota/officialdocs/ http://www.occupationaltherapyboard.gov.au/documents/default.aspx http://www.wfot.org/resourcecentre/tabid/132/did/34/default.aspx http://www.coto.org/pdf/code http://www.otaus.com.au/ http://cirrie.buffalo.edu/encyclopedia/en/article/274/ http://www.nursingworld.org/mainmenucategories/anamarketplace/anaperiodicals/ojin/columns/ethics/culturalv http://cotm.ca/upload/cotm_essential_comptencies_3rd http://www.occupationaltherapyboard.gov.au/documents/default.aspx?record=wd12%2f7135&dbid=ap&chksum=xig microsoft word 1 journal of medical ethics and history of medicine islamic bioethics: a general scheme mohamamd ali shomali imam khomeini education & research institute, qum, iran. *corresponding author: mohamamd ali shomali address: jumhuri blvd., amin blvd., department of religions, imam khomeini education & research institute, qum, iran. tel: (+98) 91 22 52 70 27 e. mail: mashomali@hotmail.com received: 2 may 2008 accepted: 6 jul 2008 published: 19 oct 2008 j med ethics hist med. 2008; 1:1. © 2008 mohamamd ali shomali; licensee tehran univ. med. sci. abstract keywords: life, abortion, euthanasia, brain death, organ transplantation. introduction in islam, life is sacred and one of the greatest gifts and blessings of god. every moment of life has great value and is irreversible. therefore, it must be appreciated and protected; even if it has a poor quality. the guiding principle in the islamic bioethics is: "whoever slays a soul, unless it is for manslaughter or for mischief in the land, it is as though he slew all men; and whoever keeps it alive, it is as though he kept alive all men " (qu´ran: 5: 32). according to this verse, saving life is an obligation and the unwarranted taking of life is a major crime. in what follows, we will try to explore more the value of life in islam and then see how life is safeguarded in the islamic law and ethics. part i: value of life life is a divine quality: among god’s attributes and names in the islamic scriptures, “the living” (al-hayy) is one of the most obvious and outstanding one. sanctity of life all forms of life are precious and are considered as signs of god. however, among all forms of life in the material world, human life is the most outstanding and the most precious. no doubt life in its all forms enjoys a very high status in islam. human life is one of the most sacred creatures of god. therefore, it must be appreciated, respected and protected. in this regard, the paper refers to different parts. the first part studies the value of life in islam. it helps to understand why life must be appreciated and respected. the second part sheds some light on the nature of the islamic bioethics. discussing the sources and authorities in the islamic bioethics, in this part we will study the way of life protection which is regulated by the islamic law and bioethics. part three reflects on some important issues in bioethics from an islamic perspective. concerning the islamic believes, physical health maintenance and disease treatment are two important aspects of the islamic teachings. in respect to the beginning of human life; firstly, we will see that reproduction must occur in the context of a legitimate and stable family. secondly, we will study family planning and abortion. with respect to the end of life, issues such as suicide and euthanasia will be studied. finally organ transplantation will be discussed. j med ethics hist med 2008, 1:1 mohamamd ali shomali page 2 of 8 (page number not for citation purposes) human life is so important that god mentions in the qur'an its development step by step and finally after referring to the creation of spirit -which is considered as “khalqan aakhar” – says: “blessed be the best of creators!” (qu´ran: 23:14). if the creator of man is the best of creators, man himself must be the best of creatures – at least potentially. life must be appreciated and respected. killing an innocent person not only is considered as a criminal act (i.e. murder), but also represents an underestimation or an insult to human life as a whole. the fact is interestingly expressed in the following verse: for this reason we prescribed to the children of israel that whoever slays a soul, unless it be for manslaughter or for mischief in the land, it is as though he slew all men; and whoever keeps it alive, it is as though he kept alive all men; and certainly our messengers came to them with clear proofs, but even after that many of them certainly act extravagantly in the land. (qu´ran: 5:32) one may conclude from the above verse that: a. causing death to one person unjustifiably is like causing death to all people. in the other words, lack of respect for an individual life demonstrates lack of respect for life as such and, therefore, for all individual lives (1, 2). this is in agreement with the fact that whoever commits a murder is likely to murder more people and endanger all people (2). b. giving life to one person or more precisely, saving one person out of one’s respect for life is like saving all people (from killing dangers). c. causing death to a murderer or someone who does mischief on the earth is permitted since it demonstrates respect for the lost life and prevents further dangers and damage to life as a whole. this is why the qur’an considers legislation of the retaliation as a source of life, though prefers pardon when there is no fear of threat to the public security (qur’an: 2:178, 179). animal life: we also found in the islamic hadiths that even killing or destroying animals unjustifiably is very severely condemned. for example, imam sadiq, the sixth imam of the shi‘a muslims, has informed about the divine punishment of a woman who had fastened a cat with a rope so the cat could not move and died out of thirst (3). a typical view among the shi'a jurists can be found in the following passage by ‘allamah mohammad taqi ja'fari: consideration of the whole sources of the islamic jurisprudence (fiqh) leads to the conclusion that animals must not be killed unless there is a legal permission (by god) like benefiting from them or being safe from their harm. there are adequate reasons for prohibiting hunting animals for fun and one can argue from these reasons for prohibition of killing animals without having a permitting cause (4). elsewhere he writes: “hunting animals for leisure and without need is prohibited. therefore, "if someone makes a trip for such hunting his trip will be a sinful trip" (5). the above idea is part of a broader islamic perspective on animal life. according to the islamic law, there are many rights for animals that must be observed. consideration of those rights show that not only their lives must be protected, but also the quality of their lives must be observed. for example, animals must not be bothered by forcing them to carry heavy goods or to move faster than they tolerate. neither animals can be cursed or sworn at. it is reported that imam ali said: “whoever curses an animal he himself will be cursed by god” (5). who is the giver of life and death? this is one of the basic questions in bioethics which can entirely influence one’s approach towards life and its treatment. if one believes that life is created by chance or by man himself, then it will lose its sanctity. therefore, it can also be destroyed by chance or by man. but if life is a gift of god for which we are held accountable, then it is not up to us to take it away. god is the only source of life. this is an idea on which special emphasis has been put in the qur’an. for example, we read: verily, it is god who causes the seed-grain and the fruit stone (like date-stone) to split and sprout. he brings forth the living from the dead, and it is he who brings forth the dead from the living. such is god, then how are you deluded away from the truth? (qu´ran: 6:95) thus, life is a gift of god, for which we are held responsible. not only just god gives life, but also just god brings life to an end. for example, we read in the qur’an: ...you bring the living out of the dead, and you bring the dead out of the living. and you give sustenance to whom you will, without limit (qu´ran: 3:27, 3:156, 9:117, 10:31, 22:6, 30:4, 50:43, 53:44, 57:2, 67:29). according to the qur’an, refuting nimrod’s claim of deity, the prophet abraham said (to him): “my lord is he who gives life and causes death.” (qu´ran: 2:258) (6). of course, it is possible to suppose that man and natural environment can have role in the process of giving life and causing death. the reason is this: in this world god usually acts through natural rules and cause-effect system. 1 it 1 of course, there have been miracles and extraordinary acts performed by the prophets or holy people. these may seem to contradict the general rule mentioned above: “in this world god usually acts through natural rules and cause and effect system”. however, it must be noted that firstly miraculous and extraordinary acts do j med ethics hist med 2008, 1:1 mohamamd ali shomali page 3 of 8 (page number not for citation purposes) is also possible to suppose that natural factors and circumstances may sometimes have role in something being created or brought into existence. however, it is only god who truly and genuinely brings into existence or gives life (qu´ran: 2:260, 3:49). we humans have no control or even complete knowledge of our existence or life. so how it is possible to suppose that we can grant existence or life to something else? dignity of man human beings have great status in islam. they are honoured by god (qur'an 17:70) and can act as god's vicegerents on earth (qur'an: 2:30). they are endowed with reason and freewill and therefore are responsible for what they do. therefore, humans bear the divine trust and can fulfill the goal of creation: we offered the trust to the heavens and the earth and the mountains, but they refused to carry it and were afraid of it; and man carried it. surely he is very unjust, very ignorant. (qu´ran: 33:72) this verse suggests that the main problems which man is faced when exercising his freewill are injustice and ignorance (qu´ran: 95:61). of course, god has provided human beings with the basic knowledge required to distinguish between what is (morally) good or bad (qur'an: 91:8, 76:3) man & the world: human beings can benefit from the world and indeed every blessing of god including their own bodies and souls in a responsible way (qur'an: 45:13, 102:8). therefore, everything in the world which is at our disposal is both a gift and a trust. if it were just a trust we would not have permission to use them. since they are gifts of god, we can use them. however, we cannot waste them or use them extravagantly as it is the case with any trust. god "does not love the extravagant" (qur'an: 6:141). in addition to this, the qur’an (11:61) tells us that we are supposed to make efforts to improve the conditions of the globe as much as possible. dignity of body and soul: in islam there is a close link between body and mind, or, more generally, between the material and the spiritual. in the same way that we need to look after our physical health we need to look after our spiritual health. dignity of man extends to his body and therefore there is no way to harm or treat with disrespect human body, including one’s own. this dignity also extends to the period after death (7). there are many rulings pertaining human corpse which all indicate the continuity of the not represent the usual procedure, and secondly even in the case of such acts there is no exception to the cause effect system. the only difference is that instead of natural causes supernatural causes are used. just as there are natural causes, say, for treatment of an ill person, there may be supernatural causes, such as prayer and giving charity. respect to human body even after separation of spirit. for example, human corpse must be properly washed, dressed, prayed on and buried. the dead body must be buried in a respected place and the direction of mecca must be observed. it is not allowed to dig the graves or unveil the buried body (8). autopsy is allowed, if necessary (say, when there is the suspicion of murder) (9). according to many hadiths, performance of any act that causes death to a living person like cutting off one’s head is forbidden, even in a dead person. for example, husayn b. khalid says that abu ‘abdillah (the sixth imam, imam sadiq) was asked about a man who has cut off head of a corpse. the imam replied: “verily, god has prohibited in respect of someone who has died the same thing that was prohibited when he was alive. so whoever does to a dead person what causes death to a living person must pay the diyah (blood money). i asked abu al-hasan (the seventh imam, imam kazim) about this. the imam replied: “abu ‘abdillah told the truth. the prophet spoke thus.” i said: “so whoever cuts off the head of a corpse, or cuts his stomach, or does anything else that causes death to the living must pay the diyah of a complete person?” the imam replied: “he must pay the diyah of an embryo in the womb of his mother before the spirit was created into it and that is 100 dinar (golden coin). the diyah of embryo belongs to his heirs, but the diyah of this dead person belongs to him and not to the heirs.” i asked: “what is the difference between them?” imam replied: “verily the embryo is something in prospect, whose benefit is hoped for (sought after), while the dead is something which has expired whose benefit has gone. therefore, when his organs are severed (muthlah) after his death the diyah belongs to him himself and not others. with this money, hajj (pilgrimage to mecca) will be performed on his behalf and other good deeds, such as giving alms, will be done.” (10) thus, causing harm to a corpse is forbidden. indeed, according to some hadiths, it is considered to be worse since the dead have no power to defend (7). part ii: islamic bioethics the islamic guidance on practical issues related to life in general and human life in particular can be sought in islamic bioethics. as we will see later, because of interconnectedness of the islamic law and the islamic ethics, the islamic bioethics has to consider requirements of the islamic law (shari‘ah) in addition to moral considerations. as a result, everything has to be double checked, that is, first against legal standards and second against moral standards. it seems that many of those who have written on the islamic bioethics have not made a distinction between these two. although it is certainly true that there is an absolute harmony and compatibility between the j med ethics hist med 2008, 1:1 mohamamd ali shomali page 4 of 8 (page number not for citation purposes) islamic law and morality, their aims and objectives are different and, therefore, they may differ in their prescriptions. for example, one difference is that while the islamic law tries to minimize requirements for perfection or happiness in both worlds which are manageable for the average or even lower than the average, the islamic ethics tries to show the people who have greater ambitions how to become more perfect and closer to god. therefore, whatever is taken to be necessary or obligatory in the islamic law is certainly treated the same in the islamic ethics. however, there may be cases which are not prohibited in the islamic law and at the same time they may be condemned in the islamic ethical system. or there may be cases which are not compulsory in the islamic law but are necessary from an ethical point of view. for instance, while idle chatter is not prohibited in the islamic law, it is considered a waste of precious time and harmful to the spiritual development of the person, and thus ethically condemned. another example is the night prayers (which should be performed after midnight and before dawn). night prayers are highly recommended to all muslims, but they are not mandatory in the islamic law. however, muslim ethicists and spiritual masters normally hold the idea that they are necessary for those who aspire to new heights and strive for perfection (11). therefore, if something like abortion is prohibited in the islamic law it is certainly prohibited in the islamic ethical system as well. however, it is quite possible to think that while something like cloning may be permissible from a legal point of view, it may still be morally challenged. thus, to discover the basis of the islamic bioethics we need to reflect on both rulings of the islamic law and prescriptions of the islamic ethics and find out the benefits they try to secure and the harms they try to prevent. moral considerations must not be undershadowed by the sheer legal approach, just as legal requirements cannot be compromised. sources of the islamic bioethics like any other enquiry about islam, the islamic bioethics is based on the qur'an, the sunnah and reason (al-'aql). instead of reason, sunni muslims may refer to things like ijmaa' (consensus) and qiyas (analogy). for the shi‘a, ijmaa' and qiyas as such are not accepted, since by themselves, they cannot prove anything. where does authority lie in the islamic bioethics? in shi‘a islam, determination of valid religious practice is left to grand ayatollahs (marji‘ of taqlid) who are the most qualified jurisprudents of each generation. they provide rulings on whether a given action is forbidden, discouraged, neutral, recommended or obligatory. it should be noted that every ayatollah is required to refer directly to the main sources i.e. the qur’an, the sunnah and reason and discover the islamic teachings in each case. although he carefully and respectfully studies his predecessors’ works, an ayatollah must develop his own original understanding and must not follow any other ayatollah, however great the others might have been. as said above, even consensus among people or scholars by itself is not a proof. this has given some kind of dynamism and vitality to shi‘a thought (12). what is the basis of the islamic bioethics? if secular western bioethics is mostly based on individual rights, what is the basis of the islamic bioethics? it has been suggested that “the islamic bioethics is based on duties and obligations (e.g., to preserve life, to seek treatment), although rights (of god, the community and the individual) do feature in bioethics, as does a call to virtue (ihsan)” (13). i think it is true that the islamic bioethics is expressed primarily as duties and obligations. however, it should be noted that in the islamic bioethics we have to meet legal requirements and, therefore, we try to infer our duties and obligations from the original sources. in the other words, the emphasis is normally put on duties and obligations. however, there seems to be no doubt that the islamic legislation is altogether to secure our interests. god, the almighty, does not gain anything if we obey him. neither does he loose anything if we disobey him. it is only out of his wisdom and mercy that he has provided us with a legal system, including commands and prohibitions so that we know what benefits us or harms us in this world and thereafter. thus, every obligation from god is indeed guidance towards some interests that one has the right to have. part iii: jurisprudential and ethical reflections on some issues in bioethics i. treatment of the sick islam emphasises the importance of maintaining one’s health and preventing illness, but when prevention fails, all efforts must be made to restore the health. one way of saving lives of people is to treat them when they become sick. it is a mutual responsibility of the patient and physician (or society in general). in the other words, seeking the treatment is a duty for the patient himself and everybody in the society is obliged to help the patient in treatment. on the necessity of treatment, the prophet said: o servants of allah, seek treatment, for allah has not sent down any illness without sending down its treatment (14). this is a sample of a set of narrations that makes treatment mandatory under the situation of availability of a treatment or considering the adverse effects of holding off a treatment. on the other hand, healing people is considered as a sacred job. the physician must do his best to heal the illness, but at the same time he must know that the j med ethics hist med 2008, 1:1 mohamamd ali shomali page 5 of 8 (page number not for citation purposes) real healer is god. in the qur’an, the prophet abraham is quoted as saying: “and when i am sick, he restores me to health” (qur'an: 26: 80). indeed, one of the names of god is “the healer” (al-shafí). the physician must also treat the patient with respect and compassion. the oath of the muslim doctor includes undertaking "to protect human life in all stages and under all circumstances, doing [one's] utmost to rescue it from death, malady, pain and anxiety. to be, an instrument of god's mercy all the way, extending medical care to near and far, virtuous and sinner and friend and enemy” (13) is necessary. ii. reproduction due to the high value of human life, islam attaches a very special attention to it before it starts and this continues after ending life with death. marriage is the only proper and legitimate way for having a child. in the other words, a male and female may have a child only when they appreciate the value of human life and therefore are committed to take the full responsibility of bringing up a child in the sacred institution of family. marriage is not just a financial or physical arrangement for having sexual relation or living together; neither it is just a legal contract between a man and woman. marriage is a sacred covenant between the two and god is the witness of it. marriage is a gift of god for human beings to supplement each other and to console themselves with each other (qur’an: 30:21). violation of this sacred covenant by adultery or by homosexual relations is unlawful and is unanimously rejected by all muslim scholars. also it seems immoral to use modern biotechnology to bypass marriage and reproduce human beings artificially and out of the context of family. of course, a married couple may use legitimate biomedical techniques for parenting. iii. family planning islam considers child having as a great gift of god and highly recommends people to get married and establish family ties and have child. however, islam does not compel people to get married or have child after marriage unless there is an overriding (secondary) reason which makes marriage and formation of family or having child necessary. for example, if the only way to protect one’s piety and chastity is to get married or if the protection of the people of faith from the attacks of enemies depends on the increase in the number of the members of society it becomes compulsory to get married and have child (15). thus, islam allows family planning to prevent pregnancy, but does not allow its termination. 2 2 family planning in itself is not forbidden, but there are methods of family planning which are not allowed. the details are discussed by muslim jurists. now, naturally the question arises as to when pregnancy starts and whether the beginning of pregnancy coincides with the beginning of human life or not. iv. abortion islam prohibits abortion unless there is an exceptional situation in which shari‘ah permits it as a lesser evil (16). a typical islamic point of view can be found in the following statements by the islamic organization for medical sciences: 1. the inception of life occurs with the union of a sperm and an ovum, forming a zygote which carries the full genetic code of the human race in general and of the particular individual, who is different from all others throughout the ages. the zygote begins a process of cleavage that yields a growing and developing embryo, which progresses through the stages of gestation towards birth. 2. from the moment a zygote settles inside a woman's body, it deserves a unanimously recognized degree of respect, and a number of legal stipulations, known to all scholars, apply to it. 3. when it arrives at the spirit-breathing stage…the foetus acquires greater sanctity, as all scholars agree, and additional legal stipulations apply to it. (17) 3 abortion especially after the spirit is blown is a case of infanticide and the qur’anic condemnation of killing one’s children applies to it (qur'an: 6:151 & 81:2). islam severely condemned the practice of the pagans who killed their children for poverty or for the shame of a girl’s birth. unfortunately we see that today millions of abortions take place every year. most of these abortions take place because the “liberated” people of our age would like to enjoy the life of sexual freedom. when does the prohibition of abortion apply? the general islamic view is that, although there is some form of life after conception, full human life begins only after the ensoulment of the foetus. most muslim scholars including the shi‘a believe that ensoulment occurs at about 120 days after conception (10) 4 . there is a minority who hold that it occurs at about 40 days after conception. of course, as soon as the zygote settles inside a woman's body, it deserves a unanimously recognized degree of respect and it cannot be aborted. the qur'an uses the word "haml" to describe pregnancy (qur'an: 19:22; 31:14; 46:15). 3 it has to be noted that although this organization mainly follows sunni understanding of the islamic law, what has been mentioned above is in general acceptable to both sunni and shi‘a muslims. 4 for example, see (7). my humble view is that the reason for fixing 120 days is to provide a practical guideline for settling the cases in which parents or medical staff need to make a decision. otherwise, in reality it may be possible that in some cases the ensoulment would take place slightly later. j med ethics hist med 2008, 1:1 mohamamd ali shomali page 6 of 8 (page number not for citation purposes) in arabic, the term "haml" means to carry, and this starts when the zygote is implanted in the uterus and not before it. the late ayatollah khu’i said: “the criterion in applying the [word] 'pregnant' for a woman is correct only after settling down (istiqrar) the zygote in her womb because just entering the sperm in her womb does not make her pregnant” (15). thus, from the very beginning of the pregnancy its termination is prohibited and the zygote must be protected. the showed respect to the zygote at this early stage does not necessarily mean that it is a real or actual human being. 5 after starting pregnancy, the zygote is in a state of active potentiality to become a human being with the full genetic code of the human race in general and of the particular individual. as we can saw above in the verse 23:13, implantation of the ovum in the uterus constitutes the first stage of the creation of man. according to a hadith, ishaq b. ‘ammar asked imam al-kazim whether it is permissible for a woman who fear pregnancy to drink some liquid to abort what is in her uterus or not. imam replied: “no.” ishaq said: “that is the zygote (nutfah).” imam replied: “verily the first thing to be created is the zygote” (18). however, after creating the spirit, it becomes a real human being. for this reason, the shi‘a jurists like late ayatollah khomeini, ayatollah khamenei, ayatollah lankarani and ayatollah sistani declare that it is allowed to abort foetus to save the mother’s life before the ensoulment. but after that, it is not allowed to sacrifice foetus for the sake of the mother (19). in his famous medical work called, “canon”, ibn sina studied techniques of bringing embryo out of womb. 6 although his discussion is medical in nature and not jurisprudential, he makes it very clear that such operations can only take place in clearly defined situations when there is no other option. in order to block the way for any misuse by those who may want to commit abortion, he restricts such operations to three cases (20). v. death islam places great emphasis on the sanctity of life and at the same time on the reality of death. indeed, to have a better appreciation of life one needs to remember death and that there is no way to escape from it. so everybody can realize that one 5 as we saw earlier in the discussion about animal life, the necessity of respect for life is not limited to human life. 6 the canon of medicine (original title in arabic al qaanun fi al-tibb) is a book by the great persian philosopher, scientist and physician, ibn sina. the book was based on both his own personal experience and on the medieval islamic medicine in general, as well as traditional persian and arabian medicine. it is considered as one of the most famous books in the history of medicine and remained a medical authority for centuries. must benefit from his/her life optimally. thus, islam considers remembrance of death as a source of vitality and spiritual power. “everyone is created for a life span and dying is a part of the contract (with god) and the final decision (of term) is up to god. the quality of life is equally or more important than duration of life” (21). in his supplication for noble characters (makaarim al akhlaaq) imam sajjad, the fourth imam of the shi'a, asks god: let me live as long as my life is used in serving thee. when my life becomes a pasture for satan, be pleased to call me back to thee before thy wrath advances towards me or thy anger be fixed upon me. death consists of separation of soul from body. in the same way that we cannot define empirically the time of ensoulment with certainty and accuracy, we are unable to define the exact time of departure of the soul scientifically. therefore, death is diagnosed by its physical signs. however, when there is a doubt, maximum caution must be taken into account. it should be noted that there is a difference between reaching an irreversible state in which death becomes decisive and actually dying. second if a person still shows some vital signs like heart beating and even if (this is really an if) we can scientifically confirm that his soul has departed from the body, nothing must be done which people may consider it as hastening one’s death or a disrespectful act to human life. it seems to me that one can distinguish between saving a respected life (which is compulsory in islam) through medical treatment or financial support or something else and prolonging life artificially. 7 for example, suppose that someone is dying definitely because of an advanced cancer and lack of cure for him and that the most can be done for him is using some medicine just to keep him alive for few days. the cost of the medicine is so high which is not affordable for the whole family and they will be greatly troubled. is it necessary for the patient himself or for his relatives or for the others to take this measure? or if this can be done by a very painful and major surgery is it necessary for the patient to undergo such an operation while there is no possibility of cure? i think it seems reasonable to suggest that “the physician and the family should realize their limitations and not attempt heroic measures for a terminally ill patient in order to prolong the artificial life (or misery). the heroic measures taken at the beginning of life (i.e. saving a premature baby) may be more justified than at the end of a life span, though each case has to be individualized” (21). 7 this is the author’s humble view which he takes to be in compliance with the views of muslim jurists. however, the issue needs further investigation. j med ethics hist med 2008, 1:1 mohamamd ali shomali page 7 of 8 (page number not for citation purposes) vi. suicide if we have not created our life and it is just a gift of god for which we are held responsible, it is obvious that we have no absolute power on our lives. life is a trust of god and we must take care of it to our best. this is the case with all blessings of god, whether they are physical or spiritual. we can benefit from them, but we cannot destroy them or waste them. no one should say i like to burn my property or harm my health or damage my reputation. our situation in this world is like a guest who is invited to a guesthouse. whatever there is in the guesthouse was put by the host for the benefit of the guest. however, the guest cannot burn himself inside the house or destroy the guesthouse or the things put there. it seems more interesting when considering our body as a guestroom for the spirit; so we must observe regulations for using this room which set out by god. we must try to please god by preserving life and health, promoting quality of life and alleviating suffering. vii. euthanasia islam is against euthanasia (mercy killing). muslim jurists regard euthanasia as an act of murder. murder can be performed with a gun or with a syringe by a series killer or by a physician or even by the murdered himself. for example, ayatollah khomeini declared that any measure for hastening death of someone is considered as a murder (22). also ayatollah makarim shirazi declares: killing a human being even out of mercy (euthanasia) or with the consent of the patient is not allowed (22). he adds that the main argument for such prohibition is applying the verses and hadiths which indicate prohibition of murder (qatl) to such cases. the philosophy beyond this prohibition may be the fact that permitting such acts leads to many misuses; for any weak and trivial excuses, acts of euthanasia or suicide may take place. moreover, medical judgements usually are not certain and there have been cases in which people who had no hope for life were mysteriously saved from death. viii. organ transplantation this is practised in almost all muslim countries. three situations can be imagined here: a. donor is living and is willing to donate some organs. this is normally allowed, provided that such donation does not pose any danger to the donor's life. for example, a healthy person can donate one kidney to another person and still live reasonably. indeed, this may become obligatory when it turns to be the only way to save a respectful life and is not going to put himself in an unbearable situation or harm him. one cannot donate any organ on which his life depends like heart or brain (23, 24). b. cadaveric donation: as said above, islam has high regard for the dead and this determines many religious and moral decisions regarding cadavers. however, many muslim scholars have permitted cadaveric organ donation, if the person has made this decision before death or his guardian (wasiyy) approves that (25, 26). c. donation after brain death: this depends on whether to accept legally brain death as death or not. therefore, it will be reduced either to a or b. many shi‘a scholars like ayatollah khamenei, ayatollah bahjat and ayatollah tabrizi, do not allow any transplantation that leads to the termination of life even in this state and even if the donor has put in his will that after death his organs can be given to those in need (27). this is to show maximum care and respect for human life. however, there is a ground for suggesting the possibility of donating organs after brain death in order to save lives of the recipients whose lives cannot be saved otherwise. of course, this can be carried out only after permission is granted by the guardians or after approving organ donation by the donor before brain death. in the year 2000, the parliament of the islamic republic of iran passed a law which allows organ transplantation after brain death under certain circumstances. the guardian council (that is responsible for checking the laws passed in the parliament against the constitution and the islamic shari'ah and endorsing them when there is no conflict) once rejected the proposed law, but in the second time made no comments during the legal time. as a result, practically the law is now in effect in the country. conclusion: in this paper, we saw how great emphasis has been attached by islam to life in all forms. indeed, life is considered as one of the most important qualities of god as well. among divine creatures, human life is certainly one of the most sacred ones. we studied human dignity from an islamic perspective and saw how this has been extended to human body both before and after the ensoulment. since human life is both a gift and a trust of god, it must be regulated according to divine instructions, that is, to its best and towards a fully human one. therefore, it must be appreciated, respected and protected. the islamic law and bioethics are responsible for introducing the islamic teachings in this regard. maintenance of physical health and treatment of patients are two important aspects of the islamic teachings. in respect to the beginning of human life, we realised that reproduction must occur in the context of a legitimate and stable family. we also saw that as soon as pregnancy starts, abortion is prohibited in the islamic law and j med ethics hist med 2008, 1:1 mohamamd ali shomali page 8 of 8 (page number not for citation purposes) bioethics, though there are differences in the level of respect given to foetus before and after ensoulment. with respect to the end of life, we saw that death consists in the departure of the soul from body and as long as we are not sure about that, we must practically assume that the person is still alive. the standard view among the shi'a jurists is that nothing can be done to hasten the death of one's self or the patient. therefore, suicide and euthanasia are condemned since they demonstrate lack of respect for human life. references 1. tabataba’i smh. al-mizan. translated by: rizvi sa. tehran: wofic; 2001, vol. 10, p. 146. 2. tabataba’i smh. al-mizan. translated by: rizvi sa. tehran: wofic; 2001, vol. 10, p. 152. 3. majlesi mb. bihaar al-anwaar. beirut: al-wafaa; 1983, vol. 76, p. 136. 4. ja‘fari mt. rasaa’il fiqhi. tehran: tahdhib & mu’assise-ye ‘allameh ja‘fari; 2002, p. 250. 5. ja‘fari mt. rasaa’il fiqhi. tehran: tahdhib & mu’assise-ye ‘allameh ja‘fari; 2002, p. 118. 6. tabataba’i smh. al-mizan. translated by: rizvi sa. tehran: wofic; 1982, vol. 4, p. 184. 7. hurr 'amili m. diyat al-a‘da. in: wasaa’il al-shi‘ah. qum: ismaa'iliyan; 1392, a.h; chapter 25. 8. khamenei sa. practical laws of islam (ajwibat al-istifta’at). tehran: islamic culture and relations organization; question 1277. 9. khamenei sa. practical laws of islam (ajwibat al-istifta’at). tehran: islamic culture and relations organization; question 1274. 10. majlesi mb. bihaar al-anwaar. beirut: al-wafaa; 1983, vol. 101, p. 425, hadith no. 5 & vol. 48, p. 75. 11. shomali ma. self-knowledge, 2nd edition. qum: jami‘at al-zahra; 2006, p. 34. 12. shomali ma. discovering shi‘a islam, 6th edition. london: islamic centre of england; 2007, pp. 4041. 13. daar as, khitamy ab. bioethics for clinicians: islamic bioethics. cmaj 2001; 164(1): 60-3. 14. majlesi mb. bihaar al-anwaar. beirut: al-wafaa; 1983, vol. 59, p. 76. 15. rizvi sm. marriage and morals in islam. scarborough: islamic education & information centre; 1990. 16. anonymous. declaration on islamic human rights (1990). url: http://www.islamset.com/bioethics. 17. anonymous. the full minutes of the seminar on “human life: its inception and end as viewed by islam”, (1985). url: http://www.islamset.com/bioethics/incept.html 18. hurr 'amili m. wasaa’il al-shi‘ah. qum: ismaa'iliyan; 1392 a.h, vol. 19, p.15. 19. rouhani m, nughani f. ahkaam-e pezeshki. tehran: teymurzadeh; 1987, pp. 107-125. 20. ibn sina. al-qaanun fi al-tibb. translated by: sharaf kandi a. tehran: sorush; 1987, p. 327. 21. athar s. islamic perspectives in medical ethics, (2008). url: http://islam-usa.com/im18.html 22. rouhani m, nughani f. ahkaam-e pezeshki. tehran: teymurzadeh; 1987, p. 180. 23. khamenei sa. practical laws of islam (ajwibat al-istifta’at). tehran: islamic culture and relations organization; question 1279. 24. khamenei sa. practical laws of islam (ajwibat al-istifta’at). tehran: islamic culture and relations organization; question 1283. 25. khamenei sa. practical laws of islam (ajwibat al-istifta’at). tehran: islamic culture and relations organization; question 1280. 26. khamenei sa. practical laws of islam (ajwibat al-istifta’at). tehran: islamic culture and relations organization; question 1285. 27. khamenei sa. practical laws of islam (ajwibat al-istifta’at). tehran: islamic culture and relations organization; question 1284. responsibility 4-122omid asemani 26-2-93 journal of medical ethics and history of medicine an exploratory study on the elements that might affect medical students' and residents' responsibility during clinical training omid asemani1, mohammad taghi iman2, marzieh moattari3, seyed ziaadin tabei1, farkhondeh sharif4, mohammad khayyer5 1department of medical ethics and philosophy of health, school of medicine, shiraz university of medical sciences, shiraz, iran; 2department of sociology, shiraz university, shiraz, iran; 3department of nursing, college of nursing & midwifery, shiraz university of medical sciences, shiraz, iran; 4department of psychiatric nursing, community based psychiatric care research center, and college of nursing & midwifery, shiraz university of medical sciences, shiraz, iran; 5college of education and psychology, shiraz university, shiraz, iran. corresponding author: mohammad taghi iman address: school of sociology, college of social sciences, shiraz university, shiraz, ir iran. po: 7194685111 email: iman@shirazu.ac.ir tel / fax: 98 711 6289661 received: 23 feb 2014 accepted: 17 may 2014 published: 22 may 2014 j med ethics hist med, 2014, 7:8 © 2014 omid asemani et al.; licensee tehran univ. med. sci. abstract we are now more or less confronting a "challenge of responsibility" among both undergraduate and postgraduate medical students and some recent alumni from medical schools in iran. this ethical problem calls for urgent etiologic and pathologic investigations into the problem itself and the issues involved. this study aimed to develop a thematic conceptual framework to study factors that might affect medical trainees' (mts) observance of responsibility during clinical training. a qualitative descriptive methodology involving fifteen in-depth semi-structured interviews was used to collect the data. interviews were conducted with both undergraduate and postgraduate mts as well as clinical experts and experienced nurses. interviews were audio-recorded and then transcribed. the data was analyzed using thematic content analysis. the framework derived from the data included two main themes, namely "contextual conditions" and "intervening conditions". within each theme, participants recurrently described "individual" and "non-individual or system" based factors that played a role in medical trainees' observance of responsibility. overall, contextual conditions provide mts with a "primary or basic responsibility" which is then transformed into a "secondary or observed responsibility" under the influence of intervening conditions. in conclusion three measures were demonstrated to be very important in enhancing iranian mts' observance of responsibility: a) to make and implement stricter and more exact admission policies for medical colleges, b) to improve and revise the education system in its different dimensions such as management, structure, etc. based on regular and systematic evaluations, and c) to establish, apply and sustain higher standards throughout the educational environment. keywords: responsibility, qualitative descriptive study, clinical training, undergraduate medical student, medical resident mailto:iman@shirazu.ac.ir j med ethics hist med 7:8 may, 2014 jmehm.tums.ac.ir omid asemani et al. page 2 of 10 (page number not for citation purposes) introduction theoretically, the concept of responsibility represents the readiness – including willingness and ability – to respond to a series of normative requirements(1). in this manner, in practice, responsibility is often explained or even known through the concepts of duty, commitment, obligation, accountability, etc. generally, health professionals are considered personally accountable for their professional practice (2). the same is true of medical trainees (mts); they are expected to accomplish their assigned educational duties and to have responsibility for their thoughts, decisionmaking and behaviors. the concept of responsibility has now found a special standing in the health care field; it is one of the pillars of medical professionalism(3), affirmed in lots of professional codes of ethics and conduct(4, 5). nevertheless, despite its wide and general scope of use, the concept itself has received less attention as an independent and ascertainable subject of research. instead, it has been often approached in the existing literature of the health domain as an intelligible and basic concept with a completely obvious meaning for readers. given the above exposition, many authors have made a secondary use of the concept, aimed to introduce new aspects or broaden its scopes with respect to a subject of research other than responsibility(6-8). we are now more or less confronting a "challenge of responsibility" among mts and some recent alumni from medical schools in iran. in fact, it seems we are going through a "responsibility crisis" that we have not experienced so sharply before. careful observations show that this ethical problem includes negative changes in both the degree and quality of responsibility among iranian mts. moreover, as there is a real shortage of related studies in the existing literature, conducting etiologic and pathologic investigations into the problem and the issue(s) involved seems necessary. therefore, this study aimed to develop a thematic conceptual framework to explore factors initiating the problem among mts. additionally, positive and constructive factors were also considered throughout the research. thus, our main research question was “what elements or factors might negatively or positively affect the concept of responsibility in mts during their clinical training?” the results can be used for improving the existing medical education and medical ethics curricula and generally enhancing the effectiveness of the present education system. methods: design semi-structured interviews were analyzed undertaking a qualitative descriptive approach. this design was selected as an appropriate modality to explore elements that might affect mts' observance of responsibility as an important phenomenon in some iranian educational settings. in this way, lived experiences of mts and a number of clinical experts and professional nurses have been analyzed. setting and participants this study was conducted at shiraz university of medical sciences (sums). we began recruitment by inviting informants –medical trainees – from a convenience sample(9) of individuals known to the researchers. snowball sampling(9) was used to identify other potential participants. we reasoned that mts' educational status (undergraduate vs. postgraduate) and their gender were important criteria that would provide maximum variation. interviews were conducted until thematic saturation was achieved. overall, fifteen interviews were conducted, 6 with undergraduates (3 males) and 5 with postgraduates (3 males). in addition, four more interviews were done with some clinical experts (n=2) and experienced nurses (n=2) to ensure the saturation state within the emergent themes and subthemes. based on the research purposes, only those undergraduate participants who were in the clinical phase of their trainings (5thto 7thyear medical trainees) had the primary inclusion criteria. all postgraduate mts or residents had the primary inclusion criteria. moreover, only those nurses who had a high professional experience in sums affiliated educational hospitals were interviewed. data collection a semi-structured, open-ended interview protocol was developed with questions aimed at enabling participants to describe their personal experiences and thoughts about the study subject. probing questions were also used to deeply investigate conditions, processes, goals and factors that participants identified as significant (10). overall, probes and reflective statements encouraged participants to provide additional details and clarify their statements. the key question asked mts to comment on their own observance of responsibility and the elements influencing it, either positively or negatively. moreover, with the aim of broadening the study scope and enriching the emergent (sub-) categories, a number of additional interviews were held with some clinical experts and professional nurses. they were asked to provide a comprehensive view about mts' responsibility in practice. on average, interviews lasted 64 minutes, were audio-recorded and then transcribed verbatim. in order to safeguard ethical considerations, each participant received a set of instructions explaining the purpose of the study, their freedom to participate and a confirmation of j med ethics hist med 7:8 may, 2014 jmehm.tums.ac.ir omid asemani et al. page 3 of 10 (page number not for citation purposes) confidentiality. eventually, written informed consents were obtained. data analysis the transcribed interviews were analyzed using maxqda 2007 software (version bi gmbh, berlin, germany). the scripts were carefully read several times and coding themes were generated employing a conventional content analysis(11). the codebook was reviewed in regular team meetings and any disagreement was settled by consensus. using the constant comparison technique(12), additional interviews were held to screen the coding structure and achieve a theoretical saturation(10). this process provided a methodological rigor because of its iterative nature for revising the initial themes and their refinement through subsequent data collection and analysis. coded data was then grouped and organized using the software. results the saturation state in each group was independent. yet, the obtained data of both groups were eventually added together and classified into a uniform set of themes and subthemes. additionally, with the aim of adding external views, the data of the interviews with clinical experts and professional nurses was also scanned and added to this set to ensure saturation state. here, the final set of data has been presented along two broad themes: i) contextual conditions, and ii) intervening conditions. as can be seen in figure 1, according to the data, each theme contained two sets of individual and non-individual (or system) based factors, which have been illustrated in the contextual and intervening conditions boxes. in the following section, we have tried to present a comprehensive and more detailed view of each theme according to the participants. figure 1: contextual and intervening conditions extracted as effective in medical trainees' responsibility in clinical settings. theme 1contextual conditions: the specific sets of conditions that were the basic groundings of responsibility according to the participants were categorized as contextual. these embedding conditions created a primary or basic responsibility in mts. generally, participants believed these basic conditions were either intrapersonal or extra-personal. in other words and according to the data, participants thought the two groups of individual and non-individual (or system) based contextual conditions play a role in forming basic responsibility in mts (figure 1). these conditions are illustrated below with reference to participants' statements. individual-based conditions: generally, most participants believed being responsible is basically an internal characteristic of persons, so it should be discussed based on mts' personality. they thought each mt comes to university with his/her unique personality and thus with a unique primary or basic responsibility. in fact, they believed mts to be of various personal backgrounds and basically differ raw, basic or primary responsibility contextual conditions individual-based conditions • personality weakness/strength • familial upbringing and demands • religious orientation &worldview • professional level of knowledge and experience system-based conditions • efficacy of official pre-university education • efficacy of university education ü programs ü structures ü management ü approaches ü role models intervening conditions individual-originated conditions • carelessness • lack of concentration • conflict of interests • inability to adapt to reality • disagreement between mts environment-originated conditions • non-standard working conditions • sensitivity and strength of system controls including: ü management ü clinical attendings ü senior students ü nursing staff ü patients and their families actual or observed responsibility j med ethics hist med 7:8 may, 2014 jmehm.tums.ac.ir omid asemani et al. page 4 of 10 (page number not for citation purposes) from each other with respect to their notion of responsibility. for example a female resident made the following comment to explain this difference: "i think much of it [responsibility] must be dependent on the personality [of students]. at least in the beginning each [student] seems really different from the other." in this way, some participants believed many instances of lapse of responsibility occurred primarily because of mts' personality or character weakness. "lacking personal commitment to do the assigned duties", "not having a correct and strong ideology of life", "lacking moral integrity, compassion, etc. toward others", "selfishness" and so on were among the negative qualities mostly expressed by the participants. in this regard, a nurse mentioned "a case of selfishness" that she believed to be rather common among undergraduates: "… for instance, some [medical trainees] are used to behave selfishly; in one case, even though i told a trainee about his mistakes, [he] indifferently continued to do the wrong [thing]." moreover, some participants believed that the concept of responsibility is largely interrelated with mts' "familial upbringing". in this way, they thought it is important how effectively mts have been taught to be responsible in the family environment. of course, attribution of responsibility to families indicates the fact that in iran, children and almost all adolescents until around 22 to 25 years old are highly dependent on their families especially economically; they usually live with their parents till they get married, and this is more true of girls. in this way, informants thought that the socioeconomic status of families could be used as a good criterion for a rough estimation of the quality of mts' primary responsibility. one of the clinical experts described the role of the family in mts' responsibility as the following: "i think that a great proportion of their responsibility has formed during their childhood, as a result of all the actions and interactions they have had in their family environment, especially with their mother and father. i think the same must be true about the surrounding society too." mts' "religious orientation and world view" was derived as another individual-based factor. all participants were muslim. roughly, the data showed that mts with stronger religious beliefs would act to some extent more responsibly than their counterparts with no or weaker religious beliefs, particularly in hard, pressing and conflicting situations. among religious beliefs, believing in the afterlife and resurrection seemed to have the strongest power to prevent mts from committing illegal or unethical doings. generally, religious trainees often considered themselves accountable to god for their actions and decisions; consequently, they often refrained from taking their duties lightly. the positive effect of having religious beliefs on responsibility was well confirmed by an undergraduate trainee: "… if i don't do it [the assigned duty] and as a result a patient is harmed or injured, even if nobody realizes it was my fault, at least i know that i have to be accountable to my god in the afterlife." "little or inadequate professional knowledge and experience" was the last factor stated to be effective in a few cases of lapse of responsibility. an example of this issue was illustrated by a resident of radiology; she explained how lack of professional knowledge and experience in junior students could cause lapses to occur: "some days a junior [undergraduate] student is sent to the mri department for a not simple, specialized consultation. unfortunately, these students often know very little about even simple mri or ct images. it is even worse when they know the disease they have been sent to the mri department for.… we often see they transfer the wrong information to their wards; this is problematic for the patients and of course ourselves." system-based conditions: our findings show that non-individual or system-based conditions were the second kind of contextual conditions that played a fundamental role in mts' observance of responsibility. participants attributed this role to both official pre-university and university education. they believed pre-university official education is very important in the healthy development of a sense of responsibility in trainees. they stated that they thought trainees should be taught, trained and acknowledged in practice with respect to the concept of responsibility through secondary and higher schools. yet, some informants believed the present pre-university education system does not meet this essential requirement so well and thus responsibility related problems usually continue to exist in the higher education period. one of the nurses expressed her opinion about this issue and said: "i really believe that the role of pre-university education in mts' responsibility is crucial and critical; i know it in my heart. of course, i think this system must be the first to be reformed fundamentally. moreover, the present system [of medical education] also seems weak and feeble in training students to be as responsible as a doctor should really be." additionally, the "efficacy of the medical education system" with respect to its various dimensions of "structure", "programming", "management" and "approach" was regarded by almost all participants as a highly effective context in mts' responsibility. overall, they thought a large proportion of responsibility related problems basically resulted from system defects. given the above explanation, j med ethics hist med 7:8 may, 2014 jmehm.tums.ac.ir omid asemani et al. page 5 of 10 (page number not for citation purposes) instances of the participants' statements regarding the aforementioned dimensions have been illustrated in table 1. table 1: examples of participants' statements with respect to different dimensions of "medical education system" with negative effect(s) on mts' responsibility. dimensions of medical education system structure programming management approach "as duties are not always well-defined, disagreement is common; as a result, some tasks might be done with delay."(ug) "we receive no briefing when we start a new ward. we are programmed to learn many things by trial and error!" (ug) "when some guys go on leave just to study a while before an exam, they just put us under pressure. there is no effective control on the furloughs!" (pg) "i think there is a problem with the system. we realize the focus is on individuals and personal development, not team work." (n) "practically, 6th and 7th year mts work almost equally in practice, and that partly has harmed the process of senior obedience." (a) "the on call resident was not from that ward, so when i called her in for an emergency case, she did not know the patient at all." (ug) "our senior [intern] seemed free to compel us [juniors] to do bonded labor when we disagreed with his unreasonable demands." (ug) "relationships and interactions seem completely physicianoriented. we prefer to ignore much of trainees' misconducts." (n) "if i fail a multiplechoice test just because of one or two questions, i have lost one year of my life." (pg) "we were notified just after we did something wrong; sometimes we were not taught punctually enough." (ug) "i noticed that the management was indifferent to my constructive criticism, so i preferred to be silent from then on.” (pg) "the values have become instrumental. mostly, the focus is on exam scores, not for example on trainees' commitment to patients or such." (a) "graduation is not based on objective and real criteria; trainees need to be assessed professionally…." (a) "in reality, commitment, responsibility and so on has no place in trainees' evaluation forms." (n) "attendings are reluctant to involve the ward nurses in evaluation of medical trainees' professional conduct." (n) "the focus is now on bureaucracy; trainees are weak in building an effective therapeutic relationship with patients." (n) "in the presence of fellows, residents and undergraduates may be bypassed by the attendings." (a) "daily, a large proportion of educational hours is wasted before starting morning rounds. students spare time with no definite task to do." (n) "i became thoroughly bored and hopeless when they [attendings] unjustly carped at me about my low score from time to time." (pg) "we sometimes do therapeutic care, while i think the definite purpose should be educational." (ug) ug: undergraduate student; pg: postgraduate student; n:nurse; a: clinical attending physician moreover, some informants alluded to "role models' fundamental part" in the development of responsibility in mts. they stated that presence of positive role models could practically have considerable positive impacts on the professional behaviors of mts. surprisingly; mts often gained positive and constructive perceptions even from negative role models. for example, a 7th year undergraduate trainee shared a distressing experience about how irresponsibly an attending physician had given an old man the news of his cancer diagnosis: "on a routine day we were standing near the patient’s bed and listening to the new clinical findings. meanwhile, the worried old man repeatedly asked, ‘what's wrong with me? ’unfortunately, after about four times, the attending physician got angry and told him loudly, ‘you have cancer and you won't get well at all!’after that the patient became completely quiet and in the following night he went into cardiac arrest. from that time on, i have behaved very conservatively about breaking bad news to patients." theme 2intervening conditions: we considered conditions as intervening when they altered mts' "primary responsibility" and transformed it into the "actual or observed responsibility". on the other hand, by utilizing intervening conditions, we could explain why mts might perform the same responsibilities differently or how a primary responsibility can transform or develop into a secondary one in reality (figure 1). it is noteworthy that according to the data, these alterations often involve negative and deteriorating changes and forms. as can be seen in figure 1, like the previous theme we categorized intervening conditions into two sets of "individual-related or individual-originated" and "non-individual or environment-related (or originated)" conditions. conditions were considered as individualj med ethics hist med 7:8 may, 2014 jmehm.tums.ac.ir omid asemani et al. page 6 of 10 (page number not for citation purposes) originated if mts themselves had a main role in their creation, and they would be considered as environment-originated if extra-personal or system factors had a primary role in their creation. below, these two conditions are explained according to the participants: individual-originated intervening conditions: “carelessness” was introduced as one of the main causes of unintentional irresponsibility. “taking the clinical practice (too) easy” and “forgetfulness” were two important underlying causes of carelessness based on the data. as an example of the former, we cite a short explanation by a senior student about one of his experiences when he was on call: “it was around 2 or 3 o’clock in the morning. the nurse in charge explained to me a patient's medical condition on the phone. given the explanations, i thought it was the normal course of her [the patient’s] disease. that was a very unfortunate mistake, because during morning round i was embarrassed to find out that i had lost the patient.” in the case of forgetfulness, mts believed “nonstandard and heavy workload” and thus the resulting "work exhaustion" was the most significant factor involved. furthermore, “lack of concentration” was expressed as the main result of work exhaustion. moreover, life hassles, whether familial, social or economic, were the most significant elements that could cause poor concentration especially among postgraduates. some of these stressors are well exemplified in the words of a fourth year resident: “sometimes you may have problems with your wife or you may not have enough money to rent a small place to live or even one of your family members falls sick; certainly, these situations could make you feel exhausted and consequently distract you from your practice.” "conflict of interests" was pointed out as another intervening condition that may occur when mts put their interests and conveniences over anything else such as their educational duties or even patients. overall, the most dominant instances of conflict occurred when mts were involved in studying for an imminent and important examination. final exam of clinical wards, promotion exams or even a residency one were as such according to the participants. this fact was demonstrated well in the interview with a first-year resident; she explained how she was studying for residency exam during her internship: "… ok, especially around the exam i tried to do my visits faster than ever to save more time for studying; i tried to limit my attendance at the ward; whenever i found time i went to the hospital studying room." "inability to adapt to the realities" of medical care environment or medicine itself were the other intervening factors that could weaken mts' motivation and thus dampen their enthusiasm in practice. participants believed medicine and its demanding conditions either during education or after graduation can be beyond the limits of some mts' endurance, and could thus get them exhausted and cause them to lose their "primary motivations" for studying or practicing medicine. "early and premature exposure to difficulties of working physicians", "looking for easy achievement of fame and wealth in medicine", and "perceiving medical practice and its requirements as overwhelming" were amongst the most prevalent elements affecting mts' primary motivations negatively. for example, a 6thyear undergraduate student expressed some of these facts and said, "i think some [students] see that they cannot reach what they expected and planned for easily; they cannot have those things [money and fame] soon and with ease and are very likely to become disinterested and bored gradually." finally, destructive "disagreements between mts" was expressed to be worth considering as one of the underlying causes of delays in meeting patients' medical needs. this issue was well illustrated in a real story narrated by a medical resident: "… i think our senior resident intended to retaliate something by neglecting the request of the senior resident of the internal department; i remember that the patient involved was detained for an additional day till the disagreement was eventually settled." environment-originated intervening conditions: based on the data, these conditions originate mostly from the education system itself and could influence mts' responsibility either negatively or positively. "non-standard working conditions" was one of the main elements expressed by many participants to have unintentional negative effects on mts’ observance of responsibility. "heavy workload", "overcrowded emergency rooms" and "inadequate number of professionals" (whether undergraduate or postgraduate mts or general physicians, nurses, etc.) were common instances of this sub theme as pointed out in lots of interviews. neglecting patients and their medical needs was the most significant consequence of these substandard conditions as affirmed by one of the participant residents: "these [conditions] occurred especially during first and second years of our residency. duties were really heavy especially when we were in charge of emergencies, when patient load was really high. you see, an additional problem was our every other day 24-hour on call duties! all that put us under a pressing stress; … it naturally might have caused some things to be overlooked." as another intervening condition, many participants stated that mts’ observance of responsibility was directly related to the sensitivity and strength of system controls. as shown in table 2, particij med ethics hist med 7:8 may, 2014 jmehm.tums.ac.ir omid asemani et al. page 7 of 10 (page number not for citation purposes) pants believed that "system control "should be seriously exerted through its different dimensions if it is going to be effective and influential in practice. these dimensions could be considered as different levels of managerial control within the education system. instances of participants' statements regarding these levels of control have been illustrated in table 2. as participants pointed out, most examples are about the control flaws in the current system of medical education. table 2: examples of participants' statements with respect to different dimensions of the current system controls dimensions of system control examples of participants' statements hospital or department management "if there was powerful supervision, the nurse could not lie so easy and escape from justice." (ug) "we might feel the system is not supportive and easily ignore our hard condition; unjust, one-sided demands are a lot.” (pg) "the way i see it, encouraging and punitive policies are absent, not enough or are implemented ineffectively."(n) "usually no incident sheet is filled; preventable events are not followed and problems are usually repeating."(n) "issues are not usually handled preventively unless [they] transform into challenging and serious problems." (n) clinical attending "when the attending was tough and strict, we did tasks carefully and attentively."(ug) "if the attending supervision was enough, the student could not have misused his position and done such an unconscionable act."(a) “the boy [student] neglected my prompt order; after i told him about the consequences, i warned him that i would report future instances and thus he would fail.”(a) senior students "clinical trainings were largely the seniors’ responsibility, whether or not they wanted to teach us."(ug) "residents easily masked errors; for they knew they were the first [one] who would be accountable to the attending about the ward incidents."(ug) “i usually assigned to juniors some duties; then, i would supervise their performance.” (pg) nursing staff “we-head nurses-have no formal role in the control of the ward disciplines to be observed by medical trainees.” (n) “sometimes, we act as the go-between; we inform mts about patients’ concerns and dissatisfactions.” (n) “i cannot ignore some mts’ misconducts and i do report to those in charge as a duty.” (n) patients and/or their families “of course, some family members’ sensitivity about their patients might compel us to act more carefully in practice.” (pg) “we notice mts are more careful about patients that not only know their rights but demand them to be observed.” (n) "when the patient is quite knowledgeable medically and asks precise questions, trainees usually became more careful in their doings." (a) ug: undergraduate student; pg: postgraduate student; n:nurse; a: clinical attending physician discussion our findings highlight important factors affecting mts' responsibility in educational settings of clinical care. participants were representatives of both groups of undergraduate and postgraduate mts. moreover, interviews with clinical experts and professional nurses were conducted to broaden and deepen the scope of the study by adding external or non-trainee views to it. as explained, two sets of contextual and intervening conditions actively played a role in mts' observance of responsibility. according to the data and as shown in figure 1, considering contextual conditions as a unit we might allocate each mt a "raw, basic or primary responsibility". a potential consequence of this statement –or claim–would be that every mt would have a primary and distinct responsibility measure that can be determined or assessed by a well designed quantitative instrument like a questionnaire. of course, as explained in the second theme, primary responsibility often changes in interaction with a number of intervening conditions to yield a secondary, actual or observed responsibility. in fact, what we see in reality as j med ethics hist med 7:8 may, 2014 jmehm.tums.ac.ir omid asemani et al. page 8 of 10 (page number not for citation purposes) each mt's responsibility is the output resulting from a complex and multidimensional interaction of intervening conditions with contextual conditions. as figure 1 indicates, two groups of individual and system-based conditions form contextual conditions. we think the best way to effectively control some individual-based conditions, especially those that are apparently incompatible with the spirit of medicine itself, is establishing and implementing stricter and more realistic university admission policies. in this way, development of powerful and reliable instruments seems to be necessary, which in turn calls for conducting more comprehensive and fundamental researches(1315)to set more confident predictors for effectively screening medical school applicants. moreover, in the case of pre-university education system, revising and if needed reforming the current educational curricula towards more efficient responsibility oriented ones is suggested as a long-term fundamental program. generally, as kyoshaba (16) has discussed in her dissertation, many scholars agree that the education system can hypothetically influence students’ academic performance; we think if students are trained to be more responsible at schools, certainly much less time and energy would be spent at colleges and universities on training responsible professionals. pragmatically, we think this concept should be formally approached in both pre-university and higher education systems through establishing coherent policies. in this way, it is also necessary that the concept of responsibility be implemented through well-structured and practical curricula, to be incorporated in tests and closely monitored in everyday educational activities and to be taught and encouraged through positive role models(17, 18). nevertheless, this study revealed that mts' "religious beliefs" might have a constructive role in their observance of responsibility, but more thorough investigations will be necessary. although for many years there has been serious skepticism about any positive effects of students’ personal religiosity on their academic performance, there is growing evidence that this relationship may exist and it has been scientifically proven in some recent studies(19, 20). given that iran is a highly religious country with dominance of islam, bolstering religious knowledge and understanding of mts might be very helpful, especially in improving the quality of their professional responsibility. as mentioned above, in the case of low "professional knowledge and experience" of some junior mts and the related negative consequences, we suggest the issue ought to be handled through more effective "senior supervisions". we believe this is an easily preventable issue that just needs more attention from seniors. thus, other than the attending physician, senior trainees should be trained at least in the general features of an effective and competent supervision and management. in order to reach this purpose, it is necessary to carry out regular comprehensive evaluations and then provide seniors with objective feedbacks on their strengths and weaknesses. moreover, establishing advisory services in the hospitals and holding a number of related informative and developmental programs regularly seem helpful. implementation of appropriate educational programs, structures, management and approach seem to be essential to the education system and are highly influential in mts' observance of responsibility; therefore, undertaking regular evaluations concerning these dimensions is also proposed for assessing the present status, determining defects and making developmental plans. generally, there are practical and helpful guidelines designed for mts to help them cope with stress and burnout as two significant individual intervening conditions(21).the problem of "work exhaustion" and its subsequent complications like "carelessness", "lack of concentration", etc, can be successfully addressed by improving the current education system and as needed, and establishing new standards throughout the system (22, 23). presently, it seems there are some critical and of course preliminary points in our education system that need to be reviewed and revised based on the appropriate global standards; "student workload", "trainee-to-patient ratio", and "content and way of conducting examinations" to name but a few. this standardization would enhance the quality of mts' responsibility according to the data. standardization also seems really influential in decreasing frequency and intensity of cases of conflict of interest among mts. it seems that lots of these cases could be efficiently handled by implementing more effective supervisions, but clearly, some difficult circumstances in the present system might have the potential to provoke conflict. for instance heavy workload might not provide enough time and energy for mts to get minimum score in some examinations. certainly, these problems require comprehensive, practical and immediate solutions; otherwise, patients in particular would suffer. according to the published literature (24, 25) and as expressed by a great number of participants, "motivation" has a highly significant role in mts' academic performance. moreover, as stated in the data, some informants believed mts' high primary motivations gradually decrease, causing mentally and/or emotionally exhausted feeling and burnout; consequently, this problem would lead to responsibility abdication. we recommend taking intrinsic motivations into consideration when admitting medical school applicants and also fostering motivation(26, 27)in the educational environment. j med ethics hist med 7:8 may, 2014 jmehm.tums.ac.ir omid asemani et al. page 9 of 10 (page number not for citation purposes) we also propose identifying, then fully comprehending and dealing with factors that are working as negative extrinsic factors in the current education system, such as those explained during nonindividual contextual or intervening conditions (figure 1); this action might alleviate the problem of "decreased motivation" among mts. a close collaboration of senior trainees, clinical attending physicians and head nurses in each clinical ward is proposed for the timely reporting of cases of "disagreement between mts" and their professional solutions. additionally, developing practical guidelines might be very helpful in handling related issues preventively (28). in this regard, we also suggest that the history of challenging cases be used – for instance by hospital or clinical department leaders –as a valuable source to prevent and manage similar forthcoming incidents. finally, as shown in table 2, the data demonstrated that there are serious problems with respect to different dimensions of the existing "system control". in this way, the meticulous attention of those in charge of hospitals, departments and wards is needed to investigate the issue more closely, take it more seriously and make prompt attempts to prevent shortcomings caused by further continuation. also, in order to achieve this purpose, we suggest holding regular and developmental programs and informative seminars or group sessions for senior trainees, clinical attending physicians, department managers or any other involved professional groups in the role of a controller or manager. moreover, it is proposed that regular and precise qualitative and quantitative evaluations be carried out with the aim of assessing the efficacy of the present controls and controllers and providing those in charge with constructive feedback. conclusion this study demonstrates that responsibility in mts practically forms from interactions between contextual and intervening conditions. moreover, as there is a real dearth of research on the subject of responsibility, this study contributes to related literature and might provide a helpful grounding for understanding the concept of responsibility in mts. conclusively and according to the study data, the following three measures seem essential for improving observance of responsibility in mts: a) to make and implement stricter admission policies for medical colleges, b) to constantly improve and revise the education system in its different dimensions such as management, structure, etc. based on regular and systematic evaluations, and c) to establish, apply and sustain higher standards throughout the educational environment. acknowledgment the authors would like to thank all participating medical students and residents, clinical experts and nurses for their kind cooperation in the collection of data. moreover, we would like to thank dr. sedigheh ebrahimi for her kind assistance in the professional editing of the article. this study comprises part of a more extensive research, a phd dissertation in medical ethics, which has been registered under number 5965 and financially supported by the vice-chancellery of research and technology of shiraz university of medical sciences. references 1. williams g. responsibility as a virtue. ethical theory moral pract 2008;11(4):455-70. 2. lynch j. clinical responsibility. united kingdom: radcliffe; 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2013.http://wbacademy.utoronto.ca/wp-content/uploads/standards-for-call-duty-and-student-workload-inclerkship_revised-2013-01-15.pdf (accessed in2013). 24. kusurkar ra, ten cate tj, vos cmp, croiset g. how motivation affects academic performance: a structural equation modelling analysis. adv health scieductheory pract 2013;18(1):57-69. 25. kusurkar ra, ten cate tj, van asperen m, croiset g. motivation as an independent and a dependent variable in medical education: a review of the literature. medical teach 2011;33(5):e242-e62. 26. ryan rm, deci el. intrinsic and extrinsic motivations: classic definitions and new directions. contemp educ psychol 2000;25(1):54-67. 27. brissette a, howes d. motivation in medical education: a systematic review. webmed central mededuc 2010;1(12):wmc001261. 28. glasson j, nc d, plows cw, clarke ow, et al. disputes between medical supervisors and trainees. jama 1994;272(23):1861-5. http://cshe.berkeley.edu/sites/default/files/shared/publications/docs/rops.geiser._sat_6.13.07.pdf http://news.mak.ac.ug/documents/makfiles/theses/kyoshaba%20martha.pdf http://docs.lib.purdue.edu/dissertations/aai3185795/ http://www.texmed.org/workarea/downloadasset.aspx?id=26900 http://www.victoria.ac.nz/documents/policy/student-policy/student-workload http://wbacademy.utoronto.ca/wp-content/uploads/standards-for-call-duty-and-student-workload-in professionalism 3(423)-final journal of medical ethics and history of medicine really good stuff training professionalism trainers fateme alipour1*, fariba asghari2, homayoun amini3 1associate professor, eye research center, farabi eye hospital, tehran university of medical sciences, tehran, iran. 2associate professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. 3professor, department of psychiatry, roozbeh psychiatric hospital, tehran university of medical sciences, tehran, iran. corresponding author: fateme alipour address: farabi eye hospital, south kargar, qazvin square, tehran. email: alipour@tums.ac.ir tel: (+98) 21 66 44 96 61 received: 07 july 2018 accepted: 1 sep 2018 published: 9 sep 2018 j med ethics hist med, 2018, 11: 9 © 2018 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. what problems were addressed?abstra ionalism, undergraduate medical student, content analysis, in-depth interview informal learning through interaction between a teacher and a learner could not be replaced or compensated by formal education (1). in fact, if attending physicians do not believe in the spirit of professionalism, or do not model professional behavior, could have a reverse effect on trainers’ attitudes. integrating and enforcing professionalism besides other scientific and technical skills, needs all clinical attending staff be familiar with its concept and theoretical basics, and actively consider it in their own behaviors and dialogues. the prerequisite of teaching professionalism to clinical residents – who are challenged more in busy clinical setting needs ensuring that all attendings are potent enough. this innovation was designed to train enough professionalism trainers of clinical staff. what was tried? a core committee of 12 clinical staff and ethicists was developed. all of these professors had previously attended the faculty development workshops in the field of professionalism. each member chose at least one topic out of the list of defined topics: the concept of professionalism, excellence, justice, responsibility, altruism, respect, autonomy, honor and integrity, conflict of interest, and ethical reasoning, and prepared for presenting it in peer-review sessions which was held monthly. after each peer-review session, feedback was provided on the content, teaching method, and teaching materials used by the presenter by all participants. concurrently, faculty development workshops were held in educational developmental center (edc) of the tehran university of medical sciences (4 times a year) by these empowered trainers. after each workshop, it was announced that any interested professors were welcomed to join the group; so the group was actively expanding. so far, 14 peer-review sessions attended by 42 participants with a combination of faculty members from the ethics and clinical departments have been held to peer-review and provide feedback on the sessions. finally, 16 new trainers in 25 person/topics have been prepared for teaching at the workshops for the empowerment of clinical professors in the context of professionalism. this team has held ten workshops at the edc and 8 workshops in 6 subsidiary hospitals of the university, and has empowered a total of more than 300 faculty members in the professionalism and its related topics. mailto:alipour@tums.ac.ir j med ethics hist med 11: 9, september, 2018 jmehm.tums.ac.ir sajjad azmand et al. page 2 of 2 what lessons were learned? with regard to the skills and capabilities of the medical practice, such as professional commitment and communication skills, impact of lessons provided by clinical trainers -familiar with real challenges-, is higher. so, potent trainers can be trained using the peer-review sessions with active participation of a team consisted of both clinical disciplines and ethicists. this method combines the advantage of being familiar with real challenges and enough self-confidence of the clinical trainers. references 1. hafferty fw. beyond curriculum reform: confronting medicine’s hidden curriculum. acad med. 1998; 73(4):403–7. ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ original article copyright © 2021 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. journal of m edical ethics and h istory of m edicine compassion-based care for covid-19 patients: a qualitative analysis of nurses’ perceptions *corresponding author marjan mardani-hamooleh address: vanak sq., zafar st., tehran, iran. postal code: 1996713883 tel: (+98) 21 88 20 19 78 email: mardanihamoole.m@iums.ac.ir received: 18 jul 2021 accepted: 1 nov 2021 published: 4 dec 2021 citation to this article: ghanbari-afra l, salamat a, hamidi h, mardani-hamooleh m, abbasi z. compassionbased care for covid-19 patients: a qualitative analysis of nurses’ perceptions. j med ethics hist med. 2021; 14: 19. leila ghanbari-afra1, akram salamat2, hadi hamidi3, marjan mardani-hamooleh4*, zahra abbasi5 1.phd candidate of nursing, department of critical care nursing, trauma nursing research center, kashan university of medical sciences, kashan, iran. 2.researcher, department of critical care nursing, imam khomeini hospital complex, tehran university of medical sciences, tehran, iran. 3.assistant professor, department of english language, school of health management and information sciences, iran university of medical sciences, tehran, iran. 4.associate professor, department of psychiatric nursing, nursing care research center, iran university of medical sciences, tehran, iran. 5.researcher, department of psychiatric nursing, nursing care research center, iran university of medical sciences, tehran, iran. abstract compassion is a basic approach to medical practice and is the core component of health care. the purpose of the present study was to explore nurses' perceptions of compassion-based care (cbc) for covid-19 patients. in this qualitative study, the participants were selected using purposeful sampling. individual and semi-structured interviews were conducted with 25 nurses, and conventional content analysis was used to categorize the data. in the care of covid-19 patients, cbc consisted of three categories including pro-social behaviors, paying attention to the beliefs and values of patients, and concern for family members. the first category had three subcategories including empathy, altruism, and helping in critical situations. the second category included the subcategories of the spiritual approach to care and respect for cultural aspects. the third category, concern for family members, had one subcategory: the need to consider the patient's family. our findings may help to develop a comprehensive model in covid-19 care according to which, in addition to routine patient care, nurses will consider concepts such as empathy, altruism, helping in critical situations, spirituality, cultural values, and the family’s needs at the end of the patient's life. keywords: coronavirus; covid-19; ethics; nursing care; compassion; qualitative research. compassion-based care for covid-19 patients: a qualitative analysis … 2 j med ethics hist med. 2021(december); 14:19. journal of m edical ethics and h istory of m edicine introduction the year 2020 may be considered as the "year of the corona" due to the coronavirus disease 2019 (covid-19) pandemic (1). the healthcare personnel responded to the covid-19 pandemic with a herculean effort at the beginning of the pandemic and were willing to provide quality care (2). accordingly, they needed the necessary skills to make flexible and rapid decisions, and effective leadership to prevent moral distress. in fact, due to their capability in addressing physical, psychological, and spiritual needs, they were able to help other healthcare personnel develop human relationships with the patients in addition to supporting them in dealing with stress and fear (3). it can be said that covid-19 has created new experiential knowledge for healthcare personnel (4). among healthcare workers, nurses have been the key factor in the development and implementation of policies related to patient care standards during the pandemic (5). covid-19 patients need nursing care to avoid further complications (6), and nurses are the first healthcare workers who care for covid-19 patients, who are suffering from a potentially deadly disease (7). nurses are actively involved in the initial evaluation, triage, and care of these patients (8). during the covid-19 pandemic, nurses experienced both negative and positive emotions at the same time. the negative emotions included fatigue, distress, and helplessness, and the positive emotions consisted of psychological adjustment, growth under pressure, and professional responsibility. in the early phase of this pandemic, negative emotions were dominant, while the positive emotions appeared slowly. for instance, by providing care to covid-19 patients, nurses have been able to achieve psychological growth and improve their professional performance (9). on the other hand, they have experienced ethical challenges in providing care for these patients (10) in addition to occupational and moral distress. as a matter of fact, nurses may even lose their lives while caring for covid-19 patients (11). however, covid-19 showed us that a healthy person and a healthy world are one. certainly, the concept that led us to this belief is compassion. compassion gives us an understanding of how we built the world and how we can make it better. this concept is based on the equality of all people in terms of social, ethnic, racial, and gender issues (12). in addition, compassion is a basic approach to medical practice and the core component of health care (13). accordingly, interest in the concept of compassion-based care (cbc) has increased among healthcare workers, especially nurses (14), so that cbc is recognized as one of the main elements of quality care (15). in fact, cbc is a pivotal value in clinical practice (16). this type of care not only reduces nurses' burnout but also improves patients' satisfaction and quality of life (17). studies worldwide have investigated the role of compassion in patient care. nurses in the uk believe that in clinical settings, the impact of compassion in responding to patients' emotional needs is complex, and ghanbari-afra l., et al. 3 j med ethics hist med. 2021(december); 14: 19. journal of m edical ethics and h istory of m edicine that compassion is a driving force for care (18). an analysis of nurses' experiences in italy showed that cbc is intertwined with positive elements such as loving and supporting the patient (19). in another study that examined the views of nurses internationally, it was found that despite cultural differences among nurses, all of them considered compassion as an important element of nursing care (20). on the other hand, research results in iran have shown that compassion for patients may be influenced by the current culture of the society (21). however, the results of a systematic review showed that while the emphasis is on improving the quality of patient care, there are shortcomings in the international health system that may be due to a lack of compassion in patient care (15). the results of a study on the care of covid-19 patients in spain showed that healthcare workers experience high levels of compassion fatigue as a result of caring for these patients (22). a study in italy also found that healthcare workers feel low levels of compassion during the covid-19 pandemic (23). since the literature review showed that cbc is a concept that is based on community culture, there is a need for a qualitative study on the perception of nurses working in covid-19 wards in iran, because it is possible that nurses’ interpretation of cbc has been influenced by the cultural context, they live in. in this regard, research shows that compassion and culture are interrelated. for example, papadopoulos et al. (2016) found that compassion is dependent on one’s cultural context (20). thus, the aim of the present study was to explore nurses' perceptions of cbc for covid-19 patients. methods to identify the nurses' perceptions of cbc for covid-19 patients, we used a qualitative methodology. we performed content analysis, which consists of analyzing written, spokenو or visual communications through inferences from the raw data to summarize and categorize them. in this study, we used conventional content analysis, that is, the categories and their titles flow from the text of the data (24, 25). the study setting consisted of the general wards and intensive care units of 2 public hospitals in iran that are designated for the treatment and care of covid-19 patients. these hospitals were affiliated with tehran university of medical sciences (imam khomeini hospital) and kashan university of medical sciences (shahid beheshti hospital). we received the names and phone numbers of eligible participants from the head nurses of covid-19 units but included only those who had at least one month’s experience in covid-19 wards and had worked full time the morning, evening, and night shifts. the exclusion criterion was being disinterested in participation. the nurses were recruited by maximum variation purposive sampling to include a wide range of participants in terms of age, gender, education level, work setting, nursing work experience, and work experience in covidcompassion-based care for covid-19 patients: a qualitative analysis … 4 j med ethics hist med. 2021(december); 14:19. journal of m edical ethics and h istory of m edicine 19 care. recruitment continued until data saturation. the nurses participated in individual and semi-structured in-depth interviews. due to restrictions in covid-19 units, for instance, full isolation, forbidden entry and exit, risk of viral spread, and participants’ work overload, the interviews were done by whatsapp voice (6 nurses) and video (19 nurses) call, based on the preference of the nurses. prior to the interviews, the researcher and the nurses reached an agreement about the time of the interviews, which were scheduled for when the nurses were not on their work shift. the duration of the interviews ranged from 35 to 50 minutes. each nurse was interviewed once, and 25 interviews were done in total. the researcher chose the interview questions based on the researcher’s expertise, the study aim, and research design. the participants answered these questions: 1) how would you describe cbc for patients? 2) how would you describe cbc for covid-19 patients? and 3) what is your experience of cbc? the interview continued with follow-up questions such as “what do you mean by…?”, “could you provide more details?”, or “can you specify an example?”. data were collected between october and december 2020. data analysis and data collection were conducted simultaneously. the interviews were recorded, transcribed, and then typed on the computer. all the interviews were transcribed verbatim so as to highlight the keywords in the text that contained meaning units, and to extract the codes. after extracting the codes from the important sentences and paragraphs, they were categorized based on their similarities and differences, and eventually, similar subcategories were combined into categories based on their associations (25). trustworthiness to determine the rigor of the study, we used the criteria for credibility, dependability, confirmability, and transferability (25). in order to assess data credibility, perspectives of the research team were used in the process of the interviews and data analysis. transcriptions of the interviews and the results were shared with some nurses. in order to verify data dependability, we used the opinions of an external person who was not part of the research team, but was acquainted with the subject matter and content analysis; there was agreement on our results. to verify confirmability, all activities were documented and a report was prepared on the process of the study. to verify transferability, the results were shared with two nurses who were not part of the study but had similar conditions, and the results were confirmed. ethical considerations this article was part of the research project number ir.iums.rec.1400.247 approved by iran university of medical sciences. the participants gave their consent after being informed about the study’s aim. also, they were reassured that their information would remain confidential and that they retained the right to withdraw from the study at any time. ghanbari-afra l., et al. 5 j med ethics hist med. 2021(december); 14: 19. journal of m edical ethics and h istory of m edicine result a total of 25 nurses participated in this study. they were aged between 28 and 49, were mostly females (17 nurses), and had a bachelor’s degree (19 nurses). in terms of work setting, 15 were employed in general wards, and their nursing work experience varied from 5 to 20 years. moreover, they had 1 to 6 months’ work experience in covid-19 care (table 1). table 1characteristics of the nurses characteristics number education level master's degree 6 bachelor's degree 19 hospital imam khomeini 16 shahid beheshti 9 work setting general ward 15 intensive care unit 10 in the data analysis phase, 885 codes were identified. the nurses' narratives indicated that cbc in the care of covid-19 patients consisted of three categories including prosocial behaviors, paying attention to the beliefs and values of patients, and concern for family members. the category of prosocial behaviors had three subcategories of empathy, altruism, and helping in critical situations. the category of paying attention to the beliefs and values of patients included the subcategories of spiritual approach to care, and respect for cultural aspects. the category of concern for family members had one subcategory of the need to consider the patient’s family (table 2). table 2results of the data analysis categories subcategories pro-social behaviors empathy altruism helping in critical situations paying attention to the beliefs and values of patients spiritual approach to care respect for cultural aspects concern for family members the need to consider the patient’s family pro-social behaviors nurses believed that in the care of covid19 patients, cbc includes a set of pro-social behaviors. these behaviors consist of empathy, altruism, and helping in critical situations. empathy according to the nurses, compassion-based inpatient care for covid-19 patients means being by their bedside, accepting them, and being kind to them. "in addition to the routine care of the patients and meeting their physical needs, listening to the patients and making sure that they are satisfied are among their needs. when the nurses see patients in this way, it means that they have compassion-based care for covid-19 patients: a qualitative analysis … 6 j med ethics hist med. 2021(december); 14:19. journal of m edical ethics and h istory of m edicine accepted them. patient acceptance is very important because it enables the nurse to provide compassionate care for the patient." [participant no. 4] according to the participants, mutual understanding and seeing the patient as a family member or relative is important in cbc for covid-19 patients. this leads to understanding the patient promptly and relieving his/her suffering. "empathy is the cornerstone of patient care. when there is mutual understanding in caring for these patients, we can take care of them better, because we can understand them in an instant ... this feature in caring for a covid-19 patient relieves his/her suffering." [participant no. 6] "i'm saying that there’s no difference if i or my sister, my parents, or one of my relatives is hospitalized here for covid-19." [participant no. 18] altruism according to the nurses, cbc is not possible for a covid-19 patient without altruism. behaviors such as going the extra mile and doing things that the patient has not asked the nurse to do are examples of altruism. "the nurses here do a number of things at the request of patients, but some of them are not requested by the patient, and the nurses really do them beyond their duties. these are actions the nurses do not expect to be rewarded for, and they do them according to their moral values and altruism. well, cbc makes no sense without altruism." [participant no. 22] "last week i was on shift. one patient’s urine bag was full, and i could not wait for the support worker anymore. emptying the urine bag is not in our job description. nobody told me to do it, but i emptied it myself." [participant no. 2] helping in critical situations according to the nurses, cbc means helping patients and standing by their side in critical situations. although covid-19 is a life-threatening disease, nurses emphasized the importance of commitment and accountability in patient care during times of crisis. "nurses have an unconditional commitment toward people. even when they know that their health and well-being may be endangered due to covid-19, they still serve the community and the sick, which means compassion in times of crisis." [participant no. 25] "when covid-19 became widespread, we faced a critical situation. our responsibility to the health system really doubled, and we became more sensitive about our work and the patients’ lives. our shifts became heavier, but we stayed beside the patients despite the risk of getting sick." [participant no. 12] "not seeing their families for a long time has been a problem for nurses and that’s how they have helped patients during the covid-19 crisis." [participant no. 17] "nurses sometimes stay in the hospital dormitory for up to 20 days for patients’ sake and may not be able to see their families, spouses, and children. well, they do that because the situation is critical and is not the same as before." [participant no. 8] ghanbari-afra l., et al. 7 j med ethics hist med. 2021(december); 14: 19. journal of m edical ethics and h istory of m edicine paying attention to the beliefs and values of patients the nurses believed that for covid-19 patients, cbc is possible with a spiritual approach to care and respect for cultural aspects. spiritual approach to care according to the nurses, a spiritual approach can help covid-19 patients to pray and perform their religious duties. in addition, a spiritual approach can show the patient the path of life. "patients who like to pray should be helped and respected. they should be able to pray any way they want because they believe that it is not possible to bear the burden of disease without god's help. if nurses can provide this type of care, patients will be spiritually happy, and cbc is delivered in such a way that the spirituality of the patient is considered." [participant no. 21] "most covid-19 patients know they are on the verge of death and are afraid. well, here cbc shows patients the path of life in a spiritual structure. it shows them that even if covid-19 is the end of life, that’s fate, and death is a part of life." [participant no. 9] respect for cultural aspects among the elements of cbc for covid-19 patients mentioned by the nurses were the right to a same-sex nurse and respect for privacy, both of which have cultural roots. "our patients want to be cared for by samesex nurses. i think this is rooted in our culture, and the patient’s culture must be respected. but we cannot always cater to that, because of the situation and shortage of staff. for instance, i was fixing a chest lead for a female patient, and she complained to me that a male nurse had done it for her the previous shift." [participant no. 14] "patient privacy is very important to me. if the curtain is not drawn for patients who are not able to change their clothes themselves, they will complain, because being exposed is not acceptable in our culture." [participant no. 23] concern for family members the nurses believed that another factor in cbc for covid-19 patients was a concern for the patient’s family. the need to consider the patient’s family according to the nurses, cbc in covid-19 is a type of care that considers not only the patient but also the family. the need to consider the patient’s family is more conspicuous when the patient is close to the end of his/her life. as a rule, families view saying goodbye to patients at the end of life as a value, and nurses strive to respect this value. in addition, nurses believe that it is important to grieve with the patient’s family after his/her death. "when the patient is at the end-of-life stage, it is a value for the family to be able to say goodbye to the patient, but due to the pandemic, it is not possible for them to see the patient before death. i talk to patients’ families over the phone and tell them that i understand that they want to say goodbye to the patient. i do this to calm them down." [participant no. 5] "when a patient passes away, the family compassion-based care for covid-19 patients: a qualitative analysis … 8 j med ethics hist med. 2021(december); 14:19. journal of m edical ethics and h istory of m edicine cannot mourn because of the social distancing that must be observed at the mourning rituals. since getting together and holding memorial services for the deceased is currently not possible due to the pandemic, we should respect the family’s values.... so, expressing our condolences and telling them that we share their grief may be comforting for them." [participant no. 11] discussion in the present study, nurses' perceptions of cbc for covid-19 patients were explored. according to the nurses, this type of care is intertwined with pro-social behaviors and consideration for the beliefs and values of patients and their families. the nurses said that pro-social behaviors in cbc for these patients include empathy, altruism, and helping in critical situations. during the covid-19 pandemic, it is vital for individuals to exhibit pro-social behaviors to support one another (26). it can be said that pro-social behaviors help people understand a situation and make decisions that benefit patient care (27). it is obvious that the rapid spread of covid-19 has affected all classes of society. covid-19 has taught people to be together, have compassion toward each other, and cooperate with others (28). in fact, covid-19 is a social crisis that has also provided an opportunity for social empathy (4). thus, during the pandemic, health systems sought to create an empathy epidemic with the goal of establishing a humanistic relationship with patients (29). in this regard, it should be acknowledged that for covid-19 patients, humanistic care based on mutual understanding between the nurse and the patient is a necessity (30). in other words, providing optimal care for these patients depends on the caregivers’ empathy, which occurs through effective communication with the patient (31). if we can listen to people wholeheartedly, we can help to restore their health considerably (12). nurses also reported that relieving patients’ suffering and understanding them by putting ourselves in their shoes are factors that lead to empathy toward patients. in this regard, it should be noted that compassion is known as an empathic concern and a desire to alleviate the suffering of oneself and others (12). in addition, by imagining that we could contract the disease at any time, we realize the need to protect ourselves and others from the disease (13). according to the nurses, cbc for covid19 patients is based on altruism. it should be noted that compassion is a state that has an altruistic nature (12). the results of a systematic review showed that cbc has ethical aspects and is based on a humanistic relationship with patients (15). the nurses in our study mentioned unconditional commitment and accountability to the health system, accepting the risk of sickness and death, and not seeing their families for a long time. similarly, caregivers in africa stated that they experienced family isolation when providing care for covid-19 patients (32). it seems that helping these patients and the health system during the covid-19 crisis has been institutionalized for the nurses participating in this study, so they have served patients by observing ethical principles such as commitment, ghanbari-afra l., et al. 9 j med ethics hist med. 2021(december); 14: 19. journal of m edical ethics and h istory of m edicine accountability, and dedication. therefore, it can be said that cbc for covid-19 patients is rooted in clinical nursing ethics and includes pro-social behaviors. nurses believed that issues such as a spiritual approach to care, respect for cultural aspects, and the need to consider the patient’s family are important in cbc. since the patients are afraid of death, this approach helps them realize that death is part of life. in this regard, researchers found that cbc also has a spiritual dimension (15). in addition, for covid-19 patients, spiritual care is a vital component of health management that helps them cope with illness and suffering (30). on the other hand, spiritual care entails showing compassion during periods of heightened crisis such as stress, distress, and anxiety (33), and therefore, providing spiritual care is of great significance for these patients (34). the findings of a study in spain also showed that nurses provided spiritual care for covid-19 patients (35). in fact, there is evidence that spiritual care may even provide a deeper type of immunity for these patients (36). the nurses in our study said that maintaining the patients’ privacy while providing care and assigning same-sex nurses are important to patients for cultural reasons, but this has been difficult during the pandemic due to a shortage of nurses. therefore, in order to ensure cbc, it is necessary for the health system to take action and recruit more nursing staff. the nurses in our study emphasized the families’ desire to say goodbye to patients before their death. in spain, in order to alleviate the suffering of families at the time of covid-19 patients’ death and to facilitate the acceptance process, healthcare workers use daily video conferencing to communicate with each other and also allow communication between patients and their families. this allows families to see their patients and expands the connection between employees, patients, and their families (37). unfortunately, due to the covid-19 crisis, funeral services have been banned. the researchers found that when covid-19 patients pass away, it is important for their families to be informed about the burial process and mourning rituals, and since memorial services are not permitted due to the pandemic, they may develop prolonged grief disorder (38). given that it is not currently possible for the families of dying patients to say goodbye or observe the customary mourning rituals, they will need the help of psychologists to cope with these problems in addition to the routine measures taken by the nurses. as a final point, it should be mentioned that the sample recruitment approach and the nature of the study limited our ability to generalize the presented findings. one main limitation of the present study was that the researchers were not allowed to enter the clinical setting due to the critical conditions in covid-19 wards. in order to overcome this limitation, the interviews were conducted using the whatsapp mobile messaging platform. in addition, since the nurses preferred voice calls for data collection, we could have missed some benefits of video calls. to compensate for compassion-based care for covid-19 patients: a qualitative analysis … 10 j med ethics hist med. 2021(december); 14:19. journal of m edical ethics and h istory of m edicine these limitations, all calls were recorded, and the number of video calls substantially exceeded that of voice calls. conclusion our study investigated nurses’ general perception of cbc for covid-19 patients through a qualitative approach. since this was the first qualitative study on iranian nurses’ views about cbc for covid-19 patients, the results can reveal the various aspects of their perceptions regarding this type of care in iran. based on our findings, cbc for covid-19 patients could comprise elements such as pro-social behaviors related to the beliefs and values of patients and their families. the results also indicated cbc for these patients to have moral, cultural, and spiritual roots. the findings of this study can be the basis for a comprehensive model in covid-19 care according to which, in addition to routine patient care, nurses need to consider concepts such as empathy, altruism, helping in critical situations, spirituality, cultural values, and family needs at the end of patients’ life. finally, nursing managers must consider the necessity for compassionate nursing care in the current covid-19 pandemic in clinical settings. acknowledgements the authors are grateful to all the nurses in this study for taking the time to share their experiences with us. conflicts of interests none declared. references 1. hermes c, ochmann t. nursing division on the current intensive care situation in germany: working group of the nursing division of the german society of medical intensive care and emergency medicine (dgiin). med klin intensivmed notfmed. 2020; 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https://pubmed.ncbi.nlm.nih.gov/?term=allande+cuss%c3%b3+r&cauthor_id=32782187 https://pubmed.ncbi.nlm.nih.gov/?term=navarro+navarro+c&cauthor_id=32782187 https://pubmed.ncbi.nlm.nih.gov/?term=porcel+g%c3%a1lvez+am&cauthor_id=32782187 https://pubmed.ncbi.nlm.nih.gov/32889037/ https://pubmed.ncbi.nlm.nih.gov/32889037/ https://pubmed.ncbi.nlm.nih.gov/32889037/ https://pubmed.ncbi.nlm.nih.gov/32414379/ https://pubmed.ncbi.nlm.nih.gov/32414379/ https://pubmed.ncbi.nlm.nih.gov/?term=roman+nv&cauthor_id=32634003 https://pubmed.ncbi.nlm.nih.gov/?term=mthembu+tg&cauthor_id=32634003 https://pubmed.ncbi.nlm.nih.gov/?term=hoosen+m&cauthor_id=32634003 https://pubmed.ncbi.nlm.nih.gov/?term=sarmiento+pjd&cauthor_id=33348354 https://pubmed.ncbi.nlm.nih.gov/?term=de+diego-cordero+r&cauthor_id=34711420 https://pubmed.ncbi.nlm.nih.gov/?term=l%c3%b3pez-g%c3%b3mez+l&cauthor_id=34711420 https://pubmed.ncbi.nlm.nih.gov/?term=lucchetti+g&cauthor_id=34711420 https://pubmed.ncbi.nlm.nih.gov/?term=badanta+b&cauthor_id=34711420 https://pubmed.ncbi.nlm.nih.gov/?term=galang+jrf&cauthor_id=33693852 https://pubmed.ncbi.nlm.nih.gov/32585665/ https://pubmed.ncbi.nlm.nih.gov/32585665/ https://pubmed.ncbi.nlm.nih.gov/?term=goveas+js&cauthor_id=32709542 https://pubmed.ncbi.nlm.nih.gov/?term=shear+mk&cauthor_id=32709542 abstract introduction references microsoft word 14 journal of medical ethics and history of medicine commentary letter medical researchers in non-english countries and concerns about unintentional plagiarism mehrdad jalalian hosseini 1* , reyhaneh bazargani 2 , latiffah latiff 3 , parichehr hanachi 4 , syed tajuddin syed hassan 3 and mohamed othman 5 1.research center of iranian blood transfusion organization, khorasan-e razavi blood center, mashhad, iran; department of community health, faculty of medicine and health sciences, universiti putra malaysia, serdang, malaysia. 2.research center of iranian blood transfusion organization, khorasan-e razavi blood center, mashhad, iran. 3.department of community health, faculty of medicine and health sciences, universiti putra malaysia, serdang, malaysia. 4.biomedical department, women research center, alzahra university, tehran, iran. 5.department of communication and network, faculty of computer sciences and information technology, university putra malaysia, serdang, malaysia. *corresponding author: mehrdad jalalian hosseini address: research center of iranian blood transfusion organization, khorasan-e razavi blood center, mashhad, iran. e-mail: mehrdad.medic@gmail.com received: 22 jun 2009 accepted: 15 aug 2009 published: 19 aug 2009 j med ethics hist med. 2009; 2:14. © 2009 mehrdad jalalian hosseini et al.; licensee tehran univ. med. sci. in the area of publishing ethics, plagiarism is addressed in all scholarly disciplines as a major academic fraud which poses a threat to the validity and reliability of published works (1). plagiarism is a hard to define term frequently used in the literature; however, the oxford advanced learn er’s dictionary of current english defined it as “to copy another person’s ideas, words or work and pretend that they are your own” (2). in most cases of plagiarism, a kind of dishonesty to mislead readers can be identified (3); but most students are confused about its exact meaning. actually, they are not efficiently skillful in correctly summarizing, paraphrasing and citing the original resources. clearly, we concern about the unintentional plagiarism by young researchers who are not familiar with strategies to avoid plagiarism but require publishing their original works or ideas in other languages than their native language (4). the problem is particularly significant in countries where the researchers, for the promise of the promotion, were compelled by the academic institutes to publish their papers in reputable english journals, whereas english is not their first language. lacking sufficient abilities in writing skills, the young scholars may feel frustrated and unable to transform their original ideas into perfectly acceptable written works. they may subsequently learn from the peers either to use internet to commit a simple cut and paste crime or to employ a word processing superficially to convert the mechanics of the other’s works into a new paper (5). it is hard to estimate how extensive the prob lem is; however, the increase in internet use has made the academic dishonesty especially in its cyber-cheating form (i.e., cut and paste plagiarism) easier than ever (6). evidences from literature suggest that there is a significant relation between the increased use of technology in academic education and plagiarism (7). in recent years, there has been an increasing amount of literature concerning the seriousness of this academic fraud. using plagiarism detection software in a 2005 study on the prevalence of plagiarism among medical students identified committing plagiarism j med ethics hist med 2009, 2:14 mehrdad jalalian hosseini et al. by 91% of the subjects (8). a large and growing body of literature has also attempted to investigate the increase in the occurrence of plagiarism among medical groups (711). one question that needs to be asked, however, is whether the plagiarism is a serious matter in medical education. gaberson kb (1997) is among the scholars who pointed out the academic dishonesty as a potential threat to the professional practice among medical practitioners (10). ten years later, harper mg (2006) considered the academic dishonesty as a predictor of workplace dishonesty and professional misconduct (7). one major criticism of previous discussion is that main expectation from medical practitioners is not being creative in academic skills but being knowledgeable and expert in their profession (11). however; it is unquestionable that careers will be damaged by detecting plagiarism and other ethical misconducts. recently we have conducted a training course on research methodology for a group of physicians, all of which were the staffs of a blood transfusion center in iran. in this four-week workshop pro gram, the participants learnt how to prepare high quality research proposals in order to overcome their stated problems through systematic research. they successfully prepared 10 research proposals based on the format given by research center of iranian blood transfusion organization. the assessments indicated a positive attitude towards research activities among the workshop partici pants. meanwhile, we found them having strong desire to see their works published in english language journals. unfortunately their perceived knowledge of english writing as well as the respective self-efficacy was assessed low. putting all these together with their zero knowledge of the strategies to avoid plagiarism and their capabilities in this regard, we are concerned about how to keep these future scientists away from unintentional plagiarism. it is suggested to avoid plagiarism by employing a combination of measures such as explicit warning, using plagiarism detection software, disseminating knowledge and improving the academic and writing skills (7, 8, 12). we believe that a kind of obligatory course in avoiding plagiarism is inevitable, and proves helpful. this can be done by disseminating awareness and knowledge about this serious ethical misconduct. serving the young authors with an online discus sion forum moderated by a native english expert in academic writing may improve the quality of english-written works and strengthening the skills of avoiding plagiarisms. references 1. bouville m. plagiarism: words and ideas. sci eng ethics 2008; 14(3): 311-22. 2. oxford advanced learner’s dictionary of current english. 7th edition: oxford university press; 2005. 3. reyes b h. plagiarism in scientific publications. rev med chil 2009; 137(1): 7-9. 4. logue r. plagiarism: the internet makes it easy. nurs stand 2004; 18(51): 40-3. 5. mohanna k. supporting learners who are studying or training using a second language: preventing problems and maximizing potential. ann acad med singapore 2008; 37(12): 1034-7. 6. arhin ao. a pilot study of nursing student's perceptions of academic dishonesty: a generation y perspective. abnf j. 2009; 20(1):17-21. 7. harper mg. high tech cheating. nurse educ today 2006; 26(8): 672-9. 8. bilić-zulle l, frković v, turk t, azman j, petrovecki m. prevalence of plagiarism among medical students. croat med j. 2005; 46(1):126-31. 9. kiehl em. using an ethical decision-making model to determine consequences for student plagiarism. j nurs educ. 2006; 45(6):199-203. 10. gaberson kb. academic dishonesty among nursing students. nurs forum 1997; 32(3):14-20. 11. osborn e. punishment: a story for medical educators. acad med 2000; 75(3): 241-4. 12. bilic-zulle l, azman j, frkovic v, petrovecki m. is there an effective approach to deterring students from plagiarizing? sci eng ethics 2008; 14(1):139-47. page 2 of 2 (page number not for citation purposes) microsoft word 1 journal of medical ethics and history of medicine the necessity of hiv testing in iranian pregnant women and its ethical considerations pooneh salari 1* , maryam azizi 2 1.assisstant professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. 2.researcher, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. *corresponding author: pooneh salari address: no.21, medical ethics and history of medicine research center, 16 azar ave., tehran, iran. tel: (+98) 21 66 41 96 61 e-mail: poonehsalari@gmail.com received: 19 dec 2008 accepted: 10 jan 2009 published: 13 jan 2009 j med ethics hist med. 2009; 2:1. © 2009 pooneh salari and maryam azizi; licensee tehran univ. med. sci. abstract keywords: hiv screening, vertical transmission, ethics, autonomy, human rights. introduction the increasing numbers of individuals living with hiv, especially the women as the swiftest– growing group of newly diagnosed hiv, made us interested in preventive measures. pregnant women are considered as representatives of all women in the child-bearing ages (1, 2). a high number of the hiv-positive women giving birth each year, so the considerable numbers a high number of hiv positive babies are born each year, whereas by highly effective preventive measures, the risk of mother‐to‐child transmission can be decreased significantly. there are different methods (for example mandatory versus voluntary) for hiv screening in pregnant women, but there are debates on conducting hiv testing by these methods. one of the most important issues in this field is its ethical considerations. also its limitations cannot be ignored. according to these facts several keywords were searched by search engines such as web of sciences, medline, google scholar, who website. the most relevant and recent articles were chosen. concerning the importance of vertical transmission of hiv, the role of preventive measures, ethical considerations, and the limitations of hiv screening, we recommend hiv testing offer to every pregnant woman at the first clinic visit by providing enough information for patient and considering her autonomy. also policy makers should provide a guideline for this test according to the pregnant women's autonomy, confidentiality, and dignity. j med ethics hist med 2009, 2:1 pooneh salari and maryam azizi page 2 of 5 (page number not for citation purposes) of hiv-infected infants are added to the population each year. in 2003, the cumulative numbers of death due to prenatally acquired aids was estimated to be 5000 in the united states (3). in addition, long dormancy period prior to launching the disease and the future reflection of epidemiologic studies in aids, hiv screening displays a more recent description (4). in iran the most hiv infected patients (75%) are men in the range of 15-49 year which are sexually active group of the society. lack of access to the high risk women for consultation and testing, the actual number of hiv positive women have not been identified (5). according to the last population study there are more than 66000 hiv positive in iran (6). considering the preventive effects of zidovudine during pregnancy in 1994 which can decrease the chance of vertical transmission of hiv, preventive efforts have focused on pregnant women as a target group for hiv testing (7). concerning these facts, prevention of mother-to child transmission (pmtct) programs launched as worldwide programs. the emergence of new antiretroviral medications and the efficacy of a combination of three highly active drugs, prevention of hiv infection in newborns and treatment of women assigned to be the primary and secondary goals of prevention respectively (8, 9). the maternal transmission of hiv infection can happen during pregnancy (antepartum), through labor and delivery (intrapartum), and after delivery (postnatal). antepartum transmission is suggested to be signified as much as 25% to 40% of the cases of maternal transmission and the rest of cases occur during labor and delivery (10). the risk of maternal transmission can be reduced by techniques which decrease the chance of the interaction between infected maternal blood and fetus (11). postnatal transmission which estimated to account for 44% of newborn cases occurs in setting of breastfeeding (12). the higher maternal viral load and the lower cd4 cell counts increase the risk of transmission (1317). the risk of vertical transmission of hiv can be reduced as less as 1% by combination anti-retroviral regimens both in mother and newborn six weeks postpartum, in addition to eluding breastfeeding and cesarean section (18-21). therefore hiv screening during pregnancy and before delivery is the most important step in the aim of preventing disease transmission (22). distinguishing hiv-infected pregnant women pave the way of choosing the best treatment option during pregnancy and reduce the risk of vertical transmission as well (22). recently, universal testing of all pregnant women is currently recommended and supported by the canadian pediatric society (cps), the american academy of pediatrics (aap), the institute of medicine (iom), the american college of obstetricians and gynecologists (acog), and the society of obstetricians and gynecologists of canada (sogc) (23). in spite of global agreement on the necessity of upraising hiv testing, the most effective way of the action and its quality is on debate in different societies (24). in the regions with high hiv prevalence, the voluntary hiv counseling and testing displaced with routine or mandatory testing (25) that is on debates (26). the question is that: is the mandatory testing a moral option in this case and how we get aware of its necessity? methods of testing previously, the worldwide strategy was based on promoting client-initiated voluntary counseling and testing (vct) and according to the consent, counseling and confidentiality (27). regarding its usefulness in public health and human rights fields, now some health care providers argue about its insufficiency in making the hiv testing more routine (28). after a while two other types of hiv testing [client initiated (voluntary) testing versus provider initiated (mandatory) testing], were introduced to the health care providers. a similar division method has divided the hiv testing methods into the other two different types of hiv testing opt-in versus opt-out hiv testing. in opt-in method a comprehensive pre-test counseling and informed consent is provided for women (29). the rate of accepting the test is related to the quality and quantity of counseling (30). in the opt out method the test is conducted routinely after giving enough information to pregnant women however they have the right to refuse (29). in the opt-out method the patient should be aware of the risks and benefits of testing, her rights and health care services if the test is positive (22). the higher screening rate was reported by opt-out testing (30). it is noteworthy that the mandatory hiv testing is the last option in the high prevalence areas when the other strategies have not provided significant reductions in the rate of vertical transmission. ethical view concerning two types of hiv testing [client initiated (voluntary) testing versus provider initiated (mandatory) testing] real conflicts have risen in this issue from ethical and legal points of views. in 2006, who and joint united nations program on hiv/aids (unaids) released a guidance for promoting provider-initiated hiv testing and counseling (pitc) in health facilities (31). the guidance consists on collaboration of j med ethics hist med 2009, 2:1 pooneh salari and maryam azizi page 3 of 5 (page number not for citation purposes) medical ethics, clinical, public health and human rights and it highlights the necessity of adjustment according to every country context (32). regarding two types of testing, voluntary versus mandatory testing, in any circumstances the mandatory testing is the most disputable strategy because even in a high standard of expertise, it limits individual autonomy and diminishes patient’s privacy. while forbidding screening tests allows more babies to be infected, according to respecting individuals and not consider them as an instrument, such a compelling target-driven authoritative to diagnose the infected women may diminish individuals autonomy (33). the conception of complying with the formal permission of health staff in support of testing, time shortage for making decision, and the power of universal routine testing all undervalue patient's autonomy (34). mandatory testing provides an estate in which the moral value of mother is secondary to that of her child and it denies her dignity. therefore she will lose her control on her future life especially when she is vulnerable and needs essential healthcare measures in the term of safeguarding her pregnancy. despite of efforts in facilitating hiv testing by clark in a study in botswana, prevention strategies did not show significant benefits (35). in this study clark consisted more on human rights and the moral frame work. confidentiality is another important issue and has to be taken into account while exchanging information between healthcare providers in the purpose of providing the most suitable post-test care. because of the psychological, social and physical distresses to newly diagnosed hiv positive pregnant women, the assurance between she and health care providers will be omitted which more endangers effective caring modalities (36). practically, a routine offer of hiv testing may predominantly serve as routine testing. in this regard, pre-test counseling will be forgotten. therefore the principles of hiv testing (consent, counseling, and confidentiality) will be undermined which disregards human rights (37). limitations of routine screening there are some obstacles in accepting hiv testing such as horror feeling of adverse consequences, having no concern about its benefit, unawareness of hiv risk, cultural and religious norm, inconvenient testing, lack of privacy in counseling and assurance of confidentiality, fear of isolation, and lack of social support (38). so there is a little probability that an hiv positive patient gets her results and co-operate for receiving treatment modalities (39). the insight of low risk to hiv infection considered as the main reason of prohibiting hiv testing in one former research (40, 41). also false positive results in low-risk patients and its outcome is a real concern and it wastes our resources and patients trust. however the rate of false positive results is rare and the harms are minimal. the harms of false-positive hiv testing may consist of elective pregnancy termination, anxiety, discrimination or altered partner relationship. also false-negative and true-negative test results can cause perpetual unsafe behaviors (42). furthermore the adverse effects of antiretroviral medications on fetus cannot be ignored. hiv positive pregnant women should be acknowledged about the possible risks of drug toxicity for fetus. they have to make decision about their own bodies according to their rights. in addition cesarean section as another preventive modality on vertical transmission does not seem to have a major role as chemoprophylaxis. regarding the two major benefits from routine hiv testing in pregnant women (early diagnosis to decrease morbidity and mortality and reducing transmission), hiv testing seems to be cost effective. conclusion considering the prevalence of hiv infection or risk characterization in each population, we (or authorities) can define a screening strategy. it has to be considered that in risk evaluation, the fear and shame of telling truth is an inhibitory force which may lead to unfair risk evaluation. one another important issue is the time of initiating drug therapy which the best time is between 15 and 19 weeks of gestation. therefore hiv screening testing should be performed at the first prenatal visit (43, 44). paying enough attention to the unaids declarations such as protecting human rights, both of those vulnerable to infection and those already infected is not only right but also produces positive public health results against hiv. concerning the low prevalence of hiv in iran or considering the low number of the confirmed hiv positive women, the reported percentage of pregnant women living with hiv who received antiretrovirals for preventing mother-to-child transmission by who which is as low as 2% (45) while the declaration of commitment hiv/aids of the united nations general assembly special session on hiv/aids consisting on preventive measures for reducing the proportion of infants infected with hiv by 50% by 2010 (46), and the cultural and religious normative, performing the opt-in hiv testing is highly recommended in j med ethics hist med 2009, 2:1 pooneh salari and maryam azizi page 4 of 5 (page number not for citation purposes) pregnant women in iran. in this regard our policy should be based on the below principles: ‐ high rates of agreement to test can be attained by applicable education and support. generally the belief of autonomy in decision making should be considered when pregnant women are offered to take hiv testing. they should be excused from social expectations as to what would be best for them and empower them to make decisions by themselves. ‐ the health policy should be based on human rights to guarantee decision making autonomously, a person is not keep in repressed by inner contextual forces like as health care provider or partner compulsion, cultural or religious pressures or fear of future access to social networks and support. the obstetricians visit is a good time for exchanging much information in an acceptable and effective way without reasoning a major concern or signal in the patient. additional methods such as audiovisual aids and informal education by a nurse counselor or social worker in the clinic may be helpful (47). the benefits of performing this screening test in pregnant women will be considerable because it is a fundamental way of reducing the outcome of hiv globally and augmenting human dignity, security and development. j med ethics hist med 2009, 2:1 pooneh salari and maryam azizi page 5 of 5 (page number not for citation purposes) references 1. colembunders rl, heywad wl. surveillance of aids and hiv infection: opportunities and challenges. health policy 1990; 15: 1-11. 2. karon jm, rosenberg ps, mcquillan g, et al. prevalence of hiv infection in the us, 1984 to 1992. jama 1996; 276: 126-31. 3. anonymous. center for disease control and prevention. hiv/aids surveillance report. 2003 (volume 15). www.cdc.gov/hiv/states/2003surveillancereport.pdf (accessed on dec 2008) 4. mertens te, low-beer 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mtct-plus initiative. reprod health matters 2005;13: 136-46. 10. anonymous. centers for disease control and prevention. revised recommendations for hiv screening of pregnant women. mmwr recomm rep 2001; 50: 63-85. 11. mandelbrot l, mayaux mj, bongain a, et al. obstetric factors and mother-tochild transmission of human immunodeficiency virus type1: the french prenatal cohorts. serogest french pediatric hiv infection study group. am j obstet gynecol 1996; 175: 661-7. 12. nduati r. breastfeeding and hiv-1 infection. a review of current literature. adv exp med biol 2000; 478: 201-10. 13. mofenson lm, lambert js, stiehm er, et al. risk factors for prenatal transmission of human immunodeficiency virus type 1 in women treated with zidovudine. pediatric aids clinical trials group study 185 team. n eng j med 1999; 341: 385-93. 14. shapiro de, sperling rs, mandelbrot l, et al. risk factors for prenatal human immunodeficiency virus transmission in patients receiving zidovudine prophylaxis. pediatric aids clinical trials group protocol 076 study group. obstet gynecol 1999; 94: 897-908. 15. garcia pm, kalish la, pitt j, et al. maternal levels of plasma human immunodeficiency virus type 1 rna and the risk for prenatal transmission. women and infants transmission study group. n eng j med 1999; 341: 394 402. 16. anonymous. mother-to-child transmission of human immunodeficiency virus in italy: temporal trends and determinants of infection. the italian collaborative study on hiv infection in pregnancy. hum reprod 1999; 14: 242-6. 17. anonymous. hiv-infected pregnant women and vertical transmission in europe since 1986. european collaborative study. aids 2001; 15: 76170. 18. mofenson lm. advances in the prevention of vertical transmission of human immunodeficiency virus. semin pediatr infect dis 2003; 14: 295-308. 19. anonymous. u.s. department of health and human services. public health service task force recommendations for use of antiretroviral drugs in pregnant hiv-1infected women for maternal health and interventions to reduce prenatal hiv-1 transmission in the united states. 2005. http://aidsinfo.nih.gov/guidelines/perinatal/per_022405.pdf (accessed on dec 2008) 20. dorenbaum a, cunningham ck, gelber rd, et al. two-dose intrapartum/newborn nevirapine and standard antiretroviral therapy to reduce prenatal hiv transmission: a randomized trial. jama 2002; 288: 189-98. 21. ioannidis jpa, abrams ej, ammann a, et al. prenatal transmission of human immunodeficiency virus type 1 by pregnant women with rna virus loads <1000 copies/ml. j inf dis 2001; 183: 539-45. j med ethics hist med 2009, 2:1 pooneh salari and maryam azizi page 6 of 5 (page number not for citation purposes) 22. walmsley s. opt in or opt out: what is optimal for prenatal screening for hiv infection? cmaj 2003; 168: 707-8. 23. keenan-lindsay l, yudin mh. hiv screening in pregnancy. j obstet gynecol can 2006; 28(12): 1103-7. 24. heywood mj. the routine offers of hiv counseling and testing: a human right. health hum rights 2005; 8(2): 13-9. 25. branson bm, handsfield hh, lampe ma, et al. revised recommendations for hiv testing of adults, adolescents, and pregnant women in health-care settings. mmwr recomm rep 2006; 55(rr-14): 1-17. 26. schϋklenk u, kleinsmidt a. rethinking mandatory hiv testing during pregnancy in areas with high hiv prevalence rates: ethical and policy issues. am j public health 2007; 97: 1179-83. 27. anonymous. world health organization (who)/joint united nations program on hiv/aids (unaids). 2004. policy statement on hiv testing. geneva: who/unaids. http://www.who.int/hiv/pub/vct/en/hivtestingpolicy04.pdf (accessed on dec 2008) 28. de cock k, mbori-ngacha d, marum e. shadow on the continent: public health and hiv/aids in africa in the 21st century. lancet 2002; 360(9326): 67-72. 29. anonymous. hiv testing among pregnant women-united states and canada, 1998-2001. mmwr morb mortal wkly rep 2002; 51: 1013-6. 30. kiarie j, nduati r, koigi k, musia j, john g. hiv-1 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al. barriers to universal prenatal hiv testing in 4 us locations in 1997. am j public health 2001; 91: 727-33. 42. chou r, smits ak, huffman lh, fu r, korthulus pt. prenatal screening for hiv: a review of the evidence for the us preventive services task force. ann intern med 2005; 143: 38-54. 43. mofenson lm, mcintyre ja. advances and research directions in the prevention of mother-to-child hiv-1 transmission. lancet 2000; 355: 2237-44. 44. connor em, sperling rs, gelber r, et al. reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. pediatric aids clinical trials group protocol 076 study group. n eng j med 1994; 331: 1173-80. 45.anonymous. epidemiological country profile on hiv and aids. http://www.who.int/globalatlas/predefinedreports/efs2008/short/efscountryprofiles2008_ir.pdf (accessed on nov 2008). 46. anonymous. guidance on global scale-up of the prevention of mother-to-child transmission of hiv. http://www.who.int/hiv/pub/guidelines/pmtct_scaleup2007/en/index.html (accessed on nov 2008). j med ethics hist med 2009, 2:1 pooneh salari and maryam azizi page 7 of 5 (page number not for citation purposes) 47. maitra n, kavishvar ab, dinkar a, desai va. antenatal hiv testing. j obstet gynecol india 2006; 56(1): 568. microsoft word 4 journal of medical ethics and history of medicine the ownership of human body: an islamic perspective kiarash aramesh assistant professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. *corresponding author: kiarash aramesh address: no. 21, medical ethics and history of medicine research center, 16 azar ave., keshavarz blvd., tehran, iran tel: (+98) 21 66 41 96 61 e-mail: kiarasharamesh@tums.ac.ir received: 20 may 2009 accepted: 29 may 2009 published: 30 may 2009 j med ethics hist med. 2009; 2:4. © 2009 kiarash aramesh; licensee tehran univ. med. sci. abstract keywords: cadaver, ownership, islam, iran, transplantation. introduction respect for the human dead body, is a consensual principle in the islamic jurisprudence. according to this principle, the dead body should be buried as soon as possible after death. in addition, mutilation of the human body, even the bodies of non-muslim enemies, is forbidden (bearing in mind that mutilation of the dead bodies of enemies was a custom among the tribal arabs at the time of prophet muhammed). the limited number of cases of dissecting dead body which were discussed in the history of jurisprudential debates were dissection the body of a recently dead woman for saving her still alive fetus and dissecting the body of a dead person for removing an amount of money who had swallowed when he was alive. both of these practices have been considered allowed with certain conditions and with some differences among different jurisprudential schools (1, 2). otherwise, any kind of mutilation of a dead body was considered as repulsive and forbidden. there was no problem with this idea, till the modern medicine has been introduced to the muslim communities. dissection of the dead bodies for learning and teaching human anatomy at first, and subsequently, the other uses of human dead body on research, education and treatment, emerged new queries about the permissibility of using and dissecting the human dead body for such purposes. using human dead body for medical purposes is a common practice in medical schools and hospitals throughout the world. iran, as an islamic country is not an exception. according to the islamic view, the body, like the soul, is a "gift" from god; therefore, human being does not possess absolute ownership on his or her body. but, the ownership of human beings on their bodies can be described as a kind of "stewardship". accordingly, any kind of dissection or mutilation of the corpse is forbidden, even with the informed consent of the dead or his/her relatives. the exception of this principle is when such procedures are necessary for saving lives of other persons. in this article using the human dead body for medical education, research and treatment is discussed and the perspective of iranian shiite religious scholars in this regard is explained. j med ethics hist med 2009, 2:4 kiarash aramesh page 2 of 4 (page number not for citation purposes) muslim physicians in iran, as an islamic country, has confronted such conflict between respect for the dead body and necessities of modern medical practice, after the introducing of the modern sciences and foundation of modern universities, about 150 years ago. the problem became more prominent after the islamic revolution in 1979, after which the government and universities became committed to conform medical practices to the islamic law. nowadays, human dead bodies are being used in medical universities and hospitals thorough iran, for the above mentioned purposes. all the medical schools have their own dissection rooms in the departments of anatomy; interventions such as intubation are being practiced on the recently dead bodies in the hospitals; autopsy for legal and medical purposes is a common practice in the authorized centers and organ transplantation from cadaver is being done frequently. there are still some debates and discussions about the religious permissibility of all these practices. the main subject of the aforementioned debates is the ownership of human body. does a person own his/her body? has he/she the authority of giving consent for such practices on his/her body after death? in this article i have described and discussed the opinions and decrees of the iranian islamic jurisprudential authorities in this regard. meaning and classification of ownership according to henk ten have and jos welie: "ownership is a complex collection of claim rights, duties, powers, and immunities. as a paradigm of ownership, reference is often made to honore's concept of "full individual ownership. honore compiled a list of standards "incidents of ownership. although the incidents are not taken individually, necessary conditions for private ownership, they may, however, together be sufficient for full individual; ownership. the standard incidents include: the right to possess a thing; the right to the exclusive use of a thing; the right to manage it; the right to its income; the right to the capital, i.e., the right to alienate (transfer) the object, and the liberty to consume, waste or destroy the object; immunity from expropriation; the power to bequeath it; the absence of term; the prohibition of harmful use; liability to execution; and residuary character. this list is useful as a frame of reference in order to determine different modes of ownership" (3). the aforementioned authors have considered three possible positions, regarding to the ownership of human body: 1. no ownership of the human body and its parts; 2. no full ownership of the body, but limited property rights with regard to body parts; 3. full ownership of the body and its parts (3). obviously, ownership of everybody to his body does not possess all the abovementioned incidents. for instance, one can not transfer his/her own body to anyone else; also, one can not waste his/her own body. in addition, selling human organs is prohibited in almost all of the juridical systems. therefore, it seems plausible to say that human being has limited ownership to his or her own body. according to the islamic view, the body, like the soul, is a "gift" from god; therefore, man does not possess absolute ownership on his body. but, the ownership of human beings on their bodies can be described as a kind of "stewardship" (1). it should be noticed that in secular schools of thought, regardless of the kind of ownership, a person is the most relevant one for decision making about his or her body after his or her death. accordingly, using advance directive can solve the ethical problems in many cases. according to the islamic schools of thought, a person has not any kind of authority, ownership or stewardship on his future dead body. therefore, advance directive is not considered an absolute right in the islamic law. using the human dead body for education dissecting of dead bodies is a standard practice for education in anatomy departments. it has been practiced in the medical schools in iran since the foundation of modern medical schools. almost all the iranian shiite religious authorities deem allowed to dissect the corpse of a non-muslim for medical educational purposes. but almost all of them consider such practice on the dead body of a muslim, as forbidden (2, 4). according to the religious decrees (fatwas) of some of iranian shiite religious authorities (e.g. ayatollah khamenei (5) and ayatollah makarem shirazi (6)) , in the cases of unavailability of the corpse of non-muslims and the necessity of educatinglife-saving medical knowledge and techniques, dissection of the corpse of a muslim would be allowed. there is another kind of using human dead body for research which seems to be more controversial, morally speaking, using the recently dead body to practice endotracheal intubation (eti). "eti is the placing of a tube in a patient's trachea and it is the preferred method of managing the airway in patients with life-threatening conditions" (7). as far as i searched, practicing eti on the recently dead has not been asked from the religious authorities in iran; however, according the logic of their answers to the similar questions and their view toward the ownership of human dead body, it may be concluded that in the cases of necessity, it would be allowed. j med ethics hist med 2009, 2:4 kiarash aramesh page 3 of 4 (page number not for citation purposes) using the human dead body for research this kind of using human dead body, for example using in car crash tests, has been objected with this argument that such practice is contrary to the principle of human dignity (8). nevertheless, such uses are commonly provided by the informed consent had been given before the death. in this regard, in iran, a national guideline has been compiled in the medical ethics and history of medicine research center of tehran university of medical sciences and communicated by the minister of health in 2006 (9). according to the special guideline for research on human organ and tissue transplantation, for using organs or tissues obtained from the dead bodies, in addition to the necessity of being approved by the research ethics committee, "obtaining the consent of person before death or the consent of his or her representative is necessary”. in the transplantation researches the consent should be based on opting in, even if this would be changed for therapeutic purposes. also, "when one is opposed to donate his or her organs or tissues, his or her representative can not permit it after his or her death" (10). although the abovementioned guideline has been approved by religious scholars in iran, it is interesting that some issues like as the deference between muslims and non-muslims have not been considered in it. using human dead body for treatment the iranian model of kidney transplantation was very successful in eliminating the long waiting list for kidney transplantation (11). however, serious ethical concerns about the commercialization of human organs are being conveyed by ethicists, from inside and outside of iran, to iranian religious and health authorities (12, 13). using organs of deceased or brain-dead persons has been discussed as a solution. religious authorities permitted such practice and consequently, in 2000, the parliament approved the organ transplantation and brain death act, allowing the use of organs from deceased or brain dead persons provided the consent by their relatives (14). the similar considerations mentioned above, about the impact of religious differences, do exist in these cases. in addition, removing the cornea of unidentified dead bodies in the forensic medicine organization has been practiced for several years. discussion and conclusion the religious perspectives toward using human dead body for medical education, research and treatment are based on some presumptions including: 1. the supreme religious authority (vali-e faghih) has the right to make decision regarding human dead bodies usage. 2. in the cases of necessity for life-saving educations, researches or treatments, use of human dead body is allowed, encouraged and even recommended. 3. in the cases of dissecting, it is preferred to use the dead bodies of non-muslims. 4. in the cases of treatment, the priority should be given to the muslim patients if the needs are equal and resources are limited. this essay is not complete without pointing out some important related points: 1. the exact relation between ethics and religious jurisprudence is still ambiguous and controversial among iranian scholars. jurisprudential decrees are considered as the basis of the rules and regulations in iran but in the cases of conflict between such decrees and universal ethical norms, some modifications seem necessary. 2. in the case of this essay, according the classical shiite jurisprudence, the decision making about using human dead body is not by the advance directive or consent of relatives. but such consents have been considered as necessary by regulations because of ethical obligations. 3. the difference between muslims and non muslims with regard to dissecting the dead body for educational purposes has not been mentioned in the formal rules and regulations which shows the difficulty of translating such decrees to rules and regulations. 4. according to the islamic law, saving the life of human beings has utmost priority and if any kind of using a corpse is necessary for life saving, it would definitely be allowed. however, judgment about the "necessity" is very difficult in many cases. acknowledgement i would like to express my many thanks to dr abdussaleh ja'fari for his very helpful comments, professor pooneh salari for her so kind cooperation and to the esteemed reviewers of the journal of medical ethics and history of medicine 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ethics. in: bayertz k. sanctity of life and human dignity. dordrecht: kluwer academic publishers; 1996, pp. 91-106. 9. larijani b, zahedi f. contemporary medical ethics: an overview from iran. dev world bioeth 2007; 8(3): 1926. 10. anonymous. the iranian ministry of health, ethical guideline for researches on tissue and organ transplantation. available at: http://mehr.tums.ac.ir/codes.aspx (accessed on may 2009) 11. ghods aj, savaj s. iranian model of paid and regulated living-unrelated kidney donation. clin j am soc nephrol 2006; 1: 1136–45. 12. griffin a. kidney on demand. br med j 2007; 334: 502-5. 13. bagheri a. compensated kidney donation: an ethical review of the iranian model. kennedy inst ethics j 2006; 16(3): 26982. 14. larijani b, zahedi f, taheri e. ethical and legal aspects of organ transplantation in iran. transplant proc 2004; 36: 1241–4. questionaaire omid asemani 4-127 journal of medical ethics and history of medicine development and validation of a questionnaire to evaluate medical students' and residents' responsibility in clinical settings omid asemani1, mohammad taghi iman2*, mohammad khayyer3, seyed ziaaddin tabei4, farkhondeh sharif5, marzieh moattari6 1assistant professor, department of medical ethics and philosophy of health, school of medicine, shiraz university of medical sciences, shiraz, iran; 2professor, department of sociology, shiraz university, shiraz, iran; 3professor, college of education and psychology, shiraz university, shiraz, iran; 4professor, department of medical ethics and philosophy of health, school of medicine, shiraz university of medical sciences, shiraz, iran; 5professor, department of psychiatric nursing, community based psychiatric care research center, college of nursing & midwifery, shiraz university of medical sciences, shiraz, iran; 6professor, department of nursing, college of nursing & midwifery, shiraz university of medical sciences, shiraz, iran. corresponding author: mohammad taghi iman address: school of sociology, college of social sciences, shiraz university, shiraz, iran. po: 7194685111 email: iman@shirazu.ac.ir tel/ fax: 98 711 36 28 96 61 received: 28 feb 2014 accepted: 11 oct 2014 published: 21 oct 2014 j med ethics hist med, 2014, 7:17 © 2014 omid asemani et al.; licensee tehran univ. med. sci. abstract there is a shortage of quantitative measures for assessing the concept of responsibility as a fundamental construct in medical education, ethics and professionalism in existing literature. this study aimed to develop an instrument for measuring responsibility in both undergraduate and graduate medical students during clinical training. instrument content was based on literature review and mainly qualitative data obtained from a published grounded theory research. the draft questionnaire (persian version) was then validated and revised with regard to face and content validity. the finalized 41-item questionnaire consists of four domains that were identified using factor analysis. test-retest reliability and internal consistency were also assessed. test-retest reliability was rather high, ranging between 0.70 and 0.75 for all domains. cronbach’s alpha coefficients were 0.75 0.76 for all domains and 0.90 for the composite scale of the whole questionnaire. correlations between the four domains of the instrument were also satisfactory (r ≤ 0.47 for most domains). the correlation between each domain and the composite scale was higher than its correlation with other domains (r ≥ 0.79 for most domains). the instrument demonstrated good construct and internal validity, and can be suitable for measuring the concept of responsibility in practice in different groups of undergraduate and graduate medical trainees (mts). keywords: responsibility, undergraduate medical student, graduate medical student mailto:iman@shirazu.ac.ir j med ethics hist med 7:17 oct, 2014 jmehm.tums.ac.ir omid asemani et al. page 2 of 8 (page number not for citation purposes) introduction the concept of "responsibility" is considered to be a core value in medical education, medical ethics and medical professionalism. it is one of the main characteristics highly expected of members of the health care profession (1). nevertheless, the existing literature consists of a limited number of scattered studies on this concept in health care (2) and more specifically in the field of medical ethics (3). a considerable bulk of related studies have merely attempted to explain this concept in relation to other research subjects or introduce new scopes of responsibility into preexisting notions (4-6). thus the concept of responsibility itself has literally been employed as an intelligible and basic concept with a completely obvious meaning for readers of scientific papers (7, 8), and has rarely been handled as an independently ascertainable subject for research. to the best of our knowledge, studies are also rare in the case of measuring responsibility as a quantitative term. in this respect, mergler's study (9) is a remarkable instance. she has developed a questionnaire for assessing "personal responsibility" in adolescents using data from focus groups and a number of related measures in the literature. additionally, a general aspect of this concept can be found in at least one item of many quantitative instruments developed for assessment of "professionalism" (10, 11). the current study aimed to develop a questionnaire to contribute to the existing literature on concrete measurement of the concept of responsibility in medical trainees (mts). this questionnaire measures responsibility in both undergraduate and graduate mts during clinical trainings. method conceptual framework the items of the questionnaire were obtained by literature review and mainly from a phd dissertation (12). the latter was a qualitative research that used “grounded theory methodology” to provide a theoretical explanation for the phenomenon of responsibility in mts and the involved processes in the clinical settings of shiraz university of medical sciences (sums). consequently, three categories were extracted that could explain how mts took on and met their educational responsibilities: 1) try to find acceptance towards expectations; 2) try to be committed to meeting expectations (including three subthemes of "commitment to others", "commitment to self-improvement", and "commitment to fulfill academic duties"); and 3) try to cope with unacceptable expectations (including two subthemes of "adopting effective strategies" and "adopting non-effective strategies"). based on the above-mentioned qualitative research and considering the objective of this study, responsibility in mts may be defined as their “ability to gain acceptance toward existing educational expectations, and their desire and attempt to meet those expectations, or their reaction to unacceptable ones using effective or non-effective strategies”. eventually, the items of the instrument were generated based on the emergent themes and subthemes of the above-mentioned qualitative study. development of the questionnaire a total of 55 initial questions were designed and collected as a draft questionnaire (persian version). in order to ensure face and content validity, these items were reviewed for syntax, appropriateness (13), difficulty, relevancy and ambiguity by a number of experts including clinical attending physicians and professional nurses as well as mts. participating trainees were representatives of all groups of mts including undergraduates and medical residents, and minor modifications were made to the layout and wording accordingly. in order to test the content validity of this initial version, each item was rated by at least ten experts and mts to calculate content validity ratio (cvr) and content validity index (cvi). since the questionnaire had to be short and easy to complete, the purpose was to determine whether each item should be retained or rejected (14, 15). finally, after a cautious rejection of 9 items, a 46-item questionnaire was developed for further validation. lack of conformity between the items and their corresponding category and content overlap were two main causes for item rejection. response to items was based on a 5-point likert scale ranging from strongly agree to strongly disagree. additionally, in the demographic section of the instrument, questions with regard to age, gender, educational level, monthly household income, marital status and total grade point average of undergraduate education were added. study population the questionnaire was administered to undergraduate mts in their 5th year (juniors or medical students), 6th year (medical externs) and 7th year (seniors or medical interns), as well as graduate mts (residents) in various specialties. mts were recruited across a wide variety of clinical wards in three educational hospitals of sums using stratified sampling. in most wards, the general population of mts consisted of a variety of undergraduate and graduate mts with different educational levels. in all cases, the questionnaires were administered directly by one of the authors to participants and then collected back. in addition to the questionnaire, each participant received a set of instructions explaining the purpose of the study, j med ethics hist med 7:17 oct, 2014 jmehm.tums.ac.ir omid asemani et al. page 3 of 8 (page number not for citation purposes) their freedom to participate and a confirmation of confidentiality. statistical analysis exploratory factor analysis and then confirmatory factor analysis were performed using varimax rotation to identify distinct domains in the questionnaire. in all items, higher score (score 5 in the likert scale) represents higher responsibility. the internal reliability was estimated overall and for each domain using cronbach's alpha coefficient. pearson correlation coefficients were calculated between each domain of the questionnaire to assess redundancy and independence. the concurrent and divergent validity of the instrument were examined by calculating correlation coefficients between the domain and composite scores of the instrument. all analyses were performed using ibm spss statistics version 21. all statistical testing was also twosided, and p ≤ 0.05 was considered to be statistically significant. results participant characteristics table 1 demonstrates mts' demographic characteristics (n = 237) stratified by their educational level. since all trainees were either single or married, we have demonstrated here only two options for marital status. in addition, monthly household income has been exchanged from rials (the currency of iran) to dollars for international comprehension. of the 237 participants that completed the questionnaires, 195 (82 %) rated all 46 questions. table 1. demographic characteristics of participating mts characteristic stratum educational level student (n = 72) extern (n = 64) intern (n = 32) resident (n = 69) gender (%) male female 40 60 46.9 53.1 40.6 59.4 46.4 53.6 mean age (years) 23.2 23.7 24.7 32.8 total grade point average (sd) 16.2 (1.3) 16.5 (1.0) 16.4 (1.0) 16.6 (0.8) marital status (%) single married 78.6 21.4 85.9 14.1 75 25 38.8 61.2 monthly household incomeb (%) < 340 340 680 680 1000 1000 1340 > 1340 33.9 37.1 12.9 3.2 12.9 32 41.5 17 5.7 3.8 21.8 37.5 18.8 3.1 18.8 25.8 39.4 9.1 3 22.7 sd= standard deviation; b in dollars. reliability to assess reliability, the internal consistency of the four domains (see validity and the factor loading results) and the composite score for the 237 participants were determined (table 2). as can be seen, the calculated internal consistency for the composite score and all domains were high with cronbach's alpha > 0.70. test-retest reliability was conducted after a two-week interval using 35 mts. the results were good with intra-class correlation coefficients all above 0.80. moreover, internal consistency of the split-half coefficients was computed using a two-way fixed model. cronbach's alpha coefficient was 0.84 for part one and 0.79 for part two, and the guttman split-half coefficient and intra-class correlation coefficient were 0.88 and 0.90 respectively. table 2. characteristics of the instrument composite and domain scores responsibility measure no. of items cronbach's alpha test-retest ctfe domain 15 0.75 0.71 scvs.dc domain 11 0.75 0.75 itbeime domain 10 0.74 0.75 aoe domain 5 0.76 0.72 composite 41 0.90 0.90 ctfe= commitment to fulfill expectations; scvs.dc= self-centeredness vs. duty-centeredness; itbeime= inclination to be engaged in meeting expectations; aoe= acceptance of expectations. validity face and content validity were assessed by our expert panel including clinical attending physicians and nurses as well as a number of undergraduates and medical residents. after the process of revision, a 46-item draft questionnaire was developed for factor analysis. in order to ensure construct validity, the questionnaire was administered to 237 mts (table 1). responses were used to assess interpretability, internal consistency, and factor j med ethics hist med 7:17 oct, 2014 jmehm.tums.ac.ir omid asemani et al. page 4 of 8 (page number not for citation purposes) loading. after exploratory factor analysis and by using component matrices and a scree plot (fig 1), it was decided that four or five components had to be retained. following a number of successive confirmatory factor analyses, the 41-item instrument was finalized with four domains. in this way, 5 items with low (one item) or negative (two items) factor loadings, and items lacking consistency with the extracted domains were deleted. the extracted domains were as follows: 1. "commitment to fulfill expectations (ctfe)" with 15 items and extracted eigenvalue of 9.77 2. "self-centeredness vs. duty-centeredness (scvs.dc)" with 11 items and extracted eigenvalue of 3.76 3. "inclination to be engaged in meeting expectations (itbeime)" with 10 items and extracted eigenvalue of 2.15 4. "acceptance of expectations (aoe)" with 5 items and extracted eigenvalue of 1.84 fig 1. the scree plot. the curve reaches a fairly stable plateau after five factors these components could explain 42.75 % of the total variance of mts' responsibility in clinical settings. the results of the principal component analysis (pca) are demonstrated in table 3. in this table, all calculated factor loadings with values larger than 0.3 are shown in addition to rotated eigenvalues and the percentage of variance by each significant extracted factor. the instrument is available in the appendix at the end of the article. table 3. results of factor loading using principal component analysis (pca) as extraction method factors ctfe scvs.dc itbeime aoe cib flc ci fl ci fl ci fl qd1 0.74 q16 0.68 q27 0.64 q37 0.71 q2 0.68 q17 0.65 q28 0.60 q38 0.60 q3 0.67 q18 0.63 q29 0.52 q39 0.56 q4 0.65 q19 0.63 q30 0.51 q40 0.47 q5 0.64 q20 0.55 q31 0.50 q41 0.36 q6 0.59 q21 0.55 q32 0.48 q7 0.57 q22 0.54 q33 0.43 q8 0.55 q23 0.54 q34 0.41 q9 0.54 q24 0.50 q35 0.40 q10 0.52 q25 0.44 q36 0.30 q11 0.52 q26 0.42 q12 0.51 q13 0.50 q14 0.50 q15 0.49 rotated eigenvalue 6.236 5.119 3.760 2.412 % of variance 15.210 12.485 9.172 5.882 cumulative % 15.210 27.696 36.867 42.749 ctfe= commitment to fulfill expectations; scvs.dc= self-centeredness vs. duty-centeredness; itbeime= inclination to be engaged in meeting expectations; aoe=acceptance of expectations; c= content of the item (see the appendix); fl: factor loadings; q: question. table 4 illustrates the intra-scale correlations between the instrument domains and the composite score. as can be seen, all inter-correlation measures between domains are lower than that of each correlation with the composite score. almost all intra-scale correlations were low with r ≤ 0.48, suggesting that the domains are measuring unique constructs. j med ethics hist med 7:17 oct, 2014 jmehm.tums.ac.ir omid asemani et al. page 5 of 8 (page number not for citation purposes) table 4. intra-scale correlations between the instrument domains and the composite score responsibility measure responsibility measure composite aoe ctfe itbeime scvs.dc composite 1.00 aoe domain 0.53 1.00 ctfe domain 0.79 0.22 1.00 itbeime domain 0.82 0.32 0.48 1.00 scvs.dc domain 0.82 0.43 0.42 0.63 1.00 ctfe= commitment to fulfill expectations; scvs.dc= self-centeredness vs. duty-centeredness; itbeime= inclination to be engaged in meeting expectations; aoe= acceptance of expectations; all correlations were significant at the 0.01 level discussion in this study, we developed a questionnaire for practical measuring of mts’ responsibility in clinical settings. the main source for generating the items of this instrument was a published grounded theory research (gtr) (12). as demonstrated by factor loading, the instrument assesses mts' responsibility with respect to four domains. overall, there was a suitable correspondence between the items of this questionnaire and the emergent categories and sub-categories of the gtr. this correspondence will be discussed in more detail below. table 5. corresponding items of the "responsibility questionnaire" generated based upon emergent categories and sub-categories of a published phd dissertation responsibility measure/corresponding items emergent categories of the grounded theory research (gtr) "try to find acceptance towards expectations" "try to be committed to meeting expectations" "try to cope with unacceptable expectations" ctfe domain/q1-q15 q1, q2, q4, q5, q10, q14 q7, q8, q9, q11, q12, q13, q15 q3, q6 scvs.dc domain/q16-q26 q17, q19, q21, q22 --q16, q18, q20, q23-26 itbeime domain/q27-q36 --q27-q36 -- aoe domain/q37-q41 q37-q41 ---- ctfe= commitment to fulfill expectations; scvs.dc= self-centeredness vs. duty-centeredness; itbeime= inclination to be engaged in meeting expectations; aoe= acceptance of expectations. there was not a close correspondence between items of the component "commitment to fulfill expectations (ctfe domain)" and its corresponding category "try to be committed to meeting expectations" in the gtr. as table 5 demonstrates, questions 1, 2, 4, 5, 10 and 14 in this domain have been generated based on the dissimilar category "try to find acceptance toward expectations" in the gtr. originally, these items aimed to assess how "acceptance parameters" of motivation, hope, attitude, etc. might influence mts' responsibility in practice. moreover, questions 3 and 6 were generated to assess how effectively mts might deal with "unacceptable duties" in this domain. while this distribution of items seemed unusual at the beginning, a more thorough contemplation revealed that despite their original purpose, these items could also measure trainees' responsibility. in fact, these items would measure trainees’ level of commitment, especially in situations where they might find their personal benefit or convenience in conflict with their duties. therefore, contrary to our expectation, factor analysis revealed that mts responded to these questions in the same manner they responded to the questions based upon the category "try to be committed to meeting expectations". as demonstrated by factor loading, the component of "self-centeredness vs. duty-centeredness" (scvs.dc domain) includes items that measure mts' real approach towards fulfilling duties, especially when duties could potentially conflict with their convenience and benefit. thus, lots of items generated based on the third category of the gtr "try to cope with unacceptable expectations" would fall within this domain. in order to facilitate understanding this component and its general meaning, the domain had to be named differently from its corresponding category. however, like the previous component, items 17, 19, 21 and 22, which had been developed according to the category "try to find acceptance towards expectations", would be placed in this domain. this unlikely distribution revealed that although these components primarily aimed to assess the role of other "acceptance criteria" pertaining to responsibility in mts, they were also indexes of selfcenteredness vs. duty-centeredness. as the collection of questions indicates, this domain could assess mts’ priorities regarding qualitative fulfillment of duties over their comfort and benefit. j med ethics hist med 7:17 oct, 2014 jmehm.tums.ac.ir omid asemani et al. page 6 of 8 (page number not for citation purposes) in the case of the extracted component "inclination to be engaged in meeting expectations" (itbeime), all items were consistent with the second category of the gtr "try to be committed to meeting expectations". according to factor loading, items of this domain would measure mts' inclination and desire for engaging in fulfillment of academic duties. on this basis, higher responsibility was usually followed by a higher inclination to be involved in meeting expectations. finally, all five items of the fourth component "acceptance of expectations" (aoe) also corresponded to the category "try to find acceptance towards expectations" in the gtr. this domain measures which criteria of duties or expectations are personally evaluated by mts to be accepted and then fulfilled. as mentioned before, the literature on responsibility as a quantitative measure is rather limited (9), especially in the fields of medical education and medical ethics. moreover, results of published works often cannot be applied to all countries alike due to social and cultural differences unless adaptability measures are implemented. there are also certain nonspecific instruments that have investigated the concept of responsibility mainly for other purposes (16, 17) or rather broadly and in order to evaluate concepts such as "professionalism" (10, 11). additionally, these instruments are often employed by third parties. therefore, we believe the present valid and reliable questionnaire could specifically contribute to the existing literature on the subject and be utilized as a selfreporting instrument for assessing iranian mts' responsibility in practice. the most important limitation of the present questionnaire may be that in general assessment of responsibility in a group of mts, only the more responsible ones complete and return the questionnaires to researchers. this is especially true when forms are sent electronically or by mail, in which case the results would most likely be false or unreliable. it is therefore proposed that in these situations the instrument be delivered and then collected back in face-to-face appointments. the questionnaire can also be administered to mts as a mandatory assignment in one of their formal courses such as medical ethics, or as a required twelve/six-monthly evaluation form for educational purposes. conclusion in this study, we aimed to develop an instrument for practical evaluation of responsibility in medical trainees. the questionnaire was prospectively validated in a diverse population of both undergraduate and graduate mts all recruited from educational settings of sums. the instrument was intended as a generic survey to supplement the literature on practical assessment of responsibility in mts within clinical settings. this instrument is intended to measure trainees' beliefs, attitudes and behaviors with regard to the concept of responsibility in practice. we believe that this questionnaire can be used to provide highly beneficial information for medical education and ethical development purposes. acknowledgment the present research would not be possible without the valuable assistance of numerous people. the authors would like to thank all participating mts for their kind cooperation in the collection of data for both the gtr and the present study. financial support this study comprises part of a more extensive research (a phd dissertation), registered under number 5965 and financially supported by the vice-chancellery of research and technology of 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[in persian] appendix all questions were based on a 5-point likert scale (strongly agree/agree/to some extent agree/disagree/strongly disagree). the instrument is presented below with the items organized according to the identified components: component i: commitment to fulfill expectations (ctfe) q1. i accept and fulfill my duties perfectly even when i do not have enough motivation for doing them. q2. i fulfill my duties perfectly even when i have no hope for positive consequences. q3. i fulfill my duties perfectly even when i do not like doing them. q4. i fulfill my duties perfectly even when i consider them beneath my dignity and professional status. q5. i fulfill my duties perfectly even when i feel offended or dissatisfied on account of misconduct or imposition, etc. on other people’s side. q6. i fulfill my duties perfectly even when i need to justify myself for doing them. q7. i hold myself accountable for my duties even if my accountability causes problems and inconveniences for me. q8. i fulfill my duties precisely and perfectly even if they cause hardships and difficulties for me. q9. i respect my patients' rights even if it creates problems for me. q10. i usually fulfill my duties regardless of my personal interests. q11. for me, it is important to fulfill duties in the best way possible, not just perform them. q12. i am respectful to patients and colleagues even if their behavior or requests are not respectful. q13. i accept constructive criticism in a positive manner even if made by a nurse or a junior colleague. q14. i usually fulfill my duties regardless of my attitude towards them. q15. i often try to follow positive role models in my practice. component ii: self-centeredness vs. duty-centeredness (scvs.dc) q16. i prefer to ignore others' (nurses, senior coworkers, etc.) professional comments or guidance and just do my own work. q17. i prefer not to consult colleagues (nurses, seniors, coworkers, etc.) on my tasks; it would save my face and my dignity. q18. i make jokes about patients with my colleagues. q19. i do not think it is really important to do one’s duties perfectly, except to avoid potential problems (for example be reprimanded or receive complaints, etc.). https://www.hcpc j med ethics hist med 7:17 oct, 2014 jmehm.tums.ac.ir omid asemani et al. page 8 of 8 (page number not for citation purposes) q20. i believe neglecting duties is not appropriate, but i may do so when i am tired, or in other extremely rare situations. q21. i do not believe in fulfilling duties unless it brings me personal gain. q22. i believe i should consider my own benefits and convenience when i am dividing professional tasks between myself and my colleagues. q23. i sometimes satisfy my dissatisfaction or irritation at others in the way i perform my tasks or duties (for instance by becoming less active or less involved, etc.). q24. i believe respect for the law and observation of rules is good, provided that it is not in conflict with my personal convenience. q25. i believe lackadaisical performing of duties is inappropriate, but i may do so when i am tired, or in other extremely rare situations. q26. i believe evading duties and imposing your own responsibilities on others is not appropriate, but i may do so in some situations (for example in the case of risky patients, during midnight hours, etc.). component iii: inclination to be engaged in meeting expectations (itbeime) q27. i believe dedication to duty is pointless/unnecessary, and i only try to perform the tasks. q28. i believe active involvement in duties to be unnecessary, and i only try to perform the tasks. q29. i do not refuse to help my colleagues (nurses, fellow students, etc.) if i can, even in cases beyond my official duties. q30. i think feeling sympathy for patients is pointless/unnecessary, and i only try to meet their medical needs. q31. i perform only the minimum amount of duties that is required of me (i do no more than i need to). i prefer not to create any unnecessary difficulties or hardships for myself. q32. i am enthusiastic and energized about fulfilling my duties, regardless of how difficult they may be to perform. q33. i believe it is not necessary to have good relations with my colleagues in order to improve my performance, and i prefer to simply perform my duties. q34. i do not refuse to help my patients if i can, even when that creates hardships and difficulties for me. q35. i believe it is pointless and unnecessary to stress over perfect fulfillment of duties, and i only try to perform the tasks that are required of me. q36. i perform my duties with delay or lower precision if i realize the task is not urgent or particularly important (in the case of midnight duties or health-obsessive patients, for instance). component iv: acceptance of expectations (aoe) q37. i believe what is assigned to me as a duty should be sensible, otherwise i do not accept it or i take it lightly. q38. i believe what is assigned to me as a duty should be fair, otherwise i do not accept it or i make light of it. q39. i do not accept or fulfill tasks or expectations that are beyond my lawful scope of duty, even if this is harmful to me in some way. q40. when i cannot satisfy myself that something (a duty, a request, etc.) is right and acceptable, i become inattentive to it (for instance i ignore a nurse request or a senior professional order, etc.). q41. i believe that fulfilling duties is important provided that it does not disturb my personal life (for example keep me from performing personal tasks, studying for an exam, etc.). microsoft word 2 journal of medical ethics and history of medicine fetus as human being: where is the cut‐off point? soroush dabbagh assistant professor, iranian institute of philosophy, tehran, iran. *corresponding author: soroush dabbagh address: no. 6, araklian alley, nophel loshato st., vali-e-asr ave., tehran, iran. tel: (+98)91 26 00 79 21 e-mail: soroush.dabbagh@gmail.com received: 03 mar 2009 accepted: 14 mar 2009 published: 17 mar 2009 j med ethics hist med. 2009; 2:2. © 2009 soroush dabbagh; licensee tehran univ. med. sci. abstract keywords: abortion, fetus, human. introduction abortion is one of the controversial issues discussed in medical ethics (1). according to the proponents of abortion, committing abortion is morally justified. in fact, one is permitted to abort the fetus during the pregnancy period whenever she wants. however, the opponents of abortion do believe that committing abortion is morally wrong. we can formulate the argument which is put forward by the opponents as follows: 1) fetus has to be regarded as an example of human being; 2) killing an innocent human being is morally wrong; 3) aborting is an example of killing and terminating a human being’s life. so, committing abortion is morally wrong (2-4). it can be seen that the second premise deals with the idea of killing and harming others. moreover, categorically speaking, some of the proponents do not believe that harming others is wrong. it follows from this that we are permitted to kill human beings in several contexts, with some reservations. in other words, in accordance with abortion is one of the controversial issues discussed in medical ethics. we can formulate the argument which is put forward by the opponents of abortion as follows: 1) fetus has to be regarded as human being; 2) killing an innocent human being is morally wrong; 3) aborting is an example of killing and terminating a human being’s life. so, being engaged in aborting is morally wrong. in this paper, i am going to argue that the proponents’ argument with regard to the implausibility of categorizing fetus as human being is unjustified and wanting. in other words, the way in which the proponents of abortion talk about the idea of personhood is, inadequate and vague, semantically speaking. the outline of the argument is as follows. the proponents of abortion are confronted with a dilemma. according to the first horn of the dilemma, the proponents have to subscribe to infanticide which is morally wrong, intuitively speaking. according to the second horn of the dilemma, there is a semantic story which needs to be expressed by the proponents with regard to the cut-off point of the concept ‘personhood’. otherwise, the first premise will not be convincing if raised in favour of the plausibility of committing abortion. j med ethics hist med 2009, 2:2 soroush dabbagh page 2 of 4 (page number not for citation purposes) their position, committing abortion which is an example of killing human beings is permissible in some ethical contexts. moreover, there are some ethicists who believe that, taking into account the pregnant woman’s rights, we are allowed to abort the fetus whenever she intends during pregnancy period. according to them, fetus is part of the pregnant’s body. if this is the case, the way she treats her body is generally justified (5). these lines of arguments deal with the second and the third premises: whether or not one finds committing abortion permissible. in this paper, i am going to discuss about the first premise and show that the proponent’s argument with regard to the implausibility of categorizing fetus as human being is unjustified and wanting. in other words, the way in which the proponents talk about the idea of personhood is semantically inadequate and vague. moreover, it does not follow from this that the proponents’ position with regard to the plausibility of abortion is categorically unjustified. rather, it just shows that resorting to the first premise in order to make an argument in favour of permissibility of committing abortion is unjustified. the proponents’ dilemma in order to see how the argument works, let us categorize, at this stage, the proponents' semantic position with regard to the idea of personhood. according to the proponents, we are not authorized to refer to 4 weeks embryo as human being, as it is just a complex of cellular elements. ontologically speaking, nothing can be added to this complex, this metaphysical position is associated with semantic point, according to which, we are not allowed to regard the fetus as something else, the way we consider human being. moreover, we are not authorized, semantically, to regard 20 weeks fetus as human being either. in fact, no substantive ontological change has happened within these 4 months. just the complex of cellular elements has become bigger and more complicated. that is it. this semantic position leads to the point that we are not authorized to categorize 30 weeks fetus as human being either. the same semantic position can be taken with regard to 36 weeks fetus. however, it seems that the story changes whenever we are confronted with a newborn, intuitively speaking. in fact, the newborn is categorized as human being by both the proponents and the opponents. now, if this is the case, then the opponents are confronted with a dilemma. according to the first horn of the dilemma, they could go ahead according to their semantic position and state that a newborn cannot be regarded as human being. it follows from this that infanticide is morally permissible and justified. in other words, we are authorized to kill the newborn with some reservations in different contexts. however, it seems that infanticide is, intuitively speaking, immoral. according to the second horn of the dilemma, the opponents owe us a semantic story with regard to the cut-off point of the concept ‘personhood’. in fact, if they believe that infanticide is immoral and we are not allowed to kill a newborn, then they have to explain us the difference between the fetus and the newborn, which makes a room for the semantic difference we are in search of. as we have seen, there is a significant connection between the metaphysical and the semantic aspects of the issue of abortion. if we are, semantically speaking, allowed to refer to a newborn as human being, the proponents have to tell an ontological story based on it; then we are authorized to regard the newborn as human being. we know that the fetus’s environment is, ontologically speaking, different from the newborns one: fetus cannot breathe the same as newborn does; the way the fetus in nourished is different from the way the newborn is nourished, etc. moreover, fetus entirely depends on its mother, while newborn is not entirely dependent, as he/she is separated from his/her mother and can grow up independently. however, it seems that these ontological differences are not adequate for the semantic story needed. in fact, the constitutive and fundamental features of the fetus and the newborn are, more or less, the same. there is a significant difference which is to be noted in the first place. based upon that, we are, semantically speaking, authorized to regard the newborn as human being. during the pregnancy period, fetus takes different shapes in several steps. for instance, when fetus is 12 weeks, its shape is different from the fetus which is 20 weeks. but, according to the opponents, these differences do not entail us to refer to different complexes with several names (even though in medicine the organism in the first 8 weeks of gestation is called embryo). for instance, we regard the entity which is 9 weeks as fetus. also, we refer to the entity which is 20 weeks as fetus as well, etc. in fact, we utilize only the same name for different steps (with the exception of the first 8 weeks, as mentioned above) during the pregnancy period. moreover, when 36 weeks fetus is born, it seems that its shape is more or less the same as the shape of a fetus. now, if this is the case, there is a metaphysical story to be told in order to make the proponents’ semantic position intelligible. in short, the opponent is confronted with a dilemma. according to the first horn of the dilemma which is a slippery slope argument, the opponents have to subscribe to infanticide at the end of the day which is morally impermissible, intuitively speaking. according to the second horn of the dilemma, there is a semantic story to be told j med ethics hist med 2009, 2:2 soroush dabbagh page 3 of 4 (page number not for citation purposes) by the opponents with regard to the cut-off point of the concept ‘personhood’. therefore, the opponents have to give us a metaphysical account in order to substantiate the constitutive difference between fetus and newborn. otherwise, the first premise is not convincing to be utilized in favour of abortion. furthermore, in order to make the above mentioned argument more watertight, let us add two more points at this stage. first, although it seems that the proponents are unable to give us a metaphysical account, based on which the cut-off point of the concept ‘personhood’ is clarified; it does not follow from this that the opponents can give us a semantic story, according to which the distinction between fetus and newborn is, semantically speaking, clear. rather, the opponents are unable to give us a semantic story required in this respect as well. in fact, it seems that both the proponents and the opponents are incapable of presenting a metaphysical story, based upon which the distinction between fetus and human being is, semantically speaking, valid. in other words, both the proponents and the opponents are on a par in this respect. moreover, if this is the case, it would be better to make an agreement in order to elucidate what we mean by utilizing the concepts ‘fetus’, ‘human being’ and ‘personhood’ in different contexts. for instance, we can regard the fetus which is 20 weeks or more as a person. alternatively, we can refer to a fetus of 12 weeks or more as human being. the crucial point to be considered here is that both the proponents and the opponents have an equal semantic position here. it follows from this that the proponent is not authorized to utilize this semantic position in order to formulate his argument in favour of the permissibility of committing abortion. second, the way in which i articulate the argument is, generally speaking, based upon the referential theory of meaning (6). alternatively, the proponents might utilize other theories of meaning such as: usage theory of meaning, etc. on the face of it, it seems that usage theory of meaning cuts no ice in this respect. as we know, the slogan of this perspective is: meaning is use. the more the language-user is engaged in utilizing the word in different contexts, the more he arrives at its meaning. this is how wittgenstein gives his philosophical account with regard to the emergence of the meanings of the concept ‘game’, for instance, in philosophical investigations. the whole idea of ‘family resemblance’ is supposed to make a room for the concept ‘practice’ and ‘being engaged in practice’ which has a fundamental role in his semantic story (7,8). however, as the plurality and diversity of using a word in different contexts is crucial in order to arrive at its meaning in this story, it seems that appealing to this semantic story cannot give us the cut-off point which we are in search of (9-11). in fact, in this wittgensteinian story, the concepts ‘fetus’ and ‘human being’ do not have sharp boundaries. to the extent that they are utilized in several contexts by different language-users, they acquire their meaning. for instance, in a religious community, unlike a non-religious community, language-users do believe in the idea of ‘ensoulment’. according to them, the fetus which is 16 weeks can be regarded as human being because of ensoulment. it follows from this that one is authorized to refer to fetus which is 16 weeks or more as human being. so, the way in which the concepts ‘fetus’ and ‘human being’ acquire their meaning entirely depends on the contexts in which these concepts are utilized by different language-users. it follows from this that usage theory of meaning cannot offer the semantic story we are in search of. moreover, if the proponents believe that there is a theory of meaning which can be utilized in order to arriving at the cut-off point we are looking for, it is their task to offer the relevant theory to be applied. otherwise, we are authorized to say that as there is no plausible semantic story with regard to the cut off point of the concept ‘personhood’, the first premise is unjustified and wanting to be utilized in favour of the permissibility of committing abortion. conclusion finally, having seen the dilemma with which the proponent is confronted, i am inclined to conclude that the proponent is not authorized to resort to the first premise in order to formulate an argument in favour of the permissibility of committing abortion. but, it does not follow from this that committing abortion is implausible, categorically speaking. rather, it just shows that the first premise is wanting and imperfect to be utilized in this relation. j med ethics hist med 2009, 2:2 soroush dabbagh page 4 of 4 (page number not for citation purposes) references 1. anonymous, (2008). url: http://www.vesq.org.au/definitions.html 2. martin p, paulus mp. neurobiology of decision-making: quo vadis? cognitive brain research 2005; 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department of medical ethics, school of medicine, tehran university of medical sciences, tehran, iran. 2professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. 3professor, epidemiology & biostatistics department, school of public health, tehran university of medical sciences, tehran, iran. 4professor, department of ethics, qom university, qom, iran. 5professor, endocrinology and metabolism research center, endocrinology and metabolism clinical sciences institute, tehran university of medical sciences, tehran, iran. corresponding author: bagher larijani address: no. 10, jalal al-ahmad st., next to shariati hospital, chamran hwy, tehran, iran. email: larijanib@tums.ac.ir tel: :( +98) 21 88631296 received: 30 july 2017 accepted: 10 march 2018 published: 9 april 2018 j med ethics hist med, 2018, 11:3 © 2018 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract scientists and researchers have examined spiritual health from different angles and proposed various definitions, but a comprehensive definition does not exist for the term as of now. the present study aimed to offer the definition, components and indicators of spiritual health from experts’ perspective. this qualitative study utilized conventional content analysis and individual in-depth interviews with 22 experts in the area of spiritual health in various fields selected through purposeful sampling. member check, credibility, reliability, transferability and allocation of adequate time for data collection were measured to increase the validity and reliability of the results. conventional content analysis was performed in three main phases: preparation, organization and reporting, and the categories, subcategories and codes emerged accordingly. participants defined spiritual health in three dimensions: religious, individualistic, and material world-oriented. the study revealed four types of connection in spiritual health: human connection with god, himself, others and the nature. the majority of participants stated that spiritual health and spirituality were different, and pointed out the following characteristics for spiritual health: it affects physical, mental, and social health; it dominates other aspects of health; there are religious and existential approaches to spiritual health; it is perceptible in people’s behavior; and it can be enhanced and improved. most experts recognized human connection with god as the most important part of the definition of spiritual health. in conclusion, the connection between humans and themselves, others and the nature was not seen as a component specific to spiritual health. keywords: spiritual health, spirituality, health-care ethics mailto:larijanib@tums.ac.ir j med ethics hist med 11: 3, march, 2018 jmehm.tums.ac.ir ahmad ghaderi et al. page 2 of 7 introduction the word “spirit” is derived from the latin words “spiritus” (meaning breath, courage, vigor, or soul) and the word “spirare” (meaning to breathe) (1). five characteristics of spirituality include: meaning, value, transcendence, connecting (with oneself, others, god/supreme power and the environment), and becoming (the growth and progress in life) (2). five decades have passed since the introduction of spiritual health and its various definitions. spiritual health is about the connection with self (personal dimension), others (social dimension), the nature (the environment) and god (transcendental dimension) (3). the basic characteristics of spiritual health are as follows: proper lifestyle, connection with others, asking about the meaning and purpose of life, and transcendence (4). spiritual health is extremely important for many researchers, to the extent that it is seen as one of the key aspects of health (5). according to numerous studies conducted on various patients, spiritual health leads to improved mental health (6), and is positively related to physical health, for instance, it may help patients experience lesser pain (7). scientists and researchers have studied spiritual health from different angles and offered various definitions for it, but have failed to propose a comprehensive definition for the term. major challenges for addressing issues related to spiritual health include: providing a comprehensive definition for it; identifying the components and indicators of spiritual health; and its effect on other aspects of health. even though a number of studies have been conducted on the subject of spiritual health in iran (5, 7), there are not enough studies on the definition of the term according to experts. given the importance of the issue, the shortage of literature, and the need to consider different views about spiritual health, this study was conducted in iran to explore the definition, components and indicators of spiritual health from experts’ perspective. method this was a qualitative study in which we arranged individual in-depth interviews with experts and analyzed the contents. experts in the area of spiritual health in various fields such as ethics, philosophy, theology, medicine, psychiatry, psychology, health and medical ethics were selected by purposeful sampling. the experts were academicians, authorities on health-care system in the ministry of health, researchers and authors in the field of spiritual health and spirituality, and members of the spiritual health department in the academy of medical sciences of iran. the selected experts had articles, books or lectures in the field of spiritual health. it should be noted that other qualified people in the field of spiritual health were also consulted who were contributed by selected experts. after explaining the objectives of the study, observing confidentiality and obtaining informed consent from participants, individual semi-structured in-depth interviews were conducted until data saturation. a total of twenty-two interviews were conducted, each lasting between 40 to 50 minutes. the time and location of interviews were determined by the experts. interview questions included: “what is your definition of spiritual health?” “what are the components of spiritual health?” “what are the indicators of spiritual health?” “do you think spiritual health and spirituality are different or not?” and “please mention other points, if any”. a voice recorder was used to record the interviews, and notes were taken of the experts’ talks. the experts were informed that they could ask the researcher to pause the recording anytime during the interview, or withdraw from the study at any stage. the experts’ responses were returned to them to check in order to increase the validity and reliability of the study (member check). other measures that were used to increase the validity of the results included credibility, reliability, transferability and allocation of adequate time for data collection. data analysis was performed through conventional content analysis in three main phases: preparation (selecting the unit of analysis, immersion in the data); organizing (coding, creating categories and abstraction); and reporting. the contents of the interview audio files were transcribed and the transcripts were carefully and repeatedly read to extract meaning units, which could be either words or sentences. thus open codes were extracted, redundant codes were eliminated, and the codes that propounded a single subject were placed in one category. next, key and abstract concepts were extracted, and categories, subcategories and codes emerged. results the results of the study showed five clusters of information about spiritual health including its definition, components, indicators, characteristics and the differences between spiritual health and spirituality. each cluster was characterized by specifications as presented in table 1. j med ethics hist med 11: 3, march, 2018 jmehm.tums.ac.ir ahmad ghaderi et al. page 3 of 7 table 1the results in the form of categories and subcategories category subcategory definition of spiritual health religious dimension individualistic dimension material world-oriented dimension components of spiritual health religious (human connection with god) individualistic (human connection with himself) material world-oriented (human connection with others and the nature) indicators of spiritual health human connection with god human connection with himself human connection with others human connection with the nature differences between spiritual health and spirituality relative coincidence between spiritual health and spirituality characteristics of spiritual health different definitions for spiritual health the effect of spiritual health on the other three dimensions of heath the dominance of spiritual health over other aspects of health the religious and existential approaches to spiritual health the manifestation of spiritual health in behavior spiritual health as a dynamic process definition of spiritual health participants believed that spiritual health has three dimensions: religious, individualistic, and material world-oriented. religious dimension: according to the participants, this dimension of spiritual health entails knowledge, attitude and practice based on divine unity so that one has a dynamic and active relationship with oneself, others and the nature because one considers god in all connections. in this regard, one of the participants said, “spiritual health means to move toward god”. individualistic dimension: the study participants indicated that this dimension may be defined as: 1) believing in the meaning and spirituality, and absence of spiritual ailments such as hopelessness and lack of love, happiness, forgiveness and common sense experiences in one’s interactions with others. one participant said, “the minimum level of spiritual health means that an individual does not suffer from spiritual ailments and has embraced spirituality”. 2) having good moral character and decent beliefs. this specification can be noted in one participant’s words: “a person who enjoys spiritual health does not have negative moral characteristics and wrong beliefs”. 3) parts of health or human existence that cannot be explained from physical, mental or social perspectives. spiritual health includes a purposeful life, transcendence and actualization of different dimensions and capacities of human beings. spiritual health creates a balance between physical, psychological and social aspects of human life. some participants presented their perception of spiritual health as follows: “those components of health that are not physical, psychological or social can be placed in the context of spiritual health”. “spiritual health promotes human capacity”. “spiritual health means a purposeful life”. “spiritual health causes a balance between internal human possibilities”. 4) individuals’ feelings about a supreme power, themselves and others; having positive feelings; balance; peace; feeling vitality and empowerment, hope and satisfaction; and reduced unpleasant feelings such as sadness, anxiety and anger. one of the interviewees stated, “i think an important parameter of spiritual health is to have positive feelings about spiritual matters”. material world-oriented dimension: this dimension is defined as well-wishing, helping others without expecting them to return favors, feeling of closeness and harmony with the universe, and human connection with himself, others and the nature based on moral virtues. with respect to the individualistic dimension, one interviewee said, “spiritual health is helping others without expecting something in return”. additionally, participants stated that spiritual health has different definitions based on individuals’ beliefs and opinions. according to one participant: “spiritual health is as varied as people’s perspectives, and therefore it is impossible to offer a single definition for spiritual health”. components of spiritual health according to the results of our study, the three components of spiritual health are: religious, individualistic, and material world-oriented. religious component according to our findings, the religious components j med ethics hist med 11: 3, march, 2018 jmehm.tums.ac.ir ahmad ghaderi et al. page 4 of 7 may be the result of human connection with god, including a sense of connection with god, love of god, prayer, the feeling that god is effective, and god-oriented knowledge, attitude, and behavior. as one of the participants mentioned, “the most important and essential component of spiritual health is communication with god”. individualistic component the individualistic component comes from human connection with himself. instances include: selfscrutiny, examining the meaning of life, hope, selfactualization, moral virtues, peace, responsibility for oneself, balance, transcendence, values, mysticism, culture, and knowledge, attitude, and behavior in relation with oneself. in this regard a participant stated, “the second component of spiritual health is the humans’ connection with themselves”. material world-oriented component: this refers to human connection with others and the nature. connection with others creates a sense of responsibility toward them, unconditional love, forgiveness, pacifism, harmony with others, and knowledge, attitude, and behavior in relation with others. human connection with the nature develops responsibility, love, and knowledge, attitude and behavior in relation with the nature. to quote a participant: “one component of spiritual health is that man should form his relationship with others and with the nature”. indicators of spiritual health according to our participants, the indicators of spiritual health entail four domains of the connection between humans and god, themselves, others, and the nature. human connection with god: the connection with god is characterized by knowing god, feeling affection and love toward god, laying one’s hopes on god, being thankful for divine blessings, and prayer. these specifications were reflected in one of the participants’ perception of god as follows: “the first and most important indicator of spiritual health is obeying god’s commands”. human connection with himself: this type of connection is a source of self-esteem, reasoning and thinking, calmness, responsibility for oneself, satisfaction, vitality, empowerment, hope, a sense of purpose, self-worth, and self-awareness. one of the interviewees stated, “the second indicator of spiritual health is rationality in personal and social behaviors”. human connection with others: the participants believed that connection with others could positively affect an individual’s behavior and result in acceptance of social responsibility, respect for the rights of others, honesty, compassion, altruism, generosity, optimism, empathy, benevolence, helping others unconditionally, humility, and lack of jealousy and grudge. one participant stated, “the indicators of spiritual health are human behaviors, for instance the sense of responsibility toward others”. human connection with the nature: the study participants presumed certain behaviors to be the result of human connection with the nature. instances included recognizing one’s duties in dealing with the nature, acknowledging the importance of interest in the nature, and showing respect for it. differences between spiritual health and spirituality the participants’ views on the differences between spiritual health and spirituality can be divided into two categories: 1) the majority of our participants believed that spiritual health and spirituality are different because: a) spirituality is a state of being, but spiritual health is a state of having; b) spirituality is a general concept, while spiritual health is a particular concept; c) spirituality is a subjective issue, but spiritual health is objective; d) spirituality is a comprehensive issue, and spiritual health is the subset of spirituality; e) spirituality is potential, but spiritual health is actual. accordingly, one participant said, “if you want to define spiritual health in medical literature, it is quite different from spirituality in the sense of valuejudgment”. 2) some were of the opinion that there is a relative coincidence between spiritual health and spirituality, and that the former is the manifestation (product) of the latter. one of the participants remarked, “if we define spirituality as whatever leads humans to perfection and happiness, then people who are more spiritual will be healthier”. characteristics of spiritual health according to our participants, spiritual health has 6 different characteristics: 1) it has different definitions. 2) it affects physical, mental, and social health. 3) it is preferred over the other aspects of health. 4) there are religious and existential approaches to it. 5) it is presented in individuals’ behavior. 6) it is a dynamic state and can be promoted. the following statements also reflect the characteristics of spiritual health according to some participants: “the definition of spiritual health varies based on the views of individuals”. “spiritual health can affect other aspects of health, meaning physical, mental, and social health”. “spiritual health encompasses physical and mental health”. “there are different approaches to spiritual health: one is the religious approach and another is the existential approach”. “spiritual health is manifested in the behavior of people”. “spiritual health can be improved”. j med ethics hist med 11: 3, march, 2018 jmehm.tums.ac.ir ahmad ghaderi et al. page 5 of 7 discussion our study revealed that in order to approach spiritual health, we need to consider five clusters of information: its definition, components, indicators, characteristics and the differences between spiritual health and spirituality. each cluster is discussed separately as follows: definition of spiritual health: according to the existing literature, spiritual health is the connection with god (a superior existence), oneself, others and the nature (3, 8). likewise, our participants’ responses indicated four types of connection in spiritual health, that is, human connection with god, himself, others and the nature. the participants believed that spiritual health encompasses those features of health or human existence that cannot be explained from physical, mental and social aspects. absence of spiritual ailments is embedded in the definition of spiritual health. based on our participants’ opinions, a suitable human connection with oneself, others and the environment reflects mental and social health, and is therefore not specific to spiritual health. in response to the claim that spiritual health means absence of spiritual ailments, it should be mentioned that these ailments need to be precisely defined. moreover, we need to develop tools to determine spiritual ailments, and then ascertain the absence of which ailments and to what degree would indicate spiritual health, which is a rather difficult thing to do. components of spiritual health: in agreement with the literature, our results show that spiritual health is determined by the components of connection with oneself, god (transcendent reality), society (others), and the nature (9, 10). indicators of spiritual health: studies show that spirituality is a way through which one communicates with oneself, others, the nature and everything that is sacred (holy entities) (11, 12). it seems that the indicators of spiritual health can be investigated in four domains, that is, human connection with god, himself, others, and the nature. as previously explained, human connection with himself others and the environment are not specific to spiritual health; therefore, it can be stated that the above-mentioned components and indicators also exist in the domain of mental and social health. differences between spiritual health and spirituality: there is a consensus among researchers that spiritual health be treated as a sub-concept of spirituality (13). after reviewing the literature, selman et al. concluded in 2007 that spirituality has six aspects and indicators of spiritual health, for instance peace and a sense of control are among the aspects of spirituality (14). it seems that spiritual health and spirituality are different, although there is a relative coincidence between the two and they overlap. characteristics of spiritual health: several definitions and characteristics were identified for spiritual health (15). in any given culture, spirituality has different meanings (16), which is in agreement with our findings that produced various definitions and characteristics for spiritual health based on individuals’ beliefs and worldviews. a large number of systematic reviews showed that spiritual health can contribute to positive health outcomes (17). heidari et al. revealed that spiritual health improves physical well-being and quality of life (18). research conducted on patients with asymptomatic heart failure in 2009 indicated that spiritual health is positively related to better mental health (19). rahnama et al. also showed that spiritual health prevents the emergence of depression and anxiety in patients with spinal cord injury (20). this is in agreement with the results of the present study that illustrated the positive effect of spiritual health on physical, mental and social health. literature review showed that spiritual health unites the physical, mental and social dimensions of people (21). moreover, some health models consider spiritual health the focus or the most significant of all other aspects of health, which emphasizes the importance of spiritual health (1). based on our participants’ responses, it can be stated that spiritual health encompasses other dimensions of health and is more important than its other aspects. however, in interpreting the results we should consider the type of the studies, because crosssectional studies cannot determine the casual relationship, but measure the correlation between two variables. spiritual health has two dimensions: religious and existential. religious health is related to individuals’ perception of their health in relation to a supreme power, while existential health is related to their socio-mental preoccupations and their way of interacting with themselves, the society and the nature (5). spiritual well-being has two components: religious well-being, which refers to the connection with god or a higher being, and existential wellbeing, which pertains to the meaning and purpose in life (22). accordingly, it can be assumed that spiritual health has two dimensions: religious health, which is shaped in connection with god or a supreme power (a transcendent and holy existence), and existential health in human connection with himself, others and the nature, the meaning and purpose in life. people with better spiritual health are more likely to select a lifestyle that enhances their health (17). an appropriate lifestyle is a fundamental characteristic of spiritual health (4). likewise, it can be concluded that spiritual health presents itself in the individual’s behavior. spirituality is a dynamic state; it can be promoted, its identities and patterns may change, and it can be hidden or invisible (23). our study participants believed that spiritual health has a dynamic nature, j med ethics hist med 11: 3, march, 2018 jmehm.tums.ac.ir ahmad ghaderi et al. page 6 of 7 i.e., it can be increased or decreased. in conclusion, the present study confirmed four types of connection in the definition of spiritual health: human connection with god, himself, others and the nature. most of the experts who participated in the current study recognized human connection with god as the most important part of the definition of spiritual health and also stated that human connection with god is the most important component and indicator of spiritual health. other studies, on the other hand, could not show the superiority of one component over the others. human connection with himself, others and the nature is not specific to spiritual health because these components of spiritual health are present in mental and social health as well. although we found different definitions for spiritual health, we believe that these may differ based on individuals’ beliefs and opinions. it is suggested that further longitudinal studies be conducted to provide more accurate explanations for spiritual health by interdisciplinary collaboration between mental health specialists, social health specialists and religious scholars. such studies would result in more accurate research on spiritual health and its causal relationship with physical health, mental health and social health. conflict of interests: none declared. j med ethics hist med 11: 3, march, 2018 jmehm.tums.ac.ir ahmad ghaderi et al. page 7 of 7 references 1. hjelm jr. the dimensions of health: conceptual models. usa: jones and bartlett publishers; 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53(12): 8704. 21. mohebbifar r, pakpour ah, nahvijou a, sadeghi a. relationship between spiritual health and quality of life in patients with cancer. asian pac j cancer prev. 2015; 16(16): 7321-6. 22. dalmida sg, holstad mm, dilorio c, laderman g. spiritual well-being and health-related quality of life among african-american women with hiv/aids. appl res qual life. 2011; 6(2): 139-57. 23. charzynska e. multidimensional approach toward spiritual coping: construction and validation of the spiritual coping questionnaire (scq). j relig health 2015; 54(5): 1629-46. http://www.eapcnet.eu/linkclick.aspx?fileticket=2skfw2qjyiq%3d&tabid=200 hhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh copyright © 2022 tehran university of medical sciences. this work is licensed under a creative commons attribution-non commercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. original article abstract this study aims to assess the psychometric properties of the persian version of the attitudes toward plagiarism questionnaire (atpq) among iranian medical sciences postgraduate students and faculty members. in this study, the atpq developed by mavrinac et al. in 2010 was translated into persian. after assessment of face and content validity, we distributed the atpq draft among 286 iranian medical science postgraduate students and faculty members. explanatory and confirmatory factor analysis were applied, and cronbach's alpha was used to measure the reliability of the atpq. all the items of our english version of the atpq were approved by the developer of the original atpq, and two were revised in the cognitive interview. construct validity assessment showed that three items were not seriously involved in the extracted factors. the persian version of the atpq had 26 items, five factors and a cronbach's alpha of 0.81%, and the combined value explained 38.24% of the total variance of this scale. *corresponding author roqayeh aliyari address: shahroud university of medical sciences and health services, hafte tir square, shahroud, iran. postal code: 3614773955 tel: (+98) 23 32 39 16 09 email: aliyari@shums.ac.ir received: 8 nov 2021 accepted: 6 feb 2022 published: 8 mar 2022 citation to this article: tajalli s, ashghali farahani m, hamzekhani m, shirinabadi farahani a, pourgholam amiji n, mavrinac m, et al. does the farsi version of attitude toward plagiarism questionnaire have acceptable psychometric properties? j med ethics hist med. 2022; 15: 1. two new factors of “perceived control” and “attitude toward self-plagiarism” were extracted and incorporated into the persian version. to conclude, the atpq is a valid, reliable, and convenient instrument to determine attitudes toward plagiarism among iranian medical science postgraduate students and faculty members. keywords: plagiarism; translations; attitude; psychometrics. does the farsi version of attitude toward plagiarism questionnaire have acceptable psychometric properties? 1. researcher, nursing care research center (ncrc), school of nursing and midwifery, iran university of medical sciences, tehran, iran. 2. professor, nursing care research center (ncrc), school of nursing and midwifery, iran university of medical sciences, tehran, iran. 3. instructor, department of midwifery, school of nursing and midwifery, shahroud university of medical sciences, shahroud, iran. 4. assistant professor, department of pediatric and neonatal intensive care nursing, school of nursing and midwifery, shahid beheshti university of medical sciences, tehran, iran. 5. professor, department of medical informatics, faculty of medicine, university of rijeka, rijeka, croatia. 6. assistant professor, ophthalmic epidemiology research center, shahroud university of medical sciences, shahroud, iran. saleheh tajalli1, mansoureh ashghali farahani2, mazlome hamzekhani3, azam shirinabadi farahani4, nima pourgholam amiji1, martina mavrinac5, roqayeh aliyari6* does the farsi version of attitude toward plagiarism questionnaire...? j. med. ethics. hist. med. 2022 ( march); 15: 1. 2 introduction: recently, academic dishonesty, cheating, deception and plagiarism have become increasingly common as a type of fraud (1). the intentional or unintentional use of words, ideas and phrases in quotations from oneself or others without proper explanation and credit to the work or the owner of the work is tantamount to plagiarism (2). plagiarism is an emerging and growing phenomenon in the academic community. it is a form of aggression and non-commitment to knowledge (3, 4), and is therefore morally wrong. plagiarism is a serious issue among researchers and academicians that is being challenged on a global scale (5). credentialism and grade orientation are the major factors influencing student plagiarism. other related factors are lack of self-efficacy of students in conducting research and writing scientific reports, absence of proper mechanisms to identify and punish plagiarizers, socio-cultural factors, and inadequate prior training in citation and identification of plagiarism types (6). teachers may fail to recognize and respond to students' plagiarism during high school or nonformal education. in addition, pressure factors, inadequate training in the identification and prevention of plagiarism at the university, having no fear of punishment and reprimand, and the opening of virtual and electronic spaces also affect plagiarism (6,7). we found attitude to be among the most influential factors in plagiarism, which is consistent with the findings of previous studies (8, 9). based on former study results, attitude toward prior research is one of the most influential factors affecting dishonest behavior (10 12). in 2016 hadji et al. conducted a study to investigate the unethical behavior of iranian authors in scientific writing. the researchers found that in iran, scientific misconduct includes data fabrication (15.4%), plagiarism (4.90%), adding guest authors (18.1%), wrong study methodology (12.65%), and salami slicing (5.6%) (13). babaii et al. investigated the reasons for plagiarism among iranian students and concluded that the main reasons were students' ignorance about plagiarism, lack of time, and poor language and academic writing skills, as well as teachers' negligence, laziness and guilelessness, high expectations, and finally shortcomings in the educational system and its policies (14). the rate of research and academic writing is increasing globally, and therefore prevention of plagiarism seems essential. ajzen (1991) found that the attitude toward an action is prediction of the intention behind a behavior and its actual performance (15). therefore, it is important to study the level of awareness about, and attitude toward, plagiarism (16). the assessment of academics' attitudes toward plagiarism, one of the most important research topics, should be done prior to practice (17). tajalli s., et al. 3 j. med. ethics. hist. med. 2022 ( march); 15: 1. in order to assess attitudes toward plagiarism, it is critical to select an appropriate scale. previous research has also identified the need for a valid measure (18), and a few reliable instruments have been developed to assess attitudes toward plagiarism (18, 19). the attitudes toward plagiarism questionnaire (atpq) developed in 2010 by mavrinac et al. is a formative general indicator of attitudes toward plagiarism (19). the main advantage of this instrument over others is its comprehensiveness and solid theoretical background based on ajzen's theory of planned behavior (tpb) (15). therefore, our aim was to evaluate the psychometric properties of the translated persian version among iranian medical science postgraduate students and faculty members. methods this methodological study aimed to translate the atpq into persian and assess its psychometric properties among iranian medical science postgraduate students and faculty members between december and february 2020. the attitude toward plagiarism questionnaire (atpq) this questionnaire was developed by mavrinac et al. in 2010. the original atpq covers three factors: positive attitude, negative attitude and subjective norms, and has 29 items based on a fivepoint likert scale (1= strongly disagree, 2= disagree, 3 = neither agree nor disagree, 4 = agree, and 5 = strongly agree). the scoring of items 18 and 24 is reversed. the total score can be calculated using this formula: sum of positive attitude + sum of subjective norms + (6*7 sum of negative attitude). an average score of 25-39 represents positive attitude, 12-20 negative attitude, and 21-31 subjective norms, and the total score may vary between 58 and 88 (19). translation technique the first author obtained the consent of the developer of the atpq (mavrinac et al) to translate and validate the atpq. next, two native speakers of persian who also spoke english and were experienced in translation of medical educational tools each translated the atpq independently according to the guidelines of the world health organization (20). then the coauthor merged and unified the draft of the two translations into a single document. next, an expert panel consisting of three professionals experienced in medical educational sciences and a bilingual translator commented on each item. then a bilingual translator whose native language was english performed the backtranslation of the atpq. finally, the original developer of the atpq (mavrinac et al) was asked to check our english version of the atpq. assessment of validity the validity of the atpq was examined on the does the farsi version of attitude toward plagiarism questionnaire...? j. med. ethics. hist. med. 2022 ( march); 15: 1. 4 basis of face validity, content validity, and construct and discriminant validity. face validity assessment the face validity of the preliminary persian atpq was assessed through lay cognitive interviews. for the cognitive interviews, 30 iranian medical science postgraduate students and faculty members were invited and asked to restate each item of the questionnaire in their own words and identify any vague items that were incomprehensible to them. the atpq was modified according to the students' comments, and the time required to complete the scale was also determined. content validity assessment the content validity of the atpq was examined using qualitative and quantitative approaches. in the qualitative assessment of content validity, the persian version of the atpq was given to 10 experts who were asked to rate and comment on the wording, item assignment, and scaling of the items (21). the persian atpq was revised according to their comments and feedback, and after the necessary modifications were applied, the final persian version of the questionnaire was proposed. the quantitative content validity assessment of the atpq was conducted by calculating the content validity index (cvi) for the items. the cvi reflects the degree of clarity, simplicity and relevance of the items, and was calculated for 1 item content validity index each item of the scale (i-cvi1) and for the total scale (s-cvi2). accordingly, we asked the expert panel to rate the clarity, simplicity and relevance of the persian atpq on a four-point scale (from 1 to 4). when rated 10 by the expert panel, an i-cvi score of 0.79 or higher was considered appropriate (22). data collection first, we uploaded the persian version of the atpq to porsline (https://porsline.ir/), an online questionnaire development system widely used in academic research in iran. then the research team shared the aim of study, informed consent and questionnaire link on whatsapp as the most common social media platform among iranian users and invited qualified individuals in their contacts to fill in the atpq. the research team used ip address restriction technology to ensure users with the same ip address could only complete the questionnaire once. three hundred responders filled the persian version of the atpq. questionnaires with up to 1% missing entries were excluded, and ultimately, 286 iranian medical science postgraduate students and faculty members participated in our research. construct validity assessment we used factor analysis to examine the construct validity of the atpq. factor analysis explicitly assumes that there are underlying factors based on the observed data. the kaiser-meyer-olkin 2 scale content validity index tajalli s., et al. 5 j. med. ethics. hist. med. 2022 ( march); 15: 1. (kmo) test and bartlett's test were used to assess the adequacy of the study data for factor analysis, as well as the adequacy of the sample for each variable in the model and the adequacy of the sample for the whole model. in general, a kmo value greater than 0.7 is considered adequate (23). two general categories of estimation methods are normally used to assess the factors. in the first method, maximum likelihood is considered. this method depends on multivariate normality assumptions, which naturally require a large sample size. the second method or main axis, however, uses least squares estimates and does not consider any hypothesis about the distribution of the data (24). in this study, the generalized least squares method with varimax and equimax rotation was used. the communality is the proportion of the variance of each item that can be explained by factors and is defined as the sum of the squares of the agent loadings for the items. the common variance is between zero and one, values above 0.3 are appropriate, and values below 0.2 should be omitted (25). in this study, variables with common variance values less than 0.2 were not observed, and factor loadings greater than 0.3 were reported. discriminant validity the discriminant validity of the atpq was evaluated by applying t-test to compare the scores of the extracted factors across groups for covariates such as gender, occupational role, participation in ethics workshops and categorical age of the participants. confirmatory factor analysis confirmatory factor analysis (cfa) was applied using the maximum likelihood method. the adequacy of the cfa model fit depends on several statistical tests. the chi-square test indicates the amount of the difference between expected and observed covariance matrices. the ratio of chisquare to degree of freedom equal to or lower than 2 indicates a superior fit (26). the comparative fit index (cfi) is adjusted to sample size and ranges from 0 to 1, with a larger value indicating a better model fit. a cfi value of 0.90 or greater is acceptable (26). root mean square error of approximation (rmsea) values range from 0 to 1, with a smaller rmsea value indicating a better model fit. in this study, an rmsea value of 0.06 or less was considered acceptable (27). reliability assessment the reliability of each extracted factor was calculated using cronbach's alpha correlation coefficient. ethical considerations the study was approved by the iran university of medical sciences ethics committee (ir. iums. rec.1398.983). the participants consisted of iranian medical science postgraduate students and faculty members, and were informed about the aims and procedures of the study and the voluntary nature of their participation. does the farsi version of attitude toward plagiarism questionnaire...? j. med. ethics. hist. med. 2022 ( march); 15: 1. 6 results the persian version of the atpq consisted of 29 items and was completed by 286 iranian medical science postgraduate students and faculty members. the value of bartlett's test (kmo) was 0.88, with p ≤ 0.001 indicating the suitability of the data correlation structure for factor analysis and the adequacy of the sample. the qualitative results of the face validity of the persian atpq showed that items 4 and 14 were difficult to understand, and therefore these two items were revised based on the suggestions of our expert panel. thus, “selfplagiarism should not be punishable in the same way as plagiarism is” and “self-plagiarism is not punishable because it is not harmful (one cannot steal from oneself)” were changed to “there must be a difference between the penalty of selfplagiarism and that of other types of plagiarism” and “there should not be any penalty for selfplagiarism, as nobody is hurt.” the result of content validity assessment showed the s-cvi/average and s-cvi/universal to be 0.98 and 0.89, respectively. for construct validation, 286 iranian medical science doctoral students and faculty members were asked to complete the persian atpq. 22.5 % of the responders were male and 77.5% were female, and their minimum, maximum and mean ages were 23, 61 and 38.8 ± 7.0, respectively. in this study, the generalized least squares method was used for hidden factor extraction. based on the results of the explanatory factor analysis (efa) and considering eigenvalues greater than 1.2, five factors were extracted from the data (figure 1). also, equamax rotation with kaiser normalization was used. the factor loadings of each of these factors are shown in table 1. totally, 38.24% variance in the data is explained by these 5 factors. the factors are named according to the theory of planned behavior (tpb):as positive attitude toward plagiarism (4 items), perceived control (6 items), negative attitude toward plagiarism (7 items), subjective norms (6 items), and finally, attitude toward self-plagiarism (3 items) as a new factor. the values for the common variance (communalities) of each item appear in the table 1. as can be seen in table 1, considering the estimation method of generalized least squares (gls), common variances lower than 0.2 were not observed for any of the items. due to the extracted factor loadings (less than ± 0.25), items 8, 12 and 20 were not seriously involved in the extracted factors and were therefore removed from the questionnaire. the discriminant validity of the atpq was evaluated by comparing the scores of the extracted factors with the independent variables, including gender, age, participation in an ethical research workshop in the last 6 months, and occupational role (faculty member or not). as can be seen in table 2, the mean scores of factors 3, 4 and 5 were statistically more likely to differ among tajalli s., et al. 7 j. med. ethics. hist. med. 2022 ( march); 15: 1. participants who had attended ethical research workshops than those who had not. the mean scores of factors 1 and 4 were also statistically lower for participants older than 40 compared to others. our data do not explain the differences between male and female participants and also faculty members or other academic staff in the 5 extracted factors. furthermore, the confirmatory factor analysis has been fitted to confirm the recommended factors by efa. in advance, according to the mahalanobis distance the 12observation forest from centroid has been excluded from the study. table 1. explanatory factor analysis of the farsi version of atpq facto r item no. factor loading eigenvalue extracted variance cronbach' s alpha 28 a plagiarized paper does no harm to science. .959 7.5 14.99 0.816 25 sometimes, it is necessary to plagiarize. .557 1 29 if one cannot write well in a foreign language (e.g., english), it is justified to copy parts of a similar paper already published in that language. .510 27 i could not write a scientific paper without plagiarizing. .494 13 sometimes i copy a sentence or two just to become inspired for further writing. .570 2.0 12.34 0.726 15 when i do not know what to write, i translate a part of a paper from a foreign language. .569 2 5 sometimes one cannot avoid using other people's words without citing the source, because there are only so many ways to describe something. .501 17 i don’t feel guilty for copying verbatim a sentence or two from my previous papers. .491 24 if a colleague of mine allows me to copy from her/his paper, i'm not doing anything bad, because i have his/her permission. .431 21 it is justified to use previous descriptions of a method, because the method itself remains the same. .383 16 plagiarism is not a big deal. .581 1.59 4.41 0.694 19 i keep plagiarizing because i haven't been caught yet. .526 18 plagiarism is justified if i currently have more important obligations or tasks to do. .515 3 23 plagiarizing is as bad as cheating an exam. -.401 2 plagiarism impoverishes the investigative spirit. -.325 7 the names of the authors who plagiarize should be disclosed to the scientific community. -.325 26 plagiarists do not belong in the scientific community. -.314 10 those who say they never plagiarized are lying. .608 3 short deadlines give me the right to plagiarize a bit. .579 4 1 sometimes i'm tempted to plagiarize, because everyone else is doing it (students, researchers, physicians). .525 1.37 3.86 0.584 22 authors say they do not plagiarize, when in fact they do .377 9 i work (study) in a plagiarism-free environment. -.362 6 plagiarized parts of a paper may be ignored if the paper is of great scientific value. .352 14 self-plagiarism is not punishable because it is not harmful (one cannot steal from oneself). .657 5 4 self-plagiarism should not be punishable in the same way as plagiarism is. .594 1.2 2.64 0.639 11 it is justified to use one's own previously published work without providing citation in order to complete the current work. .533 does the farsi version of attitude toward plagiarism questionnaire...? j. med. ethics. hist. med. 2022 ( march); 15: 1. 8 table 2. comparing the mean score of the extracted factors based on participants’ characteristics variables n (%) factor 1 factor 2 factor 3 factor 4 factor 5 female 222(77.5) 2.06 ± .78 2.76 ± .79 2.06 ± .59 2.71 ± .67 2.67 ± .81 gender male 64(22.5) 2.17 ± .87 2.77 ± .79 2.03 ± .52 2.79 ± 69 2.64 ± .93 pvalue 0.400 0.892 0.718 0.400 0.866 yes 228(79.6) 2.04 ± .78 2.73 ± .78 2.00 ± .56 2.68 ± .65 2.59 ± .83 workshop no 58(20.4) 2.25 ± .87 2.87 ± .84 2.23 ± .59 2.90 ± .75 2.92 ± .81 pvalue 0.076 0.231 0.008 0.028 0.008 faculty member 125(43.5) 1.99 ± .78 2.72 ± .86 2.02 ± .60 2.72 ± .70 2.64 ± .82 role student 161(56.5) 2.15 ± .81 2.77 ± .76 2.08 ± .55 2.71 ± .66 2.68 ± .85 pvalue 0.108 0.563 0.404 0.865 0.711 >= 40 114(39.6) 1.92 ± .69 2.66 ± .76 1.98 ± .47 2.58 ± .62 2.64 ± .84 age < 40 172(60.4) 2.16 ± .84 2.81 ± .80 2.09 ± .61 2.80 ± .69 2.67 ± .84 pvalue 0.018 0.154 0.094 0.010 0.786 the model fit indices are presented in table 3, and the indices show the cfa model fit is partially acceptable. figure1 demonstrates the standardized regression weights on the cfa diagram. table3. the model fit indices obtained through confirmatory factor analysis figure1: standardized regression weights on cfa diagram. chi-square df chi-square/df pvalue gfi cfi rmsea (l, u) pvalue 540.7 282 1.92 < 0.001 0.87 0.88 0.058 (0.051, 0.065) 0.037 tajalli s., et al. 9 j. med. ethics. hist. med. 2022 ( march); 15: 1. the overall cronbach's alpha correlation coefficient of the questionnaire was 81%. the cronbach's alpha correlation coefficient of the first five extracted factors were 0.82, 0.73, 0.69, 0.58 and 0.64, respectively. the persian version of the atpq consisted of 26 items based on a five-point likert scale: strongly disagree (1), disagree (2), neither agree nor disagree (3), agree (4) and strongly agree (5). the score of the extracted factors was calculated using the mean of the loaded items for each factor, and items 2, 7, 9, 23 and 26 that had a negative sign for their loading were inverted for scoring. the range of the scores of the atpq is set from 4-20 for positive attitude, 6-30 for perceived control, 7-35 for negative attitude, 6-30 for subjective norms, 315 for attitude toward self-plagiarism, and 26-130 for the total score. also, in order to compare the scores of the dimensions, it has been suggested to use mean scores instead of sum scores per dimension. discussion our aim was to determine the psychometric properties of the translated persian version of the atpq among iranian medical science postgraduate students and faculty members. the atpq is a valid, reliable and convenient instrument that can be used to determine attitudes toward plagiarism. mavrinac et al. designed the atpq following the theory of planned behavior. they extracted three factors in their questionnaire, that is, positive attitude toward plagiarism, negative attitude toward plagiarism and subjective norms (19). sohrabi et al. used all constructs of planned behavior, but added perceived control as another factor in their atpq (28). the main strength of our study is that in addition to these, we incorporated attitude toward self-plagiarism as a factor related to the concept of attitude toward plagiarism. we found that self-plagiarism (items 4, 11 and 14), which may be connected to negative or positive attitudes toward plagiarism, is identifiable as a factor of attitude toward plagiarism among iranian scholars. zayim extracted three factors, namely "attitude of minimal estimation toward plagiarism", "emotional attitude toward plagiarism" and "attitude toward the function of plagiarism" with cronbach's alpha correlation coefficients of 0.60, 0.82 and 0.82, respectively, which can explain 47% of the variance (29). sohrabi et al. found an overall variance of the atpq of 55.84 with four factors, namely positive attitude toward plagiarism, perceived control, subjective norms and negative attitude toward plagiarism. cronbach's alpha coefficients for these factors were 0.794, 0.748, 0.733 and 0.692, respectively (28). in the current study, five factors were extracted with cronbach's alpha coefficients of 0.82, 0.73, 0.69, 0.58 and 0.64, respectively, while the overall variance was estimated to be 0.81. the first factor of this scale is "positive attitude does the farsi version of attitude toward plagiarism questionnaire...? j. med. ethics. hist. med. 2022 ( march); 15: 1. 10 toward plagiarism", which includes 4 items and. this factor shows how desirable, pleasant, useful or enjoyable plagiarism is to an individual, and that it depends on the individual's assessment of the consequences of plagiarism. the second factor of this scale is "perceived control" which is presented in 6 items. this refers to the degree to which an individual feels they have control over whether or not to commit plagiarism. the third factor of this scale is “negative attitude toward plagiarism” in 7 items. this means how uncomfortable, unpleasant, harmful or repulsive plagiarism seems to a person, and depends on the person's assessment of the consequences of plagiarism. the fourth factor of this scale is “subjective norms” presented in 6 items and pertains to the role of social pressure in plagiarism as perceived by the individual, that is, the reflection of social influences on the individual. finally, the fifth factor of this scale is “attitude toward self-plagiarism” in 3 items. it shows the extent to which plagiarism is desirable or unpleasant, useful or repulsive to an individual, and depends on their assessment of the effects and consequences of plagiarism in the present study, we found a statistically positive relationship between participation in publication ethics workshops and factors 3, 4 and 5. in this regard, bettaieb et al. and min suggest continuing to take courses on research to prevent plagiarism (30, 31). we found no statistical association between gender and the factors in the persian version of the atpq. tindall and curtis also reported that gender did not predict an individual’s attitude toward plagiarism (32). lynch et al. concluded that it is necessary to promote awareness and improve students' attitude to reduce the significant amount of unintentional plagiarism (33). the attitude toward plagiarism indicates how a person performs an unethical task, and therefore it is critical to select an appropriate scale to assess it. several instruments have been developed for this purpose, and we found that the persian version of the atpq can be an effective tool to identify the attitude toward plagiarism. conclusion the persian version of the atpq is a reliable and valid questionnaire for researchers and teachers to identify attitudes toward plagiarism among iranian medical science postgraduate students and faculty members. our results support the validity and reliability of the atpq. we recommend to add statements to the self-plagiarism factor and reevaluate the instrument in the iranian society. funding: this study is funded by the iran university of medical science. acknowledgements the authors gratefully acknowledge the participants of this study. tajalli s., et al. 11 j. med. ethics. hist. med. 2022 ( march); 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[cited march 2022]; available from: https://eera-ecer.de/ecer-programmes/conference/6/contribution/17089/ 30. bettaieb j, cherif i, kharroubi g, mrabet a. attitudes towards plagiarism among academics of the faculty of medicine of tunis. account res. 2020; 27(8): 521-37. 31. min sk. plagiarism in medical scientific research: can continuing education and alarming prevent this misconduct? vasc specialist int. 2020; 36(2): 53-6. 32. tindall ik, curtis gj. negative emotionality predicts attitudes toward plagiarism. journal of academic ethics. 2020;18: 89-102. 33. lynch j, everett b, ramjan lm, callins r, glew p, salamonson y. plagiarism in nursing education: an integrative review. j clin nurs. 2017; 26(19-20): 2845-64. jmehm-7-18 journal of medical ethics and history of medicine nurses’ perspectives on breaking bad news to patients and their families: a qualitative content analysis abbas abbaszadeh1, seyyedeh roghayeh ehsani2, jamal begjani3, mohammad akbari kaji4, fatemeh nemati dopolani5, amir nejati6, esmaeil mohammadnejad7* 1professor, department of nursing, faculty of nursing and midwifery, shahid beheshti university of medical sciences, tehran, iran; 2department of nursing, imam khomeini hospital complex, tehran university of medical sciences, tehran, iran; 3phd candidate in nursing, department of nursing education , islamic azad university , iranshahr branch, iranshahr , iran; 4phd candidate in nursing, isfahan university of medical sciences, and young researchers club, islamic azad university, isfahan branch (khoorasgan),isfahan, iran; 5department of nursing, petruleum hospital, mahshar, iran; 6assistant professor, department of emergency medicine, imam khomeini hospital complex, tehran university of medical sciences, tehran, iran; 7phd candidate in nursing, international branch, shahid beheshti university of medical sciences, tehran, iran. corresponding author: esmaeil mohammadnejad address: first floor , no. 9, kavusi alley, urmia st, south eskandari st, tehran, iran. email: asreno1358@yahoo.com tel: 98 21 66 93 66 26 fax: 98 21 66 93 66 26 received: 21 jan 2014 accepted: 22 oct 2014 published: 12 nov 2014 j med ethics hist med, 2014, 7:18 © 2014 abbas abbaszadeh et al.; licensee tehran univ. med. sci. abstract breaking bad news is quite often not done in an effective manner in clinical settings due to the medical staff lacking the skills necessary for speaking to patients and their families. bad news is faced with similar reactions on the part of the news receiver in all cultures and nations. the purpose of this study was to explore the perspectives of iranian nurses on breaking bad news to patients and their families. in this research, a qualitative approach was adopted. indepth and semi-structured interviews were conducted with 19 nurses who had at least one year work experience in the ward, and content analysis was performed to analyze the data. five major categories emerged from data analysis, including effective communication with patients and their families, preparing the ground for delivering bad news, minimizing the negativity associated with the disease, passing the duty to physicians, and helping patients and their families make logical treatment decisions. the results of this study show that according to the participants, it is the physicians’ duty to give bad news, but nurses play an important role in delivering bad news to patients and their companions and should therefore be trained in clinical and communicative skills to be able to give bad news in an appropriate and effective manner. keywords: nurses patients relationship, bad news, qualitative research mailto:asreno1358@yahoo.com j med ethics hist med 7:18 nov, 2014 jmehm.tums.ac.ir abbas abbaszadeh et al. page 2 of 7 (page number not for citation purposes) introduction in modern medical ethics, one of the most important rights of patients is their will. thus, physicians are obliged to present the necessary information to patients so they can make decisions about their disease and the diagnostic and therapeutic procedures. in recent decades, the physicianpatient relationship has changed considerably. in most modern societies, paternalistic attitude is not acceptable in physicians and patients play a major role in making decisions about their health and therapeutic procedures (1, 2). patients’ companions and relatives are sometimes exposed to news, events and conditions that they may consider as undesirable based on their notions of customs, common values, social habits and so on. consequently, they evaluate the situation according to the above-mentioned criteria and show reactions that reflect their dissatisfaction with the circumstances (3-6). buckman was the first researcher to define bad news. according to him, anything that significantly and negatively affects the attitude of a person toward their future is called bad news (7). philosophically, it can be claimed and then proved that “bad” and consequently “bad news” is something that people regard as evil. recipients of bad news show similar reactions in all cultures and nations, and therefore it is possible to find common psychological and global elements to analyze such news (8). breaking bad news is an emotional subject among health care professionals as patients’ positive or negative experiences which can greatly affect their subsequent adaptation (9). delivering bad news to patients and their companions is one of the most difficult aspects of the medical profession, and it is necessary for the therapeutic team to recognize the patients’ social, psychological and clinical concerns (10). telling patients that they are not emotionally prepared can have a negative effect on the course of treatment and communication with the therapeutic team. some studies indicate, however, that giving information to patients does not necessarily cause anxiety, hopelessness, fear, depression and insomnia, and may even improve the patients’ condition and their relationship with their relatives and the therapeutic team (11-13). hiding information from patients prevents them from making proper therapeutic decisions based on their personal goals, as such decisions can increase costs, impose unnecessary distress, cause emotional and physical tension and lead to hopelessness and anxiety (14). when the therapeutic team can successfully recognize the patients’ social, psychological and clinical concerns, it can identify and evaluate their absolute power and relative potential for handling the bad news and help establishing effective communication with patients and their families. absolute power means social support and relative potential refers to stressors. by keeping a balance between these two, patients can be prepared to confront bad news (15). as important members of the therapeutic team, nurses can give necessary information to patients and their families and communicate to them facts about the disease. based on ethical principles and the principle of beneficence in particular, patients should be fully informed about their conditions (16). studies have shown that nurses are among the most valuable members of the therapeutic team and can play a key role in delivering bad news. although nurses play an important part in communication between physicians, patients and their companions, their role in breaking bad news has been less emphasized. the present study was therefore conducted to investigate the subject of delivering bad news to patients and their families with a focus on the experiences of nurses in this regard. method this qualitative study explored the experiences of nurses regarding breaking bad news to patients and their families. nurses were selected from the imam khomeini complex hospital, a teaching hospital in tehran, the capital city of iran, affiliated with tehran university of medical sciences (tums) during 2012 and 2013. nurses were included if they were willing to participate and had at least one year experience in the ward. in this study we used a content analysis approach. qualitative content analysis can be described as a bridge between the original text and the presented results. it consists of a slow and systematic transformation of the original text into condensed categories and themes of meaning (17). the participants were asked to describe one full day at work and then to explain their own experiences and perceptions about “breaking bad news to patients and their families”. the main focus of the interview was the following question: ‘what is your experience regarding breaking bad news to patients and their families?’ the in-depth interviews lasted from 25 minutes to an hour, and some participants were interviewed twice by necessity. in this study, a total of 22 interviews were conducted with 19 nurses, who all had bachelor’s (bs) or higher degrees in nursing. inclusion criteria was having at least one year work experience in the ward. content analysis was conducted to analyze data. data collection and data analysis were performed simultaneously. qualitative research requires that the researcher be immersed in the data, so the researcher listened to the interviews and reviewed handwritten notes several times. the meaning units were extracted based on the participants’ statements in the original codes. then, based on the similarity of semantic and conceptual classifications, they were condensed and made as short as j med ethics hist med 7:18 nov, 2014 jmehm.tums.ac.ir abbas abbaszadeh et al. page 3 of 7 (page number not for citation purposes) possible. in the data reduction stage, the overall trend was to condense all analysis units, categories and subcategories. the data were then placed in the main categories which were more conceptual, and eventually the themes were extracted (17-19). in order to ensure trustworthiness throughout our research, we used confirmability, credibility, dependability and transferability as advocated by aein and delaram, and lincoln (20, 21). credibility was established through prolonged engagement with the participants and applying their revisions using member checking procedure and peer debriefing. the findings and explanations of this study were reviewed by two supervisors with a sturdy background in qualitative research methodology. moreover, maximum variation of sampling ensured conformability and credibility of the data. the study also provided sufficient descriptive data for researchers to determine whether the findings were transferable, which established applicability. permission to conduct this study was obtained from the ethics committee of the imam khomeini complex hospital. other ethical issues in this study included the assurance of confidentiality and anonymity of the participants and their responses. all participants were informed about the objectives and methods of the study. they were also informed that participation in the study is voluntary, so they could refuse to participate or withdraw from the study at any time. lastly, those who agreed to be included in the study were asked to sign a written consent. results there were 19 nurses in this study, 11 females and 8 males, aged between 27 and 45, and most were employed as regular nurses. the mean age of the participants was 37.2 ± 4.1 years, and the mean of work experience was 13.2 years (table 1). five themes emerged as a result of data analysis: effective communication with patients and their families, preparing the ground for delivering the bad news, minimizing the negativity associated with the disease, passing the duty to physicians, and helping patients and their families make logical treatment decisions (table 2). table 1demographic profile of the participants sex male: 8 (42.1) female:11 (57.8) marital status married: 15 (78.9) single: 4 (21.05) educational level bsc (bachelor’s degree): 14 (73.6) higher than bsc: 5 (26.3) age < 35: 6 (31.5) 36 40: 9 (47.3) > 41: 4 (21.05) position nurse: 13 (68.4) head nurse: 4 (21.05) supervisor: 2 (10.5) years of work experience < 5: 2 (10.5) 6 10: 6 (31.5) 11 15: 8 (42.1) > 16: 3 (15.7) table 2main categories and subcategories main categories subcategories effective communication with patients and their families listening feedback request empathy and sympathy respect for the other side preparing the ground for delivering the bad news offering an introduction to the bad news considering patient morale appropriate wording assessment of the situation minimizing the negativity associated with the disease considering possible deterioration of the patient’s clinical status avoiding/postponing delivery of bad news passing the duty to physicians responsibility of the physician adequate education carelessness and irresponsibility by some nurses helping patients and their families make logical treatment decisions clarification of the nature of the disease education on treatments, expenses, etc. j med ethics hist med 7:18 nov, 2014 jmehm.tums.ac.ir abbas abbaszadeh et al. page 4 of 7 (page number not for citation purposes) effective communication with patients and their families nurses in this study emphasized the role of effective communication and believed that the exchange of information is essential in delivering bad news. below are excerpts from the interviews: “… if you are going to tell a patient that she or he has a tumor, you should first prepare them for the news. the environment should be prepared and the patient’s companions should not be present when you deliver the news …” [nurse no. 9]. “nurses should not have to give bad news to patients or their families. they should listen to patients, sympathize with them and establish a sort of bilateral communication, but allow physicians to inform patients of the diagnosis and give them the news” [nurse no. 17]. “we should direct the patients or their companions to a quiet and private place and then deliver the bad news. we should prepare them for hearing the news and pay attention to their feelings. if possible, we should cautiously give the news to the patient’s companions” [nurse no. 11]. preparing the ground for delivering the bad news research indicates that members of the therapeutic team and nurses in particular should be trained in delivering bad news, for instance news related to incurable diseases such as chronic illnesses, cancer, medical errors and death. some participant comments in this regard were as follows: “there should be educational courses in hospitals to help us deliver bad news more efficiently. sometimes patients’ companions are agitated. they have right to be agitated. i don’t know how to tell them that their patient died” [nurse no. 15]. “i don’t know how to communicate bad news to patients’ families. for some reason, i always try to leave it to my other colleagues. each patient’s situation is different, so there are different strategies for different people because characteristics of each patient are different. that’s why there is a need for special skills” [nurse no. 8]. on the other hand, one nurse believed that skills for communicating bad news can empower the therapeutic team. one nurse said, “training in bad news communication should be a clinical requirement. unfortunately, most of us don’t have the necessary knowledge and skills for breaking bad news, and those of us that do can’t use them in clinical settings. it would be useful for us and other members of the therapeutic team to have more knowledge and training in that area” [nurse no. 10]. minimizing the negativity associated with the disease participants stated that sometimes they did not tell patients and their families the bad news in order to mitigate the seriousness of the situation. one participant said, “i try not to tell patients the truth about their disease because their condition may be aggravated. i don’t talk about the disease in the first session of chemotherapy. i just inform them about the nature of the disease and that they should receive medication. and if a patient has intensive hypertension, i tell them that their blood pressure is quite high and should be supervised by the physician” [nurse no. 2]. another nurse said, “a patient who has brain tumor cannot undergo surgery due to metastasis. if they ask about their condition, i won’t tell them that the tumor is metastatic, but rather that their condition may improve with medical treatment depending on the type of disease” [nurse no. 13]. passing the duty to physicians nurses in this study believed that physicians should tell their patients the bad news and it is not the nurses’ responsibility to do so. below are what some participants said in this respsct: “when patients ask me about their disease, i don’t answer because i think it’s the responsibility of the physician to answer such questions, and patients should ask those questions during doctor visits” [nurse no. 6]. “telling patients about diagnosis and treatment increases the stress in the ward, both for me and my colleagues. i may not have full information, and when a patient asks me, i just say that i don’t know and the physician will explain everything to them as soon as possible” [nurse no. 10]. “a patient comes in with abdominal pain and the physician’s diagnosis is abdominal aneurysm. in this case, the physician should explain the patient’s condition at the time of receiving informed consent …” [nurse no. 1]. helping patients and their families make logical treatment decisions when nurses talk to patients who have cancer or incurable diseases, they can help them make informed decisions about continuation of treatment. some nurses comments in this regard appear below: “if i tell the patients or their companions that the patient has a metastatic bladder tumor, they can make the proper decision about continuing treatment, and they may choose not to go to the hospital for pain relief. in such cases i will tell them to seek help at palliative care centers instead” [nurse no. 4]. “sometimes patients think that their disease will be cured. they say that they will spare no expense and they don’t care about the cost. they say that they will sell everything they have to cure their disease, but their disease is incurable …” [nurse no. 9]. discussion one major problem that health care providers are facing is communicating diagnostic and j med ethics hist med 7:18 nov, 2014 jmehm.tums.ac.ir abbas abbaszadeh et al. page 5 of 7 (page number not for citation purposes) therapeutic clinical facts to patients and other members of the family (22-25). patients and their companions may not be fully aware of the causes of the disease, the associated mortality rate or treatment options. on the other hand, patients have the right to be informed about their condition and the treatment process. nurses believe, however, that it is not their responsibility to inform patients of diagnostic facts, and therefore try to leave the task to the physician. in this way they will avoid the reactions of patients and their companions after receiving the bad news and possible legal consequences (26). breaking bad news has always been regarded as one of the duties of the physician, which is in line with the findings of the present study. telling bad news has also been mentioned as an issue which can involve all members of the medical community (27). in the present study, one category that emerged as a result of data analysis was effective communication with patients and their families. communication refers to a transaction and a process of creating messages that occurs in a setting comprising the physical environment, cultural and social standards and psychological situations (28). communicative skills are at the heart of clinical abilities and play an effective role in the promotion of health, therapeutic procedures and patient satisfaction (29). studies have also shown that medical teams have trouble delivering bad news. the main reason for physicians’ reluctance to give bad news may be lack of skills (20, 30). effective communication is the basis of trust and mutual understanding and weak communication prevents tasks from being performed properly, which in turn reduces efficiency and increases misunderstanding (31). the relationship between therapeutic teams and patients is at the center of all clinical actions, and may well be the cornerstone of medical activity (32). effective communication plays an important role in health care and is a mixture of communication, education, anthropology, behavioral skills and a number of basic sciences (33). the nurse-patient communication begins with the initial encounter between the two and lasts for the duration of the therapeutic relationship. the nurses’ objective would be to create and maintain a suitable professional relationship with patients, and they should therefore try to win their patients’ trust from the start. this is possible only if communication takes place in proper settings and is accompanied by compassion and respect on the part of the nurse (28). there are different protocols and instructions with regard to giving information to patients. kirshblum and fichtenbaum proposed a three-step protocol for breaking the news, including preparation, dialogue and conclusion (34). disclosure of facts, particularly bad news, should be done in a step by step manner, and like all therapeutic procedures, success of each stage depends on the desirable completion of the previous stage. the spikes clinical protocol can be applied when delivering bad news to patients. the protocol includes providing the proper setting for breaking the news, checking the patient’s perception of the condition, obtaining the patient’s invitation, presenting the knowledge and information, recognition of the patient’s emotions through empathic responses, and strategy and summary (35). a similar model has been proposed by rabow and mcphee which includes the following stages: preparation, creation of an environment suitable for therapeutic communication, effective communication, dealing with reactions of patients and their families, and encouragement and validation of patients’ emotions (36). another strategy for announcing news is the pewter model. this model includes six main steps of preparation, evaluation, warning, telling, emotional response, and regrouping. these instruments can be used by emergency service providers who are responsible for delivering news such as deaths, crimes and unexpected events while providing emergency services (37). one finding of the present study was that the medical team may give inaccurate information to patients. the amount and content of information they communicate to each patient may vary according to the patient’s condition. based on our findings, factors such as complexity of treatment, hazards of medical and surgical interventions and personal demands of patients can affect this issue. there is evidence that medical teams prefer to minimize the negative aspects of the disease so that patients do not lose hope and their symptoms are not aggravated (27). the amount of the information that is presented to patients is based on their level of understanding and needs. too much information can increase confusion, fear and anxiety in patients (13). skillful, tactful, prudent and comprehensive announcement of bad news to patients and their families will comfort them and provide control over the present and future consequences of the news (38, 39). one benefit of delivering bad news to patients is that they can make logical decisions to continue treatment. from the islamic viewpoint, people have the right to know the facts that directly concern them so they can make plans about their future. holy quran states that valuable actions are performed based on divine values, freely and consciously. in fact, islam declares that if a person is competent, they should be allowed to make decisions. on the other hand, islam places special emphasis on making preparations before one’s death. a person’s final days can be a suitable opportunity for believers to compensate loss, return trusts and settle displeasures (1, 15). on the other j med ethics hist med 7:18 nov, 2014 jmehm.tums.ac.ir abbas abbaszadeh et al. page 6 of 7 (page number not for citation purposes) hand, withholding facts about the disease causes problems such as failure to make proper therapeutic decisions based on personal goals, increased costs, unnecessary stress and distress (11, 12). hence, bad news must be communicated to patients and their families so they can make logical and proper decisions. conclusion giving bad news to patients is one of the most difficult tasks that members of the therapeutic team have to perform. breaking bad news is the duty of the physicians, but nurses may play an important role in delivering news to patients and their companions, and should therefore be trained in the clinical and communication skills that are necessary for doing so. it 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[in persian] 34. kirshblum s, fichtenbaum j. breaking the news in spinal cord injury. j spinal cord med 2008; 31: 7-12. 35. baile wf, buckman r, lenzi r, glober g, beale ea, kudelka ap. spikes-a six-step protocol for delivering bad news: application to the patient with cancer. oncologist 2000; 5(4): 302-11. 36. rabow mw, mcphee sj. beyond breaking bad news: how to help patients who suffer. west j med 1999;171: 260-3. 37. watson la. informing critical care patients of a leved ones death. crit care nurs 2008; 28(3): 53-63. 38. avery ja. ethical issue: giving bad news in a beautiful way. am j geriatr cardiol 2002; 11(6): 413-5. 39. singer gr, koch ka. communicating with our patients: the goal of bioethics. j fla med assoc 1997; 84(8): 486-7. jmehm-7-13 journal of medical ethics and history of medicine breaching confidentiality: medical mandatory reporting laws in iran alireza milanifar1, bagher larijani2*, parvaneh paykarzadeh3, golanna ashtari3, mohammad mehdi akhondi4 1medical ethics phd candidate, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran; 2professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran; 3reproductive biotechnology research center, avicenna research institute, acecr, tehran, iran; 4professor, reproductive biotechnology research center, avicenna research institute, acecr, tehran, iran. corresponding author: bagher larijani address: 23# 16 azar ave, keshavarz blvd, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. email: larijanib@tums.ac.ir tel: 98 21 66419661 fax: 98 21 66419661 received: 1 jan 2014 accepted: 9 jul 2014 published: 6 aug 2014 j med ethics hist med, 2014, 7:13 © 2014 alireza milanifar et al.; licensee tehran univ. med. sci. abstract medical ethics is a realm where four important subjects of philosophy, medicine, theology and law are covered. physicians and philosophers cooperation in this area will have great efficiency in the respective ethical rules formation. in addition to respect the autonomy of the patient, physician's obligation is to ensure that the medical intervention has benefit for the patient and the harm is minimal. there is an obvious conflict between duty of confidentiality and duty of mandatory reporting. professional confidentiality is one of the basic components in building a constant physician-patient relationship which nowadays, beside the novelty, it is the subject of discussion. legal obligation of confidentiality is not absolute. in physician-patient relationship, keeping patient’s secrets and maintaining confidentiality is a legal and ethical duty, and disclosure of such secrets is mainly through specific statutes. thus, there are a number of situations where breach of confidentiality is permitted in different legal systems. one of the situations where breaching confidentiality is permitted is the medical mandatory reporting to the relevant authority which is in accordance with many countries’ legal systems. some situations are considered in many countries legal systems’ such as notification of births and deaths, infectious diseases, child abuse, sport and relevant events, medical errors, drug side effects and dangerous pregnancies. in this paper, we will examine and discuss medical mandatory reporting and its ethical and legal aspects in the judicial and legal system of iran and few other countries. finally we will suggest making medical mandatory reporting law in iran. keywords: mandatory reporting, medical reporting, confidentiality, patient’s rights, public interest mailto:larijanib@tums.ac.ir j med ethics hist med 7:13 aug, 2014 jmehm.tums.ac.ir alireza milanifar et al. page 2 of 10 (page number not for citation purposes) introduction the scope of medical ethics is wide and physicians-philosophers cooperation in order to codify the ethical principles and also accompanying patients while respecting their autonomy, have plenty of benefits. professional confidentiality is the basis of the physicianpatient relationship. physicians’ duty of confidentiality has an ethical background and that’s why being loyal to it, is mentioned in the medical oath. moreover, a physician should always attempt to improve the health level of the public. it means that treatment of a patient is not only reducing his pain and caring about his recovery but also a treatment which manifests its effects in the society. regarding the mutual relationship between physician-patient and physician-society, some patterns of conflicts or at least disturbance in the professional confidentiality should be considered. it is physician’s legal duty through specific statutes to report private information to the relevant local authority. this is known as "medical mandatory reporting". medical mandatory reporting is one of the most important subjects of conflict between physician’s duty to confidentiality, respecting patient's confidentiality, and his duty to breach confidentiality in order to serve the patient or the public. method in this paper, first we will briefly analyze medical confidentiality and breach of this principle in form of medical mandatory reporting. then by searching through the legal contexts in the laws of iran and some other countries some examples of the mandatory reporting, will be presented. the phrases of "medical mandatory reporting" and "medical confidentiality" and “infectious diseases” both in persian and english, have been searched alone and in combination with term “rights” in the websites of ssrn.com, irandoc.ir, dastour.ir, ghavanin.ir, pubmed and the official websites of the world health organization (who) and the ministry of health and medical education (iran). this study started in december 2011 and ended in december 2013. medical confidentiality as a principle confidentiality is an important principle which is not only an integral part of professional practice but also a duty recognized by the law. patients' referral to the surgeon and sharing his secrets with physician is due to this principle. therefore, it is essential that physicians keep patients’ secrets as a trust. a physician understands patient’s said and unsaid secrets during the examination so he ought to maintain confidentiality. in fact, truthfulness is the most important element in the physician-patient relationship. in addition to his medical knowledge, a physician utilizes his or her experiments and feelings to understand and treat the patients in the moments of fear, and confusion. in their paper," physician professionalism for a new century", holsinger and beaton argue that one reason for physicians' dissatisfaction in late 20th century is liability crisis in their profession (1). disclosing patients' secrets leads to loss of trust toward doctors and a patient may make a compliant and take the case to the court, and consequently the physician is liable to pecuniary punishment. disclosure of personal health information means disclosing others’ secrets in any possible way like writing, expressing or indicating them; however, they seem trifle and insignificant (2). disclosure of patients′ information should only include information which is necessary for preventing the risk of harm and it should only be shared within the healthcare team who may need such information for preventing those harms or minimizing the risk of harm and discomfort to the patient (3). physicians must respect the laws, however it is sometimes very difficult to keep path between the duty to maintain patient’s confidentiality in the society and physician’s duty to disclose information as a member of the same society. the meaning and the basis of right, autonomy and will the definition of "right" is that we consider rights as trumps against adequate reasons for political decisions. this means presenting rights theory as prevailing evidence against utilitarian view (4). therefore the informed consent for treatment is patient’s right but exercising such right requires patients' cooperation with physicians (5). in many countries, applicants of some positions such as attorney, physician and registrar (registry office) should take a professional oath. once they start their profession, they are prohibited from breaching their professional oath. considering that the concept of the public order is more important than the imperative and mandatory laws, since violating any obligatory law does not mean that it is opposite to the public order, the maintenance of public order is to protect the public and their interests (6). it can be said that every rule related to the public order is an obvious example of the imperative laws. evidently, good morals are an independent factor in limiting liberty of contracts that some people believe that it is not an obvious example of the public order. although some other people believe that good morals are an example of public order, but due to its special importance in iranian society, the legislators have preferred to mention it separately (7). j med ethics hist med 7:13 aug, 2014 jmehm.tums.ac.ir alireza milanifar et al. page 3 of 10 (page number not for citation purposes) confidentiality of personal health information in the law patient's rights to privacy are recognized in the laws and regulations of the most countries. violation of this right not only has a negative effect on physician-patient mutual trust, but also has effects on public order. moreover, there are many differences in the various countries about breaching professional confidentiality due to the mandatory reporting. in the legal system of canada, physicians and the medical personnel should consider any information collected within their work as confidential. no medical information related to patients outside medical team and without their consent should be disclosed (8). the duty of the physician and healthcare providers to maintain confidentiality is explained in the legal system of australia. this duty has been mentioned in provisions of contracts and in tort law in australia. in fact the legal obligation of physicians in maintaining patients' confidentiality can be found in specific statutes (9). in germany, the german federal data protection act was passed in 1977 to protect patient's secrets, while protecting individual rights has been considered in the civil code of germany. in german penal code, patient's right to confidentiality is recognized and the law imposes the duty of confidentiality not only on physicians but also on all medical staff in hospitals and public or private clinics (10). in anglo-saxon law, medical confidentiality is recognized as a fundamental principle. in english law there is no specific statute on issue of confidentiality; however the general medical council (gmc) provides guidelines which are taken seriously by the courts (11). in france, to the extent that maintaining confidentiality has interest for patient, is mandatory for all physicians. in french law no one in any position or no authority can access the client's secrets from professionals which are based on mutual trust. perhaps it seems that we consider the professional secrets only for those which are related with an illness, but french law has imposed this oath to the physicians which cannot be violated (12). according to article 4 of the french public health code, the professional secrets not only refer to the secrets which are obvious to the physician due to his profession, but also refer to all information received, heard or understood in relation to the patient. this information is protected from disclosure and the legislator has made penalty provisions on those who violate the law (12). the french judicial procedure follows the same criteria and the duty of confidentiality is imposed on every physician as a professional duty. additionally, this duty will continue to exist even after patient's death and personal information should not be disclosed even if it is ordered by a judge. in france the duty of confidentiality for the physicians and similar professions, are not limited to patient’s illness and it generally covers all dimensions of patient's life. sphere of confidentiality is to an extent that even if patient's personal information has been discussed by others in the press and the public is also informed about such information, the physician is not allowed to disclose any information (12). iran according to article 648 of the penal code of iran, disclosure of patients’ secrets by medical team is an offence since this article states that:"whenever physicians, surgeons, midwives, pharmacists and all other people who are recognized as confident people due to their profession and position, disclose peoples' secrets in cases when it is not authorized by law, they will be subject to pecuniary punishment ………. or imprisonment"(13). it seems that the legislator’s emphasis on the term “in cases when it is not authorized by law” refers to confidentiality which is not absolute in iranian law. it is necessary to mention that article 331 of the civil code states that “disclosure of patient's information without patient's consent may expose risk of serious harm on the patient based on causation and consequently the physician or the person who has disclosed such information are responsible”. medical mandatory reporting: breaching confidentiality in law sometimes a physician is obliged to breach the duty of confidentiality due to specific statute, and it is physician’s duty to balance between the duty to maintain confidentiality and duty to breach this confidentiality and report patient's medical information. breach of confidentiality occurs whenever the risk of harm to others is evident. in fact, the difficulty in violating the medical or professional confidentiality is because it is against professional values and medical activities (14). medical mandatory reporting: specific statutes the following paragraph will examine cases that are mentioned in the law and provisions in different countries, where the law obliges physicians to breach the duty of confidentiality. besides, we will mention specific statutes of other countries and iran: notification of births and deaths in iran in order to prevent infanticide, exchange of babies and child trafficking, every birth (even illegal birth) must be registered, therefore maintaining confidentiality about issuing the birth certificate is absurd. according to article 19 of the "registration of births and deaths" act 1976, undoubtedly, issuing birth certificates, death certificates with cause of death, has been mandatory. currently, according to article 2 of "offences, crimes and criminal penalties related to the birth j med ethics hist med 7:13 aug, 2014 jmehm.tums.ac.ir alireza milanifar et al. page 4 of 10 (page number not for citation purposes) certificates" act, enacted in 1991, offenders who have violated article 19 of the "registration of births and deaths" act 1976 are obliged to perform definite legal obligations and they are sentenced to jail or pecuniary punishment (15). therefore, law has made an exception on the duty of confidentiality for healthcare providers in article 19 of the aforementioned act about the necessity of issuing birth certificates and sending one copy of the certificate to the national organization for civil registration. thus physicians and midwives are exempt from criminal responsibilities resulting from disclosing patient's secrets (15). according to this, neither a physician nor a midwife who is present at the child’s birth or intervenes in child's birth, can cite the article 648 of the islamic penal code and avoid reporting the birth of the child to the national organization for civil registration even if one of the parents or both of them asks for maintaining confidence in this matter (13). according to the registration of births and deaths act, article 24, due to legal consequences related to the individuals’ death reporting, one copy of the death certificate with the physician’s assessment must be sent to the registrar. in this case, in the same way as issuing the birth certificate, the doctor cannot be blamed by the legal heirs for violating the law. thus, issuing the death certificate like issuing the birth certificate are considered as an exception among the exception categories of article 648 of islamic penal code (13). infectious diseases diseases mandatory reporting system is designed to maintain and improve individual and public health level in the society and to prevent risks that they may not be aware of. in england, according to the public health (infectious diseases) 1988 act, all infectious and epidemic diseases have to be reported mandatory to the relevant local authority officer (16). also in all states, physicians have to report acquired immune deficiency syndrome (aids), and this is considered as a part of the personnel's duty of hospitals, clinics and blood banks (17). in canada, infectious diseases are reported according to the law (18). in some states of australia such as new south wales and tasmania, disclosure of sexual activities of a person diagnosed with aids and human immunodeficiency virus (hiv), is permitted in some exceptional situations (19). also in sweden, the law states that the identity of a person who has been diagnosed with aids must be reported (20, 21). governmental office of public health in india has categorized diseases according to the duration of reporting to diseases which have to be reported within 72 hours after the physician’s diagnosis, and also the diseases which have to be reported immediately after diagnosis. it should be said that animal bites have to be reported within 24 hours (22). it should be noted that due to articles 77 and 125 of constitutional law of iran, and according to the article 9 of civil code, provisions of conventions which enter into an agreement between iran and other countries are considered as law. undoubtedly, it can be said that the health care authority of iran, has not achieved enough success in designing a system for the medical mandatory reporting (23). according to the specific statutes in iran, physicians are obliged to report the diseases listed below: venereal diseases according to the article 3 of “control of venereal diseases" act 1941, and regulations related to this act in 1946, if a patient does not attend for medical examination during a determined period, he or she must be recalled by legal authorities to approved medical centers and once diagnosed with venereal diseases, a doctor must treat the patient (23, 24). communicable diseases according to the article 19 of "control of venereal diseases and infectious diseases" act 1941 and the same act amendment 1968, every physician has to report patients diagnosed with infectious diseases to the ministry of health, as soon as possible after observing an incident (24). pregnancy related diseases and conditions in the us, pregnant women must inform their physicians if they have consumed alcohol or drug during the pregnancy. government can provide health and welfare services for pregnant women who wish to terminate their pregnancies due to living in unhealthy and unsafe environments .by doing this, healthcare providers try to keep fetus safe from contagious diseases resulted from the pregnant mother’s addictions like drinking alcohol and consumption of drugs. in fact the law not only protects pregnant women but also protects her future baby's health. in other words, the law respects pregnant women's rights and of their future babies (25, 26). there is no law about this subject in iran. some special diseases and clinical conditions in the united kingdom, certain clinical conditions are notifiable according to the law, and are included in mandatory reporting. such conditions consist of resistance against taking drugs against some microorganisms (e.g. mycobacterium tuberculosis) and side effects of few drugs (e.g. pinicillin and vancomycin) (19). in iran, only cancer has been considered in the law. in situates where the doctor is obligated to breach confidentiality of patients who experience faint, seizures, or loss of consciousness, the physician-patient relationship faces a challenge. some physicians in the us do not report medical information about j med ethics hist med 7:13 aug, 2014 jmehm.tums.ac.ir alireza milanifar et al. page 5 of 10 (page number not for citation purposes) patients who suffer from epilepsy (27). additionally in the us, reporting chronic diseases, diabetes, especially in the newborn babies is necessary from 2000, since 1 baby out of 3 suffers from diabetes during his or her lifetime (28, 29). in australia, according to motor vehicle act 1959, a health professional has a duty to inform the registrar the name, address and the nature of the illness and deficiency of a person who is suffering from a physical or mental illness or has a deficiency to drive which put the public in danger (30). in iran, physicians perform according to the "mandatory reporting and registering of cancer diseases" act 1984 (31). occupational and environmental diseases in the us, diseases such as work-related asthma, respiratory problems, silicosis, asbestosis, working with arsenic or other toxic substances, jobs which have risk of harm to children and young people under 18 years of age, fatalities caused by occupational accidents and work-related diseases have to be reported within 30 days after being diagnosed (32). according to the law of germany, once a physician suspects any patient with occupational disease, he must report the incident to the insurance company or to a governmental medical institution that are responsible for protecting the public health (33). there is no law or regulation about this subject in iran. domestic violence: finnish child protection act 1983, article 40, obliges everyone to inform the social welfare office, once they notice that a child needs protection and care (34). moreover in 1994, in the us, the violence against women act (vawa) passed by the congress based on reporting domestic and sexual violence against women (35). in this law also physician's duty to deal with cruelty against children under the legal age and elderly people or people who are not able to protect themselves (handicapped and those who suffers from mental deficiency), was recognized. there are cases when women or girls come forward with self-reports to health providers or police (36). in these cases, if a physician suspects any incident of violence he has a duty to report. he must report the incident to the relevant authorities regardless of whether this incident already occurred or may occur in the future. surprisingly, in many states of the us, the physicians who report such cases according to their medical knowledge are protected from the claims against them (37, 38). it should be said that anyone's cruelty and violence towards their spouses is an unacceptable behavior from medical and legal point of view (39, 40). article 1130, section 4 of iran civil code states that violence and misbehavior towards wives by their husbands is not prohibited, unless the violence is unbearable (41). child abuse according to the definition of world health organization (who), “child maltreatment” sometimes referred to as “child abuse”, including all forms of physical and emotional ill, sexual abuse, neglect and exploitation by a parent or guardian that results in actual or potential harm to child's health or dignity (42). it is impossible to maintain professional confidentiality at the time when there is an incident of child abuse, especially when there is no safety or security for the child (43). child abuse, especially sexual abuse is an undeniable issue which has negative effects on children's mental health (44). we should consider multiple roles for the physicians dealing with issues of child abuse and prevent such incidents to occur (45). child abuse is a serious and common issue which has attracted the attention of the governments .it is considered in the state laws and the u.s federal law, civil law of all european countries and some asian countries (46). child abuse reporting laws introduced in the usa by the late 1960s with the purpose of protecting the children. this law introduced to the healthcare systems of australia and england years later (40-46). in canada one of the main duties of the medical team especially dentists, is mandatory reporting of child abuse. most of physicians are wellinformed about this duty and they practice accordingly (47, 48). despite major changes in iran’s laws related to child abuse, the child protection laws are inefficient. in iran, according to the article 4 of "child protection" act 2002, there are some penalties for child abuse. article 6 of the same act refers to the duty to report child abuse (49). in spite of explicit wording of the child protection act which states “child abuse is a crime and there is no need for private plaintiff to report the incident, anyone who observes the incident must report it” (49), processing time for each case, numerous case failures and lack of legal protection of anyone who reports the incident, has resulted in loss of concern among people especially among physicians in a way that they tend not to get involved in this matter and report such incidents. actually, physicians must report the child abuse from ethical point of view, but as no legal obligation exists to oblige a physician to report child abuse to relevant authorities and in case of providing no protection for the physicians, most physicians try to just treat these children (50). elder abuse and negligence elder abuse and negligence is another issue which physicians may notice and it occurs in form of physical, emotional, sexual, financial abuse or even by negligence. mandatory reporting of elder abuse is the best way of preventing and prosecuting such torments (51). for example, in the us, 33 states have j med ethics hist med 7:13 aug, 2014 jmehm.tums.ac.ir alireza milanifar et al. page 6 of 10 (page number not for citation purposes) mandated reporting any incident of elder abuse (52). dentists in canada must report any kind of torments as soon as they observe it or at the time of medical examination. it should be noted that in the us, canada, england and australia, elder abuse is recognized in laws (47, 48). in iran, there is no law related to this matter; however, the article 633 of iran penal code has considered some penalties for neglecting elderly people (53). sexual abuse of patients by healthcare professionals one of the important cases that have been protected by the law in some states of the usa is reporting patients’ sexual harassment by medical staff. the cornerstone of physician-patient relationship is holiness. whenever incidents of patient sexual abuse occur such holiness is ruined forever (54). in iran, there is no law related to this matter for protecting patients in critical situations however, reporting, investigating and prosecuting such incidents will be done through the islamic penal code. epilepsy in many parts of the world, there is a specific attention to the relationship between unreasonable cases and public health in order to increase public health and it is considered as a part of physicians’ main duties. one of the cases is epilepsy. for instance, people who have special disease like epilepsy or for some reasons they do not have enough competency to drive, must avoid driving. by doing this, they keep themselves and the others safe and protect the public from harm. it is necessary that physicians, report the situation to the authorities once they notice such incidents (55). in iran, there is no law related to this matter. sport and relevant events the value and the goal of medical mandatory reporting are to protect public health and their needs in daily life. presence of physicians is necessary in sport teams in order to fulfill this goal. in the us, reporting sport injuries to the national association of physicians is considered as a professional duty for the medical team and any physical and psychological athlete abuse, must be reported, effectively (56). boxing and martial arts act 2000 of australia, states "a medical practitioner must conduct the examination of contestants before and after events and record the results". failure to report would be subject to maximum penalty of 5000 australian dollars. the medical practitioner must notify not only the contestant but also the promoter of the event and the minister of the declaration (57). in iran, there is no law related to this matter. human trafficking mandatory reporting cases and their related laws are evolving day by day and most laws support physicians so that they feel they are protected from any claims and litigations. the important point is that laws are reflection of society's needs, physicianpatient relationship and social needs (56). the difficulty of the medical profession in this issue stems from weak and inefficient laws. human traffickers misuse such inefficiency in laws in order to continue human trafficking especially when there is no international cooperation for reporting such incidents. an efficient specific statute in reporting such incidents by physicians will decrease such incidents to occur. there is no law related to this matter in iran. gunshot injuries or wounds countries have considered some rules about deadly serious wounds resulted from weapons (crimes). different countries have considered different requirements for reporting about firearms (like gun…) and cold steels (like knife …) and the wounds resulted from them. in california, physicians and other health care providers have to report any kind of wound or injury caused by deadly weapons e.g. a gun, to the police (58). medical mandatory reporting laws of gunshot wounds enacted in canada in 1995 (59). reports of forensic personnel for people who injured by firearms or any other deadly weapon is necessary. physicians in all states of australia have to report patients’ wounds resulted from knife, gun or any other deadly weapon (60). moreover, the law obliges the hospital staff to report gunshot wounds and in the special situations, hospital staff has to allow the police to speak with the wounded patient especially when the crime is highly important (critical) to access information (17, 61). there is no law related to this matter in iran. high risk pregnancies reporting death of infants, infectious disease of the pregnant women and their addiction to drugs or alcohol are physicians' duties which have been emphasized by world health organization and the governments. in the us, pregnancies of young people under the age of 18 must be reported in order to reduce birth rate and to increase facilities and health services to these people (62). physicians must report any cases where pregnant women diagnosed with contagious disease affecting their fetus. any kind of dangerous behavior during pregnancy such as alcohol consumption, usage of drugs and exposure to xrays must be reported to relevant authorities (63). there is no law related to this matter in iran. medical errors it is possible that, the physicians fault causes damage to the patients' health. in this case, responsible physician is obliged to report the incident to authorities. world health organization called the patient’s safety as public concern in world j med ethics hist med 7:13 aug, 2014 jmehm.tums.ac.ir alireza milanifar et al. page 7 of 10 (page number not for citation purposes) alliance for patient safety in 2004 and called for the necessary considerations for patient safety. some countries reported damages and death of patients due to medical errors and it was discovered that one out of ten patients suffers from complications and injuries of medical errors (64, 65) danish act on patient safety passed in parliament in 2003. in early 2004, denmark was known as the first country legislating mandatory reporting related to medical errors. imperative law of mandatory reporting obliges hospital and medical staff to report any medical practice which is against the health to the national system of mandatory reporting (66). in the us, 23 states passed the law for mandatory reporting of diseases and severe wounds and deaths due to such injuries in 2005 (67). finally, in 2005, the us congress passed the law on mandatory reporting of the medical faults in order to promote patient safety and quality of life (68). in iran, the iranian legal medicine organization has considered the duty of mandatory reporting of death. however, from a legal viewpoint, this is not one of the responsibilities of the aforementioned organization. drug side effects adverse event (or side effect) is an undesirable experience which occurs due to medication (69). in canada, reporting adverse drug reaction is either mandatory or voluntary for manufacturers, professionals and consumers. trial sponsors must report any serious and unexpected adverse drug reaction (adr) to health canada while the drug is in clinical trial. it also applies to natural health products in clinical trials. however, professionals are encouraged to report adverse reactions to marketed products such as food, consumer products, drugs for humans, vaccines to prevent diseases in humans…., and it is voluntary to report an adverse reaction to health canada (70). in iran, there is a guideline about reporting side effects of the drugs but this guideline cannot impose any obligation on physicians unless it is with patient’s explicit informed consent (71). animal cruelty animal cruelty is one of those situations where physicians and dentists have legal obligation to report in some countries (72). it should be noted that generally, animal cruelty is not done by healthy people and it is possible that a child or a young person being abused by animal abusers. therefore, it is necessary to attract public’s attention to this matter and try to provide operations and guidelines, make animal cruelty laws and provide targeted treatment to animal abusers. conclusion the important issue for physicians is that sometimes a physician is obliged to disclose patients’ secrets due to necessity, and failure to do so may have risk of harm to the patient or others. this raises a conflict for the physician; “necessity” and “respect for the patient” at the same time (to treat the patient with respect and dignity and to keep patient’s secrets confidential and necessity to prevent harm to patient or others). disclosure of personal health information, in order to help and prevent some diseases and consequently preventing harm to others, requires a comprehensive guideline which defends violation of law by physicians. world health organization tries to consider all human beings health. in this respect, guidelines are provided to protect the rights of those who have been affected due to consequences of such disclosure. as we explained earlier, there are significant differences between medical mandatory reporting laws of iran and the laws of other countries. it is necessary to carefully review current acts and set guidelines in order to protect public order, respect human dignity and basic rights of individuals. in this regard, domestic violence, child abuse, drug side effects, human trafficking, dangerous pregnancies and other abovementioned situations are to be considered in mandatory reporting law of iran. undoubtedly, determining the level of importance of such incidents subject to medical mandatory reporting, providing guidelines with details about how to report are inevitable. alternatively, specific statute for each situation needs be made by the parliament so that the law explicitly defines and imposes duties on doctors to disclose specific information. however these alternative views require separate studies. acknowledgements the study was supported due to a contract between the national institute of health research of the tehran university of medical sciences and avicenna research institute (contract no: 241/m/91117) in which codification of a comprehensive draft of medical mandatory reporting law was requested. the authors would like to express their sincere thanks to everyone who involved in completion of this study and special thanks to dr. arash rashidian for his genuine support. j med ethics hist med 7:13 aug, 2014 jmehm.tums.ac.ir alireza milanifar et al. page 8 of 10 (page number not for citation purposes) references 1. holsinger jw, beaton be. physician professionalism for a new century. clin anat 2006; 19(5): 473-9. 2. anonymous. confidentiality and disclosure of health information. guidance from bma medical ethics department. 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http://www.hc-sc.gc.ca/ahc http://fdo.behdasht.gov.ir/index.aspx?fkeyid=&siteid=114&pageid=32102&siteid=114 jmehm-11-5 journal of medical ethics and history of medicine letter antibiotic prescribing behavior among physicians: ethical challenges in resource-poor settings saurav basu1*, suneela garg2 1junior resident, department of community medicine, maulana azad medical college, new delhi, india. 2director professor, department of community medicine, maulana azad medical college, new delhi, india. corresponding author: saurav basu address: department of community medicine, maulana azad medical college, 2 bahadur shah zafar marg, new delhi, india. postal code: 110002 email: saurav.basu1983@gmail.com tel: 91-8447527452 received: 8 jan 2018 accepted: 30 apr 2018 published: 12 may 2018 j med ethics hist med, 2018, 11:5 © 2018 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract prescribing antibiotics to patients represents an ethical dilemma for physicians since the current health needs of the patients have to be balanced with concerns for long term containment of antimicrobial resistance in the community. overuse of antibiotics is a major pathway for development of antimicrobial resistance. in resource-poor settings a complex social reality can influence antibiotic prescribing behavior among physicians which apparently violates the conventional biomedical ethics principles especially beneficence and justice. these social factors include patient socioeconomic class, patient demand for antibiotics, competition among practitioners and conflict of interest arising from the physician’s social relationship with his/her patient. current approaches for combating antimicrobial resistance in the developing countries are inadequate in factoring and dealing with those irrational prescription practices which are driven predominantly by subtle violation of medical ethics as opposed to blatant economic and professional profiteering. keywords: ethics, antibiotics, antimicrobial resistance mailto:saurav.basu1983@gmail.com j med ethics hist med 11: 5, may, 2018 jmehm.tums.ac.ir saurav basu et al. page 2 of 4 introduction prescription of antibiotics presents an ethical dilemma for physicians since the current health needs of patients have to be balanced with concerns for their safety due to adverse effects and restricting antimicrobial resistance (amr) throughout the community (1 2). the alarming increase in amr is a major public health challenge worldwide (3). overuse of antibiotics is a major pathway for development of amr, which adversely impacts population health by increasing mortality and disability rates due to infectious diseases, escalating treatment costs and reduction of economic productivity (4). as no new classes of antibiotics have been developed in the past 2 3 decades, antibiotics represent a scarce resource that should be used in a sustainable manner in order to protect the health needs of future generations (1, 5). therefore, promoting judicious use and avoiding irrational prescription of antibiotics is considered a key strategy for containing amr in communities. factors like financial incentives from pharmaceutical companies and lack of knowledge about antibiotic prescription guidelines can lead to erroneous antibiotic prescribing practices. however, it could be argued that there exists a complex social reality underlying the antibiotic prescribing behavior that apparently violates the conventional biomedical ethics principles of patient autonomy, beneficence, non-maleficence and justice. some of these situations in mostly resource-poor outpatient settings are discussed below: clinical judgment influenced by patients’ socioeconomic status while prescribing antibiotics, especially in resourcepoor settings, physicians often have to rely upon clinical evaluation alone in the absence of adequate diagnostic support. empirical therapy is not always unwarranted; however, the high cost of investigations like blood/urine culture and sensitivity testing, which are not affordable or easily accessible for poor patients, can influence the physician’s behavior (6). similarly, even in developed countries, physicians are more likely to prescribe antibiotics to socioeconomically deprived patients due to concerns about complications (7), which may actually arise from poor hygiene, sanitation and nutrition (6). nevertheless, this mode of antibiotic prescription may be an example of what is socially just but ethically unacceptable since the health of future generations can be compromised through potentially increased antibiotic resistance resulting from empirical therapy. the physician here decides that the benefit incurred to the patient through empirical therapy outweighs the consequences of potential increased antibiotic resistance or environmental degradation in the future (8), although this decision is not evidence based. patient demand for antibiotics there is global evidence that physicians can be pressured into prescribing antibiotics even against their clinical judgment (7). patients can employ a variety of both direct and indirect measures in this process. direct demands for antibiotics may arise from patients’ expectation of medicine during their very first visit even in the absence of investigation. in most developing countries like india, it has been observed that intense competition between private practitioners can distort physicians’ prescribing practices. the reason is the concern that the patient may not turn up again (9) and instead get antibiotic medications anyway from another practitioner or even directly from a pharmacist. indirect demands for antibiotics have been reported worldwide and include patients enquiring and citing past instances of medical improvement after taking antibiotics (7). consequently, such actions can result in prescription of antibiotics when they are not required at all, as in the case of viral illnesses. the result will be a compromise of beneficence for the patient and longterm promotion of antibiotic resistance in the environment and community. conflict of interests and bias even during unavoidable empirical therapy, narrowspectrum antibiotics should be prescribed as opposed to broad-spectrum antibiotics, even though nonclinical and social factors can influence the type of antibiotic prescribed. it is ethically appropriate for physicians to write prescriptions for their family members to cure short-term minor problems, that is, if they possess the necessary expertise to treat the condition (10). nevertheless, such assumptions do not cater to the possibility of ethical conflicts arising from flawed antibiotic prescription. while prescribing antibiotics to their family, friends or influential patients, physicians may tend to prescribe the “better” antibiotic, which is likely to be broad-spectrum or one against which little resistance has been reported. this is because prescription of a narrow-spectrum antibiotic for empirical therapy inevitably involves the risk of lack of benefit, especially in communities where prevailing amr is high. consequently, a physician anticipating potential failure of narrowspectrum antibiotic therapy and concerned with the risk of prolonged sickness in those with whom he or she is emotionally attached may prescribe broadspectrum antibiotics. a physician who adheres to a rational prescription of antibiotics to patients who are strangers may therefore fail to do so with patients with whom he or she shares an intimate relationship. this kind of differential treatment is unethical since it often follows a distinct class bias as affluent patients are more likely to exert bargaining power upon a physician compared to those who are economically weak. moreover, such practice violates the ethical principle of justice, which requires fair distribution of scarce resources. in developing countries, current approaches to containing amr focusing on prescription audits, j med ethics hist med 11: 5, may, 2018 jmehm.tums.ac.ir saurav basu et al. page 3 of 4 sensitization and training of physicians tend to rely upon clinical worldviews in which pharmaceutical incentives and the urge for gratifying patient expectations preclude rational antibiotic prescribing (11 12). nevertheless, there is a need to distinguish between the following antibiotic prescription practices: 1) an irrational approach guided by blatant economic and professional profiteering, and 2) one involving a subtle ethical violation with the intention to overcome existing clinico-social challenges. public policies for containing amr in developing countries focusing upon promotion of rational drug prescription need to envisage best practices for physicians in outpatient settings when confronted with such ethical dilemmas and challenges in treating their patients. j med ethics hist med 11: 5, may, 2018 jmehm.tums.ac.ir saurav basu et al. page 4 of 4 references 1. jog pp. rationale of antibiotic therapy think before you ink. indian pediatr. 2016; 53(9): 775–7. 2. leibovici l, paul m, ezra o. ethical dilemmas in antibiotic treatment. j antimicrob chemother. 2012; 67(1):12–6. 3. laxminarayan r, matsoso p, pant s, et al. access to effective antimicrobials: a worldwide challenge. lancet. 2016; 387(10014):168-75. 4. laxminarayan r, duse a, wattal c, et al. antibiotic resistance-the need for global solutions. lancet infect dis. 2013; 13(12):1057-98. 5. leibovici l, paul m. ethical dilemmas in antibiotic treatment: focus on the elderly. clin microbiol infect. 2015; 21(1): 27–9. 6. kotwani a, wattal c, katewa s, joshic pc, holloway k. factors influencing primary care physicians to prescribe antibiotics in delhi india. fam pract. 2010; 27(6): 684–90. 7. stubbe m, dowell a, plumridge e, mac donald l, dew k. prescribing dilemma: do our gps say one thing while doing another? new zealand pharmacy journal. 2008; 28(3): 28–30. 8. balch a, schoen jh, ms, patel pk. should physicians consider the environmental effects of prescribing antibiotics? ama journal of ethics. 2017; 19(10):957–65. 9. chandy sj, mathai e, thomas k, faruqui ar, holloway k, lundborg cs. antibiotic use and resistance: perceptions and ethical challenges among doctors, pharmacists and the public in vellore, south india. indian j med ethics. 2013; 10(1): 20–7. 10. korenman sg, bramstedt ka. your spouse/partner gets a skin infection and needs antibiotics: is it ethical for you to prescribe for them? yes: it is ethical to treat short-term, minor problems. west j med. 2000; 173(6): 364. 11. hoque r, mostafa a, haque m. intern doctors’ views on the current and future antibiotic resistance situation of chattagram maa o shishu hospital medical college, bangladesh. ther clin risk manag. 2015; 11: 1177– 85. 12. kotwani a, chaudhury rr, holloway k. antibiotic-prescribing practices of primary care prescribers for acute diarrhea in new delhi, india. value health. 2012; 15(1 suppl):s116-9. jmehm-7-3 journal of medical ethics and history of medicine the relationship between moral distress, professional stress, and intent to stay in the nursing profession fariba borhani1, abbas abbaszadeh2, nouzar nakhaee3, mostafa roshanzadeh4* 1 assistant professor, faculty of nursing & midwifery, medical ethics and law research center , shahid beheshti university of medical sciences, tehran ,iran; 2 professor, faculty of nursing & midwifery, shahid beheshti university of medical sciences, tehran ,iran; 3 professor, kerman university of medical sciences, kerman, iran; 4 faculty member of birjand university of medical sciences, birjand, iran. corresponding author: mostafa roshanzadeh address: birjand, ghafare avenue, birjand university of medical sciences, birjand, iran. email: mroshanzadeh62@gmail.com tel: 98 09397952522 fax:98 05618825875 received: 26 aug 2013 accepted: 12 dec 2013 published: 18 feb 2014 j med ethics hist med, 2014, 7:3 © 2014 fariba borhani et al.; licensee tehran univ. med. sci. abstract moral distress and professional stress are common problems that can have adverse effects on nurses, patients, and the healthcare system as a whole. thus, this cross-sectional study aims to examine the relationship between moral distress, professional stress, and intent to stay in the nursing profession. two hundred and twenty full-time nurses employed at teaching hospitals in the eastern regions of iran were studied. a 52-item questionnaire based on corley’s moral distress scale, wolfgang’s health professions stress inventory and nedd questionnaire on intent to stay in the profession was used in the study. additionally, demographic details of the study population were collected. no significant correlation was observed between the intensity and frequency of moral distress, professional stress, and intent to stay in the profession among nurses (p > 0.05). there was a significant correlation between moral distress, professional stress, and age, number of years in service and work setting (p < 0.05). given the important effect of moral distress and professional stress on nurses, in addition to the educational programs for familiarization of nurses with these concepts, it is recommended that strategies be formulated by the healthcare system to increase nurses’ ability to combat their adverse effects. keywords: moral distress, professional stress, intent to stay, nursing profession, nursing ethics mailto:mroshanzadeh62@gmail.com j med ethics hist med 7:3 feb, 2014 jmehm.tums.ac.ir fariba borhani et al. page 2 of 8 (page number not for citation purposes) introduction there is a high level of human contact in the nursing profession, and therefore nurses are inevitably faced with issues like moral distress and professional stress. moral distress is created when the conditions contradict an individual’s beliefs and inner moral values, and he or she has to act against those values as a result of those conditions and real limitations (1). the occurrence of moral distress can entail different repercussions for nurses, patients, and healthcare organizations (2). in facing these conditions, nurses may experience sadness, contradiction, futility, and affliction. prolonging these conditions can lead to exhaustion of their resistance resources and cause dissatisfaction with the workplace. those who continue to work despite these conditions experience stress and burnout along with dissatisfaction (3). stress is a wellknown phenomenon in the nursing profession that can entail positive as well as negative consequences. professional stress can be created under different conditions such as moral distress, nursing shortages, and organizational limitations, and affect nurses directly, followed by the patients and finally the healthcare system (4). the dissatisfaction of nurses with their workplace resulting from moral distress and professional stress may lead to absenteeism, and strengthen the thought and desire to resign and leave the profession (5). in addition to these conditions, limited human resources, lack of support systems for nurses in clinical environments, organizational pressures, and the feeling of guilt when they are unable to provide quality care, can all cause the thought and desire to leave the profession to turn into action (6). leaving the profession can have different effects on the healthcare system. shortage of skilled human resources can cause a decline in the quality of care and cause financial and legal challenges for the health service providers, and in a vicious circle, increase moral distress and professional stress in the remaining nurses (7). the importance of moral distress and professional stress, and their relationship with intent to stay in the nursing profession are reviewed in this article. studies conducted on the moral distress reveal its high prevalence in nurses with different rates of intensity and frequency in different clinical environments. evidence shows that there is a much higher level of moral distress in special care units where conditions of patients are more critical and nurses have higher responsibility (8-14). in their 2005 study, elpern et al. investigated moral distress in critical care units. while reporting high levels of moral distress among nurses, they stated that conditions conducive to moral distress created a kind of reluctance in nurses for performing nursing care (8). lazzarin et al. reported high levels of moral distress in nurses in oncology and pediatric hematology units (9). corley also stated that the moral climate in nurses’ working environment plays an important role in their level of moral distress (10). also, the ethical climate in the workplace is identified as a factor affecting moral distress with consequences like burnout, job dissatisfaction, and professional stress, forcing nurses to leave their profession (1, 15, 16). review of studies in connection with stress indicates that stress is a common phenomenon in the nursing profession. a person’s mental status and self-satisfaction are directly related to the intensity of stressful factors, and circumstances such as inadequate logistics and work pressure are identified as important factors in creating professional stress (17-19). healy et al. investigated workplace stressors and their effects on job satisfaction in nurses, and concluded that this effect existed (20). cummings investigated the relationship between moral distress, professional stress, and critical care unit nurses leaving the profession, and concluded that high levels of moral distress and professional stress are associated with nurses leaving the profession (3). considering the religious and cultural differences between iranian nurses and nurses from other countries, and given the different organizational structures and managerial patterns in the healthcare system in iran, this study was conducted to examine levels of moral distress and professional stress and their relationship with the intent to stay in the profession in iranian nurses. theories of moral distress and intent to stay moral distress theory moral distress is a concept first introduced by jameton (21). he believed that when a person is aware of the right ethical course of action but is prevented by organizational constraints from taking that course, he is faced with moral distress (21). the organizational constraints in his opinion were: time limitations, lack of support of nurses by the management, organizational policies and procedures, and legal limitations. jameton identified different conditions that cause moral distress including: unnecessary actions, inadequate performances, entanglements and conflicts with the patient’s family requirements, and making the decision to end a dying patient’s life. he then expanded the concept of moral distress and expressed it as initial and reactive distress. initial distress involves feelings of frustration, anger, and anxiety when people face organizational constraints and come into conflict with others about values. j med ethics hist med 7:3 feb, 2014 jmehm.tums.ac.ir fariba borhani et al. page 3 of 8 (page number not for citation purposes) reactive distress occurs following initial distress and its negative consequences where the person is unable to perform his duties (20). based on jameton’s concept of moral distress, corley et al. presented the theory of moral distress in 2002. they considered the following points in jameton’s theory: 1) nursing is an ethical profession, and 2) a nurse is an ethical person. they considered nursing as an ethical profession with vast moral standards that are reflected in caring and performance standards. when nurses perform as ethical means, they are exposed to moral distress. in their theory, corley et al. stated how moral distress can affect nurses, patients, and healthcare organizations. when facing moral distress, nurses experience exclusion, depression, and misfortune, and if these conditions persist, they may experience frustration and dissatisfaction with work, and ultimately leave. also, moral distress can affect the quality of the care provided by nurses and cause nurses to avoid facing the patients in need of quality care. corley et al. believed that the effects of distress on organizations are connected with job resignations, reduced job satisfaction and quality of care. they also stated that the intensity and frequency of moral distress are different in different situations (21). intent to stay in the profession theory this theory was presented by kim et al. in 1996 and was formed on the basis of vroom’s theory of expectancy (22). the main idea is that employees come to an organization with certain expectations and values, and the assumption is that if these expectations are met, then they stay with the company, and if not, they begin to consider leaving. disinclination to remain can preempt leaving the profession (23). kim et al. argued that there are three main variables that lead to job satisfaction and organizational commitment including environment, organizational structure, and the individual. job satisfaction and organizational commitment determine a person’s behavior regarding staying in the profession. the environmental variable includes two main factors of relations and opportunities. relation is associated with the family and a person’s responsibility within the group. opportunity relates to the job market and the ability of workers to adapt to a new profession. the more available the opportunities in other work environments, the less the desire and intention of employees to stay in a profession. the individual variable in this theory includes general education, work motivation, individuals’ expectations and positive and negative emotions. motivation refers to pleasant and unpleasant emotional experiences and whom they may affect. expectations refer to whether the job can meet a person’s beliefs about that job. other variables include authority, justice, occupational hazards, job stress, salaries, professional growth, advertizing opportunities, and social support. these variables provide a framework for a person’s adjustment with working conditions, expectations, independence, a sense of fairness and justice, and opportunity for professional growth. workers expect to be protected from workplace hazards and stress and be paid well for the job they do. in addition, they prefer to have promotional opportunities and be successful in the system. ultimately, a social support system affects employees and their decision to stay in the healthcare system. in any case, the desire to stay in the profession depends on numerous factors, and the relationship between these factors is also important. the main factors are ethical distress and job stress. professional stress emphasizes personal and organizational factors like occupational motivation, general education, authority, wages and expenses, and professional growth. it appears that organizational structure plays an important role in the accumulation of stressful factors. ethical distress essentially affects factors like expectations and positive and negative emotions. generally, this theory is closely related with the individuals’ expectations and experiences (21). method this study was a cross-sectional study aiming to examine the relationship between moral distress, professional stress, and intent to stay in nursing. the participants were assessed in terms of intensity and frequency of moral distress and professional stress, and then the correlation between moral distress, professional stress, and the desire to stay in the profession was analyzed. study population and sampling study units included 220 nurses selected by census from two teaching hospitals (imam reza and valiasr) in the city of birjand. inclusion criteria included at least one year’s experience in clinical wards, minimum level of education as bachelor’s degree in nursing, and full-time employment. study nurses were selected from all clinical wards in these hospitals. tools research tools consisted of a 52-item questionnaire containing demographic information as well as three sub-questionnaires based on corley’s moral distress scale (21 questions) (24), wolfgang’s health professions stress inventory (30 questions) (25), and nedd questionnaire on intent to stay in the profession (1 question) (7). the first section was the moral distress scale, designed by corley et al. in 1995. the preliminary form of this questionnaire comprises 38 items, but in this study, the 21-item brief form developed by corley & hamrick in 2007 was used (10). the second section consisted of a 30-item professional stress questionnaire, designed by wolfgang in 1998 (25). the third section included one 4-option j med ethics hist med 7:3 feb, 2014 jmehm.tums.ac.ir fariba borhani et al. page 4 of 8 (page number not for citation purposes) question that assessed the desire to continue working as nurses, designed by nedd in 2006 (7). the validity and reliability of the 51-item moral distress and professional stress questionnaire were determined by cummings in 2009 (3). its reliability was determined to be 95% using cronbach’s alpha. the moral distress and professional stress questionnaire was in the form of 51 continuous questions with 6-point likert answers including 6 options in intensity and 6 in frequency dimensions. the options in the intensity dimension were (0 to 5) from “not at all” to “very much”, and in the frequency dimension were (0 to 5) from “never” to “frequently”. the original questionnaire was in english and was translated in backward-forward fashion. the validity was confirmed using content validity method and the opinions of 10 faculty members familiar with ethical issues. the reliability was calculated using internal consistency method (cronbach’s alpha) and reported to be 0.93. data collection after obtaining written legal permissions and ethical codes from affiliated hospitals, the questionnaires were given to the nurses, and collected by the researcher after completion. this process took 14 days (from march 29th to april 12th, 2012). all participating nurses completed the questionnaire, and all questionnaires were collected. data obtained from questionnaires were registered in the spss version 16 software, and descriptive statistics (mean, standard deviation, frequency, frequency percentage) and inferential statistics (pearson’s correlation, independent t-test, one-way anova, and so on) were used to analyze the data to achieve the study objectives. ethical considerations the study proposal was approved by the ethics committee of kerman university of medical sciences (ethical code: k90.477) and legal permissions were obtained prior to collection of data. the participants were briefed on the voluntary nature of their participation in the study and were provided with all the necessary information on study objectives and how to complete the questionnaires before beginning to do so. furthermore, participants were asked not to write their names on questionnaires and were informed that their personal information would be confidential. results demographic characteristics demographic characteristics of the study units included age, gender, ward, number of years in service, and type of employment. the age of participating nurses ranged from 23 to 47 years, and the mean age was 31.12 (sd = 5.13) years. the highest number of years in service was 24 years and the lowest was 1 year, with the mean of 6.54 years (sd = 4.4). seven wards were recognized and nurses were divided into 7 groups accordingly (table 1), and in terms of type of employment, nurses were divided into 3 groups of official, contractual, and project-based (table 2). table 1 responses by clinical unit work setting no. (%) surgical 65 (29.5) critical care 81 (36.8) pediatrics 7 (3.2) medical 33 (15) emergency 20 (9.1) obstetrics 6 (2.7) psycho-medicine 8 (3.6) total 220 (100) in terms of education level, all participants had bachelor’s degree in nursing. table 2responses by type of the employment type of employment no. (%) official 105 (47.7) contractual 85 (38.6) project-based 30 (13.6) total 220 (100) intensity and frequency of moral distress, professional stress, and intent to stay in nursing profession the results reveal mean moral distress intensity of 2.25 (sd = 0.6) and a mean moral distress frequency of 2.11 (sd = 0.56) (total intensity and frequency ranged from 0 to 5). in terms of stress, the mean intensity of professional stress was 2.21 (sd = 0.58) from a total range of 0 to 5, and the mean frequency of stress was 2.26 (sd = 0.63) from a total range of 0 to 5. in terms of intent to stay in the profession, study units were divided into 4 groups: 12.3% were inclined to leave the profession as soon as possible, 26.8% stated that they may leave the organization in the coming year, 22.7% expressed that under no circumstances would they leave the organization voluntarily, and 32.3% said that they had plans to stay with the organization for as long as possible. there was a significant correlation between the mean total moral distress and the mean total professional stress (p < 0.05), and the correlation coefficient was calculated at 0.6. no significant correlation was observed between the total scores of moral distress, professional stress, and intent to stay in the profession (p > 0.05) (tables 3 & 4). j med ethics hist med 7:3 feb, 2014 jmehm.tums.ac.ir fariba borhani et al. page 5 of 8 (page number not for citation purposes) table 3 analysis of variance examining the relationship between the mean score of moral distress and intent to stay intent to stay no mean (sd) mean (md intensity) (sd) md frequency) i plan to leave the institution as soon as possible 27.06 (12.3) 2.16 (0.57) 2.2 (0.53) i may leave the organization within the next year 58.96 (26.8) 2.24 (0.57) 2.13 (0.56) under no circumstances would i voluntarily leave the organization 49.94 (22.7) 2.32 (0.65) 2.04 (0.56) i plan to stay with this organization for as long as possible 71.06 (32/3) 2.24 (0.63) 2.11 (0.57) no response 12.98 (5.9) total 220 (100) no=frequency; md= moral distress; sd= standard deviation. table 4analysis of variance examining the relationship between mean score of professional stress and intent to stay intent to stay (sd) no mean (sd) mean (md intensity) (sd) md frequency) i plan to leave the institution as soon as possible 27.06 (12.3) 2.29 (0.58) 2.26 (0.56) i may leave the organization within the next year 58.96 (26.8) 2.14 (0.57) 2.11 (0.55) under no circumstances would i voluntarily leave the organization 49.94 (22.7) 2.35 (0.73) 2.27 (0.53) i plan to stay with this organization for as long as possible 71.06 (32/3) 2.27 (0.64) 2.21 (0.67) no response 12.98 (5.9) total 220 (100) no=frequency; md= moral distress; sd= standard deviation. mean and standard deviation of study units answering the questionnaire: in assessing moral distress, the highest means in distress intensity and frequency were related to the question “i find myself caring for the emotional needs of patients” (for intensity (2.65 ± 1.41), and for frequency (2.52 ± 1.48). the lowest means in distress intensity and frequency were related to the question “i have experienced conflicts with supervisors and/or administrators at work” (for intensity (1.78 ± 1.33, and for frequency (1.77 ± 1.31). in assessing professional stress, the highest means in stress intensity and frequency were related to the question “i have found myself in situations where there was not enough staff to adequately provide the necessary services” (for intensity (2.83 ± 1.66, and for frequency (2.83 ± 1.66). in terms of stress, the lowest level of stress was related to the question “i have let medical students perform painful procedures on patients solely to increase their skill.” (1.59 ± 1.48) and in terms of frequency, the lowest level of stress was related to question “i have increased the dose of intravenous morphine in end of life situations that i believe will hasten the patient’s death” (1.7 ± 1.51) (table 5). table 5 mean and standard deviation of study units answering the questionnaire question intensity mean (sd) frequency mean (sd) 1i find myself providing less than optimal care due to pressures to reduce costs. 2.14 (1.56) 2.16 (1.43) 2i have so much work to do that i cannot do everything well. 2.17 (1.46) 2.15 (1.4) 3i have asked the patient’s family about donating organs when the patient’s death is inevitable. 2.05 (1.58) 1.93 (1.5) 4i have experienced conflicts with supervisors and/or administrators at work. 1.78 (1.33) 1.77 (1.31) 5i find myself caring for the emotional needs of patients. 2.65 (1.41) 2.52 (1.48) 6i have let medical students perform painful procedures on patients solely to increase their skill. 1.65 (1.56) 1.66 (1.54) 7i find myself dealing with “difficult” patients. 2.59 (1.31) 1.37 (2.62) 8i have provided care that does not relieve the patient’s suffering because i fear that increasing the dose of pain medication will cause death. 2.1 (1.41) 1.9 (1.38) 9i have found myself in situations where there was not enough staff to adequately provide the necessary services. 2.83 (1.66) 2.83 (1.66) j med ethics hist med 7:3 feb, 2014 jmehm.tums.ac.ir fariba borhani et al. page 6 of 8 (page number not for citation purposes) correlation between moral distress and professional stress and demographic characteristics there was a significant correlation between moral distress and age (p< 0.05, r = -0.2) as well as between professional stress and age (p < 0.05, r = 3). there was a significant correlation between moral distress and number of years in service (p < 0.05, r = -0.3) and between professional stress and number of years in service (p < 0.05, r = -0.4). there was a significant correlation between moral distress and work setting (p < 0.05) and also between professional stress and work setting (p < 0.05). no significant correlation was observed between moral distress, professional stress, and sex or type of employment (p> 0.05). the highest mean score of moral distress was observed in the pediatric ward (2.63 ± 0.26), and the lowest in emergency (1.37 ± 0.45). moreover, the highest mean score of professional stress was observed in the psychiatric ward (2.85 ± 0.3), and the lowest in emergency (1.64 ± 0.5). discussion the results obtained in this study indicate that despite a medium level of moral distress, nurses did not wish to stay in the profession. results of other similar studies, however, report a positive correlation between moral distress and the intent to stay in the profession (3, 11, 16, 19). there may be a number of reasons that can explain the difference between this study and similar ones. one of these reasons is that there are several obstacles a person leaving his or her profession in iran has to face. special organizational conditions do not make it easy for personnel to leave as and when they decide to. thus, sometimes complicated stages and hard clerical and legal processes may deter personnel from leaving, which can be due to difficult employment regulations and huge costs of employing and training these people. as there is a shortage of jobs compared to demands in iran, it is likely that people leaving their jobs may not be able to find another suitable one. people leaving employment can face several problems including financial hardships, and the inability to find another job would make daily life extremely difficult for them. all these situations and obstacles reduce nurses’ motivation and desire to leave the profession and force them to remain in the profession despite all the moral distress they may have to tolerate in the workplace. investigation of the intensity and frequency of moral distress in study units shows they are in average range. in order to investigate the level of moral distress, 21 questions were posed, and question number 12 “i find myself caring for the emotional needs of patients” was the most relevant and attracted the highest mean intensity and frequency of moral distress in nurses, and was related to concern for patients’ feelings and emotions. in the opinion of study units, emotional involvement with patients’ problems and their relatives is an important source of stress. the lowest mean score for distress in terms of intensity and frequency pertained to question 4 “i have experienced conflicts with supervisors and/or administrators at work”. previous studies also considered the emotional problems of patients and their relatives and conflicts with supervisors and management as important factors in moral distress (26, 27). the level of effectiveness of these factors in creating distress depends on the type of workplace and characteristics of people. in general, the level of moral distress in this study was in the medium range. in most studies, the level of moral distress was different depending on the type of ward, and in most cases it ranged from medium to high (8, 28). in this study, the moral distress score related to all wards was medium, whereas in other studies this score appears to be higher. this may have been due to assessment of the nurses in special wards such as special care units where ethical distress would surely be higher compared to other wards. investigation of the intensity and frequency of professional stress in study units revealed a medium level of professional stress in nurses. other studies place this level in the medium to high range {30-32}. for assessment of professional stress, 30 questions were posed {21 to 51}, of which the highest stress in terms of intensity and frequency was related to question number 35 “i have found myself in situations where there was not enough staff to adequately provide the necessary services” (29). in fact, shortage of human resources can be one of the most important factors in creating stress. many studies introduce shortage of human resources and high workload as important factors in creation of stress in workplace (29, 30). the lowest level of stress in terms of intensity was related to question 26 “i have let medical students perform painful procedures on patients solely to increase their skill”. this question created the least amount of stress in the nurses under study. the lowest level of stress in terms of frequency pertained to question 34 “i have increased the dose of intravenous morphine in end of life situations that i believe will hasten the patient’s death”. in his study, burnard et al. also regarded patient care complications as an effective factor in creation of professional stress (30). given the particular belief system in the nurses in the present study, cases of euthanasia do not occur in iran because they contradict religious beliefs, and consequently in terms of frequency of professional stress, they are unimportant. the correlation between moral distress and professional stress proved significant. according to j med ethics hist med 7:3 feb, 2014 jmehm.tums.ac.ir fariba borhani et al. page 7 of 8 (page number not for citation purposes) previous studies, conditions creating distress are also effective in creation of professional stress. case studies investigating distressing conditions introduce these conditions as effective factors in incidence of professional stress, and find a positive correlation between these variables (27, 29, 31). examining the relationship between moral distress, professional stress, and parameters of age and number of years of service revealed a significant and inverse relationship. these results indicate decreasing moral distress and professional stress with increasing age and service years. studies revealed a significant correlation between these parameters (20, 32-35). these studies state that with increased age and years of service, nurses gain more experience, and in facing moral challenges and stressors, they use effective defensive mechanisms, and thus, they are less affected. also, with increasing service years, nurses prefer to work in easier environments and avoid moral challenges and high stress. moreover, in the beginning of their service years, nurses are not sufficiently experienced to face moral challenges and stress, and are often involved and influenced by crisis and confusion. in assessing the relationship between moral distress and type of the ward, the highest level of distress was seen in the pediatric ward (28, 36). however, studies generally consider critical care units as having the highest level of distress for nurses (29, 36). the height of distress in these units is due to particularly acute conditions in these treatment settings that in turn are associated with higher challenges in moral terms. perhaps in this study, special conditions and vulnerability of children was a factor for higher moral distress in participating nurses. the highest level of professional stress was observed in the psychiatric ward. studies in this area revealed that stress level is generally higher in treatment settings, and this level is higher still in acute care conditions like critical care units. psychiatric wards can also have high levels of stress due to peculiarities of treatment and encountering special patients. while our study shows that the level of moral distress and professional stress in the emergency ward is low; other studies regard emergency ward nurses to be faced with high levels of moral distress and professional stress (30, 28, 36). in the present study, it could perhaps be stated that the special characteristics of this ward have made less time available for nurses to interact with patients, and also higher levels of experience of the emergency ward nurses in facing stressful cases has elevated their capabilities to cope with stressful conditions with less distress and stress. the present study was carried out in a particular region in iran and it is necessary to study other parts of the country. also, sampling was conducted in census method. all these affect the generalizability of results. given the study method and its analysis, it is no possible to assess the cause and effect relationship between variables. conclusion this study reveals medium levels of moral distress and professional stress in nurses and that the majority of nurses do not intend to leave their profession. on the other hand, there is a significant correlation between moral distress and professional stress. these can be due to different healthcare system structures and working environments, as well as characteristics of people in different geographical locations in iran. in the present atmosphere, to prevent the spread of moral distress and professional stress and their consequences, the following means ought to be considered: educating and familiarizing nurses with ethical distress and professional stress and factors causing them, setting up ethical committees in clinical and university centers for research into various dimensions of ethical distress, drawing the attention of management particularly in clinical settings to identify cases of ethical distress and professional stress in nurses, and finding suitable means to improve nurses’ ability to cope in such situations. while further study is needed to cover other parts of the country, it is recommended that the correlation between leaving the profession and variables like financial status of personnel as well as people’s desire to enter the profession be investigated. acknowledgements the authors wish to thank all participating nurses from the teaching hospitals in the city of birjand. this article is the result of a master’s degree thesis. references 1. corley m, minick p, elswick rk, jacobs m. nurse moral distress and ethical work environment. nurs ethics 2005; 12(4): 381-90. 2. corley m. nurse moral distress: a proposed theory and research agenda. nurs ethics 2002; 9(6): 636-50. 3. cummings cl. the effect of moral distress on nursing retention in the acute care setting [dissertation]. florida (usa). university of north florida; 2009. 4. 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http://faculty.ksu.edu.sa/omar%20omari/research%20paper/the%20impact%20of%20unit%20differences.pdf jmehm-11-1 journal of medical ethics and history of medicine original article do patients know that physicians should be confidential? a study on patients’ awareness of privacy and confidentiality mohammad mohammadi1, bagher larijani2*, seyed hassan emami razavi3, akbar fotouhi4, ahmad ghaderi5, seyed javad madani5, mohammad naser shafiee6 1phd candidate in medical ethics, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran; faculty of medicine, department of medical ethics, tehran, university of medical sciences, tehran, iran; faculty of medicine, department of medical ethics, mashhad university of medical sciences, mashhad, iran. 2professor, endocrinology and metabolism research center, endocrinology and metabolism research institute, tehran university of medical sciences, tehran, iran. 3associate professor, brain and spinal cord injury research center, neuroscience institute, tehran university of medical sciences, tehran, iran; 4professor, department of epidemiology and biostatistics, school of public health, tehran university of medical sciences, tehran, iran. 5phd candidate in medical ethics, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran; faculty of medicine, department of medical ethics, tehran, university of medical sciences, tehran, iran 6assistant professor, department of english language, faculty of medicine, mashhad university of medical sciences, mashhad, iran. corresponding author: bagher larijani address: no. 10, jalal al-ahmad st., next to shariati hospital, chamran hwy, tehran, iran. email: larijanib@tums.ac.ir tel: :( +98) 21 88631295 received: 7 oct 2017 accepted: 13 dec 2017 published: 13 feb 2018 j med ethics hist med, 2018, 11:1 © 2018 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract privacy and confidentiality are among the inalienable rights of every human being that contribute to preservation of a sense of reverence and dignity. the present study was conducted to examine patients’ awareness of their entitlement to these important rights. this cross-sectional study was conducted on 200 patients in tehran, iran during the year 2010. collected data included patients’ demographics (age, gender, marital status, place of residence, and educational level), type of hospital ward, frequency of hospitalization, duration of hospital stay, and patients’ awareness of privacy and confidentiality. two trained interviewers gathered the data using a self-made questionnaire, which was specifically designed to assess patients’ awareness of privacy and confidentiality. validity and reliability of the questionnaire were determined using content validity and cronbach's coefficient alpha (a = 0.7), respectively. to analyze data, patients were assigned to three categories of poor (0 ≤ scores ≤ 3), moderate (4 ≤ scores ≤ 7) and good (8 ≤ scores ≤ 10) levels of awareness. statistical analysis was performed by spss software version 21. the results showed that 21% of the patients had poor, 72% moderate, and 7% good awareness of privacy and confidentiality, with a mean of 4.61 ± 1.63. in this study, 153 patients (76.5%) provided a correct definition of privacy, and 161 patients (80.5%) were aware of instances of privacy violation. in addition, a good level of awareness was found in 77 patients (38.5%) in terms of physician confidentiality, and in 158 patients (81.4%) regarding confidentiality of examination results and medical consultations. our study results highlight the necessity to inform patients about the ethical and legal issues related to privacy and confidentiality, before or during admission. keywords: privacy, confidentiality, awareness, medical ethics mailto:larijanib@tums.ac.ir j med ethics hist med 11: 1, february, 2018 jmehm.tums.ac.ir mohammad mohammadi et al. page 2 of 7 introduction privacy and confidentiality are among the main features of ethical medical practice and are of great significance in all communities (1). confidentiality is regarded by the uk general medical council and many other organizations as an ethical obligation (1). chapter 4 of the iranian patients’ rights charter states that every individual has the right to privacy and confidentiality (2). privacy refers to an individual’s control over how much, when, and under what circumstances they may share details of their physical, behavioral, or intellectual life with others, and their right to restrict other people’s access to their personal information (3). thus, confidentiality means that providing information to another person will create a commitment on his or her part not to reveal it to anyone else. accordingly, both that individual and the community will expect that information trusted to a health professional in a clinical context not be revealed to third parties. hospitalized patients have limitations that may jeopardize their privacy and thus result in serious consequences (4). moreover, confidentiality commitment provides the basis for trust in therapeutic communication. respecting the confidentiality of patient information is a major principle in ethics and effective medical activities. confidentiality guarantees patients’ privacy (5). from the perspective of ethics, competent patients must be in full control of their personal information, and sharing such details without the patients’ permission is a breach of their autonomy. this type of conduct on the part of a health care team member is ethically unacceptable, even if the patient never learns about the circumstances, or no harm follows (4). to ensure accurate diagnosis and determine the appropriate course of treatment, patients should be able to confide the most intimate details to their physicians. breach of patient confidentiality leads to nonpresentation, which can bring about incorrect diagnoses and jeopardize all therapeutic measures (1). it is also perceptible that confidentiality cannot be absolute, and breach of confidentiality may sometimes be morally or legally permissible. as a general rule, risk of a serious injury to the patient or others can justify a breach of confidentiality (4). the duties of physicians have been clarified in the world medical association international code of medical ethics, and it is considered among the duties of a physician to respect patients’ secrets even after their death (6). patients’ awareness of privacy and confidentiality can bring about a lot of advantages such as increased quality of healthcare services, decreased risk of irreversible physical and spiritual damages, promotion of patients’ health, and reduced hospital stay (7). therefore, only patients who fully trust in physicians will reveal personal and intimate information regarding their health status. in addition, keeping patients’ matters confidential is crucial to maintain the faith of the public in medical professionals and healthcare services. an increasing number of studies have investigated the knowledge of patients regarding issues of privacy and confidentiality. most of these studies have shown that patients have poor awareness of their rights (7 10), and some studies have indicated that many patients are either unaware of, or misunderstand the legal and ethical duty of confidentiality. furthermore, minority of patients distrust clinicians in terms of confidential information protection and may consequently delay or forgo medical care (11). to our knowledge, most of the previous research on the iranian population has investigated patients’ awareness of the patients’ rights charter. since no studies have specifically examined patients’ awareness of privacy and confidentiality, the present study was conducted to investigate these issues in an iranian context. this study may provide an appropriate measure of patients’ awareness of their rights and the principles of medical ethics. an assessment of patients’ awareness can help policy makers devise appropriate regulations to improve physician-patient relationships. moreover, the findings of this study may help finding necessary modifications for better respecting of patient privacy. method this was a cross-sectional study, and the study protocol was approved by the ethics committee of tehran university of medical sciences. since the level of patients’ awareness of their privacy and confidentiality had not been measured in previous studies, it was estimated to be 0.50. the sample size was calculated at 149, with a margin of error of 0.08, and confidence level of 95%. in order to enhance accuracy, the sample size was increased to 200, i.e., 100 patients in each hospital. the study population consisted of patients from the internal, surgical, and obstetrics and gynecology wards of imam khomeini and shariati hospitals in tehran during the year 2010. patients were selected in a systematically random manner. the reasons for selecting these wards were the wide variety of patients and diseases, as well as the possibility of further violations of privacy and confidentiality. inclusion criteria consisted of patients' nonemergency admission, willingness to participate, and at least two days of hospitalization. data were collected through a two-part questionnaire administered by two interviewers. the first part recorded demographic characteristics (age, gender, marital status, place of residence, and educational level), type of hospital ward, frequency of hospitalization, and duration of hospital stay. the second part consisted of ten multiple-choice questions. there were three options for response, scoring 1 for each correct answer, and 0 for each incorrect answer. to analyze data, patients were j med ethics hist med 11: 1, february, 2018 jmehm.tums.ac.ir mohammad mohammadi et al. page 3 of 7 assigned to three categories of poor (0 ≤ scores ≤ 3), moderate (4 ≤ scores ≤ 7) and good (8 ≤ scores ≤ 10) levels of awareness. to determine the validity of the questionnaire, we used the content validity method. the content of the questionnaire was prepared on the basis of the research objectives through the study of textbooks and related articles, and evaluated by a panel of 5 experts in the field of medical ethics and epidemiology. the questionnaire was reviewed in terms of literary structure, clarity of the questions, and coverage of the items to be investigated. the final version constituted five questions on privacy and five on confidentiality. the section on privacy covered the definition, fields and violations of privacy, and women’s privacy issues. the part exploring confidentiality addressed patients’ awareness about respecting and observing confidentiality, disclosing patient's information and breaching confidentiality. each question was designed to address one aspect of privacy or confidentiality, and the response options were devised in such a manner as to cover all dimensions of the issue (tables 2 & 3). a test retest method was carried out to assess the external reliability of the questions in the ‘awareness’ part. twenty patients with homogeneous characteristics were randomly selected in a systematic manner. they were asked to complete the questionnaire in two stages, seven to ten days apart. pearson's correlation coefficient was used to evaluate the strength of concordance between the results of the two tests (> 0.7). the split-half method was used to determine the internal reliability. subsequently, the reliability coefficient was determined at 0.723 and 0.724 respectively based on the spearmanbrown formula and cronbach's coefficient alpha. thereafter, the trained interviewers completed the questionnaires; data were extracted and inputted into the database of spss version 21. to analyze data, we used descriptive statistics (mean, median, and frequencies), one-way anova, bonferroni, and chi-square test. in order to observe the principles of research ethics, all completed questionnaires were kept confidential and anonymous. in addition, at the beginning of the interview, the research scheme was presented, patients were asked to voluntarily cooperate in the study, and the interviewers attended the study hospitals after obtaining the required permissions. results in this study, the mean age of the patients was 39.7 years. the largest group (29.2%) were 20 29 years old, and a few (6.7%) were aged less than 19. the demographic characteristics of the patients are presented in table 1 below. table 1the demographic characteristics of the participants frequency n % gender male 87 43.5 female 113 56.5 marital status single 59 29.5 married 135 67.5 uncertain 6 3.0 place of residence urban 179 89.5 rural 13 6.5 uncertain 8 4.0 admission ward internal 42 21.0 surgical 97 45.5 obstetrics and gynecology 55 27.5 uncertain 6 3.0 frequency of hospitalization once 143 71.5 more than once 41 20.5 uncertain 16 8.0 duration of hospital stay < = 3 days 47 23.5 4 5 days 67 33.5 6 7 days 32 16.0 > = 8 days 48 24.0 uncertain 6 3.0 education level illiterate 18 9.0 elementary school 22 11.0 middle school 26 13.0 junior high school 21 10.5 senior high school 59 29.5 associate degree 23 11.5 bachelor’s degree 26 13.0 master’s degree 3 1.5 uncertain 2 1.0 the overall response rate was 93.45% (200 out of 214). table 2 shows the frequency of correct j med ethics hist med 11: 1, february, 2018 jmehm.tums.ac.ir mohammad mohammadi et al. page 4 of 7 answers to each question in the ‘awareness’ part. one hundred fifty three patients (76.5%) provided a correct definition of privacy, and 161 patients (80.5%) were aware of instances of privacy violation (table 3). in addition, 77 patients (38.5%) had good awareness of physician confidentiality. table 2the frequency of correct answers to each question in the questionnaire correct question content field % n 76.5 153 awareness of privacy definition privacy 80.5 161 awareness of privacy violations 38.0 76 awareness of privacy fields 16.0 32 awareness of privacy in medical settings 40.5 81 knowledge about women's privacy 38.5 77 awareness of physician confidentiality confidentiality 23.5 47 awareness of patient's permission for breach of confidentiality by the physician 14.0 28 awareness of legal issues of confidentiality 56.5 113 awareness of confidentiality in specific cases 79.0 158 awareness of confidentiality violations also, only 46 patients (23.0%) believed that physicians could disclose patients' information to reduce or eliminate a significant risk of serious harm to others. meanwhile, 47 patients (23.5%) did not think it was necessary for physicians to obtain patients’ consent before consulting with their families. moreover, 105 patients (52.5%) did not believe that physicians needed patients’ permission to consult with their colleagues or other members of the medical team in cases of multidisciplinary diagnosis and treatment. twenty-eight patients (14.0%) were aware that disclosing patient’s information is unethical, against religion, and illegal. one hundred and thirteen patients (56.5%) had previously known that medical information pertaining to mentally retarded patients should be recounted to their parents or guardians. thirty-nine patients (19.5%) did not consider the results of medical examinations and tests as confidential in cases where patient security, employment, insurance issues and legal competency were concerned, and 47 patients (23.5%) were not aware that in research studies it is essential not to disclose patients’ identity (table 3). one hundred and fifty eight patients (79.0%) had good awareness of the confidentiality of examination results and medical consultations (except for the cases falling under the category of legal obligations). this study showed that 15 patients (7.5%) were not aware that in case of patients’ decision to commit suicide or homicide, physicians must inform the relevant authorities (table 3). table 3sample questions about privacy and confidentiality included in the questionnaire #1 questions and options 1 the definition of privacy is.... a. to stay away from the community and live alone b. the right to stand alone and practice control over personal information c. to hide all information from others 2 which option is privacy violation? a. interpretation of statements and actions of individuals b. meddling in patients’ private affairs and disclosing their inconvenient information c. obtaining information about the intellectual beliefs of individuals during medical examination 9 which option is wrong about confidentiality? a. the health information of children and mentally retarded patients should not be disclosed to their parents or guardians. b. the results of medical examinations and tests may be disclosed to the requesting organization in situations pertaining to patient security, employment, insurance issues and legal competency. c. patients’ individual profile should not be disclosed in medical research. 10 which option is true about confidentiality? a. the physician should not disclose information about a patient who is considering suicide or homicide. b. the results of examinations and medical consultations are confidential, except in legal cases. c. members of the medical staff who are not directly involved in the treatment process are allowed to access patient information. 1 number of question in the questionnaire j med ethics hist med 11: 1, february, 2018 jmehm.tums.ac.ir mohammad mohammadi et al. page 5 of 7 finally, in response to the question of whether male physicians should be allowed to perform physical examinations on female patients, 81 patients (40.5%) answered that they should, where it was a matter of saving lives. it may therefore be concluded that they had a good level of awareness in this regard. the mean of the acquired score in the ‘awareness’ part was 4.61 ± 1.63 out of 10, and the median was 4. table 4 demonstrates the frequency distribution of the patients’ total awareness. table 4the frequency distribution of the patients’ total awareness % n awareness 21.0 42 poor 72.0 144 moderate 7.0 14 good no significant difference was found between the patients’ mean of awareness scores and variables including age, gender, marital status, place of residence, educational level, admission ward, frequency of hospitalization, and duration of hospital stay. the mean score of the postgraduate group (master’s degree) was the highest, and the greatest difference was observed between the two groups of illiterate and postgraduate patients (0.064). discussion in general, this study showed that patients had moderate awareness of privacy and confidentiality. it demonstrated that most of the patients provided a correct definition of privacy and confidentiality, but they were not aware of the more subtle instances of the two rights. most of the previous research on iranian patients has investigated their awareness of the patients’ rights charter, and none has specifically dealt with their awareness of privacy and confidentiality. in the study by parniyan et al. on 472 patients in two hospitals located in the city of jahrom during 2014, the mean score of patients’ knowledge of their rights was 15.99 ± 5.82 (out of 24 scores) (12). similarly, in a study by mastaneh and mouseli performed in two tertiary teaching hospitals affiliated with shiraz university of medical sciences during 2012, 30.5% of the patients had weak, 59.4% moderate, and 10.1% good awareness of their rights (7). a study by bateni et al. conducted on 385 patients in eight hospitals across the city of isfahan during 2006 showed that over 50% of patients were not aware of the patients' rights charter (13). regarding patients’ awareness of the concepts of privacy and confidentiality, our findings are consistent with the above-mentioned studies. an iranian study by emami razavi et al. performed on 70 medical assistants and 140 hospitalized patients from the emergency ward of imam khomeini hospital investigated observance of some provisions of the patients’ rights charter (including privacy and confidentiality). the results showed that 57.9% of the patients were not aware of their rights at all (14). findings of another iranian study conducted by mossadegh rad et al. on 160 patients showed that 40% of them have very poor, 41.9% poor, and 18.1% moderate awareness of patients’ rights (15). the findings of a study by yaghobian et al. on 336 patients from four teaching hospitals of sari in 2011 indicated that 58.9% of the patients had poor, 12% moderate, and 29.1% good knowledge about patients’ rights. the patients’ awareness about 'the right of privacy and confidentiality' and 'the right of confidentiality and the necessity of the patients’ permission for disclosure of information' were respectively 34.8% and 33.6% (16). another study conducted by hojjatoleslami and ghodsi on 416 inpatients in hamadan hospital indicated that 56.2% of the patients were not familiar with the patients’ rights charter, and only 29.3% were aware of it (17). zeina et al. in south egypt reported that 75.0% patients did not know about patients' rights (18). in turkey, kuzu et al. showed that few patients (9%) knew about their rights (19). the findings of these studies suggest that the level of the patients’ awareness of privacy and confidentiality was lower than that of the subjects in our study. on the contrary, a 2012 study in saudi arabia conducted by almoajel on 250 patients hospitalized in the country’s largest governmental hospital showed good awareness of confidentiality (80.3%) (20). similarly, in gonabad, basiri moghadam et al. showed in 2010 that only 5.6% of the patients had weak awareness, and most of the others had good awareness of the patients’ rights charter (21). in malaysia, a study by yousuf et al. on 250 hospitalized patients showed that 90.8% patients were aware of their rights, and almost all of them appreciated privacy and confidentiality (22). the ravaghi et al. study performed on 306 inpatients across three hospitals in tehran indicated that the level of patients’ awareness of the right to privacy and confidentiality was 68.6% (23). in these studies, the level of patients’ awareness about their rights was higher than that of our study. these studies have not clarified the cause of the high level of patients' awareness of their rights, and it is unclear whether patients had received training regarding these issues. in these studies, the right to privacy and confidentiality has been part of the research, but our study focused on privacy and confidentiality issues, which may be the main reason for the difference j med ethics hist med 11: 1, february, 2018 jmehm.tums.ac.ir mohammad mohammadi et al. page 6 of 7 between results. although the patients in our study were generally familiar with privacy and confidentiality, they were little aware of the more subtle instances of these rights. zulfikar and ulusoy believe that patients must first be aware of their own rights and responsibilities and then expect the physicians and nurses to observe them (24). according to our study, one-third of the patients did not assume the physician-patient relationship in the scope of privacy. therefore, it is necessary to keep patients informed and educate them to better perceive these issues. in their study in greece, merakou et al. stated that 94.2% of the patients responded negatively to the question of whether they had ever claimed their rights. they also stated that in order to respect the rights of patients, it is essential to establish ethics committees, hire lawyers and experts who are aware of patients’ rights in hospitals, provide patients with information about their rights, and familiarize them with the relevant new rules (10). in another study in the uk in which 30 patients were asked about confidentiality, all were in favor of physician confidentiality, and 83.0% demanded absolute confidentiality. however, in the case of child abuse, epileptic patients driving, drunk driving, etc., this percentage dropped to 69 (1). in the united states, fuzzell et al. showed that most patients concerned about their discussions to remain confidential and private (25). but our study showed that a little more than one third of the patients were aware of the right of privacy. based on our findings, although patients knew that those not directly involved in the treatment process must not attend patients’ bedside, most patients did not raise any objections against this situation. in australia, knowles and mcmahon found that the public is in favor of disclosing secrets in cases of child abuse or conspiracy, or when a patient confesses to murder, or intends to commit suicide or homicide (26). furthermore, our study showed that patients knew that the relevant authorities must be informed of cases of homicide or suicide. in addition, patients agreed that the information of mentally retarded patients should be provided to their parents. in consistence with the results of two review articles by joolaee (8) and abedi (9), our study showed that the level of patients' awareness about privacy and confidentiality is inadequate and has remained unchanged over recent years. conclusions based on the results and considering the patients’ weak or moderate awareness of privacy and confidentiality, it is the ethical and professional responsibility of the medical professionals to train and observe confidentiality and privacy issues, and thereby promote the observance of patients’ rights. in addition, it is necessary that both healthcare providers and recipients be informed about these issues. in terms of patients’ awareness, education may be provided upon admission or at any other appropriate time via provision of oral explanation as well as written media such as pamphlets, brochures, booklets, etc. health policy makers should develop and implement a plan for raising patients’ awareness of privacy and confidentiality to improve physician-patient relationships. finally, much remains to be learned about strategies to improve patient's awareness of their rights, and it is necessary to conduct further studies with a focus on the impact of interventions in this regard. acknowledgements the present study was part of a thesis submitted by the first author for a master's degree in public health and was funded by tehran university of medical sciences. the authors are grateful to all the patients for their valuable participation in this study, and would also like to thank ms. fahime baradaran eftekhari in particular for her support. we would like to express our gratitude to the technical support staff of tehran university of medical sciences. we gratefully acknowledge the contribution of ms. m. hassanpour in giving her critical comments and revising the manuscript. conflict of interests all authors declare that they have no significant competing financial, professional, or personal interests that might have influenced the performance or presentation of the work described in the manuscript. j med ethics hist med 11: 1, february, 2018 jmehm.tums.ac.ir mohammad mohammadi et al. page 7 of 7 references 1. jones c. the utilitarian argument for medical confidentiality: a pilot study of patients' views. j med ethics. 2003; 29(6): 348-52. 2. parsapoor a, bagheri a, larijani b. patient's rights charter in iran. acta med iran. 2014; 52(1): 24. 3. anonymous. privacy and confidentiality.http://ccnmtl.columbia.edu/projects/cire/pac/foundation/#1. 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[in persian] 22. yousuf rm, fauzi ar, how sh, akter sf, shah a. hospitalised patients' awareness of their rights: a crosssectional survey from a tertiary care hospital on the east coast of peninsular malaysia. singapore medical journal. 2009; 50(5):494-9. 23. ravaghi h, gohari m, adham marellelu d, et al. assessing the inpatients awareness from patients’ rights and their satisfaction from observance of that rights in the general-educational hospitals of tehran university of medical sciences. j health. 2016; 7(1): 26-34. [in persian] 24. zulfikar f, ulusoy mf. are patients aware of their rights? a turkish study. nurs ethics. 2001; 8(6): 487-98. 25. fuzzell l, fedesco hn, alexander sc, fortenberry jd, shields cg. "i just think that doctors need to ask more questions": sexual minority and majority adolescents' experiences talking about sexuality with healthcare providers. patient education and counseling journal. 2016; 99(9): 1467-72. 26. knowles ad, mcmahon m. expectations and preferences regarding confidentiality in the psychologist‐client relationship. aust psychol. 1995; 30(3): 175-8. http://ccnmtl.columbia.edu/projects/cire/pac/foundation/#1 hhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh copyright © 2022 tehran university of medical sciences. this work is licensed under a creative commons attribution-non commercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. original article abstract role modeling is one of the most influential components of teaching professional behaviors to nursing students. the role model apperception tool (romat) was designed in the netherlands to measure role modeling behaviors in clinical educators. the aim of this study was assess the psychometrics of the persian version of this tool. in a methodological study, the persian version of the romat tool was developed using the forward-backward translation method. face validity was confirmed through cognitive interviews, and content validity was done by a panel of 12 experts. construct validity was assessed through exploratory factor analysis (n = 200), and confirmatory factor analysis (n = 142) was evaluated after the tool was completed online by undergraduate nursing students. reliability was confirmed using internal consistency and test and retest methods. furthermore, ceiling and floor effects were assessed. *corresponding author tahereh nasrabadi address: headquarters building of islamic azad university of medical sciences of tehran, no. 16, west gol-e-gharbi, ayeneh blvd., shahid paberja, gholhak intersection, shariati st, tehran, iran. postal code: 1949635881 tel: (+98) 21 22 64 04 42 email: nasrabadi.t@iautmu.ac.ir received: 30 dec 2021 accepted: 1 aug 2022 published: 25 oct 2022 citation to this article: azadian m, nasrabadi t, ebadi a, mokhtari nouri j. translation and psychometric evaluation of the persian version of the role model apperception tool (romat) in undergraduate nursing students. j med ethics hist med. 2022; 15: 5. the two components of "professional competencies" and "leadership competencies" emerged with a cumulative variance of 62.01%, a reliability with cronbach's alpha of 0.93 and 0.83, and an intraclass correlation of 0.9 and 0.78, respectively. it was concluded that the persian version of the role model apperception tool is a valid and reliable tool and can be used to investigate the role modeling behaviors of clinical instructors of nursing students. keywords: role modeling; nursing student; psychometric properties. translation and psychometric evaluation of the persian version of the role model apperception tool (romat) in undergraduate nursing students 1. phd candidate of nursing, department of nursing, faculty of nursing and midwifery, tehran medical science, islamic azad university, tehran, iran; instructor, department of nursing, firoozabad branch, islamic azad university, firoozabad, iran. 2. associate professor, department of nursing, faculty of nursing and midwifery, tehran medical science, islamic azad university, tehran, iran. 3. professor, behavioral sciences research center, life style institute, baqiyatallah university of medical sciences, tehran, iran; nursing faculty, baqiyatallah university of medical sciences, tehran, iran. 4. professor, quran and hadith research center, nursing faculty, baqiyatallah university of medical sciences, tehran, iran. marzieh azadian 1, tahereh nasrabadi 2*, abbas ebadi3, jamileh mokhtari nouri 4 mailto:nasrabadi.t@iautmu.ac.ir translation and psychometric evaluation of the persian version of the role model apperception tool … j. med. ethics. hist. med. 2022 (oct); 15: 5. 2 introduction the main purpose of nursing education is to train qualified nurses who have the necessary knowledge and skills to maintain and improve the quality of care provided to patients (1). training can immensely affect job productivity, job satisfaction, job motivation, promotion and personal growth, and therefore it is very important to ensure monitoring and assessment in order to apply quality training measures to the evaluation process (2). among the characteristics of an effective clinical instructor are being a good, positive and, above all, functional role model (3). a role model is a person whose behavior is praised or imitated by others, and this process is known as role modeling. in the educational context, role modeling is a unique teaching method for transferring knowledge, skills and values of the medical profession as well as promoting academic achievements (4). jenkins et al. stated in their research that the term role modeling was first coined by sociologist merton in a 1950 study of the socialization of medical students. people compare themselves to a reference group (5, 6). horsburgh and ippolito used bandura’s theory of social learning to study the process of learning from role models in clinical settings. in his study, he stated that role modeling relies mainly on imitation and observation, which is one of the basic tenets of bandura's social learning theory. according to proponents of the social learning theory, the most important type of human learning is observational learning, and it can be concluded that learning from role models in clinical environments is a very challenging process (7). in a qualitative study of spirituality-based education by role model nursing educators, mokhtari nouri et al. acknowledged that role modeling is a method that is based on modeling and providing basic and practical examples. in this method, the teacher tries to initiate appropriate behavior from the learner's perspective in order to create the necessary conditions for modeling and imitation of his/her role (2). the findings of khan et al.'s study showed that interestingly, clinical educators are not always aware of the role modeling process and there is a risk of transmitting negative behavior. therefore, the instructor’s awareness of the process will result in improved role modeling behavior (8). many studies have been done on the importance of role models in nursing education, including qualitative research by mokhtari nouri et al. on the azadian m., et al. 3 j. med. ethics. hist. med. 2022 (oct); 15: 5. experiences of role model instructors and nursing students about the facilitating factors of the role modeling process. according to this study, role modeling is among the most important functions of nursing teachers and a sign of professional competency. being a role model is one of the 12 essential roles of a teacher (9). nursing educators believe that the role modeling teaching method is the most effective approach to developing students' experiences and professional attitudes in clinical settings. role models not only teach professional thinking, behaviors and attitudes, but also facilitate the development of learner beliefs and practices, which will increase the quality of care in the future. it is believed that the development of students' skills and self-confidence in the field of nursing is influenced by having good role model teachers (10). role modeling is an important strategy in the learning process of nursing students. the existence of qualified role model instructors is essential to improving the nursing profession, and being one is a sign of competency and successful education (3). to reinforce this behavior, we need to be able to measure it properly. the role model apperception tool (romat) was developed and its psychometric properties were examined in 2012 in the netherlands by jochemsen-van der leeuw et al. (11). also, the psychometric properties of the tool were assessed among clinical instructors of general practitioners and residents in the netherlands (12, 13). this tool includes the features of positive role modeling, obtained from a systematic review in order to distinguish between positive and negative role modeling and to evaluate the performance of clinical instructors in this regard. romat consists of 17 items obtained on a 5-point likert scale and is divided into two components: "caring attitude" and "effectiveness". both components contain an equal number of items that are related to personal, educational and clinical characteristics, and very high reliability (11). hosseini m. et al. (2022) citing the research of cook dr and hatala r (2016) et al. found the use of valid and reliable tools in studies to be effective in increasing confidence in research results, and mention limited resources and the amount of time and money spent on research as another reason to support this view. it is important, however, to ensure that the tools are valid, reliable and trustworthy (14, 15). romat is a tool that takes less than 5 minutes to complete, but it has not been translated into persian and its psychometric properties have not been examined in iran so far, although in previous studies, samples of this tool have been given to general medical interns and residents. since role model clinical instructors of translation and psychometric evaluation of the persian version of the role model apperception tool … j. med. ethics. hist. med. 2022 (oct); 15: 5. 4 undergraduate nursing students play an essential part in the nursing profession and providing care to patients, this study was carried out with the aim of translating and examining the psychometric properties of the role model apperception tool among nursing students in iran. methods this is a methodological study conducted from march to may 2020. attempts were made to select universities with greater geographical dispersion in order to access the maximum variety of samples. participants consisted of 342 undergraduate nursing students studying at the islamic azad university of medical sciences in tehran and nursing schools affiliated to the islamic azad universities of fars province, bandar abbas and shirvan, selected via convenience sampling and based on inclusion criteria. the inclusion criteria were: being third semester nursing students or above, and having the willingness to participate in the study. introduction of the tool the main tool used in the present study was the role model apperception tool (romat), designed in 2011 by joachmson, a general practitioner and ph.d. student at amsterdam university of medical sciences in the netherlands, based on a systematic review study in consultation with medical education experts and clinical instructors and trainees (11). the tool consists of a 5-point likert scale with 17 items and responses ranging from "strongly disagree" to "strongly agree", assigned a score of 1 to 5, respectively, with a higher score indicating more agreement (13). this tool was accompanied by demographic questions on gender, age, marital status, semester, place of residence, and name of the university, distributed among the participants in the final stage of the research. in most studies, the guidelines of the world health organization are used in order to translate and psychometrically evaluate the research tools, which was also the case in the present study. implementation of this method includes the following steps: forward translation, expert panel back-translation, pre-testing and cognitive interviewing, and final version. first, romat was translated into persian using the forward-backward translation method (16 20). the developer obtained permission to use and translate romat via email correspondence, which was done by two translators, one of whom was a translator of general texts and the other a professional translator of medical texts. after comparing the translations, the questions were matched in terms of meaning and azadian m., et al. 5 j. med. ethics. hist. med. 2022 (oct); 15: 5. content and the most appropriate options were chosen, and finally a persian version of this tool was developed. the original translation was then translated into english by two other professional english translators to ensure that the persian translation matched the original text and that the persian sentences were accessible. after comparing the english versions and making the necessary corrections, the final version of the english questionnaire was developed. the tool was then sent to the original designer, who made suggestions regarding items 5, 7, 8 and 13. corrections were made accordingly, and the final persian version of the tool was developed. validity face validity: for a preliminary assessment of the comprehensibility of items, the persian version of the questionnaire was delivered to 10 sophomore and junior students. they were asked for their ideas on legibility, writing style and grammar, clarity, spelling, and ease of completion of the tool. the completed questionnaires were reviewed, and two ambiguous items were modified. content validity: in order to determine the content validity, the tool was examined both qualitatively and quantitatively. with regard to the qualitative evaluation, 8 experts specialized in psychometrics were asked to examine the tool and offer recommendations on appropriate wording in terms of grammar, cultural relevance, validity of translation and semantic convergence, and to provide the necessary feedback on the modifications they had made. in order to quantitatively evaluate the tool, the content validity ratio was used and 12 experts were asked to rate each phrase based on a three-part spectrum of "necessary", "useful but not necessary" and "not necessary", and the expressions were accepted according to the lawshe table (21) item analysis after confirmation of face and content validity, a pretest was performed. at this stage, the instrument was completed by 30 undergraduate nursing students. internal consistency was measured by calculating the cronbach's alpha coefficient as well as inter-item correlation to determine which items needed to be removed because they did not correlate with other items and the whole tool. following the loop method, it was established that each item was correlated with the sum of other items. it is expected that the correlation of each item with the total score be more than 0.3, and at least each item with the other two items is more than 0.3 (22). structural validity: with regard to factor analysis, the minimum sample size required for each translation and psychometric evaluation of the persian version of the role model apperception tool … j. med. ethics. hist. med. 2022 (oct); 15: 5. 6 subscale was determined at 5 to 10 people. for exploratory factor analysis (efa) 200 undergraduate nursing students were included in the study and the principal component analysis test with promax rotation was used. munro recommended 20 to 30 samples per factor, therefore for confirmatory factor analysis (cfa), 142 students were evaluated after completing the tool online (23). in general, the indicators that are used to check the fit of the model are divided into three general categories: 1) absolute fit: the root mean square error of approximation (rmsea), standardized root mean square residual (srmr), goodness-of-fit index (gfi), and chi-square; 2) comparative fit: comparative fit index (cfi), relative fit index (rfi), normed fit index (nfi), and tucker-lewis index (tli); 3) affordable fit: parsimonious normed-fit index (pnfi), adjusted goodness-of-fit index (agfi), which is commonly used in determining fit in confirmatory factor analysis (24). in order to evaluate the sampling adequacy, kmo1 test and bts2 test were used to examine the inter-item correlation matrix (22). reliability 1 kaiser-mayer-olkin of sampling adequacy we used internal consistency (cronbach's alpha) to ensure the reliability of the questionnaire, and the test-retest method to evaluate the relative and absolute stability. the intra-class correlation coefficient (iccc) was implemented to assess relative stability with standard error of measurement (25). in order to assess repeatability, the test-retest method was used where 30 students were asked to complete the persian version of the questionnaire within a two-week interval. an index between 0.7 and 0.8 indicated a desirable degree of stability (26). floor or ceiling effect (minimum and maximum percentage scores): this effect occurs when more than 15% of respondents get either the highest or the lowest achievable score (22) . in order to analyze the data, spss statistical software version 16 and lisrel 8.8 were used. ethical considerations first, a written permission was obtained from the main designer of romat, and then the ethical code ir.iau.ps.rec.1399.283 was received from the ethics committee of tehran azad university of medical sciences. written informed consent was obtained from all participants, and they were reminded that participation in the study was 2 bartlett’s test of sphericity azadian m., et al. 7 j. med. ethics. hist. med. 2022 (oct); 15: 5. voluntary and that their information would remain private. the tool was delivered to the participants virtually using the porsline application, and all participants received a link to the tool and were assured that their information would be kept confidential. results the majority (67.9%) of the participants were female, the oldest being 21 to 22 years of age, and most were in the 6th semester (38.2%). a detailed description of other demographic characteristics of the subjects are shown in table 1. in the first phase, the romat questionnaire was completed by 30 nursing students, and an analysis of 17 items yielded a cronbach's alpha of 0.92, which is very good. table 2 shows the cronbach's alpha for each item, if the item was removed. since cronbach's alpha for all items was less than the total cronbach's alpha, the items in this tool were retained. face and content validity due to simplicity and clarity of the items, no changes were made in terms of face validity, and as for content validity, only two words were altered. the content validity index (cvi) for the items of the tool was evaluated by 12 experts, and all items that had a value greater than 0.79 were accepted (21). therefore, all items entered the next phase of the study. construct validity exploratory factor analysis (efa): in the present study, the kmo test result of the scale was 0.959, which is at a favorable level, and bts result was 3823.805, which is statistically significant (p = 0.000). all items had a factor loading greater than 0.3. the tool consists of 17 items in a 5-point likert scale, and as figure 1 shows, two components were extracted: “professional competencies” (12 items: 4, 6, 5, 10, 1, 16, 8, 17, 2, 7, 3 and 12), and “leadership competencies” (5 items: 15, 14, 11, 9 and 13) with eigenvalues of 9.5 and 1.02, respectively. some leadership competencies included: being aware of the status of one's role model, having leadership qualities, having selfconfidence, having positive interaction with other health-care team members, being honest and having integrity. the rest of the items including teaching, personal and clinical characteristics were placed under the component of “professional competencies”, with responses ranging from “strongly agree” to “strongly disagree”. the results are shown in table 3. confirmatory factor analysis (cfa): as shown in table 4 and figure 2, the goodness-of-fit index values of the final model and the fit of 17 items are translation and psychometric evaluation of the persian version of the role model apperception tool … j. med. ethics. hist. med. 2022 (oct); 15: 5. 8 good. the results showed that cfa based on the two-component model extracted from efa with the obtained data also has a good fit. reliability cronbach's alpha coefficient for all items of the romat tool was 0.92. in order to measure the stability of the instrument, the total intra-class correlation coefficient was calculated as 0.89 in a range of 0.95 0.76, which is within the acceptable limit and indicates that if the instrument is used at different times, the same results will be obtained (table 5). as table 6 shows, the correlation between component 1 and 2 is 0.798, while the correlation between component 1 and the total score is 0.985, and the correlation between component 2 and the total score is 0.891, which indicates a high correlation. in addition, the ceiling and floor effects were good and acceptable since the floor effect was 0.3% and the ceiling effect was 5.3%, which are both below 15%. table 1. distribution of the demographic characteristics of the participants (n = 342) variable n % gender (missing: 10) female 233 67.9 male 100 29.2 university (missing: 10) fars 200 58.4 tehran 65 19 shirvan 18 5.2 bandar abbas 50 14.6 age (missing: 21) 19 37 mean: 22.38 standard deviation: 2.46 semester (missing: 20) 3 8 mean: 5.5 standard deviation: 1.4297 table 2. item analysis item corrected item-total correlation cronbach’s alpha if the item was deleted q1 0.817 0.911 q2 0.698 0.915 q3 0.496 0.920 q4 0.763 0.913 q5 0.465 0.920 q6 0.582 0.918 q7 0.685 0.915 q8 0.685 0.915 q9 0.678 0.915 q10 0.644 0.916 q11 0.611 0.917 q12 0.541 0.919 q13 0.333 0.923 q14 0.651 0.916 q15 0.404 0.924 q16 0.622 0.917 q17 0.807 0.912 azadian m., et al. 9 j. med. ethics. hist. med. 2022 (oct); 15: 5. table 3. structural validity of the persian version of the professional and leadership competencies components items factor loading % variance eigenvalue professional competencies 4. understands learners’ needs and is committed to the growth of learners 0.97 56 9.5 6. has a positive attitude toward learners 0.94 5. establishes rapport with learners 0.88 10. makes learning exciting and stimulating 0.86 1. has excellent clinical reasoning skills 0.75 16. is nice and easy to work with 0.72 8. is patient 0.69 17. is professionally competent in difficult clinical situations and able to cope with adversity 0.56 2. conveys empathy to patients 0.52 7. demonstrates enthusiasm for his/her work 0.51 3. communicates well with patients and their relatives 0.45 12. is available for learners 0.44 leadership competencies 15. is aware of his/her role model status 0.96 6.02 1.02 14. has leadership qualities 0.79 11. has self-confidence 0.72 9. has a positive interaction with other health-care workers 0.51 13. is honest and has integrity 0.42 figure 1. scree plot for the romat scale translation and psychometric evaluation of the persian version of the role model apperception tool … j. med. ethics. hist. med. 2022 (oct); 15: 5. 10 table 4. goodness of fit indicators of confirmatory factor analysis of a 17-item romat name and index abbreviation for goodness of fit normal limit for goodness of fit results in the present study (x2) p-value (chi-squared p-value) > 0.05 397.80 (p = 0.0) rmsea (root mean square error of approximation) good < 0.08, medium < 0.08 to 0.1, poor < 0.1 0.084 srmr (standardized root mean square residual) < 0.1 0.043 pnfi (parsimonious normed-fit index) > 0.5 0.84 nfi (normed-fit index) > 0.9 0.97 agfi (adjusted goodness-of-fit index) > 0.8 0.84 gfi (goodness-of fit index) > 0.9 0.88 rfi (relative fit index) > 0.9 0.97 tli (tucker-lewis index) > 0.9 0.98 cfi (comparative fit index) > 0.9 0.98 cmin/df (minimum discrepancy function divided by degree of freedom) good < 3, acceptable < 5 3.1 figure 2. confirmatory factor analysis results of the main components of “professional competencies” and “leadership competencies” azadian m., et al. 11 j. med. ethics. hist. med. 2022 (oct); 15: 5. table 5. the internal consistency and relative and absolute reliability components components mean (standard deviation) cronbach's alpha intraclass correlation coefficient (icc) confidence interval standard error of measurement (sem) 1 professional competencies (12 items) 43.2 (6.5) 0.93 0.90 0.77 0.95 2.08 2 leadership competencies (5 items) 20.11 (2.8) 0.83 0.78 0.52 0.90 1.31 total 67.21 (9.7) 0.95 0.89 0.76 0.95 3.21 table 6. pearson’s correlation between factors and the total score component 1 component 2 total component 1 1 0.798 0.985 component 2 0.798 1 0.891 discussion the present study was the first attempt to psychometrically evaluate the persian translation of jochemsen’s romat tool among nursing undergraduate students, with focus on the rolemodeling of their clinical instructors. the findings showed that the persian version of the role model apperception tool enjoys high validity and reliability, as well as internal correlation and construct validity. after factor analysis of a total of 17 items of the role model apperception tool (romat), two components emerged: "professional competencies" and "leadership competencies", with a cronbach's alpha of 0.93 and 0.83, respectively, and a total cronbach's alpha of 0.95. jochemsen et al. designed this tool in the netherlands and assessed its psychometric properties with clinical instructors of medical students, and came up with two components of "caring attitude" and "effectiveness" with high reliabilities of 0.92 and 0.84, respectively (11). also, said et al used this tool online on first to last year medical residents with focus on their role model clinical instructors, and the same two components of "caring attitude" and "effectiveness" emerged with a cronbach's alpha of 0.940 and 0.93, respectively (27). it must be added that the present study had high reliability, which confirms the repeatability of this tool. translation and psychometric evaluation of the persian version of the role model apperception tool … j. med. ethics. hist. med. 2022 (oct); 15: 5. 12 in the present study, "professional competency" is primarily about the clinical instructor's relationships and interactions with students, and then his/her teaching skills and personality traits, and finally his/her interactions with patients and their relatives. in contrast to “leadership competency”, “professional competency” includes awareness of being a role model, leadership characteristics of the clinical instructor, good interaction with staff and positive moral qualities. “professional competency” had a higher variance compared to “leadership competency”, which, as discussed elsewhere, shows that from the perspective of iranian undergraduate nursing students, the most important component of the role model clinical instructor is having a positive interaction with the students, and the other traits come next in their order of preference. however, in jochmsen et al.’s study, equal amounts of items were allocated to personality traits (heart), teaching (head) and clinical (hand) skills, and therefore, it determined the competency in the form of (3 hs), indicating the positive role modeling conditions. although this tool was designed to identify role model instructors, the characteristics of students were also influential in the process as shown in other studies. there was a significant difference between students with more experience and caring attitude score, thus, beginning trainees tended to focus on the personal characteristics of their clinical mentors and the learning environment, while more experienced trainees tended to focus on the professional competence and teaching skills of their clinical mentors. however, novice trainees' greater attention to personal characteristics did not fully explain the higher caring attitude scores these trainees assigned to their mentors. (11). in the study by said et al. the component of "caring attitude" covers a set of items including the relationship between clinical instructors and patients, residents and others. the component of "effectiveness" is a set of items related to the ability of the clinical instructors to meet the needs of patients and residents (27). this issue highlights the importance of the good rapport the nursing students expect from their clinical instructors. moreover, in this tool, the student's personality traits should also be taken into account. as shown in the review study by mohammadi et al. there are three main issues with regard to improving role modeling in clinical educators: 1) the characteristics of a good role model, consisting of educational, clinical and interpersonal skills, 2) self-improvement role modeling, and 3) faculty development programs (28). in the study by vohra et al. interviews with students and general azadian m., et al. 13 j. med. ethics. hist. med. 2022 (oct); 15: 5. practitioners showed that role models were the key factor influencing the participants’ lived experiences and personal relationships with people, and had a lasting effect on their choice of specialty (29). therefore, clinical instructors should develop teaching, clinical and communication skills in themselves, because the improvement of these skills helps in the improvement of the "leadership competencies" component. reid and alberti consider role modeling as an important part of the informal curriculum in leadership learning, stating that the fallibility (admitting one's own mistakes and errors) of leaders can have a positive effect on learning (30). naturally, leadership competency is influenced by the policies formulated by relevant organizations and universities. perhaps one of the reasons why this component is more prominent in iran is that the development of leadership competency characteristics as well as modeling are possible through an exemplary role modeling of a clinical instructor, but this component has not been reflected in other studies. in the study by said et al. the psychometrics of romat yielded a low internal correlation, which they believed was probably due to the similarity of the responses (27). on the contrary, in the present study, a good internal correlation of the instrument was obtained, because students completing the questionnaire were from different iranian universities. in our study, item 1 had a high correlation with item 17 (0.82), indicating that from the perspective of the students, item 1 (has excellent clinical reasoning skills) and item 17 (is professionally competent in difficult clinical situations and able to cope with adversity) mean the same; nevertheless, both items were retained. in the study by said et al. items 7 and 17 both referred to the same component, with item 17 falling under the component of "caring attitude" (27), while in the initial study of this tool it was related to the "effectiveness" component. (11) however, in the present study, items 17 and 1 were part of the "professional competencies" component, which indicates that item 17 is mainly influenced by students' personal opinion of their clinical instructor, and also the "professional competencies" component had more weight than “leadership competencies”. professionalism training is not the same as transferring a technical clinical set of skills, and professionalism is transmitted to health-care students during their course of study (31). in a systematic review study of the impact of role modeling on the future work of general practitioners, lamb et al. found role modeling to be very important in medical education, and also very effective on the future translation and psychometric evaluation of the persian version of the role model apperception tool … j. med. ethics. hist. med. 2022 (oct); 15: 5. 14 workforce of general practitioners in both primary and secondary care. an arrangement that has the potential to shape perceptions, attract or deter people to or from the profession, and support their advancement as professionals is indeed very important (32). also the study by mackie and alberti showed that the role model general practitioner teacher and the experience of consulting patients promote a sense of efficacy in students, which will in turn inspire them to become the general practitioner of the future (33). therefore, clinical educators should pay attention to the fact that their professional behaviors are effectively observed and modeled by students, so the right techniques for transmitting professionalism should be used alongside leadership competency workshops. however, in other studies the "effectiveness" component was more important than the "caring attitude" component (27), which is probably due to the importance that nursing students and clinical instructors attach to clinical competency characteristics. therefore, professionalism is not a single skill, but a multidimensional competency that is built with many different components (34). probably due to the cultural, social and economic differences between iran and the netherlands, the components of the present study are different from those of the mentioned studies, while one other possible reason may be the samples of the previous two studies of medical students. they have been somewhat different in terms of educational planning in the clinical environment and the type of relationship with clinical educators. the clinical instructors’ awareness of their being role models promotes role modeling characteristics, and the present tool is helpful in this regard as well. in general, based on the findings of the present study, the persian version of the roamt enjoys an acceptable validity and reliability in the study population consisting of undergraduate nursing students. it should be added that one of the advantages of this tool is the small number of questions, which makes it a user friendly and efficient one. one limitation of this study was that the instrument was completed online, although previous studies showed no difference in evaluation of psychometric properties between paper-based and web-based administration of the tool (27). also, psychometric studies of this instrument have been performed only in the netherlands, which limited the comparison of findings. conclusion azadian m., et al. 15 j. med. ethics. hist. med. 2022 (oct); 15: 5. romat is a valid and reliable tool in examining the role modeling behaviors of clinical nursing instructors. academic managers such as vice chancellors for academic affairs and heads of departments can use romat to develop clinical instructors’ awareness of their position as role models. clinical instructors can also use romat to understand the dimensions of their professional behavior and try to improve them. acknowledgements we would like to thank all the undergraduate nursing students and their professors who helped us complete the questionnaires. conflict of interests the authors declared no conflicts of interest regarding the publication of the present article. references 1. mokhtari nouri j, ebadi a, alhani f, rejeh n, ahmadizadeh mj. qualitative study of humanization‐based nursing education focused on role modeling by instructors. nurs health sci. 2013;15(2):137-43. 2. mokhtari noori j, ebadi a, alhani f, rejeh n. spirituality-based education by role model nursing instructors: a qualitative study. iranian journal of medical ethics and history of medicine. 2013; 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educ prim care. 2021; 32(3): 149-56. 34. chawla n, singhal a, shaw sc. role modeling: a powerful tool to imbibe professionalism in medical practices. journal of marine medical society. 2022; 24:1-3. jmehm-11-8 journal of medical ethics and history of medicine original article public preferences and attitudes towards the disclosure of medical errors: a survey in iran akram heidari1, masoomeh razaghi2, fariba asghari3* 1assistant professor, spiritual health research center, qom university of medical sciences, qom, iran. 2researcher, spiritual health research center, qom university of medical sciences, qom, iran. 3associate professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. corresponding author: fariba asghari address: no. 23, 16 azar ave, tehran, iran. email: fasghari@tums.ac.ir tel: (+98) 21 66 44 96 61 received: 28 nov 2017 accepted: 24 jul 2018 published: 4 aug 2018 j med ethics hist med, 2018, 11: 8 © 2018 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract awareness of the occurrence of medical errors is the right of patients and duty of the health service providers. this study was conducted to evaluate to what extent people want to know the occurrence of an error in their medical care, what they expect to be disclosed about medical error, and what are the influential factors in filing a lawsuit against physicians in disclosed medical errors from their point of view. in this cross-sectional survey, 1062 people residing in the city of qom, iran, were telephone interviewed using the random digit dialing method. the questionnaire used consisted of 4 demographic questions and 2 scenarios of major and minor medical error; the participants were asked if the physician should disclose the error in each scenario. the questionnaire also consisted of 16 questions about other issues related to error disclosure. data were analyzed through descriptive and inferential statistics in spss software. about 99.1% of the study population believed that errors had to be disclosed to patients. they all wished to know that measures would be taken to prevent further errors. moreover, 93.1% of the participants expected an explanation on the incident. as for the factors that decreased the likelihood of taking legal action against the physician from the viewpoint of the study population, treatment of the complications (96.1%) and honesty of the physician (95.8%) had the highest frequency. based on the considerable preference of patients for error disclosure, it is recommended that physicians disclose all minor and major errors sympathetically and with transparency, honesty, and efforts to prevent future errors. keywords: medical error, disclosure, consumer preferences mailto:fasghari@tums.ac.ir j med ethics hist med 11: 8, august, 2018 jmehm.tums.ac.ir akram heidari et al. page 2 of 6 introduction medical errors jeopardize the safety of patients (1). evidence suggests that medical errors are of paramount significance in the quality control of health care (2, 3). in line with patient autonomy, awareness of the occurrence of medical errors is the right of patients and a duty of health service providers. lack of error disclosure is patient deception and results in mistrust to medical staff. regarding error disclosure, there is a considerable gap between what the patients expect and what physicians do (4). studies have shown that people have a great desire to learn about medical errors (58). in a study by mazor et al., 98.8% of the participants wished to learn about medical errors (9); hobgood et al. reported this rate as 99% (10) and 76% (11) in their studies. this rate was 89% in the study by ushie et al. (8). in the study by matlow et al., all parents stated that they would like to be informed of the error and 77% of them reported that they would also like their child to be informed (6). despite the great desire of the patients to have information on medical errors, physicians are not very interested in error disclosure (12-15). a study by ghalandarpoorattar et al. showed that only 16.7% of the studied surgeons had admitted their last medical error to their patients (16). in a study by loren et al., only 53% of pediatricians and pediatric fellows declared that they would definitely admit their mistakes to patients (17). physicians have different reasons for avoiding error disclosure. according to studies, the most important obstacles to error disclosure are legal complaints by patients, concerns regarding patients’ trust, fear of losing their professional reputation, and inadequate education (16, 18, 19). since one of the greatest concerns of physicians regarding error disclosure is legal complaints of the patients, it is necessary to evaluate if error disclosure is correlated with legal complaints against physicians, which factors are related to higher likelihood of a formal complaint by patients, and the information that patients wish to acquire when an error occurs in order to maintain their trust and confidence in their physician. this study was conducted to evaluate to what extent people want to know the occurrence of an error in their medical care, what they expect to be disclosed about medical errors, and what factors are related to filing a lawsuit against physicians in disclosed medical errors. method this study was a cross-sectional survey. the study population consisted of individuals residing in the city of qom, iran. the sample size was estimated at 1024 individuals for α = 0.05, p = 0.60, and d = 0.03. thus, 1062 individuals were entered into the study. sampling was performed using the random digit dialing method. an internet software program was used to list random telephone numbers (randomnumbergenerator.intemodino.com/en/genera te-random-numbers.html). the inclusion criteria consisted of being older than 18 years of age, residency in qom, complete consciousness, and the ability and willingness to answer questions. for the random selection of the interviewees from among the family members, the person whose birthday was closer to the interview date was selected since this variable is independent of attitude and unrelated to other demographic variables such as gender and age (20, 21). all telephone interviews were conducted by one person between 6-9 pm. an average of 10 minutes was dedicated to each interview for every person (30 to 40 interviews per week). at the beginning of each interview, the operator introduced herself to the participants, explained the objectives of the project, and obtained an oral consent of participation to continue the study. the telephone numbers of non-residential places were excluded. the interviews were conducted from june 2013 to january 2014. the questionnaire used in this study contained 4 demographic questions (age, sex, educational level, and marital status), 1 question about whether the participants, their family members, or relatives had experienced any medical errors, 2 scenarios, and 17 questions about other issues related to error disclosure. the first scenario was constructed on a minor medical error (with limited and controlled adverse effects on the patients) and the second on a major medical error [which resulted in injury and intensive care unit (icu) admission], and the participants were asked whether the physician should disclose the error to patients in each situation (table 1). table 1the two scenarios suggested in the questionnaire minor error scenario: you are admitted to the hospital. the physician prescribes insulin for elevated blood glucose levels, but makes a mistake in the prescribed dose. due to receiving excess insulin, your blood sugar drops and you faint. the physician administers an intravenous sugar solution and you feel better after one hour. major error scenario: you are hospitalized. you go into shock due to the injection of the wrong medicine and require a few extra days of icu admission after resuscitation. in addition, 14 questions were asked on the attitude j med ethics hist med 11: 8, august, 2018 jmehm.tums.ac.ir akram heidari et al. page 3 of 6 of the patients; 7 questions were related to components of the expected information when disclosing an error and 7 questions addressed the factors that increased or decreased the likelihood of pressing charges against the physician. moreover, 3 questions were asked to evaluate the possibility of pardoning or taking legal action against the physician in case of the self-disclosure of the medical error, possibility of terminating the physician-patient relationship in case of selfdisclosure, and the possibility of pardoning or taking legal action against the physician in case of error disclosure by a colleague. the questionnaire was designed by the authors based on a review of the relevant literatures. the psychometrics of the questions was reviewed by 3 medical ethics experts using a qualitative method. the face and content validity of the questions and the comprehensiveness of the questionnaire for the study objectives were confirmed after a few revisions. to enhance the clarity of the questions, a pilot study was conducted on 10 individuals. the reliability of the questionnaire was evaluated using the test-retest method on 30 participants with a 1week interval. the cohen's kappa coefficient of the questions ranged between 0.87 and 1. the data were analyzed using descriptive (frequency, mean, and standard deviation) and inferential statistics (pearson coefficient, chi-square test, fisher's exact test, and odds ratio) in spss software (version 20, ibm corporation, armonk, ny, usa). all p values < 0.05 were considered significance. this study was approved by the ethics committee of qom university of medical sciences, iran. results of the 1327 individuals contacted through telephone calls, 1062 individuals participated in the study (rr = 80%), among which 786 (74.2%) were women. the mean age of the study population was 35.20 ± 11.24 years (range: 18-75 years) (table 2). among the study population, 229 (21.6%) stated that they, their family members, or their relatives had experienced medical errors. among the study population, 99.1% expressed their preferences for error disclosure; 962 (90.6%) and 1055 individuals (99.5%) reported their preferences for error disclosure in the minor error scenario and the major error scenario, respectively. table 3 presents the required components of medical error disclosure and table 4 shows the likelihood of taking legal action against physicians in case of error disclosure from the people’s point of view. the results showed that error disclosure by the physician compared to error disclosure by another physician had lower possibility of formal complaints (or = 2.87, ci = 2.22-3.70) (p < 0.0001). table 2the frequency of demographic variables in the study population variables number % age groups (year) ≤ 20 51 4.8 21-30 394 37.1 31-40 345 32.5 41-50 161 15.2 51-60 83 7.8 > 60 27 2.5 total 1061 100 education illiterate 36 3.4 reading and writing 14 1.3 elementary school 199 18.8 middle school 162 15.3 high school 365 34.5 academic education 283 26.7 total 1059 100 marital status married 893 84.2 single 143 13.5 divorced 2 0.2 widowed 22 2.1 total 1060 100 table 3the required components of medical error disclosure component yes n (%) no n (%) total n (%) measures to prevent further errors 1050 (99.7) 3 (0.3) 1053 (100) disclosing the cause of error 1042 (98.1) 20 (1.9) 1062 (100) disclosing what exactly happened 989 (93.1) 73 (6.9) 1062 (100) compensation for injury 745 (70.2) 317 (29.8) 1062 (100) expressing regret and apology 713 (67.2) 348 (32.8) 1061 (100) table 4the frequency of the likelihood of taking legal action against physicians in case of medical error disclosure from the viewpoint of the study population condition forgive n (%) legal action n (%) it depends n (%) total n (%) error disclosure by physician 544 (51.3) 113 (10.7) 403 (38) 1060 (100) error disclosure by another physician 431 (40.7) 257 (24.2) 372 (35.1) 1060 (100) in the present study, 386 participants (36.4%) stated that they would continue their treatment course with j med ethics hist med 11: 8, august, 2018 jmehm.tums.ac.ir akram heidari et al. page 4 of 6 the physician who made the error while 517 individuals (48.8%) stated that they would change their physician. the rest of the participants (n = 157, 14.8%) said that their decision depended on various factors. as for the factors that reversely correlate with the likelihood of legal action against the physician, compensation for the error and treatment of the complications and honesty had the highest frequency (table 5). table 5factors affecting the likelihood of taking legal action against physicians in case of medical errors from the viewpoint of the study population factor increased the likelihood of taking legal action n (%) no effect n (%) lowered the likelihood of taking legal action n (%) total n (%) error compensation and treatment of complications 3 (0.3) 38 (3.6) 1010 (96.1) 1051 (100) honesty and truthfulness of the physician 2 (0.2) 43 (4) 1017 (95.8) 1062 (100) physician’s compassionate communication 1 (0.1) 242 (22.8) 818 (77.1) 1062 (100) physician’s apology 8 (0.8) 311 (29.2) 743 (70) 1062 (100) informed about error by another person 330 (31.1) 621 (58.5) 111 (10.5) 1062 (100) high cost of treatment 782 (73.6) 242 (22.8) 38 (3.6) 1062 (100) severity of complications 899 (84.6) 128 (12.1) 35 (3.3) 1062 (100) the participants who reported that they, their family members, or their relatives have experienced medical errors believed that the physician should undertake error disclosure about minor medical errors significantly more than other participants (94.8% versus 89.4%) (p < 0.05). the effect of the history of exposure to medical error on the attitude of the participants regarding the factors changing the likelihood of taking legal action from their point of view was only significant regarding the severity of the complication. about 90.4% of the participants with a history of exposure to medical errors believed that the severity of the complications increased the likelihood of taking legal action against the physician while 83.1% of the participants with a negative history of exposure were of this opinion (or = 1.92, ci = 1.19 to 3.08) (p < 0.05). discussion honest and complete disclosure of the medical error is a sign of the physicians’ respect for patient autonomy, respect for the patients, and effort to maintain their trust. in line with other studies, the results of the present study showed that people wish to know about the occurrence of medical errors (6, 811). the most important aspect of error disclosure to the participants, besides knowing what has happened and its cause, was that error would lead to measures to prevent further errors as it made them believe that the harm or suffering had a valuable effect on the improvement of patient care. the present study showed that the participants believed that people had lower tendency toward filing a complaint if the physician disclosed his/her error compared to error disclosure by another physician. however, the results revealed that the participants believed that learning about medical errors from another physician had no effect on the likelihood of legal action (table 5), while they believed that it was the physician’s honesty that lowered its likelihood. in the study by coffey et al., participants believed that transparency in error occurrence could rebuild trust in the patientphysician relationship (5). despite the fact that physicians are concerned with legal action upon error disclosure, the results of the study showed that people had a tendency to receive the truth from the physician in a compassionate way, and honesty and error compensation decreased their tendency to take legal action. in addition to the efforts to decrease physical and mental injuries resulting from the error, people believe that the physician’s sympathy and honesty help to maintain a good relationship with the patient which lowers the likelihood of legal actions. a study by mazor et al. also showed that full disclosure of medical error decreased the reported likelihood of changing physicians and increased the satisfaction, trust, and positive psychological responses of the patients (9). in an experimental study by nazione and pace, the findings showed that empathy could reduce anger and complaint rate among participants (22). j med ethics hist med 11: 8, august, 2018 jmehm.tums.ac.ir akram heidari et al. page 5 of 6 many studies showed that people’s views were negative toward health care providers in cases in which the error caused a severe complication and patients were not informed about the error (8, 2325). cleopas et al. in their study found that slow and ineffective disclosure of the error makes a negative impression on patients (26). ushie et al. in their study showed that volunteer disclosure would significantly reduce the patient’s tendency toward taking legal action (8). medical idealism does not accept medical errors. it is therefore very painful to disclose medical errors, and thus, inability to satisfy the patients’ needs. in addition, fear of legal action is one of the greatest concerns of physicians regarding error disclosure (16, 18, 19). in these circumstances, consultative and supportive services provided by the employing hospital or clinic are essential for coping with the situation and managing it appropriately according to the interests of the patients. studies have shown that physicians lack the necessary capabilities in this regard and do not have the required self-confidence to face these situations (16). on the other hand, many factors like systemic factors are involved in medical errors and it is not therefore fair to blame it all on physicians. a systemic approach to medical errors not only helps with an appropriate and prompt disclosure of the error, but also provides the required support for the physician regarding emotional pressures and also enhances the culture of error discourse and planning for service improvement (27). this study had some limitations. many participants had no exposure to medical errors in the real world so the results may not be generalizable to those who have experienced medical errors personally. however, we tried to create an appropriate understanding of the situation through presenting 2 scenarios. the appropriate timing of the interviews in order to benefit from the presence of all family members and the good response rate were the strong points of this study; however, women comprised the majority of the participants, which decreases the generalizability of the results. according to the results of this study, people accept medical errors from physicians provided that they are disclosed honestly and sympathetically and efforts are made to prevent and avoid future errors, and hence, they are less likely to take punitive action. based on the result of this survey and considerable preferences for error disclosure in the study population, it is recommended that physicians disclose all minor and major errors sympathetically and with transparency, honesty, and efforts to prevent and avoid future errors. the findings of the present study emphasize the importance of an honest patient-physician relationship. patients desire an acknowledgment from their physicians of even minor errors, and doing so may actually reduce the risk of punitive actions. these findings reinforce the importance of open communication between patients and physicians. conflict of interest authors declare having no conflict of interest. acknowledgement according to contract number 91333, this study was funded by qom university of medical sciences. j med ethics hist med 11: 8, august, 2018 jmehm.tums.ac.ir akram heidari et al. page 6 of 6 references 1. grober ed, bohnen jm. defining medical error. can j surg. 2005; 48(1): 39-44. 2. brennan ta, leape ll, laird nm, et al. incidence of adverse events and negligence in hospitalized patients: results of the harvard medical practice study i.1991. qual saf health care. 2004;13(2):145-51. 3. forster aj, asmis tr, clark hd, et al. ottawa hospital patient safety study: incidence and timing of adverse events in patients admitted to a canadian teaching hospital. cmaj. 2004; 170(8): 1235-40. 4. chan dk, gallagher th, reznick r, levinson w. how surgeons disclose medical errors to patients: a study using standardized patients. surgery. 2005; 138(5): 851-8. 5. coffey m, espin s, hahmann t, et al. parent preferences for medical error disclosure: a qualitative study. hosp pediatr. 2017; 7(1): 24-30. 6. matlow ag, moody l, laxer r, stevens p, goia c, friedman j. disclosure of medical error to parents and paediatric patients: assessment of parents' attitudes and influencing factors. arch dis child. 2010; 95(4): 286-90. 7. norrish mi. disclosure of medical errors in oman: public preferences and perceptions of current practice. sultan qaboos univ medj. 2015; 15(2): e283-7. 8. ushie b, salami k, jegede a, oyetunde m. patients’ knowledge and perceived reactions to medical errors in a tertiary health facility in nigeria. afr health sci. 2013; 13(3): 820-8. 9. mazor km, simon sr, yood ra, et al. health plan members' views about disclosure of medical errors. am j manag care. 2005;11(1):49-52. 10. hobgood c, tamayo-sarver jh, elms a, weiner b. parental preferences for error disclosure, reporting, and legal action after medical error in the care of their children. pediatrics. 2005; 116(6): 1276-86. 11. hobgood c, peck cr, gilbert b, chappell k, zou b. medical errors—what and when: what do patients want to know? acad emerg med. 2002; 9(11): 1156-61. 12. al-nomay ns, ashi a, al-hargan a, alshalhoub a, masuadi e. attitudes of dental professional staff and auxiliaries in riyadh, saudi arabia, toward disclosure of medical errors. saudi dent j. 2017; 29(2): 59-65. 13. hs as, rashid a. the intention to disclose medical errors among doctors in a referral hospital in north malaysia. bmc med ethics. 2017; 18(1): 3. 14. bari a, khan ra, rathore aw. medical errors; causes, consequences, emotional response and resulting behavioral change. pak j med sci. 2016; 32(3): 523-8. 15. mazor k, roblin dw, greene sm, fouayzi h, gallagher th. primary care physicians’ willingness to disclose oncology errors involving multiple providers to patients. bmj qual saf. 2016; 25(10): 787-95. 16. ghalandarpoorattar sm, kaviani a, asghari f. medical error disclosure: the gap between attitude and practice. postgrad med j. 2012; 88(1037): 130-3. 17. loren dj, klein ej, garbutt j, et al. medical error disclosure among pediatricians: choosing carefully what we might say to parents. arch pediatradolesc med. 2008; 162(10): 922-7. 18. levinson w. disclosing medical errors to patients: a challenge for health care professionals and institutions. patient educ couns. 2009; 76(3): 296-9. 19. mardani hamooleh m, shahraki vahed a. the obstacles in reporting nursing error: a nurses’ perspective. medical ethics and history of medicine. 2009; 2(4): 55-62. 20. waksberg j. sampling methods for random digit dialing. journal of the american statistical association. 1978; 73(361): 40-6. 21. lavrakas pj. encyclopedia of survey research methods. usa: sage publications; 2008, pp. 716-19. 22. nazione s, pace k. an experimental study of medical error explanations: do apology, empathy, corrective action, and compensation alter intentions and attitudes? j health commun. 2015; 20(12): 1422-32. 23. blendon rj, desroches cm, brodie m, et al. views of practicing physicians and the public on medical errors. n engl j med. 2002; 347(24): 1933-40. 24. schwappach dl, koeck cm. what makes an error unacceptable? a factorial survey on the disclosure of medical errors. int j qual health care. 2004; 16(4): 317-26. 25. witman ab, park dm, hardin sb. how do patients want physicians to handle mistakes?: a survey of internal medicine patients in an academic setting. arch intern med. 1996; 156(22): 2565-9. 26. cleopas a, villaveces a, charvet a, bovier p, kolly v, perneger t. patient assessments of a hypothetical medical error: effects of health outcome, disclosure, and staff responsiveness. qual saf health care. 2006; 15(2): 136-41. 27. perez b, knych sa, weaver sj, et al. understanding the barriers to physician error reporting and disclosure: a systemic approach to a systemic problem. j patient saf. 2014; 10(1): 45-51. jmehm-7-4 journal of medical ethics and history of medicine mission impossible: upholding successfully a charge of infanticide in the albanian legal practice kreshnik myftari1, gentian vyshka2* 1 department of criminal law, faculty of law, university of tirana, tirana, albania; 2 biomedical and experimental department, faculty of medicine, university of medicine in tirana, tirana, albania. corresponding author: gentian vyshka address: lagja 1, rr. kostaq cipo, pall. 2/19, tirana, albania. email: gvyshka@yahoo.com tel: +355 697566130 received: 21 sep 2013 accepted: 16 feb 2014 published: 18 feb 2014 j med ethics hist med, 2014, 7:4 © 2014 kreshnik myftari et al.; licensee tehran univ. med. sci. abstract infanticide is a horrendous crime universally condemned from all ethical, juridical and moral standpoints. however, legislation on infanticide foresees mitigating circumstances for infanticidal mothers, with sentences by far disproportionate to the severity of the crime. the main justification for this abstaining from severe punishments has been the so-called post puerperal psychosis, whose diagnostic criteria and existence are still very confusing. psychiatric experts and even jurors show excessive feelings of empathy toward defendant mothers, and fair verdicts under this setting and with this judicial tradition are questionable. albanian courts have in some cases even denied defendant mothers the unwilling albeit necessary psychiatric treatment, thus exposing them to recidivism and to other social difficulties. upholding the charge of infanticide in an albanian court is hereby an impossible enterprise, with high chances for defendants to achieve acquittal on mental insanity grounds. through describing three cases of infanticide and filicide in recent years of albanian judicial proceedings, authors raise the concern formulated from other sources regarding the excessive empathy surrounding infanticidal mothers, a deleterious obstacle toward achieving justice. keywords: infanticide, maternal psychopathology, legal issues, postpartum depression mailto:gvyshka@yahoo.com j med ethics hist med 7:4 feb, 2014 jmehm.tums.ac.ir kreshnik myftari et al. page 2 of 4 (page number not for citation purposes) introduction infanticide has been a standing concern for legal professionals, medical teams and the society in general. the killing of a child by one of his biological parents has been a widely discussed subject, from the philosophical, legal, medical, psychological and sociological points of view. the overall societal point of standing towards infanticide has been a shortcut in between mental health problems and the act itself; when perpetrated by the biological mother, infanticide is mostly associated with postpartum depression (1). sources make a substantial difference between the neonaticide (killing of a newborn less than one month old), infanticide (murder during the first year of life) and filicide in general (2). connecting indiscriminately a filicide or an infanticide with parental psychopathology leads nowhere; in fact, there are authors clearly stating that mental illness in the majority of cases is not a feature of filicide (3). the accidental or nonpurposeful settings surrounding an unlucky event have been investigated as well, with münchhausen syndrome by proxy being among causative factors (4). we have previously reported an unusual case of infanticide following an overzealous cardiac massage and here the maternal psychopathology was found present (5). in all cases, cultural background and ethnic differences might play a role toward a continuum, starting with child maltreatment and eventually ending in fatally; hereby the sex of the victim seems to be a significant parameter as well (6, 7). due also to methodological and registration biases, it seems very difficult to offer precise figures regarding the worldwide prevalence of child maltreatment or infanticide (8). some sources have performed a methodological scrutiny of selected historical periods trying to find out a time trend in the overall prevalence of infanticide, with conclusions suggesting infanticide to have been widespread in classical times (9). punishing murder proportionally to the severity of this crime has been argued for centuries. the modern society obviously cares very much about the preservation of life, and this has been extended to the criminal law as well (10). case series three cases of infanticide tried in three different albanian courts during the period 2010-2012 were followed by the public and mass media with an impressive zeal. the mainstream of all processes, however, was the acquittal of the mother (infanticidal in two cases) or a mitigated sentence, and the acquittal of the father (infanticidal in the third case). all reasons of acquittal were related to mental health problems or ‘disorders’, with only one parent out of three undergoing thereafter unwilling psychiatric treatment in a criminal psychiatric facility. case one: a mentally unstable mother caused cardiac contusion and thereafter a violent cardiac death to her child (5). the mother had never been treated by psychiatrists before; however, a psychiatric expertise commissioned by the state prosecutor was performed thereafter that confirmed a slight mental retardation. this was sufficient to mitigate the sentence and to drop the charge for murder. she was sentenced to twelve years for manslaughter, one third of which was almost immediately pardoned through a general amnesty. the reason why she received such a sentence was that the child at the moment of death was 18 months in age, and thus she was not prosecuted and charged for infanticide, but rather conforming to the general homicide penal law. case two: a neonaticide happening in a district hospital was never tried by the city court. the prosecution office of the city commissioned an expertise and the psychiatrist suggested that the mother was suffering from postpartum psychosis. the mother, however, had never had a psychiatric anamnesis or been treated for such disorders. the prosecution office closed the file immediately thereafter, and the case was never sent to court. due to such a decision, the mother was never put under (unwilling) psychiatric treatment. case three: a neonaticide happening in the capital of the country (tirana) shocked the public when the father threw the neonate from the window of the fourth floor of the maternity ward. the neonate was pronounced dead immediately thereafter and the father was put into custody. although he had a negative psychiatric history, an expertise was duly commissioned. he was confined to a criminal psychiatric facility and had to undergo unwilling treatment, but was declared by the court as not guilty due to mental insanity. with the albanian law foreseeing a revision of all unwilling psychiatric treatments within one year after a competent trial has decided upon the application of such a measure, the chances of him being put unto ambulatory treatment (or no treatment at all), and being released, remain high. discussion infanticide is a punishable crime according to all penal laws in force, and culturally speaking, it is an unacceptable and abhorrent act. nevertheless, selecting progeny through refraining from rearing unhealthy children is unfortunately an unacceptable advice that plato gave more than two millennia before (11). this might explain, to some extent, why in the ancient greco-roman times, a father j med ethics hist med 7:4 feb, 2014 jmehm.tums.ac.ir kreshnik myftari et al. page 3 of 4 (page number not for citation purposes) was allowed to kill his own child without legal repercussions (12). questioning the worth of a child under the law, damme has impressively reached the conclusion that verdicts have almost not changed in a seven hundred year time lapse, from the pardoning of joanna le vagh in 1284, charged with the murder of her daughter (13). in fact, infanticide laws generally foresee mitigating and reduced penalties for mothers, based on the principle that “the balance of the mind (of an infanticidal mother) is disturbed by reason of her not having fully recovered from the effect of giving birth to the child” (14). on the other hand, the drama of infanticide relies on the fact that medical evaluation overwhelmingly bypasses legal evaluation, and a ‘strange’ doctrine on infanticide has been postulated (15). the profile of an infanticidal mother has been sketched from a ‘manifest madness’ (15). a thorough and detailed description of all medical hypotheses raised and tested in relation to infanticide would be out of the scope of this paper; however, some hypotheses actually are clearly devaluated, although they have been under consideration for decennia. such is probably the case of the so-called ‘lactational insanity’, actually considered as non-scientifically founded (16). from a sociological and medical point of view, infanticide is a complex issue needing careful analysis. this criminal act is particular because one of the biological parents, mainly the mother, commits it, and also because the victim is completely innocuous to the perpetrator, and therefore the act is premeditated and apparently purposeless. due to these peculiarities, instead of reinforcing legal measures toward its prevention, verdicts and penal codes have not changed almost at all during the past centuries, thus conceding mothers mitigated sentences or even acquittal. the albanian penal code still considers infanticide a felony, albeit with sentences foreseeing prison terms not longer than two years (17). hereby we are coming close to downgrading it to a criminal act, if we consider that misdemeanour is sentenced with a maximum of one year prison term. nevertheless, the albanian penal code is uncertain about the time frame of charging the crime as a minor offense. to quote the code verbatim, infanticide is a situation of the ‘mother killing her infant immediately after birth”; however, the code does not clarify what the definition of immediately is, an omission which is creating serious problems for prosecutors, as well as helping attorneys to find unfair ways for mitigating the circumstances of defendant mothers. the whole judicial process of murder will therefore turn out to be framed via a reduced charge of minor offense, and will end up in a disproportionate sentence, whose accomplishment is not merely the decision of a single district judge. these mitigating circumstances and sentences are also supported through empathic psychiatric expertises, and this is an issue raised by authors questioning the professional positioning of a psychiatrist vis-à-vis the infanticidal mother (18). distinguishing mentally unstable mothers from ‘killer mothers’ is an important diagnostic and legal step, particularly in countries with much more orthodox penal codes, like the us, where a ‘killer mother’ will face the death penalty. such a distinction is not simple, since dsm-iv offers no formal diagnostic criteria for the postpartum psychosis, a condition leading to a disparate treatment under the law (19). it is therefore understandable that even jurors will not be immune from such a questionable empathy with infanticidal mothers, with biases in juror decision-making depending on whether the victim is disabled or non-disabled (20). turning to the roots of the phenomenon, it is necessary to perform a thorough medical, sociological and psychological analysis of each separate case, taking into account the cultural and economic background of the wrongdoing mother. authors have identified a variety of psychosocial stressors driving mothers to infanticidal behavior. the most important of these factors seem to be lack of marital support, economic difficulties, family stress, and unrealistic expectations from motherhood (21). once a traditional fertility regulation method, nowadays infanticide as such is encountered very rarely, and almost exclusively in remote and underdeveloped rural areas (22). sex of the progeny is an ominous predictive factor, with girls eliminated much more frequently, mainly in strong patriarchal societies (23). albanian society remains largely a patriarchal one, albeit we possess no comprehensive data regarding the sex of murdered infants to suggest that gender is a significant determining factor for the victims’ selection. the critical line which separates abortion from infanticide is another ethically and morally discussed frontier line (24). from a semantic point of view, approximations in between abortion and infanticide are frequently made. the risks of indifferently accepting abortion as morally permissible might lead to an extension of such an indifference to justification (although contextual) of infanticide (25). the issue is by no means a very simple one, but legally mitigating the circumstances of infanticidal mothers or dropping respective charges in not an option. moreover, the excessive empathy of psychiatrists acting as forensic experts in trials of infanticide, and routinely diagnosing postpartum psychosis in defendant mothers is certainly not a viable and logical option. j med ethics hist med 7:4 feb, 2014 jmehm.tums.ac.ir kreshnik myftari et al. page 4 of 4 (page number not for citation purposes) although written almost 130 years before, the rhetorical question and the eloquent answer that nietzsche gave to his moral dilemma still remain valid: “where are your biggest threats? in the compassion…” (26). in his theory of compassion nietzsche has been considered as closer to inverting platonic metaphysics, but here it seems that his theory still falls within the magic circle of thoughts two millennia after plato’s writings (27). in an attempt to make peace with these moral dilemmas, other philosophers have become almost as uncertain as the jurors trying these cases. michael tooley has gone so far to assume that an entity lacking a ‘consciousness of itself…’ might not have a right to life (28). conclusion too much leniency shown by judicial courts is an apparent phenomenon when infanticidal mothers are charged for their wrongdoings. uncertain and inaccurate terminologies such as those adopted by the albanian penal code, with artifactual concepts related to the ‘immediacy’ of the killing after birth, need to be corrected. such ‘immediacy’ is a fluid time concept, leaving plenty of interpretative ways. the legal terminology, especially the one used in law codes, has to be precise and unambiguous. extreme caution is needed as well in cases when the infanticidal parent, mainly the mother, presents no previous psychiatric history. overestimating the severity of the adaptive psychological changes that follow the birth of a child, to the scale of a psychosis, might be an over diagnosis. this over diagnosis will almost certainly grant an insanity defence to the parent. attempts to legitimate infanticide have found little space in albania. however, the courts and the general public are unfortunately still reluctant to treat this act as a mere crime, with the obvious 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39(5): 289-92. 25. dabbagh s. fetus as human being: where is the cut-off point? j med ethics hist med 2009; 2:2. 26. nietzsche f. die fröhliche wissenschaft, 3rd book, aphorism 271. leipzig: verlag von e. w. fritzsch; 1887. 27. frazer ml. the compassion of zarathustra: nietzsche on sympathy and strength. rev polit 2006; 68: 49-78. 28. paul ef, paul j. self-ownership, abortion and infanticide. j med ethics 1979; 5(3): 133-8. http://ligjet.info/kodipenal ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ original article copyright © 2021 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. journal of m edical ethics and h istory of m edicine telephone communication with relatives of hospitalised covid-19 patients by a specialised family support team: lessons learned *corresponding author ara ayora address: scientific communication research group (grecc), department of communication, universitat pompeu fabra (upf), roc boronat 138, 08018 barcelona, spain. tel: (+34) 62 96 88 196 email:ara@ayora21.com araceli.ayora01@estudiant.upf.edu received: 12 jul 2021 accepted: 21 oct 2021 published: 3 dec 2021 citation to this article: ayora a, nogueras c, jiménez-panés s, cortiñas rovira s. telephone communication with relatives of hospitalised covid-19 patients by a specialised family support team: lessons learned. j med ethics hist med. 2021; 14: 18. ara ayora1*, carme nogueras2, sonia jiménez-panés3, sergi cortiñas rovira 1.member of scientific communication research group (grecc), department of communication, pompeu fabra university, barcelona, spain. 2.member of geriatric department at germans trias i pujol university hospital in barcelona, spain. 3.member of social work department at the germans trias i pujol university hospital, barcelona, spain. 4.coordinator of the scientific communication research group (grecc), department of communication, pompeu fabra university, upf-bsm barcelona school of management, barcelona, spain. abstract during march and april 2020, the number of hospital admissions and deaths due to the first wave of covid-19 peaked. the objective of this study was to analyse the experiences of a team of health professionals in charge of breaking bad news over the telephone to the relatives of patients admitted to the respiratory ward of a large hospital in barcelona. this was a qualitative research based on semi-structured individual interviews with all the members of the team and a group interview. the interviews were analysed using condensation of meaning techniques. three central themes emerged after analysing the interviews: (1) the call itself, (2) the need for good organisational support both before and during a crisis, and (3) the care that the professionals themselves need. to set up a large-scale operation to break bad news over the phone, some organisational aspects must be considered that go beyond the call itself. all these aspects are interrelated to a large extent, and due attention should be given to proper communication and adequate care practices for both relatives and health workers. keywords: health communication; communication barriers; professional-family relations; covid19. telephone communication with relatives of hospitalised covid-19 patients … 2 j med ethics hist med. 2021(december); 14:18. journal of m edical ethics and h istory of m edicine introduction the high contagion and potential mortality rates of the sars-cov-2 virus (1) necessitated the isolation of affected patients as well as extensive confinement measures in many countries, including spain (2). in normal circumstances, information including bad news is delivered in person by the doctor in charge of the patient. however, the circumstances were anything but normal, given both the extraordinary influx of patients and the fact that relatives were not allowed into the hospital. as the respiratory ward became overwhelmed, doctors informally asked for support and the idea of forming a team dedicated to providing a channel of communication between hospital staff and the relatives of admitted patients took form. all health professionals will have to give bad news at some point during their career, but this is a task that is hard to do correctly and might have a major impact on the wellbeing of many people. however, this skill is not regarded as particularly important either by those in charge of the training of future professionals or by the professionals themselves. according to buckman, bad news is “any news that drastically and negatively alters the patient's view of their future” (3,4). nomen defines it as news that “drastically and negatively alters the vision somebody holds about their future, either because they are directly affected or because a loved one is” (5). this reference to relatives is quite meaningful in the context of the covid-19 pandemic as during the initial stages, the information that needed to be transmitted consisted mostly of uncertainties and bad news. the spanish law states that “every professional involved in healthcare has the obligation not only to properly apply all techniques, but to fulfil all duties related to information, documentation and respect for the decisions made freely and voluntarily by the patient” (6). in order to align the health system’s response with the ethics of patientcentered care and comply with the law, the family support team (fst) was formed to take charge of communications with the relatives of patients admitted to the respiratory ward of a major public hospital in the province of barcelona. the fst consisted of five people. four were in charge of the calls: a senior geriatrician experienced in breaking bad news, a social worker from the geriatrics department of the hospital with relevant experience, a volunteer pediatrics intern, and a student in her last year of medical school. the fifth member was an occupational therapist who took care of record keeping. the fst was stationed in the respiratory ward and would in fact meet with the doctors daily to be briefed about the status of all patients. over the 5 weeks with the highest workload during the pandemic peak in barcelona, the fst made almost 1200 calls related to 211 patients, with a median of 6 calls per family. calling people, one has never met who are not allowed to visit their hospitalized relatives or meet with the medical team in charge presented an unknown scenario, so a ayora a., et al. 3 j med ethics hist med. 2021(december); 14: 18. journal of m edical ethics and h istory of m edicine search of the scientific literature was conducted to seek guidance. unfortunately, no guidelines were found but rather a consensus on the inadequacy of the telephone for communicating this kind of news. as buckman stated in the reference book for breaking bad news, unless it is absolutely unavoidable, an interview should be carried out in person and not over the telephone (3). certain exceptions have been proposed, however, for instance if there is an urgent need to obtain approval for specific procedures (7), or when the closest kin is overseas (8). this exact situation applied to the relatives of all covid-19 patients due to the lockdown. since many patients were incapacitated, some form of communication was necessary both to alleviate the uncertainty of relatives and to involve them in the decision-making process. therefore, the team had to modify the protocols that considered the use of the telephone as poor practice and learn what worked and what did not, using the six-step buckman protocol (3) as a framework and making the necessary adjustments. in this article, we present the lessons learned as a result of this experience. methods the present study aimed to analyse the experiences of the fst members, who were in charge of calling the relatives of all patients admitted to the respiratory ward between march 23 and april 24, 2020 during the peak of the first wave of the pandemic (9). under the circumstances, many of the calls imparted bad news including death; so, we aimed to describe the lessons learned as part of this exceptional communication process between health professionals and relatives of covid-19 patients. participants and data collection this study was undertaken by a researcher external to the hospital and consisted of individual semi-structured interviews with all members of the fst, as well as a group interview with all the members. the individual interviews averaged 50 minutes, while the group meeting lasted 2 hours and 15 minutes. all five members of the team were women, between 22 and 53 years of age. the interviews were conducted on-site except for an individual one, which was conducted online. the structure of the interviews was built on blocks, as presented in table 1. data analysis a qualitative analysis was performed, focusing on the perceptions of the interviewees and the way they related to the different roles they assumed, as calls were assigned to different team members according to their background, area of expertise and experience. for instance, a regular discharge call might be made by the social worker who would be better qualified to evaluate a patient’s situation at home, while a difficult discharge call would be handled by the senior geriatrist. telephone communication with relatives of hospitalised covid-19 patients … 4 j med ethics hist med. 2021(december); 14:18. journal of m edical ethics and h istory of m edicine table 1the structure of the interview guide block sample questions 1st block: setup of the fst how did you join fst? did you have any previous experience in breaking bad news? what was the situation like when you joined? how did the medical team react to the fst? 2nd block: carrying out the work describe your work during those weeks. what kind of relationship did you have with other members of the fst team? how did you deal with the situation after work? at home, with your family? did you share the details of your day-to-day work routines with anybody? 3rd block: assessment and subsequent situation what do you think worked best? and worst? how do you feel after the experience? how would you assess the fst experience? is there anything else you would like to add or any important issues you wish to mention? the analysis was centred on meaning and, more specifically, the condensation of meaning in five distinct steps (10). at first, we conducted a reading to acquire an overall impression of the content of the interview. second, we performed an in-depth reading of the transcriptions to determine the different units of meaning and understand the overall concept. third, we simplified the units of meaning obtained from the words of the interviewees, expressed in a streamlined manner. after that, we tried to establish the relationships between these units of meaning and the study objective, tying up the nonredundant essential themes into a statement. once the condensation was completed, an inductive interpretation was undertaken. an example of condensation of meaning analysis is presented in table 2. table 2illustration of the condensation of meaning analysis natural meaning unit simplified meaning subtheme central theme “if one of us went down with covid, whoever took their place had to have all the history and information available”. everything had to be registered need for accurate recordkeeping the call “we didn’t know what to do, we felt like headless chickens, but then we reinvented ourselves and came up with something”. everybody at the hospital had to improvise and do their best without guidance lack of leadership organisational support “what am i doing here? i started thinking about how i was lying to my family, being exposed, and i stopped by the sagrada familia and just cried and cried and cried”. fear, uncertainty and psychological stress overwhelmed them care for the team care of the team members “you arrive there thinking well, let’s see how this works out, because in medical school we get very limited training in communication (…)”. they did not know what to do owing to a lack of training lack of training in a specific skill organizational support ayora a., et al. 5 j med ethics hist med. 2021(december); 14: 18. journal of m edical ethics and h istory of m edicine the situation during the first wave of the sars-cov-2 pandemic has clearly been very difficult, if not impossible, to replicate. therefore, the validity and reliability of the results have been ensured through revision of the methodology by independent experts, from the choice of method to the type of analysis, including the structure of the interviews themselves. result analysis of the interviews yielded several recurring issues that can be grouped in three central themes, each including some subthemes, as seen in table 3. table 3central themes and descriptions of the subthemes central theme subtheme the call before the call, collecting clinical and follow-up information before the call, allocating calls to the members of the fst according to their expertise before the call, making time for the psychological preparation of the professional during the call, establishing a trust-based relationship with the family during the call, adapting to the preferences, values and expectations of the patient and the family during the call, adapting the discourse of the professional to that of the person being called during the call, providing precise and clear information, making sure it is understood during the call, paying attention to the possible psychological issues of the relatives and refering them to the necessary health services after the call, recording all the information, both given and acquired organizational support need for training in communication need for leadership need for planning promotion of collaborative culture, and setting up teams resource availability care of the team members care during the crisis care after the crisis self-care the call the call itself stands at the center of the process, so all of its stages must be carefully considered: what needs to be prepared before making the call, how the call ought to be conducted, and what needs to be done after hanging up. patient-centered care demands that callers consider the values, beliefs and expectations of the specific person they are calling, as well as the overall cultural and material background of the society. in the words of one interviewee: “you have to adapt to what you receive. it isn’t the same when you talk to a cousin or a wife, a daughter, or a sibling… or a 16year-old girl. that happened to me once. i had to talk to a girl who was 16”. [participant no. 3] three stages were identified during the interview: before the call: in this stage, some tasks telephone communication with relatives of hospitalised covid-19 patients … 6 j med ethics hist med. 2021(december); 14:18. journal of m edical ethics and h istory of m edicine have to be undertaken, such as allocating the call to a specific team member according to the situation and the team members’ skills, gathering all the necessary information about changes in the patient’s condition or any outstanding issues pending from previous calls, and ensuring the psychological preparation of the caller. during the call: the professional should adjust their discourse to that of the person they are calling and be empathetic but clear, not hiding the gravity of the situation. after the call: great effort must be devoted to accurate record keeping, as each call is both an act in itself and part of an on-going exchange between the team and the family, as some patients spend weeks hospitalised. with regard to the need for accurate recordkeeping, one team member said, “if one of us went down with covid, whoever took their place had to have all the history and information available”. [participant no. 5] organizational support it became apparent during the interview that the inadequacy of organisational support was one of the outstanding issues affecting the team. the aspects in which organisational support was found to be lacking were manifold and ranged from insufficiency of the efforts devoted to training future health professionals in communication skills, to inadequate contingency planning and a general lack of resources allocated to the task of communication in such an exceptional situation. all interviewees placed great emphasis on a lack of leadership, stating that most of the hospital staff acted ad hoc and were constantly reinventing and adapting themselves and their processes to an exceptional and fastchanging situation with little to no guidance. as to the lack of training, we were told the following: “you arrive there thinking well, let’s see how this works out, because in medical school we receive very limited training in communication …. i was the envy of my classmates, and the great team atmosphere and support made me feel reassured in spite of my lack of experience”. [participant no. 4] it could be argued that this pandemic inevitably led to situations where improvisation was the only answer and that nobody could have expected such a crisis. however, managerial teams have to consider critical scenarios that may never arise in order to avoid a collapse of the system. all interviewees felt that the weight of the responsibility for handling the situation fell on health workers, who relied almost entirely on their personal initiatives, lacking supervision or guidance from their superiors. as can be seen in the following statement: “we didn’t know what to do, we felt like headless chickens, but then we reinvented ourselves and came up with something”. [participant no. 1] care of the team members although at first the focus rested on a shortage of material resources such as personal protective equipment (ppe), during the interviews it came to light that the ayora a., et al. 7 j med ethics hist med. 2021(december); 14: 18. journal of m edical ethics and h istory of m edicine professionals felt the lack of psychological support both during and after the crisis to be the most outstanding issue. the members of the team felt a shortage of resting periods as well as psychological support and therapy, and resorted to means of self-care such as humour and peer-support to try and weather the difficult times. another recurrent complaint was that although health professionals received praise and recognition in the media, this did not translate into concrete and real support. in the group interview, many statements were centered on the psychological state of the team during and after the calls. “it takes a great amount of physical and mental toll. i’m empty, to watch a film and burst out crying is no longer enough. i need rest”. [participant no. 2] “what am i doing here? i started thinking about how i was lying to my family, being exposed, and i stopped by the sagrada familia and just cried and cried and cried”. [participant no. 3] discussion the main finding of the study was that in a situation like this, the calls themselves are only part of what must be an institution-wide effort. such efforts include preparation tasks (offering proper training), budgetary management (providing the necessary material and it support), administration issues (rostering and shift scheduling) and offering psychological support to the people assigned to this task. at the time the fst started operating, scientific literature on medical communication by telephone was almost non-existent, except to point out the undesirability of such a medium. therefore, medical professionals had to improvise. one year later, numerous papers are being published, offering insight on how best to engage in this kind of communication. for instance, there are papers presenting guidelines on how the doctor in charge of a given patient should provide information to his/her relatives (11) or convey to them the conclusions reached by a panel of experts that reviewed relevant literature. moreover, some papers have proposed (12) a set of good practices to follow, including different checklists for phone or video calls, and guidelines for deciding when and which clinical information should be given to the families in order to improve the outcome of the calls. there is also plenty of literature about the psychological impact of the covid-19 pandemic on health professionals and the need to alleviate it (13), the importance of providing adequate training (14, 15), and concern about the technological aspects and the future of remote healthcare as an aspect of standard healthcare (16). in the case of our subjects, the doctors working in the respiratory ward had to deal with an unprecedented workload and could not provide information to patients’ families. therefore, a decision was made to dedicate to this task a multidisciplinary team consisting of senior professionals with extensive experience in breaking bad news. telephone communication with relatives of hospitalised covid-19 patients … 8 j med ethics hist med. 2021(december); 14:18. journal of m edical ethics and h istory of m edicine the specifics of this pandemic have brought into sharp relief the difficulties of large-scale communication over the telephone, specifically when so many patients with such diverse medical prognoses were involved. in some cases, a single devastating call had to be made, but in others, many calls (up to 30) were made to the relatives of the same patient, creating a sort of personal rapport. thus, team members had to put in a great deal of effort to make sure that no details were lost from one call to the next, and to adapt their language to that used by the person they were calling, from both cultural and technical aspects; for instance, it had to be considered whether the relatives were unfamiliar with medical terminology or were well-trained professional health workers themselves. all of the above has resulted in a unique experience out of which valuable insights on the overarching issues that need to be addressed can be obtained, most falling under the scope of organizational support. one of the main insights pertained to the need for better training in communication, as those crucial skills are often undervalued in medical education. in addition, health facility managers often take communication as a given that does not demand resources or attention, and this lack of preparation will not only exacerbate the distress of the relatives receiving bad news, but also increase the stress suffered by the physician (17). thus, it is necessary to promote training in communication skills and telecommunication in particular (both telephone and video calls). moreover, at the managerial level, emphasis must be given to communication with patients and relatives as well as internal communication, which in turn will help to build a collaborative culture and cohesive teams. a second finding was related to the need for better planning, including thinking the unthinkable. it may be argued that the specifics of a pandemic are always unexpected and that it was not possible to prepare for this one. however, some needs should be addressed, like providing the essential supplies and ensuring that key managerial positions are staffed by people with the right leadership skills to avoid burdening the already overworked frontline health professionals with the need to improvise solutions to unexpected problems. literature about managing crises usually centers on logistics and other material aspects (18), but communication needs are often left out. the importance of having access to material support and the existence of a culture of planning ahead cannot be underestimated, and even though unforeseen scenarios might evolve, policies can be formulated in order to better manage them (19). the aforementioned matters must be addressed before any crisis sets in. once the unexpected has happened, a swift response from the organisation is necessary in order to acquire or relocate technical equipment, adapt rostering and shifts to the new necessities, and provide extra support by reallocating staff where they might be most needed. if the right leadership and culture are in place, the response from the whole system will be much more adequate and burdens will be shared, so nobody will have ayora a., et al. 9 j med ethics hist med. 2021(december); 14: 18. journal of m edical ethics and h istory of m edicine to bear unmanageable loads. the third finding was about caring for caregivers so that everything keeps on working. even in normal situations, breaking bad news is a stressful experience, but when relatives are prevented from visiting the patient and their only means of communicating with the doctors is by telephone, it will be a greater challenge still. some of the members of the fst had extensive experience in end-of-life care and communicating bad news, which helped to ease some of the psychological stress that such heavy conversations create. however, the accumulated burden endured by a 4member team that was dedicated exclusively to this task and performed over 1,200 calls corresponding to 211 patients in 5 weeks was enormous. in a similar experience, chisholm et al. recounted that the team assembled to provide information to patients’ families consisted of over 30 professionals, including not only health workers, but also administrative personnel and experts in service excellence, and that a specific program to provide support to physicians and families had been set up in a few days (20). in the single other example that we found of a similar setup (21), the team had 39 members for 174 patients. these two instances showcase the difference good support makes when setting up an operation like this, and this has substantial impact on the wellbeing of the professionals involved. in any case, the importance of previous experience in breaking bad news cannot be underemphasized. clinicians that have had extensive experience in this area have a deep understanding of the principles involved and a wide and flexible repertoire that allows them to adapt. when massive needs for communication arise, however, less experienced clinicians must also step in and share the burden, something that might turn into a demoralizing experience (22). this agrees also with our findings, as in the fst team the more experienced professionals took the most difficult calls and supported and helped their junior colleagues. even though it is well known that giving bad news is only slightly less stressful than receiving it (23), this acquires more relevance during a pandemic. many studies exist on the physical and psychological impact of the pandemic on professional health workers that have faced covid-19. one such example is a study from the university of turin in italy where results showed that the professionals who worked in covid-19 wards reported higher levels of symptoms like depression or post-traumatic stress disorder than those in other units. this reflects the unique aspects of dealing directly with the pandemic and its effect on patients and relatives (24). there was another study in singapore and india where health professionals reported high levels of stress attributed not only to the fear of transmitting the infection to their families, but to the fact that the system was so strained that they were hesitant to apply for sick leave, a situation that often ends in burnout (25). in both studies, multiple issues affecting health workers are referenced and telephone communication with relatives of hospitalised covid-19 patients … 10 j med ethics hist med. 2021(december); 14:18. journal of m edical ethics and h istory of m edicine special emphasis is placed on the greater incidence in women, younger or less experienced individuals, and those working in the frontline. monitoring the people most at risk is a necessity that goes beyond the concern for the individual worker, as the number of people that can potentially be affected is large enough to threaten the sustainability of the healthcare service itself (26). as women form the majority of health workers (27), their care merits special attention from health authorities. carers must be cared for, or the system may fail. those who look after the health of the rest must feel valued and well treated, knowing that their needs are covered and that they receive the acknowledgment they deserve. this includes providing them with adequate rest and psychological support, since, also for professional health workers, primum non nocere (first, do no harm). limitation the present study was centered on professionals’ experiences and did not aim to establish the degree of satisfaction of the relatives, so their opinions have not been gathered. the setup of the fst in the respiratory ward was done on the professionals’ own initiative and was not replicated in other areas of the hospital. therefore, all the information we have available comes from the five members of this unique fst. finally, this work was based on the perceptions of the fst team members and might be biased since they relied on memories acquired at a time of great distress, which might have affected their accuracy and reliability. conclusion the aim of this study was to learn from the experiences of the fst team taken as a whole, how it interacted with the rest of departments of the hospital. the fundamental insight derived from this study was the need to build a system that lends weight to communication as a whole, from basic training to receiving the proper managerial support. we highlighted the main aspects that need to be taken into consideration to help medical institutions set up their own protocols to better address similar situations in the future. meanwhile, it should be stressed that all of these aspects are heavily interrelated, for instance good organizational support will bring about improvements in the quality of communication and lessen the mental load of health workers, which will in turn result in a stronger institution and better care. in figure 1 we present a broad outline of the main concepts that we think must be considered when facing such a demanding scenario. after all, we should not forget that communication does not just humanize care; it is what makes it possible. disclosures this research received no specific funding/grant from any agency in the public, commercial or not-for-profit sectors. ayora a., et al. 11 j med ethics hist med. 2021(december); 14: 18. journal of m edical ethics and h istory of m edicine figure 1main concepts to be considered conflict of interests the authors have no conflict of interests to declare. approval for this study was obtained from the germans trias i pujol university hospital ethics committee for clinical research; ref.cei pi-20-276. acknowledgements our many thanks go to fst members, who have so graciously shared their experiences in spite of the sad memories this research may have brought up, and to the members of the respiratory team for their support and tireless work. we extend this acknowledgment to all health workers who, sometimes at the expense of their own health and even their lives, worked and still do to care for their patients and the society as a whole. telephone communication with relatives of hospitalised covid-19 patients … 12 j med ethics hist med. 2021(december); 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[informe del sistema sanitario: spain health system report]. [cited dec 2021]. available from: https://www.sanidad.gob.es/gl/bibliopublic/publicaciones/recursos_propios/resp/pdf/revision_siste ma_sanitario_espanol_2018.pdf https://www.sanidad.gob.es/gl/bibliopublic/publicaciones/recursos_propios/resp/pdf/revision_sistema_sanitario_espanol_2018.pdf https://www.sanidad.gob.es/gl/bibliopublic/publicaciones/recursos_propios/resp/pdf/revision_sistema_sanitario_espanol_2018.pdf abstract introduction references microsoft word dignity 6 (320)galley proof journal of medical ethics and history of medicine original article concept analysis of human dignity in patient care: rodgers' evolutionary approach maliheh kadivar1, marjan mardani-hamooleh2*, marjan kouhnavard3 1professor, division of neonatology, department of pediatrics, children’s medical center, tehran university of medical sciences, tehran, iran. 2assistant professor, department of psychiatric nursing, iran university of medical sciences, tehran, iran. 3pediatrician, children’s medical center, tehran university of medical sciences, tehran, iran. corresponding author: marjan mardani-hamooleh address: vanak sq, zafar street, tehran, iran. postal box: 1996713883 email: mardanimarjan@gmail.com tel: :( +98) 2188201978 received: 2 sep 2017 accepted: 17 march 2018 published: 18 apr 2018 j med ethics hist med, 2018, 11:4 © 2018 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract human dignity (hd) in patient care is an important concept in clinical ethics that has various definitions in existing literature. this study aimed at analyzing the concept of hd in patient care. to this end, rodgers' evolutionary concept analysis was used. for this purpose, scientific databases pubmed, elsevier, sciencedirect, scopus, ovid, web of science, cinhal, irandoc, google scholar, magiran, sid and iranmedex were searched fusing the words “human dignity”, “patient care” and “ethics”. the main criterion for inclusion in the final analysis was the literature published in english and persian from 2006 to 2016 in online scientific journals within the context of health care disciplines. ultimately, 21 articles were selected for the study. the attributes of the concept under study were identified in two areas of individual hd and social hd. antecedents included facilitators and threats, and the consequences consisted of both favorable and unfavorable consequences. hd forms the essence of patient care and is a value-based and humanistic concept based on respect for the integrity of human beings and their beliefs. this concept, with its holistic approach to humans, takes into account all stages of disease, old age and the end of life period. hd in patient care is influenced by cultural, social, spiritual and religious factors, and with its justice-based approach emphasizes equality of all patients and extends patient care to all areas of society rather than restricting it to hospital settings. in this study, a clear definition of hd is introduced. keywords: human dignity, patient care, ethics, rodgers’ evolutionary approach j med ethics hist med 11: 4, april, 2018 jmehm.tums.ac.ir maliheh kadivar et al. page 2 of 11 introduction human dignity (hd) has been emphasized throughout history by philosophical schools and various religions, especially islam. the concept is rooted in ancient schools and religions, middle ages, and modern times. hd follows all the principles of biomedical ethics (1). on the one hand, maintaining hd is one of the primary rights of human beings (2). according to holy quran, god breathed his spirit into man, and therefore man has a unique nature. god created the entire world for man so that he could enjoy the numerous bounties, and he dignified him as he ordered the angels to bow before him. these matters clarify the intrinsic dignity of humankind (3). in fact, hd is an innate value that has been vested in people because they are human. (2) according to the iranian constitution, hd is one of the basic rules of the islamic republic, and the government should therefore offer health services to all nationals based on respect and observance of hd (4). privacy is one of the most important dimensions of hd, and healing environments are among the places where privacy may be threatened or invaded. maintaining hd creates pleasant feelings in patients that should not be disrupted through care provision (5). in fact, it is essential to preserve patient privacy in order to establish effective communication between patients and care staff, and preserve the former’s peace of mind. if this is neglected, consequences may include anxiety, aggression, partial withholding of the history of the disease, refusal to undergo physical examinations, and a general decrease in the quality of care services (6). some factors that may threaten the dignity of hospitalized patients are: an inability to perform important roles in life, the feeling that life is meaningless, lack of support from friends and the health care staff, a sense of uncertainty, and concern for the future (7). furthermore, whenever patients’ autonomy is compromised, respect for their dignity decreases (8). it can be stated that maintaining hd is one of the ethical goals in care (9). in other words, preserving hd is among the most significant ethical requirements in medical sciences, especially nursing, so that respect for patients’ hd is widely emphasized in nursing standards and lies at the heart of care (10). according to these ethical considerations, since promoting the quality of clinical services is now at the top of the medical care pyramid, maintaining patient privacy has become more important (1). nevertheless, while the concept of hd in care is closely interlinked with medicine and medical sciences, the existing knowledge about this concept is not well-defined and there is no comprehensive definition for it. in the field of research, the paucity of studies on this concept has limited its utilization to some extent. therefore, considering that a single definition of the concept of hd in patient care is not available and its application is still unclear, the present study aimed to analyze the concept of hd in patient care using rodgers’ evolutionary approach (rea). method this study was a qualitative concept analysis of hd in patient care using rea (11), which included the definition of the concept as well as its alternative statements and terms. the study involved the determination and selection of scope for data collection, the collection of data on the characteristics of the concept according to context variability’s such as social and cultural changes, interdisciplinary and temporal changes, and the expression of an appropriate case in terms of the concept and determination of the hypotheses and analytical implications for further development of the concept (11). at first, scientific databases pubmed, elsevier, science direct, scopus, ovid, web of science, cinhal, irandoc, google scholar, magiran, sid and iran medex were searched using the headings defined in mesh system that included “human dignity”, “patient care” and “ethics” in the title, abstract and full text of the published articles. a summary of the search is shown in figure 1. the inclusion criterion in the final analysis was the literature published in english and persian in online scientific journals within the context of health care disciplines between 2006 and 2016. literature analysis was conducted using content analysis. the information units included either related words and sentences, or answers given to the following questions: how is hd defined in patient care? how is hd formed in patient care? what factors play a role in maintaining hd in patient care? what are the consequences of not respecting hd in patient care? the papers were classified according to the conceptual analysis characteristics that were considered in this study. in order to ensure objectivity, validity and reduction of bias, the analysis process was carried out by two phd nurses who were not members of the research team, but had clinical records and were familiar with rea. j med ethics hist med 11: 4, april, 2018 jmehm.tums.ac.ir maliheh kadivar et al. page 3 of 11 fig.1. summary of the search results after reading the articles, the appropriate points and the attributes, antecedents, consequences, related concepts, surrogate terms, and concept definition were extracted. next, in each section, the data were reviewed several times so that the researcher could become immersed in them and extract key points and labels to provide clear descriptions of each aspect of the concept. finally, the inductive analysis of information on the concept was carried out and the themes were identified (table 1). table1characteristics of the articles consequencesantecedentsattributesresearcher/year reference no. taking hd into account leads to providing care that considers patients’ values and beliefs and their cultural diversity. providing health care services by preserving hd brings about patients’ respect and strengthens their independence. in order to provide care services while preserving hd, one needs to get help first and foremost. in order to preserve hd, autonomy of patients and respect for their individuality must be taken into account. providing care services while preserving hd requires truthclarification, observance of patients’ rights, and equity in care provision. dignity is an inner feeling of being good, personal valuation and self-esteem. preserving hd is not limited to clinical environments and involves all patients in various areas of the community. hd is influenced by the relationship with others. coventry/2006 5 disease and the need for care threaten hd. dignity is rooted in people’s beliefs. dignity is influenced by social relationships, including those with family and friends. pleschberger/2007 14 the sense of hd improves patients’ ability to cope with their disease providing patients with relevant information about the disease helps them slettebø et al./2009 24 papers found in database searches 1521 papers selected based on inclusion criteria and elimination of the repeated cases 624 paper abstracts assessed 202 papers excluded after assessing the abstracts 98 full texts assessed 104 papers excluded after assessing the full texts 83 papers included 21 j med ethics hist med 11: 4, april, 2018 jmehm.tums.ac.ir maliheh kadivar et al. page 4 of 11 consequencesantecedentsattributesresearcher/year reference no. and gives them a sense of meaningfulness in life. maintain their hd. if patients are neglected by staff or are faced with staff who lack adequate knowledge, their hd will be threatened. preserving hd increases patients’ satisfaction with care services. preserving information about the disease and meeting the needs of patients will enhance their dignity. hd is based on the values, attitudes and perceptions of individuals. hd is a cultural concept. lin et al./ 2011 9 taking patients’ privacy into consideration and effective communication with care workers lead to the preservation of hd. the paucity of supplies such as blankets and linen in the ward, which prevents patients from using the existing facilities and leads to admission into a dirty and noisy ward, adversely affects their hd. ebrahimi et al./2012 2 hd is promoted in patients through nurses’ moral responsibility in taking care of patients. restricting patients undermines their hd. lindwall et al./ 2012 27 having authority in interpersonal relationships plays a role in promoting hd. bagheri et al./2012 26 preserving hd improves patients’ self-esteem and their trust in nurses. holmberg et al./2012 28 preserving hd helps patients with their lives in the future. violation of hd in patient care leads to spiritual and psychological distress and loss of the will to survive. hd forms the essence of patient care. hall et al./2013 15 hd-based care services provision comprises respect for patients, paying attention to their values and empathy. hd is achieved by respecting patients’ values. hd is an important concept in care that considers the integrity of patients and sees them as human beings to the very last moment of their life. hamooleh et al./2013 19 hd is a complex concept combined with elements such as respect, assurance and security for patients. lohne et al./2014 17 preserving hd in old age is possible through respect, observing their privacy and autonomy, and considering elderly people as human beings. hd is an important aspect of a person's quality of life structure. hall et al./ 2014 12 respecting patients and providing patient-centered care are effective in providing hd-based care hd is based on social, cultural, religious and spiritual factors. cheraghi et al./2014 22 j med ethics hist med 11: 4, april, 2018 jmehm.tums.ac.ir maliheh kadivar et al. page 5 of 11 consequencesantecedentsattributesresearcher/year reference no. from patients’ point of view, factors promoting patients’ hd include respect for human nature and the rights of patient’s companions. all humans have dignity and must always be respected, but patients deserve special attention in this respect. manookian et al./2014 10 taking hd into consideration leads to providing care services based on kindness and affection. taking hd into consideration means regarding patients as human beings and not as objects. in patient care, hd is characterized by equality of all human beings. cheraghi et al./2015 18 considering patients as unique human beings, paying attention to their preferences, confidentiality, and preserving their privacy and autonomy are factors that help promote hd. respect for hd is one of the essential parts of care. papastavrou et al./2016 16 having a disease is a threat to people’s dignity. hd is a fixed value in end-oflife care. gysels et al./2016 20 preserving hd will make patients feel that they matter to the care system. paying attention to the needs of patients at the time of admission and after discharge, and the proper nurse-patient relationship are effective factors on preserving patients’ dignity. borhani et al./2016 25 violation of patient privacy, lack of patients’ participation in the decision-making processes and lack of support threaten patients’ dignity. dignity is an intrinsic characteristic of human existence that is experienced mentally. bagheri et al./ 2016 13 lack of proper space in the ward to provide patients with end of life care and lack of palliative care services lead to a decline in hd. hd is one of the pillars of good death for patients at the end of life stage. granero-molina et al./2016 21 preserving hd in providing care services causes patients to have fewer problems adapting to the community. violation of hd harms patients. preserving hd is an important goal in caring for the elderly people. høy et al./ 2016 23 a. attributes attributes are the elements that identify the concept under study (11). the two following attributes were identified in connection with the concept of hd in patient care: a. 1. individual hd the concept of individual hd is characterized by those aspects of patient care that acknowledge patients’ individuality and integrity, and respect their dignity as human beings throughout the life stages. hd is an important component of the individual quality of life structure (12) and is an intrinsic characteristic of human existence that is perceived mentally (13). the concept of dignity is rooted in people’s beliefs (14) and is based on their values and perceptions (9). dignity is a kind of inner feeling of being good, personal valuation, and self-esteem (5). all humans have dignity and must be respected in any case, but patients deserve special attention in this regard (10). since hd forms the basis of patient care (15), respect for hd has been taken into account as one of the essential components of patient care (16). hd is a complex concept combined with elements such as respect, assurance and security for the patient (17). attention to hd means considering the patient as a human being and not an object (18). thus, hd is a meaningful concept in care that makes it possible to respect patients’ integrity and regard them as human beings till the end (19). accordingly, hd is a fixed value in end-of-life care (20) and is one of the pillars of good j med ethics hist med 11: 4, april, 2018 jmehm.tums.ac.ir maliheh kadivar et al. page 6 of 11 death for patients in terminal stages (21). a. 2. social dignity the concept of hd in the social domain includes attributes that reflect the social and cultural factors involved in hd. this attribute also emphasizes its holistic aspect and the fact that it can be influenced by communication. dignity can be affected by social relationships, including those with family and friends (14). hd is a cultural concept with a religious and spiritual basis (22), and in patient care it is characterized by considering all human beings equal (18). on the other hand, preservation of hd is not restricted to clinical settings and patients who are admitted to hospitals; it covers all patients in various areas of the community (5), and is an important goal in caring for elderly people living in sanatoriums (23). b. antecedents antecedents are the preconditions of the concept under study and affect the occurrence of the concept (11). in the present study, they have been identified as facilitators and threats. b. 1. facilitators facilitators include items that help to provide, preserve, and promote hd in patient care. in order to preserve hd while offering care services, first and foremost, one needs to get help (5). effective factors in providing hd-based care include respect for the patient and provision of patient-focused care (22). hd is shaped by respecting patients’ values (19). to preserve hd, autonomy of patients and respect for their individuality must be taken into account. care that is based on preservation of dignity relies on patient autonomy, truth-telling, respect for patients’ rights and equity in care provision (5). with regard to the privacy of patients admitted in hospitals, some factors that may ensure the preservation of hd are effective communication with caregivers (2), and receiving relevant information about the disease (24). hd-focused care services entail empathy and respect for patients’ values (19). considering the needs of patients at the time of admission and after discharge, and proper nurse-patient relationship are effective in hd preservation (25). in old age, preservation of hd is possible through autonomy of elderly people and regarding them as human beings (12). factors that can promote patients’ dignity include recognition of their authority in interpersonal relationships (26), respect for human nature and the rights of patients’ companions (10), keeping information about the disease confidential, and meeting the needs of patients (9). other effective factors on dignity in patient care include considering the patient as a unique person, confidentiality and paying attention to his preferences (16). in general, hd is promoted through nurses’ moral responsibility in taking care of patients (27). b. 2. threats threats refer to factors that jeopardize hd in patient care and may be patient-related or organizational. as a general rule, having a disease can threaten people’s dignity (14, 20). violation of privacy, lack of patient participation in the decision-making process, and insufficient or non-existent support can compromise patients’ dignity (13). in addition, being neglected by the medical team or encountering staff who lack adequate knowledge pose a threat to patients’ hd (24). moreover, restricting patients, which includes emergency measures in sectors such as the psychiatric ward, undermines their hd (27). other factors that lead to a reduction in patient dignity include lack of suitable hospital space in end-of-life care, and a shortage of palliative care services (23). paucity of supplies such as blankets and linen in the wards prevents patients from using the existing facilities, and admission to dirty and noisy wards adversely affects their hd (2). c. consequences consequences refer to events that follow the emergence of a concept (11). in this study, the consequences of the concept of hd in patient care were divided into two categories: favorable and unfavorable. c. 1. favorable consequences favorable consequences have positive effects on hd in patient care. taking hd into consideration leads to respect for patients’ values, beliefs and cultural diversity in care provision. preservation of dignity enhances patients’ sense of respect and autonomy (5) and helps them feel worthy of the care system (25); moreover, it leads to care services that are based on kindness and affection (16), increases patients’ satisfaction with the care process (9) and promotes patients’ self-esteem and trust in nurses (28). preservation of patients’ dignity helps them adapt to the community with greater ease (23), improves their ability to cope with the disease and gives them a sense of meaningfulness in life (24). preserving hd helps patients with their future life, especially in the case of cancer patients (15). c. 2 unfavorable consequences just as preservation of hd in patient care has favorable consequences, paying no attention to hd has unfavorable outcomes. violation of hd harms the patients (23), and in the case of cancer patients for instance, may lead to spiritual and psychological distress and loss of the will to survive (15). related concepts and surrogate terms related concepts include some of the relationships included in the main concept, but do not comprise all of its characteristics (11). the term “patient dignity” in this study was most closely related to the concept under study in the analysis of the relevant literature. surrogate terms refer to the expression of the concept through words and statements other than the concept selected for the study (11). it was established in the analysis process that the concept of hd in patient care could be replaced by terms such as dignity in care and dignified care. environmental context environmental contexts are the fields and situations in which an issue is utilized (11). healthcare and clinical j med ethics hist med 11: 4, april, 2018 jmehm.tums.ac.ir maliheh kadivar et al. page 7 of 11 settings are the most general environments utilizing the concept of hd in patient care. model case model cases help to identify the important characteristics of the concept under study in the main context and lead to clarity and a more effective use of that concept (11). m. is a 34-year-old woman who has referred to the oncology department with a gastric cancer diagnosis and needs to have a part of her cancerous stomach removed. she is accompanied by her brother. the patient cries and is afraid of the future. she claims that in her opinion, life is worthless and this is the end of the world for her. the nurse realizes that the patient is suffering from emotional distress due to cancer and needs help. so first, the nurse lets her cry and then she asks the ward staff to admit her with respect. next, the nurse goes to the patient’s room and, gives her the facts about cancer and its treatments, and proceeds to provide empathic care in order to reduce the emotional distress of the patient. she also tries to help the patient to go on with her life by reinforcing the meaning of life for her. the nurse believes that providing palliative care for all cancer patients as well as giving special attention to them are essential for improving their quality of life to the last moment. over the entire care period, the nurse feels responsible for keeping the patient’s information confidential and respecting her autonomy. contrary case ms. b., a 57-year-old woman with heart failure, was admitted to the cardiology unit of a hospital at night. she had no companions. that night the unit was quite busy, and the patient used the nurse call button frequently. due to her heavy workload that night, the nurse did not pay attention to the calls. another patient’s visitor informed the nurse that b. was unable to go to the bathroom by herself. this annoyed one of the nurses, who went to b.’s room and told her rudely that she should have brought in a companion because the unit was busy and service was limited. at the same time, the nurse ordered a serviceman to give her a bedpan. the patient refused to use the bedpan, but the nurse did not allow her to leave her bed as a precautionary measure. the patient started to cry because of the nurse’s negligence and disrespect, and the threat to her autonomy. the nurse, however, left to go back to her station while the patient was still crying. in this case the study concept cannot be covered, and is in fact recognized by paradoxical characteristics. related case related cases do not reflect all the aspects of the concept, but are related to it, and in comparison with the contrary case are closer to the study concept and could even be listed in the same network. mr. f. was a 29-year-old man diagnosed with schizophrenia and was scheduled to receive electro convulsive therapy. because of the psychotic nature of the disease, he could not sign his consent. his father decided that his son should undergo the procedure based on his pre-disease beliefs about health and out of respect for his ideas. borderline case cases that do not improve knowledge or contribute to science in a specific field are considered borderline cases. ms. t, is an 87-year-old woman who can take care of her personal needs if she does not have a backache or sore feet. she has a good relationship with her young son, and asks for his help when she cannot do her selfcare. one time she could not get out of bed and her son was not there. she asked another patient for help and fell on the ground. her nurse was informed and said, “what you did was wrong, and you should have informed us”. the patient insisted that she had done the right thing decisively and with self-respect, and after her son arrived, she also told him that she believed she was right. identifying assumptions of the concept analysis this stage provides a debate opportunity to utilize the findings of an analysis (11). the concept analysis showed both individual and social hd to be important issues in the definition of the concept. the favorable and unfavorable consequences associated with hd in patient care are affected by a series of simplifiers and threats. in addition, hd is a connecting issue between the advances and consequences, and without the main concept, the connection is disrupted; as a result, it becomes impossible to link the advances and consequences with each other. discussion an analysis of the concept of hd in patient care has several dimensions. our findings showed that this concept includes a range of attributes, antecedents, and consequences. our study revealed that the concept under study has individual and social attributes. individual attributes indicate that it is necessary to raise public awareness about this issue, especially among patients, because hd is the essence of patient care (15). the results of the studies conducted in the united states (5), iran (13), taiwan (9), germany (14) and cyprus (16) demonstrate that human beings have an inherent dignity, and hd in patient care is a complex concept that includes elements such as respect for human individuality, values and beliefs. in addition, a review of literature on research conducted in england (12), spain (21) and iran (19) shows that hd in patient care includes an important aspect of quality of life structure and should be preserved as a value throughout life. evaluation of the social attributes of the concept under study indicates a sort of justice-centered approach. the results of an iranian study revealed that preservation of hd is intertwined with the notion of equality of all patients (18). hd encompasses all patients in various areas of the society in addition to hospitals (5). therefore, it is an important goal in j med ethics hist med 11: 4, april, 2018 jmehm.tums.ac.ir maliheh kadivar et al. page 8 of 11 caring for seniors living in elderly sanatoriums across scandinavian regions (23). in its social dimension, hd is influenced by relationships with others. the results of a study in germany showed that the concept of dignity could be influenced by social relationships, including those with family and friends (14). the results of a study in taiwan demonstrated that another social feature of the concept is its cultural origins (9). from the perspective of iranian patients, hd is based on social, cultural, religious and spiritual factors (22). this indicates the need to consider the culture of patients when providing dignified care, because their cultural beliefs and perceptions can affect this type of care. indeed, care is a context-based concept influenced by cultural settings and the values governing societies. consequently, those receiving care in the same cultural context will have common characteristics that affect the process of providing dignified care, which is characterized by observance of hd. considering the findings on the features of this concept, we can define hd in patient care as follows: “hd is the essence of patient care. hd in patient care is a value-based and humanistic concept that demands respect for the integrity of human beings and their beliefs. this concept has a holistic approach to humans and takes into account the stages of disease, old age and the end of life. hd in patient care is influenced by cultural, social, spiritual and religious factors, and views all the patients equally with a justice-based approach. accordingly, hd focuses on patient care in all social arenas and is not specific to the hospital environment”. based on the antecedents of the concept under study, there are facilitators and threats to providing dignified care to patients. the facilitating antecedents showed that in order to provide care and preserve patient dignity, one needs to receive help first. in addition, the patient’s autonomy and respect for his individuality must be considered. dignified care is possible by observing factors such as truthfulness, patients’ rights, and equity in care services (5). a number of studies have focused on the facilitating antecedents of this concept from the perspective of patients in general or patients with a particular disease. in this regard, a review of iranian literature showed that from the viewpoint of hospitalized patients, some factors that lead to the preservation of hd are: respect for patient privacy, effective communication with caregivers, respect for the human nature and the rights of companions, provision of patient-centered care, proper nurse-patient communication, and paying attention to the needs of patients at the time of admission and after discharge (2, 22, 25). from the viewpoint of patients admitted to taiwan hospitals, preserving disease information and responding to patients’ needs helped promote their dignity (9). a study in norway showed that from the perspective of patients with head injury, receiving proper information about the disease would help preserve their hd (24). in one study conducted in iran on patients with heart failure, factors such as having authority in interpersonal relationships contributed to the promotion of hd (25). a number of studies have dealt with the facilitators of the concept from nurses’ point of view. from the perspective of swedish nurses, hd in patient care improves with the moral responsibility of nurses (27). in a study conducted in cyprus, nursing students believed factors promoting dignity in patient care include perceiving the patient as a unique person, taking into account patients’ preferences, and respecting their privacy and autonomy (16). from the perspective of iranian nurses on caring for cancer patients, hd is shaped by paying attention to patients’ values, providing care focused on preserving their dignity, respecting them, and empathy (19). according to nurses who care for the elderly in england, preservation of hd in old age is possible through respect, considering the elderly as human beings, and observing their privacy and autonomy (12). other facilitators consider patients with chronic illnesses such as cancer and acute illnesses such as strokes. it can be stated that the preservation and promotion of hd in patient care is not limited to acute or chronic illnesses and covers all states of disease. the other antecedents of the concept under study are factors that threaten the concept. these antecedents indicate that having a disease threatens hd (14, 20). in addition, issues such as violation of patients’ privacy, lack of participation in the decision-making process and lack of patient support lead to a threat to their dignity (13). studies have examined conceptual threats for both patients and clinical practitioners, namely doctors and nurses. the opinions of practitioners focused both on the general environment of the hospital and on the particular ward. from the viewpoint of hospitalized patients in iran, lack of supplies such as blankets and linen in the wards makes it impossible for patients to use the existing facilities properly, and their admission to noisy and dirty wards undermines their hd (2). norwegian patients believed that their dignity is threatened if they are neglected by medical staff or encounter employees with inadequate knowledge (24). a study in spain showed that from the viewpoint of doctors and nurses, a shortage of appropriate space in the emergency department to provide end-of-life care for patients and lack of palliative care services would reduce patients’ dignity (21). from the perspective of swedish nurses, limiting the patient, as one of the emergency measures in psychiatric wards, threats patients’ hd (27). literature review revealed that advances in the concept of dignity in patient care presented as facilitators and threats are important from the point of view of both patients and medical professionals. furthermore, concept analysis of the antecedents indicates that hd in patient care is not in a steady state and may be promoted or threatened under different j med ethics hist med 11: 4, april, 2018 jmehm.tums.ac.ir maliheh kadivar et al. page 9 of 11 circumstances. therefore, caregivers should be more aware of the factors that threaten the concept, and show greater moral sensitivity. other findings of the study showed that the consequences of the concept of hd in patient care could be either favorable or unfavorable. concerning the favorable consequences, attention to hd in care provision leads to respect for patients’ values and beliefs and their cultural diversity, and helps preserve their dignity and improve their autonomy (5). according to hospitalized patients and nurses in iran, preservation of hd helps patients feel that they are considered valuable in the care system (25). from the viewpoint of iranian patients, attention to dignity in patient care leads to the provision of services based on compassion and love (18). for taiwanese patients, preserving hd led to increased satisfaction with care services (9). from the perspective of swedish patients, promotion of hd in homecare nursing was shown to improve patients’ self-esteem and their trust in nurses (28). findings of a study in the scandinavian region indicated that dignified care helps the elderly to better adapt to the community (23). patients in norway who had suffered stroke found that preservation of hd improved their ability to cope with the illness and gave their life a sense of meaningfulness (24). from the viewpoint of cancer patients and their family caregivers in the uk, preserving hd helped patients with their life in the future (15). these findings suggest that the desired consequences of dignified care are social, cultural, moral, mental and spiritual. the results emphasized the importance of addressing factors that affect preservation and promotion of hd in patient care, since ignoring these issues leads to unfavorable consequences in this regard. the findings of a scandinavian study showed that violation of dignity of the elderly increases their vulnerability (23). according to a study in england, cancer patients and their family caregivers believed that neglecting hd in care leads to spiritual and psychological distress and loss of the will to survive (15). in general, the results of the concept analysis indicated that in patient care, preservation and promotion of hd is necessary and its violation leads to unfavorable consequences. in order to prevent the unfavorable outcomes, threatening antecedents must be prevented. to this end, caregivers should be more sensitive to identifying the unfavorable consequences of hd violation in patient care and, while managing them properly, reduce their incidence and subsequent consequences. it should be noted that one of the limitations of this study was our inability to use full text papers published in non-english languages, and this may have resulted in presenting an incomplete image of the examined concept. additionally, analysis of the concept of hd in the care of a specific disease was not performed, and therefore other researchers are encouraged to perform a similar study on a particular illness. conclusion in this study, a clear definition of hd was introduced. through this definition, health policy makers can revise effective care frameworks in clinical settings. since moral patient care with emphasis on hd preservation is an essential component of care provision, it can be concluded that attention to the attributes, antecedents and consequences identified in this study can be useful in better identification of this concept. in addition, awareness of this concept can lead to the promotion of its status, importance and application for medical professionals in the field of clinical ethics as they are deeply involved with the care of patients. through identification of the concept attributes, the medical team will be able to provide a suitable platform for further development of its facilitating antecedents and, as a result, will have more exposure to the favorable consequences of hd care. in addition, recognizing the features of the concept helps the team to reduce the unfavorable consequences resulting from violation of hd in patient care by preventing the occurrence of threatening antecedents. the findings can help develop theories in this regard through clarification of the concept under study. finally, the findings could be a guide for practitioners in the field of medical ethics in order to incorporate this important concept into educational programs for the students. acknowledgements this study was supported by medical ethics and history of medicine research center of tehran university of medical sciences (code no. 28555). conflict of interests none declared. j med ethics hist med 11: 4, april, 2018 jmehm.tums.ac.ir maliheh kadivar et al. page 10 of 11 references 1. aramesh k. human dignity in islamic bioethics. ijaai. 2007; 6 (suppl 5):25– 8. 2. ebrahimi h, torabizadeh c, mohammadi e, valizadeh s. patients' perception of dignity in iranian healthcare settings: a qualitative content analysis. j med ethics. 2012; 38(12): 723-8. 3. lavasani smh, kalantarkousheh sm. the roots of human dignity according to quranic verses. australian journal of basic and applied sciences. 2013; 7(10): 393-7. 4. salehi hr. human dignity from the viewpoint of iranian law. j bioeth inq. 2013; 10(2): 135-6. 5. coventry ml. care with dignity: a concept analysis. j gerontol nurs. 2006; 32(5):42-8. 6. hemati z, 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int j community based nurs midwifery. 2016; 4(1): 36-46. 26. bagheri h, yaghmaei f, ashktorab t, zayeri f. patient dignity and its related factors in heart failure patients. nurs ethics. 2012; 19(3): 316-27. 27. lindwall l, boussaid l, kulzer s, wigerblad a. patient dignity in psychiatric nursing practice. j psychiatr ment health nurs. 2012; 19(7): 569-76. j med ethics hist med 11: 4, april, 2018 jmehm.tums.ac.ir maliheh kadivar et al. page 11 of 11 28. holmberg m, valmari g, lundgren sm. patients' experiences of homecare nursing: balancing the duality between obtaining care and to maintain dignity and self-determination. scand j caring sci. 2012; 26(4): 70512. jmehm-7-2 journal of medical ethics and history of medicine end-of-life care ethical decision-making: shiite scholars' views mina mobasher1, kiarash aramesh2, farzaneh zahedi3, nouzar nakhaee4, mamak tahmasebi 5, bagher larijani6 1 medical ethics phd candidates, medical ethics and history of medicine research center, and medical ethics department, faculty of medicine, tehran university of medical sciences, tehran, iran; 2 associate professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran; 3 md, medical ethics and history of medicine research center, and endocrinology and metabolism research centre,tehran university of medical sciences, tehran, iran; 4 professor, neuroscience research center, kerman university of medical sciences, kerman, iran; 5 assistant professor, palliative care department, cancer institute, tehran university of medical sciences, tehran, iran; 6 professor, medical ethics and history of medicine research center, and endocrinology and metabolism research centre,tehran university of medical sciences, tehran, iran. corresponding author: professor bagher larijani address: 23# 16 azar ave, keshavarz blvd, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. email: emrc@sina.tums.ac.ir tel: 98 21 66 41 96 61 fax: 98 21 66 95 38 32 received: 16 dec 2013 accepted: 30 dec 2013 published: 14 jan 2014 j med ethics hist med, 2014, 7:2 © 2014 mina mobasher et al.; licensee tehran univ. med. sci. abstract recent advances in life-sustaining treatments and technologies, have given rise to newly-emerged, critical and sometimes, controversial questions regarding different aspects of end-of-life decision-making and care. since religious values are among the most influential factors in these decisions, the present study aimed to examine the islamic scholars’ views on end-of-life care. a structured interview based on six main questions on ethical decision-making in end-of-life care was conducted with eight shiite experts in islamic studies, and was analyzed through deductive content analysis. analysis revealed certain points in islamic views on the definition of death and the persons making decisions about end-of-life care. according to the participants, in addition to conventional criteria (‘urf) such as absence of heartbeat and respiration, the irreversible cessation of human voluntary acts (as a sign that the soul has control over the body and the faculty of thinking) are considered to be the criteria in establishing death. the participants also recognized physicians as the main authorities in verifying signs of death. furthermore, it was emphasized that life preservation and continuation of care must be sensible, and the patient can request not to have death-prolonging procedures started or continued. in the view of participants, patient’s autonomy cannot be the sole basis for all measures, but islamic ethical and jurisprudential principles should be relied upon to make correct and sensible decisions whether to continue or stop terminal patients’ care. final decisions should be made by a team of experts, and physicians must be at the center of such a team. finally, we suggest that a guideline in keeping with islamic norms on human life and death, purpose of life, god’s will, boundaries of man’s authority, and the physician’s ethical duties and obligations should be developed. keywords: islamic views, secular views, death, life, terminal patient mailto:emrc@sina.tums.ac.ir j med ethics hist med 7:2 jan, 2014 jmehm.tums.ac.ir mina mobasher et al. page 2 of 11 (page number not for citation purposes) introduction the overall burden of diseases has changed in the past century, and emerging, hard to cure and chronic illnesses have appeared in modern societies. many people become dependent on advanced medical care at some point in the course of their illness and life. in some cases the patient is kept alive despite multiple organ failures, and he or she is deprived of a normal, active life and only continues to have heart and lung function with the help of medical devices and special care. these are referred to as terminal patients, and such measures are called end-of-life care. there are different definitions for terminal patients in various areas of the medical science, but there is consensus that there is no real cure for their underlying illness (1). considering that 85% of the 56 million annual deaths occur in developing countries, if in each case a minimum of 5 caregivers or friends and family members are involved, a simple estimation shows that 300 million people will be engaged in performing end-of-life care worldwide every year. this shows the importance of end-of-life care as a global public health problem (2), and therefore, terminal patients’ care and treatment expenses can be of great significance (3, 4). in view of the increase in population growth during the past decade in iran, it appears that our nation will experience an aging of population in the future (5), which will in turn lead to an increased rate of conditions that specifically affect the elderly (6). in iran, it is estimated that more than 35 thousand deaths occur due to cancer every year, and that is the second largest number of deaths in the whorl health organization mediterranean region (7-9). such diseases entail important economic, social and political outcomes, and will greatly influence the health services industry on account of their dependence on additional resources and the personnel needed to provide care to patients in the final stages of life (6). although there is no accurate estimation of these expenses in iran, a number of cross-sectional studies on some of these diseases, for instance cancer, confirm this fact (4). according to a recent qualitative study, iranian oncologists believed that financial problems were the most influential of issues affecting end of life care decision making and treatment withdrawal of terminal patients (10). access to various treatment and care possibilities has transformed end-of-life decisions and care. today, discussions on life and death from thousands of years ago have been revived, and a newfound necessity to pay deep attention to them is felt. healthcare providers are once again concerned with questions such as: what indicates death? how long and how far should life go on? can patients’ wishes put an end to all these decisions and discussions? or must there be limits to the extent of patients’ wishes? ethical issues in end-of-life decision-making are extensive and have their roots in the four key principles of biomedical ethics, namely autonomy, non-maleficence, beneficence and justice. revival of the topic of end-of-life decision-making confirms the inadequacy of previously existing answers. this is linked to numerous factors, including culture, religion, convictions and beliefs, with religious values being among the most influential (11). acquiring an ethical and legal stance on the subject of end of life in various ethical schools and religions greatly depends on their perception of “dignity of human beings” (11). clearly, perspectives on stopping life-prolonging treatments are contingent on evaluation of the assumed fundamental ethical principles in taking human life (12). from the islamic viewpoint, human life is so valuable that the holy quran equals saving one life to saving the life of all mankind. on the other hand, people’s lives do not belong to themselves, but are divine loans entrusted to them for safekeeping, and must be protected as an indisputable obligation. posing questions and studying views enable us to see the issues that are discussed in this sensitive area in a new light, and to find more accurate and useful answers. this may be a novel attempt at establishing forbidden realms in the practice areas of those offering health services and care to terminal patients. therefore, in extensive research, it is essential to analyze end-of-life issues based on islamic principles of ethical medical decision-making, and to examine the views of shiite muslim thinkers. research and knowledge in this respect is of great importance to healthcare providers. consequently, a study was developed to evaluate islamic views on answers to the questions about ethical decision-making in end-of-life care by conducting interviews with experts in islamic sciences. the six axes of these questions included: indicators of death in religious concepts and the individuals who could determine them, criteria for starting or continuing life-prolonging treatments such as cardiopulmonary resuscitation in terminal patients and the decision-maker in this respect, the patient’s role in decision-making, the financial burden of treatments borne by the patient’s family, and the criteria for choosing between two patients when offering treatment and care. the objective was to clarify answers to these questions from the islamic point of view. j med ethics hist med 7:2 jan, 2014 jmehm.tums.ac.ir mina mobasher et al. page 3 of 11 (page number not for citation purposes) method this study is part of a dissertation for a phd degree in medical ethics approved in the tehran university of medical sciences and authorized by the medical ethics research committee. the dissertation was developed in three sections, and what is presented here is part of the second stage of the study. a deep structured interview with shiite experts in islamic sciences was arranged. participants were initially selected from among islamic experts in areas of jurisprudence (fiqh) and islamic law, philosophy and ethics by consulting the dissertation advisor and committee member. participants were well-known professors in the above-mentioned fields employed in accredited universities and research centers of tehran, and all had research experience in the topic of discussion. a text was then developed on the importance of the subject in the area of medical ethics. additionally, six main questions on ethical decision-making in end-of-life care were devised and developed according to the objectives of the research. a package consisting of the above-mentioned text, the questions, a number of related articles, and a letter requesting participation in the interview were sent to the participants’ workplace. approximately 2 to 4 weeks after the package was sent out, appointments were made with each of the participants in their workplace. consultation meetings and deep semi-structured interviews were held between one principle researcher and eight of these respected experts. after gaining their consent to audio recording, the interview was conducted which lasted 60 to 90 minutes, and was mainly structured around the 6 afore-mentioned questions. audio recordings were transcribed, typed and laid out for content analysis. for the purpose of confidentiality, audio recordings and hard copies were filed in a safe place with restricted access. content analysis was performed using the deductive method1. in this study we aimed to examine islamic viewpoints on ethical decision-making in end-of-life care, and to acquire a novel method and approach in a new context to ask some well-known experts in islamic sciences questions on the subject, and retest existing concepts. the content analysis process was conducted in three main phases: preparation, organizing and reporting. after the interviews were conducted and implemented, the words and discourse were classified into smaller content categories. the preparation phase started with selecting each 1 deductive content analysis is used when the structure of the analysis is prepared beforehand, and the research objective is to test a theory, so it moves from the general to the specific. in fact, the researcher aims to retest existing data in a new context. thus, new concepts, models and hypotheses can be tested (13). question as a unit of analysis. the most suitable unit of analysis was therefore all the texts related to the question. during the process of analysis, we read the texts several times in order to become immersed in the data. the next step in the analysis was to develop a categorization matrix. in this study, the structured categorization matrix was prepared based on the questions (tables 1 through 6). after developing the matrix, once more the data were reviewed for content and coded for correspondence with two or more concepts or typical exemplification of the categories. based on the analysis, the general response to each question was extracted. credibility, reliability and transferability methods were used to increase scientific reliability and validity of the results2. results for this study, experts in islamic sciences were identified, and the following were then interviewed: three researchers in islamic philosophy from the institute of wisdom and philosophy, two experts in islamic law and jurisprudence from the university of tehran and shahid beheshti university, two experts in islamic philosophy and ethics from humanities and islamic research centers in tehran, and one islamic ethics expert from the faculty of traditional medicine of the tehran university of medical sciences. the abovementioned experts were selected based on their expertise and research backgrounds. the participants’ respective responses to each question are presented below. 2 constant involvement, integrated research, supervisor reviews, probing for contrary evidence and credibility of the researcher were measures that were taken to increase research credibility. the researcher tried to follow the data as an outside evaluator by including his personal views within parentheses, reviewing and continuously perfecting his notes, and fully comprehending them. regarding reliability or accuracy criteria of the present study, a detailed report on the research process has been presented, and the researcher has tried to fully explicate all stages of the research from data collection to content analysis and formation. as regards transferability, a precise and extensive description of the research process and the methods of attaining data make it possible for the reader to evaluate applicability of the results to similar contexts. therefore, in addition to clarification of the area under study, necessary information on the participants and direct quoteswere measures taken in this respect (14). j med ethics hist med 7:2 jan, 2014 jmehm.tums.ac.ir mina mobasher et al. page 4 of 11 (page number not for citation purposes) question 1: what is the criterion for death in religious concepts? who can determine this criterion and how? the participants’ views on this question were classified under four categories: jurisprudence (fiqh), philosophy, law and medicine (table 1). in response to this question, various criteria were proposed for determination of death. among them were the traditional indicators such as absence of heartbeat and respiration, presence of human voluntary acts as a sign that the soul has control over the body, faculty of thinking, and the medical criteria for death. one thing stands out in the viewpoints expressed by the participants though, and that is the emphasis they place on joint decisions and expert opinions. in fact, the people interviewed in this study all agreed that death should ultimately be verified by a physician. table 1. classification matrix of question 1 field opinions jurisprudence (fiqh) “in the past, before the concept of brain death existed, the fatwa of fuqaha (islamic experts) was quite clear. they would look for signs of death, for instance the body becomes cold, the heart stops beating, breathing stops, and the combination of these symptoms would indicate death.” “they typically consider the heart.” “in jurisprudence (fiqh), sometimes common conventions apply and sometimes individual principles in cases of conflict of the commandments, however, matters can be so complicated that the common conventions may not be sufficient, and therefore expert opinions are required…” philosophy “the ability to perform voluntary acts is the criterion for being considered alive. as long as the soul has control over the body, the person is alive in my opinion.” law “brain, faculty of thought and intellect can be quite helpful in resolving end of life issues. the power of thought and its sanctity has been much discussed and emphasized in sharia. thinking is what preserves humans and brings them responsibilities.” medicine an expert must determine whether a patient is dead or alive, and that expert is undoubt-edly the physician here. medical science must verify death. question 2: what are the determining criteria for starting or continuing life-prolonging treatments in terminal or dying patients? the participants’ responses and viewpoints in this respect were divided into four categories: jurisprudence (fiqh), law, ethics and medicine.(table 2) regardless of their standpoints, the participants believed that life-prolonging treatments should not aim at keeping the patients alive only to save their lives, and health care providers need to take other factors into account as well. from the point of view of islam and jurisprudence (fiqh), for instance, it was mentioned that life is considered valuable and therefore needs to be saved, although this is a sufficiency duty, and conventional wisdom must be applied so that it is done in a rational manner. on the other hand, it was pointed out that according to islamic commandments, prolonging death must be avoided by all means. from the legal standpoint, presence of human intellect in the patient was the determinant for continuation of life prolonging treatments. what stood out in this section of the interview were the responses from the ethical perspective, as those indicated the most important criteria to be the moral obligation to save the patients’ lives and respect their wishes. they also emphasized that in this stage of life, spiritual values, human development and dignity, and other ethical values be considered, and decisions be based on the totality of the situation. the decision to stop life-prolonging treatments should therefore not be confused with or compared to euthanasia. question 3: in cases where there are doubts or disagreements about resuscitation, or if life prolonging treatments entail great expenses, who should make the final decision? the responses were divided into two categories: jurisprudence (fiqh) and medicine (table 3). in general, the participants believed that based on islamic teachings, people cannot endanger their lives and request a do-not-resuscitate (dnr) order, euthanasia, or hastened death, but if there is no cure, they can refuse death-prolonging procedures. the ultimate decision-maker, however, is a physician-centered team of experts, as physicians would know best whether the patient should be saved or not. opinions of a number of other experts in fields such as religion (faith) and philosophy must be solicited in this respect as well. j med ethics hist med 7:2 jan, 2014 jmehm.tums.ac.ir mina mobasher et al. page 5 of 11 (page number not for citation purposes) table 2. classification matrix of question 2 field opinions jurisprudence (fiqh) “resuscitation is a moral obligation and one decreed by sharia, and to answer the question of how long it should go on, i would say until there is no more hope.” “life inherently belongs to god. god is the one who gives it, and the one who takes it. and if someone has the ability to save a life, he or she is responsible for doing so. the criterion here is conventional wisdom (aghle urfi).” "the obligation here is to avoid prolongation of death." law “when a person is alive, they should be protected, and nothing should be done to hasten their death. therefore the stance of legislators and god almighty on human dignity is an entirely spiritual one, as is stated in the verse ‘we created man dignified and superior’. this spiritual life originates from intellect, and if we are incapable of restoring this faculty to the patient, we are tormenting her/him.” ethics “under ideal circumstances, it is unethical to disregard the patient’s will. it is a moral obligation to listen to them and act on their will, unless a greater predicament arises, which should then be resolved by a committee similar to a jury. such a predicament is not a medical issue; it depends whose case is being discussed, what the hospital conditions are, and what the cultural situation is. prioritization of the case components is essential, for instance the value of human dignity, life preservation, and unbiased resource allocation. the results, however, cannot be predicted by any kind of algorithm.” “the obligation to save a life, when it is unstable (ghayrmustaqarr) and will not last, in case of an ailment that is incurable... does the obligation apply to saving such a life? saving it is definitely preferable, but as for obligation, i believe it is not obligatory. obligation applies to cases where life is stable (mustaqarr), and if it is not in conflict with other moral obligations. it also depends on whose life needs to be saved: it might be a person who plays an important role in the society, and therefore it is important to extend his life, even if for only 10 more days.” medicine life should be sustained for as long as it is sustainable. human life is dignified. decisions need to be made based on the patient’s situation. table 3. classification matrix of question 3 field opinions jurisprudence (fiqh) “one must be prepared and write a will for the sake of one’s family. sometimes a patient says that if the sickness gets to a stage where there is no cure, the family does not need to spend money and should just let the process of dying not be prolonged.” "conventional criteria for prolongation of the dying process are definitely noted by fuqaha". medicine “the authority here is the person who knows better than anyone else whether this should be done. in the absence of respiration, a medical committee must be appointed to determine whether or not to start life saving procedures.” question 4: what is the patient’s role in consenting to or refusing life prolonging treatments? can a person make recommendations or decisions regarding future healthcare treatments beforehand, or write a will in this regard? the statements of participants were categorized under the four groups of jurisprudence (fiqh), law, ethics and medicine (table 4). it appears that there are disagreements as to the role of the patient in making decisions about future care and life prolonging treatments. from the jurisprudence (fiqh) and legal point of view, it is clearly stated that such patients have no authority over their bodies and cannot make decisions about ending their lives. patients can ask health care providers not to prolong the process of dying only if there is no cure, and this is considered to be among the patients’ rights. from the ethical stance, however, a completely different theory was proposed: that patient autonomy was rather important and that the patient’s wishes had to be respected. all respondents agreed on the significance of informing the patient, however, and believed that the final decision must be made by the physician. j med ethics hist med 7:2 jan, 2014 jmehm.tums.ac.ir mina mobasher et al. page 6 of 11 (page number not for citation purposes) table 4. classification matrix of question 4 field opinions jurisprudence (fiqh) “truth telling and the manner in which the direness of the situation is revealed to the patient is very important. the patient can make decisions about care and refuse a particular treatment. he or she does have a say in methods and extent of health care and similar matters.” “patients themselves cannot make decisions about saving their lives, that is, their decisions cannot prevail as they are not theirs to make. law “it is the patient’s right to refuse treatment, and he or she can exercise that right through a will.” ethics “it is unethical to disregard the patient’s wishes, so i believe the general philosophical principle of autonomy and having control over one’s body is fundamentally defendable, unless circumstances deem it inapplicable.” medicine “decision makers in this respect should be those who are informed about saving lives, so the responsibility falls mainly to the physicians, and they are the ones who should pass the final verdict.” question 5: what should be done if the financial burden of treatment is too much for the family to afford? three components of health system, patient and family were recognized in the responses of participants (table 5). by application of islamic jurisprudential principles, our participants examined strategies to avoid such expenses from the stance of the health system and the patient’s family, and maintained that if the patient can afford the expenses, end-of-life treatments should be continued to a reasonable extent. if he patient’s family or the health system is paying for the treatments, their resources must be considered in addition to sensibility of care. if they cannot afford the treatments, they cannot be held responsible, and financial hardships (al-‘usr wa alh.araj) imposed on the family releases them of their sharia obligations to keep the patient alive. nevertheless, the moral obligation to save lives and its value in the society were mentioned, and it was emphasized that financial hardship should be determined by a team of experts and a judge who rules in accordance with sharia. table 5. classification matrix of question 5 field opinions health system “if the system has the capacity, then treatments should be continued, and if not, it falls under the category of unbearable financial hardship (al-‘usr wa al-h.araj)." patient "patients should not continue to remain uninformed and use up all their possessions and deplete their family’s means. informing patients of the direness of their situation must occur in a responsible manner.” "in my opinion, financial hardship cannot be confirmed by just anyone, and it should be determined by a judge who rules in accordance with sharia." family “if my father is the person in this situation, i must say i feel a sort of moral obligation toward him that i do not feel toward many others. it is ethically quite valuable if the society believes that people must try and save their parents’ lives under such circumstances.” question 6: if limitations in resources necessitate choosing between two patients, what are the criteria for making this choice and offering health services? the responses were placed in three categories: jurisprudence (fiqh), ethics and health system (table 6). our participants believed that there should be certain criteria for determining which of the two patients had to be saved. from the standpoint of jurisprudence (fiqh), these criteria were regulations on dispensing public funds, and the jurisprudence (fiqh) principle of the most important and the important (aham va mohem). from the ethical viewpoint, moral values and obligations were mentioned, and that life preservation should not be the only objective; other matters that need to be considered are human dignity, fair allocation of resources and other moral values, and that preserving life must be done in a sensible manner. likewise, it was emphasized that the capacities and regulations of the health system should be taken into account, and conventional precepts must be acted upon. therefore, although the participants adopted different stances on the subject, they noted the limitations and stated that in complex situations a team of experts must be the joint decisionmakers. j med ethics hist med 7:2 jan, 2014 jmehm.tums.ac.ir mina mobasher et al. page 7 of 11 (page number not for citation purposes) table 6. classification matrix of question 6 field opinions jurisprudence (fiqh) “regulations regarding the dispensing of public funds can be specified through fatwa, which will be based on what is conventional (‘urf). resuscitation is an obligation, but it is contingent on the circumstances and facilities.” “if there are medical limitations, conflicts (tazahom) may arise. for instance, continuing to dedicate medical equipment to a terminal patient will deprive other non-terminal patients from it. this is a conflict between two important things, but one is more important than the other. it is therefore acceptable if the physician stops life prolonging treatments for the terminal patient and lets the other patient use the medical equipment. fuqaha unanimously believed that such an action is permissible.” ethics “the criterion here is conventional wisdom (aghl ‘urfi). choices must be made based on priorities. at this point, spiritual principles and the society’s welfare from the point of view of human development are the criteria. according to determination criteria, the right to live is also a form of spiritual development, so it should be determined whether saving such a life will lead in that direction.” “this should be done if it does not conflict with other moral obligations. there are criteria of this sort, criteria of intellect, and there must be no cases of extremes, such as saving someone’s life when it is entirely senseless to do so.” health system “if public funds must be expended and insurance is in effect, there should be regulations. the best reference is the medical ethics committee, as it acts according to the regulations and functions of the health system. limitations in human resources result in the responsibility being assigned to human intellect.” discussion in the present study, participants mentioned different jurisprudential, legal, philosophical and ethical standards in answering the questions. in speaking of death, generally the definition and criteria for death are mentioned. from the islamic point of view, death is defined as the separation of the soul from the body that happens in the real world and indicates death of the human body (15). the exact moment of death can be determined through clinical symptoms, and even the imams have pointed these symptoms out (16, 17). the true nature of the relationship between body and soul is the main topic of discussion in determining the criteria for death. the soul is a sign of life (18, 19). the immaterial soul can have control over the body and bring about manifestations of faculties such as thought, resolution and free will, and while its command continues, human life carries on (20, 21). it is essential to determine a criterion for death to indicate that the body and soul are separated. from the point of view of jurisprudence (fiqh), common conventions (‘urf aam) are observed, so absence of heartbeat or respiration are viewed as indicators of death (20, 22, 23). also participants in our study mentioned common conventions (‘urf aam). with the emergence of current diseases and new treatments, these conventions have been questioned. physicians believe that all parts of the human body work together as a whole organism and when vital organs stop functioning, life cannot go on (18, 24). on the other hand, physicians are now able to prolong life by using medical devices and facilities, and this adds to the confusion about the criteria for death. there certainly exists no doubt in considering cardiac death as a criterion for death in any of these areas. what is not so certain is the case of brain death, as well as those patients considered terminal, as cardiac or brain death do not apply in their case, while they cannot continue to exist as an organism either, unless medical devices and facilities are used to keep them alive. another concept in jurisprudence (fiqh) is that of stable (mustaqarr) and unstable life (ghayr mustaqarr) (18, 25, 26), which may be useful in making better decisions about life-prolonging treatments in terminal patients suffering from multiple organ failure. these patients are not dead according to any of the criteria, but based on the concept of unstable life, they are already moving toward the separation of body and soul (25, 26), and therefore measures such as cardiopulmonary resuscitation cannot help them. by applying these concepts, futile care takes on a clearer meaning. furthermore, in cases of unstable life, the patient is unable to go on living, and the process of separation of body and soul has already started. the same interpretation, however, makes decision-making different in the case of patients with multiple organ failure, as any form of life is grounds for attempting to save it according to islam. participants in our study considered preserving human life an obligation according to sharia, which may necessitate using all facilities to save even moments of a person’s life (16, 22, 27). in resolving these situations, the status quo of diseases and health system facilities are naturally taken into account and affect people’s responses. the participants in our study were of the opinion that special attention needs to be paid to diseases and advantages in treatment, and therefore emphasized the jurisprudence (fiqh) principles of illegitimacy of harm (la darar wa la dirar) and financial hardship (al-‘usr wa al-haraj), and stated that life j med ethics hist med 7:2 jan, 2014 jmehm.tums.ac.ir mina mobasher et al. page 8 of 11 (page number not for citation purposes) cannot go on indefinitely, but it has to be done sensibly, and capacities must be taken into consideration. one of the most important points that muslim thinkers have always referred to regarding patients’ resuscitation and life preservation (16, 22, 27) is sanctity of human life, and respect for all people’s right to live; moreover, it is emphasized that life is a gift from god: he gives and takes life, and all life and death come to be by his permission (28). these valuable concepts can be found in a number of verses in the holy quran3. for this reason, decisions in this respect cannot be left to patients, their families, or the physician alone (22, 27) and must be based on suitable criteria. they declared that correct decisions can be made about such patients by referring to valuable islamic teachings, including those stating that the process of dying should not be prolonged (29), and that accepting death as the will of god is something that muslim physicians must keep in mind (28, 30). they can use islamic teachings to determine the advantages and objectives of treatments for different patients in addition to the medical science (31, 32). several studies have cited jurisprudence rules such as the principle of illegitimacy of harm (la darar wa la dirar), and encourage muslim physicians to use procedures that are useful and beneficial (33). nevertheless, studies show that there is no clear directive on the do not resuscitate order in islamic sources, and this issue has not been fully resolved (34). sources have repeatedly pointed out, however, that physicians are permitted to stop offering futile treatments (18, 23, 35-37). like the participants in this study, these sources leave the decisions about complicated cases, especially terminal patients, to a team of experts in various fields, who would make the decision to continue or stop lifeprolonging treatments by examining the situation thoroughly and respecting the patients’ and their families’ requests (18, 35, 38, 39). furthermore, this issue has been observed in the iranian patient’s rights charter and there is emphasis that the aim of care should be the comfort and welfare of patients who are terminal and their death is inevitable (40). regarding the challenges of the patient’s right to making choices and decisions, one respondent stated that a person’s autonomy extends as far as god will allow it. god limits the patients’ autonomy for ending one’s owns life, and requires them to decide based on their best interests. there seems to be disagreements in this respect among the participants in our study. it was emphasized that physicians must tell capacitated patients the truth about their conditions, 3suraal-ma'ida, verse 23 suraal-hadid, verses 1 & 2 sura al imran, verse 145 sura al-baqara, verse 258 and patients should have the right to decide against life-prolonging treatments, and it was considered the patients’ right to voice their opinions in such cases. in agreement with our participants, other scholars believe, however, that patients cannot ask for their lives to be ended, even though muslims’ wills and wishes are greatly respected in islamic sources (29, 39). a will should not be valid in case of incapacitated patients (41). it appears therefore that from the islamic point of view, such decisions cannot be left to patients simply on account of autonomy and free will, and wills cannot be written on the subject beforehand. nevertheless, the patient’s wishes regarding prolongation of the dying process, particularly in the case of incurable diseases, must receive careful attention from the medical team. in discussions surrounding end-of-life care, one challenging issue is the expenses borne by families and the health system. such as the results of this study, other islamic resources have emphasized that the patients’ welfare must not be the only focus of attention. saving such patients’ lives will be in conflict with their families’ interests and can pose financial hardships (al-‘usr wa al-haraj) (42). considering the principle of illegitimacy of harm (la darar wa la dirar), the patients’ interests should not result in harm to their families, so they will not be responsible to save the patient’s life. it is emphasized that stopping such patients’ treatment must not be confused with euthanasia, as they have no hope for a cure or normal life (30, 43). on the other hand, saving one’s parents’ lives was applauded as a moral value in a society. limitations in the resources of the health system bring us face to face with prioritization and choosing between patients when offering health services. particularly in cases where patients suffer from incurable diseases, choosing to continue treatment or allow the normal process of dying to take place is a great challenge for physicians, the society, and the patients’ families. islam also focuses on saving lives sensibly and the capacities of the health system. in islamic sources there is emphasis on the principle of greater importance (aham va mohem) (42), based on which the level of importance is measured, and facilities that must be dedicated to patients whose lives can be saved sensibly. some sources consider limitations and recommend use of invasive procedures and better allocation of resources (44). the experts we interviewed also emphasized that in addition to unbiased resource allocation, man’s spiritual growth and development must be considered and keeping patients alive should not be the only principle. in other words, islam lays emphasis on the benefits of treatments and considerations on their futility in choosing between patients. limitations of this study: interviews were conducted with a limited number of experts in j med ethics hist med 7:2 jan, 2014 jmehm.tums.ac.ir mina mobasher et al. page 9 of 11 (page number not for citation purposes) islamic sciences due to accessibility issues. almost all participants were usuli4. considering the fact that our social studies and information on end-oflife care are limited on the level of patients, the society and the health system, we tried to ask fewer questions so that the initial evaluations could be performed in a practical manner. conclusion the aim of examining ethical issues in end-oflife care in an islamic society is achieving a process for making correct and accurate decisions when treatments are futile to start or continue. such a process must be in keeping with the principles of the society and the health system, and should be capable of offering quantitative and practical solutions. ultimately, ethics committees and multispecialized teams in medical centers must be consulted in complicated cases, and the need for complaints to authorities must be minimized through the above-mentioned process. with this approach, value-orientedness is not a hindrance, as it guides us in our path and helps healthcare providers for making better decisions. thus, considering the sanctity of human life and the value of man’s existence, treatments that bring about severe consequences and violate human dignity are not continued. terminal patients or those with multiple organ failure will not be subjected to futile and invasive procedures such as cardiopulmonary resuscitation or surgeries. valueorientedness leads to a balance in offering health services. 4 “usulis are the majority shiite muslim group. they use of ijtihad i.e. reasoning in the creation of new rules of jurisprudence (figh). they believe that the hadith collections contain traditions of varying degrees of reliability, and that critical analysis is necessary to assess their authority” (45). in islamic viewpoint, although patient autonomy cannot be the basis for all measures according to islam, ethical and jurisprudential principles can be used to make correct and sensible decisions whether to continue or stop terminal patients’ care. it seems necessary to develop a guideline that can assist decision-makers regarding end-of-life care through emphasis on islamic principles and islam’s valuable notions of human life and death, purpose of life, god’s will, boundaries of man’s authority, and the physician’s ethical commitments. such a guideline can be used to clarify limitations and solutions to the ethical problems posed by endof-life care, and offer recommendations on making the right decisions about starting or continuing procedures that seem futile based on scientific considerations. acknowledgment the authors wish to express their deepest gratitude and warmest appreciation to the following people who in any way have contributed and inspired the researchers to the overall success of the undertaking: to islamic scholars who have participated in interviews and dr. sayed mahmood tabatabaei for his guidance in providing the interview guide. this study was supported by a grant (number 91-03-50-19313) from the research deputy of tehran university of medical sciences. conflict of interest the authors declare that there is no conflict of interests. j med ethics hist med 7:2 jan, 2014 jmehm.tums.ac.ir mina mobasher et al. page 10 of 11 (page number not for citation purposes) references 1. 1gavrin jr, mcmenamin em. pain management in palliative care oncology patients. curr pain headache rep 2008; 12(4): 257-61. 2. singer pa, bowman kw. quality end of life care: a global perspective. bmc palliat care 2002; 1: 1-10. 3. niezen mgh, stolk ea, steenhoek a, uyl-de groot ga. inequalities in oncology care: economic consequences of high drugs. eur j cancer 2006; 42(17): 2887-92. 4. farokhi mr, holahooii naiini k, haghdoost aa, emami a. cost of cancer in kerman. iran j epidemiol 2012; 8(1): 6270. 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[in persian] 43. saiyad s. do not resuscitate: a case study from the islamic viewpoint. j islam med assoc north america 2009; 41: 10913. 44. takrouri m, halwani t. an islamic medical and legal prospective of do not resuscitate order in critical care medicine. internet j health 2008; 7(1). 45. wikipedia. the definition of usuli. http://en.wikipedia.org/wiki/usuli (accessed in 2014) http://siasat.behdasht.gov.ir/index.aspx?siteid=291&pageid=34985 http://en.wikipedia.org/wiki/usuli nurse ethics 5 (415)final journal of medical ethics and history of medicine original article the lived experiences of clinical nurse managers regarding moral distress alireza nikbakht nasrabadi1, mitra khoobi2*, mohammad ali cheraghi3, soodabeh joolaei4, majid ahmadi hedayat5 1professor, school of nursing and midwifery, tehran university of medical sciences, tehran, iran. 2phd candidate of nursing education, medical-surgical group, school of nursing and midwifery, tehran university of medical sciences, tehran, iran. 3 professor, school of nursing and midwifery, tehran university of medical sciences, tehran, iran. 4professor, school of nursing & midwifery, nursing care research center, iran university of medical sciences, tehran, iran. 5msc, research deputy of applied sciences university, ibn sina hospital, tehran, iran. corresponding author: mitra khoobi address: school of nursing and midwifery, tohid sq., tehran, iran. email: mitra.khoobi@yahoo.com tel: (+98) 21 66 92 55 60 received: 29 may 2018 accepted: 9 june 2018 published: 26 sep 2018 j med ethics hist med, 2018, 11: 13 © 2018 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract ethical management with minimum moral distress is one of the main duties of nurse managers. there is no doubt that a better understanding of the experiences of nurse managers in morally challenging situations could have an effective role in improving health care systems. the present study aimed to investigate the lived experiences of clinical nurse managers regarding moral distress. this hermeneutic phenomenological qualitative research involved the use of semi-structured interviews with nurse managers. the interviews were transcribed and analyzed by the diekelman, allen and tanner approach. for this purpose, a total of 14 iranian nurse managers with at least five years of experience in nursing management in hospitals were purposefully selected. the findings related to nurse managers’ experiences of moral distress contained two main themes (psycho-emotional trauma and professional desperation syndrome) and four sub-themes (shame, emotional dissociation, helplessness, impaired professional identity). the findings of the study indicated that in order to understand the phenomenon of moral distress among nurse managers, it is essential to investigate the moral distress experienced by them. we also found that although they experience moral distress in their daily decisions repeatedly, they are not fully aware of this phenomenon according to the results, for clinical nurse managers, moral distress is an ambiguous situation like suspension along with uncertainty, fear and so on. they believed that experiencing this kind of conscious mistake is the reason for the occurrence of professional desperation syndrome and psycho-emotional trauma. keywords: nurse manager, lived experience, moral distress, desperation syndrome, psycho-emotional trauma mailto:mitra.khoobi@yahoo.com j med ethics hist med 11: 13, september, 2018 jmehm.tums.ac.ir alireza nikbakht nasrabadi et al. page 2 of 10 introduction moral distress is a kind of response by human beings to a situation in which the individual is prevented from performing or following-up a right, moral act. in general, moral distress is a psychosomatic phenomenon that would cause a feeling of discomfort and dissatisfaction in the individual at any time (1). since moral issues are intertwined with the nursing profession, moral distress has become a serious concern for nurses (2). the canadian nurses association has defined moral distress as having painful emotions in a situation where the correct and ethical act is known but cannot be performed (3). therefore, when experiencing moral distress, individuals act against their personal and professional principles (1, 2, 4 6). although moral distress is a part of the conditions governing human beings, nurses’ experiences of moral distress were first addressed about 5 or 6 decades ago (7, 8). the importance of moral distress in nursing practice has been mentioned in various studies and has been discussed in the american nurses association and north american nursing diagnosis association (6, 9). most of the international and national studies in the field of moral distress have been performed on clinical nurses, especially those working in critical care units. the focus of most of these studies has been on moral distress in the context of poor interprofessional communication, professional ethical environment, physician-nurse relationship, and nurse-patient relationship (10 15). however, there are about 2.5 million nurses in america, and about 10% of them (250,000 nurses) hold managerial positions (16). in iran the number of employed nurses is between 140,000 and 150,000, and about 10 percent of them (14,000 nurses) are managers in public and private sectors (17, 18). strategically, nurse managers have a unique position in the health system as their actions, behaviors and decisions have the greatest impact on their work environment and the profession in general (19, 20). a managerial work environment free from moral distress affects not only the managers, but the personnel as well (21, 22). clinical nurse managers in these environments should play the role of managers, facilitators, supervisors and advocates. the latter role pertains to caregivers and therapists (physicians and nurses), clients (patients and their families), and organizations (health organizations or centers, and the executive and supportive management body). in addition to all these duties, nurse managers should consider resource allocation in accordance with their organizational policies and rules. under the circumstance, role duality, moral distress and tension will occur as a result of an imbalance between the needs and values of the organization, nurses, patients and their families. respecting moral standards for decision-making is associated with tension in every field (22 25). ethical management with minimum moral distress is the main duty of nurse managers (26). since managers’ performance is one of the effective factors in the improvement of efficiency, effectiveness and eventually organizational productivity, the efficiency of nurse managers is of utmost importance in the success of health systems (25). it is clear that managerial levels affect all stratums of care. therefore, nurse managers require an environment free from tension and distress so that they can achieve effective care outcomes and job satisfaction along with the rest of the medical team (27, 28). in the reviewed national and international articles published between 2005 and 2016, no comprehensive report was found on nurse managers’ experiences of moral distress. however, some studies have shown that when clinical nurse managers encounter moral challenges and conflicts, their responsiveness to their organization, colleagues, and patients and their families will be affected (15). a review of former research produced numerous studies with a focus on clinical nurses during recent years. it seems essential, however, to conduct studies on nurse managers’ moral distress due to the sensitivity of their job and constant involvement with unplanned or even routine decisions (23). therefore, a better understanding of the experiences of nurse managers in the field of moral distress could greatly improve occupational satisfaction, efficiency, effectiveness and organizational productivity, nurses’ health and their professional relationships, identity and self-esteem; other outcomes may include creation of a favorable and growing organizational climate, enhancement of patient safety, and a decrease in occupational burnout and quitting. eventually, all these factors would bring about an overall improvement of the quality of care, which is the end goal of every health system (13, 14, 29,34). we hope that the results of the present study will improve the performance of clinical nurse managers in decision-making and direct their actions and managerial activities toward moral decision-making. in fact, picturing the lived experiences of clinical nurse managers in their occupational context can help their managerial group resolve the moderator obstacles to moral distress. as a result, they will be able to make more appropriate moral decisions and decrease their moral distress. the most important product of phenomenology is gaining insight into a j med ethics hist med 11: 13, september, 2018 jmehm.tums.ac.ir alireza nikbakht nasrabadi et al. page 3 of 10 phenomenon, which adds to the nursing profession's knowledge in this field. considering that ethical decision-making by nurse managers is the most important aspect that affects the overall quality of nursing care, this insight can increase nurse managers' ability to fulfill their management role in a more effective, holistic and comprehensive manner by enhancing the power of moral reasoning. method the present study was based on qualitative research. the author used hermeneutic phenomenology to find an appropriate answer to the research question about clinical nurse managers’ lived experiences of moral distress. participants in the present study were 14 clinical nurse managers including matrons, supervisors and head nurses. participants had at least five years of nursing management experience in hospitals, and therefore boasted rich experiences of the subject. the study was performed in places where the participants lived their professional lives as clinical nurse managers. interviews were conducted in the teaching hospitals affiliated with tehran university of medical sciences. in the present study, the main method of data collection was in-depth semi-structured personal face-to-face interviews. interviews lasted from 40 to 75 minutes. fourteen participants (six men and eight women) were selected based on the mentioned criteria and using purposeful sampling method. the effort was to select participants with maximum diversity. the topic of the study was rather subjective and required pre-contemplation on the part of the participants to understand and remember the experiences. accordingly, the researcher visited the study environment one week before every interview and gave the prepared narrative paper to the participants to ensure their understanding of the study topic. this paper included the title of the study, its aim, and definitions of the words and concepts. also, it requested the participants to explain one of their experiences of moral distress in detail. on the day of the interview, the completed papers were gathered so that a comprehensive analysis could be performed on the data at the same time the data transcription took place. interviews started with open questions such as “what comes to your mind when you hear the term ‘moral distress’?” or “what does moral distress mean to you?” then the interviews continued with more focused questions in line with the topic of the research, which was the nature of clinical nurse managers’ lived experiences of moral distress. four of the participants needed to be interviewed twice to clarify the ambiguous points in their first interviews. data analysis data analysis was performed in line with the aim and method of the study using the diekelmann, allen and tanner method (1989), which is a seven-stage process based on hermeneutic phenomenology (35). accordingly, the interviews were transcribed verbatim after being repeatedly reviewed on the same day. the transcriptions were reexamined several times to gain a comprehensive understanding of the data. subsequently, key phrases in the texts were marked as the meaning units. at the next stage, the entire texts of the interviews and narrative papers were reviewed and the interpretative summary was written. considering the emphasis of phenomenology on discovering the meanings of phenomena, the researcher’s effort was to search for and extract all the main and sub-themes during the data analysis process based on the “lived experiences of clinical nurse managers regarding moral distress.” to explain, categorize and resolve any disagreements and conflicts in the interpretations, the process of referring to the texts or the participants was regularly performed through phone calls and direct contacts. the process of consensus of the ideas and extracted concepts led to the formation of subcategories. during the next steps, and by eliminating similar or overlapping and merging options, the subcategories became more comprehensive and the main themes were formed. ethical considerations the study protocol was approved by the irb of the tehran university of medical sciences; register number 9323199001. we provided the necessary information about the goals and method of the study to the potential participants and obtained their written informed consent at that time. the participants also provided permission for recording the interviews; moreover, they were reminded of their right to withdraw from the study at any time and were assured that their confidentiality, including anonymity and data protection, was valued. study rigor concepts of credibility, confirmability, auditability and transferability were used for maintaining the rigor of the study (35, 37). credibility of the study was evaluated by keeping a prolonged engagement with the data (more than 12 months), and employing the member and peer checking techniques. after the analysis, the participants were contacted and given a full transcript of their respective coded interviews with a summary of the emergent categories to approve the interpretations of the researchers. the study process was checked by expert supervisors and two doctoral students of nursing, and all evidence and documents were saved securely to maintain auditability. moreover, an adequate thick description j med ethics hist med 11: 13, september, 2018 jmehm.tums.ac.ir alireza nikbakht nasrabadi et al. page 4 of 10 of the context was carried out so that a judgment of transferability could be made by the readers. results the findings related to nurse managers’ experiences of clinical moral distress contained two main themes and four sub-themes. these themes were the result of 18 interviews with 14 participants. the main themes were psycho-emotional trauma and professional desperation syndrome. psycho-emotional trauma contained the subthemes of shame and emotional dissociation. the second main theme was professional desperation syndrome, with the subthemes of helplessness and impaired professional identity. table 1 presents the demographic characteristics of the participants, and the themes, subthemes and their meaning units are shown in table 2. table 1a summary of the participants’ demographic characteristics interview duration (minutes) managerial position hospital years of service education level marital status age gender number 65 matron public 20 bs married 45 female 1 70 supervisor public 5 bs single 28 male 2 50 head nurse private 10 ms married 31 male 3 55 matron public 25 bs married 51 female 4 60 supervisor private 6 ms married 30 female 5 45 supervisor private 5 bs single 32 female 6 55 head nurse public 5 bs married 27 female 7 40 head nurse public 10 bs married 33 male 8 45 head nurse public 7 ms married 26 female 9 45 matron private 18 bs married 40 male 10 50 supervisor public 9 bs married 25 female 11 45 head nurse private 10 phd single 34 female 12 75 supervisor private 13 phd married 39 male 13 60 matron public 10 ms married 35 male 14 table 2achieved results from the participants’ experiences main theme subtheme meaning units psychoemotional trauma shame words sticking in one’s throat being crushed under the hidden mental pressure endurance of nervous pressure being stuck in a weak position feeling heaviness in the heart self-blame feeling ashamed the tendency to disguise oneself regret and remorse feeling sorrow and hatred emotional dissociation having a breakdown collapsing conflictcontradiction and duality inconsistency, struggle and contradiction between learning and performance a sense of paradox emotional destruction professional desperation syndrome helplessness loneliness the sense of being in a black hole isolation self-absorption depression lack of motivation unpleasant feeling of doing the wrong thing sadness and sorrow associated with wrong decisions spiritual suffering mental and spiritual disorganization mental disorder and disturbance fear and discomfort mental destruction distress exhaustion stress concern anxiety the sense of burnout lack of energy while working disappointment intellectual inability and disability impaired professional identity lack of courage to perform one’s duties decline of professional relationships stepping out of the professional mission impaired occupational integrity professional incompetency feeling of incapability professional irresponsibility decreased professional self-esteem disruption of teamwork professional dishonesty main themes: ∑ psycho-emotional trauma: psycho-emotional trauma was one of the main themes of moral distress among clinical nurse managers, and contained the subthemes “shame” and “emotional dissociation.” this theme indicated that clinical nurse managers’ experiences of moral distress had been associated with resentment, selfblame, and lack of peace of mind. furthermore, j med ethics hist med 11: 13, september, 2018 jmehm.tums.ac.ir alireza nikbakht nasrabadi et al. page 5 of 10 some of the managers mentioned a kind of moping and embarrassment that accompanied them at all times. they also stated that tolerating the pressure for a long period would lead to breakdown and collapse. a) shame the first subtheme was shame, which is defined as feeling embarrassed or guilty because of one's actions, characteristics, or associations. in this regard, nurse managers from various levels stated that when an individual knows right and wrong but is forced to do the wrong thing for organizational reasons or on account of the work environment and lack of supportive laws, he or she will experience incomprehensible and constant pressure. it feels like constant self-blame and embarrassment, and will interrupt one’s professional performance. in this regard one of the managers stated: “for example, i may have a good opinion of an employee and believe that he or she has an appropriate professional behavior, but when that person is punished by one of the supervisors, even though i know the employee is right, i cannot defend him or her and have to stay quiet. this will make me blame myself constantly. i feel stuck in a weak position and under great pressure.” [participant no. 3] similarly, another participant stated: “on one of my work days, the ambulance brought in a 70-year-old man and immediately started cpr on him by order of the emergency physician who was also one of the shareholders of the hospital. after the patient died, the physician ordered his secretary to admit him in the critical care unit. i could not refuse the orders because if i did, i would be fired. whenever i think about it, i feel like something is stuck in my throat that i cannot get rid of, and i can’t speak to anyone about it either…” [participant no. 5] b) emotional dissociation one of the extracted subthemes confirmed by the participants was “emotional dissociation”, which is a feeling of isolation, emotional management problems, sudden and unexpected conflicts, depression or anxiety. participants expressed their general understanding and impression of the experienced moral distress through terms such as breakdown, collapse, conflict, contradiction and so on. “in the nursing profession, every day is filled with distress. for example, a physician visits a patient every day, and i know that the patient does not need daily visits, but the physician does it for financial reasons; i cannot object to this behavior because the entire system is working this way. this makes me break down silently every day from the inside” [participant no. 11] another participant mentioned that their experience of distress was a constant conflict and contradiction between learning and performance and stated: “i have been the head nurse for a long time. sometimes we have patients who should undergo chemotherapy, and you know that chemotherapy drugs should be prepared in the incubator and under the fume hood. i know that without the necessary equipment, this procedure could threaten my nurses’ health, but i ask them to do it anyway. i know that it is completely wrong, but there is no other way. i have talked about this to the higher managers several times, and they have responded that we cannot afford the costs for a couple chemotherapy patients a month, and i cannot stop the treatment. but when i see the blisters caused by drug preparation on the nurses’ hands, i feel distressed and conflicted for several days” [participant no. 9] ∑ professional desperation syndrome: another main theme that emerged was “professional desperation syndrome”, which is a feeling of despair and hopelessness, and typically one that results in a certain behavior. this main theme contained the subthemes of “helplessness” and “impaired professional identity”. it is clear that desperation at exhibiting professional behavior has become a disturbing issue in the nursing profession. a) helplessness helplessness, which is a feeling or state of despair, or lack of hope, is one of the subthemes of desperation in performing professional behavior. participants used the following phrases to describe their experiences of moral distress: loneliness, the sense of being in a black hole, isolation, selfabsorption, and depression. “i was a manager in a center for lung transplant. the night before this particular case of transplant, a nurse from the medical human resources was assigned to the patient, and the physician went home. the charge nurse also took the day off, so a nurse with one year of work experience stayed with the patient. when we arrived at the center in the morning, the patient was deceased. while i was writing a report for the forensics office, i was stopped by the chief executive officer of the hospital, who was one of the friends of the physician in charge. there, i felt the worse kind of mental disturbance. i was filled with distress and desperation. i will never forget that day. even as i think about it now, i feel completely drained” [participant no. 14] another participant also described their experiences of moral distress with concepts such as exhaustion and disability: “occasionally, personnel should perform a j med ethics hist med 11: 13, september, 2018 jmehm.tums.ac.ir alireza nikbakht nasrabadi et al. page 6 of 10 procedure for the patient, such as dressing. but they did not have. you know that they overlooked it and performed the wrong action, so you should be on the patient’s side. on the other hand, if you say this to the patient, there will be trouble. the complaints and the [possible] refusal to pay the costs… it can get complicated. it might even cause the personnel to get fired. in such situations, i feel worried and mentally disturbed. my brain stops working, and i feel disabled for not reporting the incident” [participant no. 9] b) impaired professional identity impaired professional identity means diminished professional self-concept based on one’s attributes, beliefs, values, motivations and experiences, and was the second subtheme of desperation in performing professional behaviors. regarding their experiences of moral distress, one of the participants said: “sometimes it happens that the patient does not need hospitalization, but has been hospitalized in the ward for a long time by the physician’s order; or the patient receives daily visits while we know that these visits are not necessary. we just have to close our eyes and ignore these things and not report them. here, we think we are incompetent in our profession, because we feel incapable and dishonest. this feeling eats you from the inside and will get worse every time you confront such situations” [participant no. 4] another participant said about their experiences: “there was once this person who applied for a job with us, but had not completed the medical human resources program and was still a student. we were not legally allowed to hire that person, but you know, due to a shortage in the nursing staff, we hire whoever comes for employment, unless they are really not qualified. whenever i hire someone like this, i feel irresponsible toward my patients. these issues cause distress and exhaustion in me. but now i am used to the feeling, because i have no other option” [participant no. 10] discussion in order to understand the phenomenon of moral distress among nurse managers, it is necessary to investigate the moral distress experienced by clinical nurse managers. although clinical nurse managers repeatedly encounter moral distress in their daily decisions and duties, they are not fully aware of the phenomenon (19). an examination of clinical managers’ experiences and perceptions of moral distress led to the extraction of two main themes: “psycho-emotional trauma” and “professional desperation syndrome”. the main theme of psychoemotional trauma contained two subthemes of “shame” and “emotional dissociation”. the main theme of professional desperation also contained subthemes of “helplessness” and “impaired professional identity”. these themes and their related subthemes are new concepts that are presented in this study. the first main theme of the present study: as one of the main themes in the present study, “psychoemotional trauma” has provided a clear image of nurse managers’ experiences of moral distress in their profession. the subthemes of “shame” and “emotional dissociation” are correlated with each other and with the main theme, and certainly confirm it. the term “psycho-emotional trauma” was selected due to the mental and emotional damage that nurse managers endure upon experiencing moral distress. psycho-emotional trauma may not only lead to burnout in managers, but it can also cause them to lose motivation and quit their job. the first subtheme of psycho-emotional trauma was “shame”. in their study “moral reckoning in nursing”, nathaniel stated that nurses who are forced to take the wrong action despite their knowledge and awareness will experience selfblame, shame, embarrassment and regret (6). the results of their study are rather similar to the present study and indicate pressure on nurses who experience moral distress. in both of these studies, nurses who considered themselves responsible for an unethical act suffered from constant self-blame. this would cause mental and emotional damage in nurses. austin et al. also mentioned in their study that such experiences were associated with psycho-emotional symptoms such as disappointment, feelings of worthlessness, shame and self-blame in nurses (4). in this regard, the results of a study by kelly showed that when nurses acted against their interests and beliefs, they experienced moral distress, followed by moral judgment. the latter would cause individuals to constantly blame themselves for knowingly committing an immoral act, and thus feel ashamed. this constant feeling of shame would make the nurses feel disappointed, which would in turn cause them to suffer from mental and emotional distress (38). the second subtheme was “emotional dissociation". this subtheme entails conflict and contradiction. clinical managers described their experiences of moral distress using words and phrases such as breaking down, collapsing, conflict, contradiction and duality, inconsistency and conflict between learning and performance, paradox, and emotional destruction. when clinical nurse managers know what the right act or decision is but they are forced to commit an immoral act, their emotional integrity is damaged and they may consider quitting the nursing j med ethics hist med 11: 13, september, 2018 jmehm.tums.ac.ir alireza nikbakht nasrabadi et al. page 7 of 10 profession. in fact, the sense of conflict and paradox is like an alarm for managers that something is wrong. hendel et al. has defined conflict as an internal inconsistency rooted in thoughts, values or emotions (39). in a qualitative study on moral distress conducted in 2016, dzeng et al. mentioned that the differences between individuals’ internal moral values and their professional organizational values and principles would push them toward emotional dissociation. the conditions that cause conflict and emotional dissociation could create the grounds for negative outcomes that might affect the health and medical systems (40). henrich et al. conducted a qualitative study in 2017 titled “consequences of moral distress in intensive care units: a qualitative study.” in line with the results of the present study, they stated that nurses would suffer from negative emotional conflicts when they experienced moral distress. they also found that the conflict and inconsistency between nurses’ learning and performance affect the quality of the care they provided (41). the second main theme of the present study: the second main theme was “professional desperation syndrome”, which contained two subthemes of “helplessness” and “impaired professional identity”. christodoulou-fella et al. and meltzer and huckabay conducted a study about the factors influencing burnout and exhaustion in nurses as the main reasons for quitting the job. they stated that stressful work environment, moral or emotional distress, mental and emotional disturbance, exhaustion, lack of motivation, lack of professional self-esteem, inability, doubt, ambiguity and confusion were the main reasons for burnout and quitting the job in nurses. the above-mentioned reasons are in consistence with clinical nurse managers’ experiences of moral distress. in total, they led to the main theme of “professional desperation syndrome”, which contains various aspects that are mentioned in the results (42, 43). regarding the subtheme of “helplessness”, results of a study by wilkinson is in line with those of the present study. they found that at various levels of nursing, the experience of moral distress was generally associated with sleep problems, anger, disappointment, discomfort and lack of energy, and would also cause severe helplessness in the individual. when lasting for a long period of time, this sense of helplessness could lead to professional burnout, and would affect the quality of care directly and indirectly (33). similarly, a study by abbaszadeh et al. revealed that morality is an inseparable part of clinical performance, and professional helplessness is always associated with moral distress (45). in a study by joolaee et al., 41% of the nurses stated that they would not choose this profession again. they also stated that they were feeling powerless, disabled, disappointed and professionally burnt-out due to the moral distress they were experiencing in the work environment (46). flinkman et al. also conducted a study about professional helplessness in nurses and quitting the job, which showed that one of the main reasons for nurses to quit their job and change their work shift was the sense of helplessness. the feeling of helplessness and disability caused by long-term occupational and moral distress in nurses would lead to burnout and decrease the quality of care (47). regarding the subtheme of “impaired professional identity”, harrowing and mill found that in nursing, professional identity and integrity are influenced by moral factors, which is confirmed by the results of the present study. they also stated that experiencing moral distress would affect the professional identity of nurses (48). in a qualitative study on disrupted professional identity, baraz-pordanjani et al. mentioned that working in an environment where individuals felt impaired identity, professional incompetence and decreased self-esteem could severely disrupt their professional identity. therefore, it may be concluded that moral distress and organizational pressures could disrupt professional identity and even the quality of nursing care (49). another qualitative study that confirms our findings was conducted by vaismoradi et al., and examined factors affecting the formation of professional identity in nurses, for instance the existing gap and inconsistency between learning and performance, disrupted professional relationships, and work environment moral distress. moreover, work environment and perceived moral distress by the nurses are considered as factors that help shape nurses’ professional identity (50). finally, it should be mentioned that in comparison with previously existing research, the present study presented a deeper description and interpretation of clinical nurse managers’ perception of moral distress. understanding these experiences will be an introduction to modifying the associated negative outcomes in the future, and creating a suitable environment for moral decision-making. therefore, recognizing moral distress in clinical managers can improve their planning and management skills in dealing with it, and this will be of great help to the healthcare system of any country. conclusion moral distress is an important phenomenon in nursing management that affects the body and soul of managers. the present study explored moral distress based on iranian nurse managers’ lived j med ethics hist med 11: 13, september, 2018 jmehm.tums.ac.ir alireza nikbakht nasrabadi et al. page 8 of 10 experiences. for clinical nurse managers, moral distress is an ambiguous situation like suspension between the earth and the sky in uncertainty and fear, and may be a reaction to having to knowingly cover up intentional and unintentional mistakes. the experience is like a hidden suffering and spiritual torment caused by betraying moral principles. in the experience of clinical managers, moral distress is equal to confusion, anxiety and concern about the outcomes. not only would it cause unbearable mental suffering and self-blame, but it could also lead to resignation and quitting the managerial position. the managers stated that it seemed as if their organizational commitments had priority over their human obligations. 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article copyright © 2021 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e professional moral courage and moral reasoning among nurses in clinical environments: a multivariate model *corresponding author seyedeh nayereh falahan address: hamadan university of medical sciencesschool of nursing and midwifery shahid fahmideh boulevard, hamadan, iran. postal code: 38698-65178 tel: (+98) 81 38 38 04 39 email: falahiyan@umsha.ac.ir received: 15 jul 2021 accepted: 1 nov 2021 published: 5 dec 2021 citation to this article: khatiban m, falahan sn, soltanian ar. professional moral courage and moral reasoning among nurses in clinical environments: a multivariate model. j med ethics hist med. 2021; 14: 20. mahnaz khatiban 1, seyedeh nayereh falahan2*, ali reza soltanian 3 1.professor, mother and child care research center, department of ethics education in medical sciences, department of medical-surgical nursing, school of nursing and midwifery, hamadan university of medical sciences, hamadan, iran. 2.instructor, chronic diseases (home care) research center, school of nursing and midwifery, hamadan university of medical sciences, hamadan, iran. 3.professor, modelling of noncommunicable diseases research centre, department of biostatistics, school of health, hamadan university of medical sciences, hamadan, iran. abstract improving ethical practice needs recognizing the relationship between moral reasoning and moral courage among nurses. we examined factors (moral reasoning, practical consideration, moral dilemmas familiarity, and demographic and work characteristics) associated with moral courage among nurses. a cross-sectional design was run at all five hospitals affiliated to hamadan university of medical sciences in west of iran. a proportionate random sampling due to the total size of the nurse population in each hospital, 224 eligible nurses were completed the study questionnaires: demographic-work characteristics, professional moral courage (pmc), and nursing dilemma test. the relationships were examined by multiple regression analysis. participants reported a more than moderate level of moral reasoning and pmc (43.21±5.98 and 56.16±10.18 respectively). the multivariate model showed the nurses’ pmc is positively predisposed with moral reasoning (β=0.21, p<0.01), but negatively with practical consideration (β=-0.16, p<0.01). more moral courage was found in the nurses who were never married (p<0.001), graduated from a public university (p<0.01), working in the critical care and emergency environments, as well as night shifts (all p<0.001). moral reasoning is a predictor of moral courage, and both should be considered in designing nursing education to improve ethical nursing practice. keywords: decision-making; ethics courage; ethical analytic; nursing thinking. professional moral courage and moral reasoning among nurses in clinical environments … 2 j med ethics hist med. 2021(december); 14:20. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e introduction moral practice is a component of providing nursing care informed by ethics and morals. ethics refers to systematic guidelines for practice provided by external sources such as professional codes of conduct. morals, on the other hand, come from internal sources such as individual beliefs, behaviors, and principles related to right and wrong (1). morals are derived from moral reasoning, which underlies ethical nursing practice. moral reasoning involves cognitive processes that underpin moral decisionmaking and lead to ethical behavior or put ethical decisions into practice (2, 3). ethical nursing practice is a complex process of moral reasoning, decision making, and implementation of the decision in practice (2).through moral reasoning, professionalism will be promoted, and nurses will be prepared for responsible and ethical practice (4), knowing the right thing to do can be achieved by moral reasoning(5), but courage is required to do right (6). in clinical environments, when ethical dilemmas regarding patient care arise, nurses actively engage in the decision-making process and express their concerns (7), but they need moral courage (8) to act ethically and according to the results of their moral reasoning. moral courage is an individual’s capacity to overcome perceived or actual threats and to act according to his/her core values and ethical reasoning when moral principles are vulnerable. morally courageous behavior may have negative consequences such as stress, anxiety, isolation from colleagues, or potential loss of employment (9 17). moral courage is an important virtue in clinical nursing practice that fosters personal and professional development and empowerment, but its enactment demands moral sensitivity, conscience, experience (16) and rationalism (6). in their literature review, bickhoff et al, found a small number of studies that examined moral courage in nursing students, using a primarily qualitative methodology (18). others found that empirical nursing research about moral courage is extremely scarce (9, 11, 19, 20). both moral reasoning and moral courage are important in developing and enacting moral and ethical nursing practice and promoting personal morals and nursing professionalism (4, 6, 16). although moral reasoning and moral courage are fundamental components of ethical nursing practice, we could find no studies that investigated the association between the two. therefore, this study was carried out to determine the predictors of professional moral courage by focusing on moral reasoning through the following research questions: what is the level of nurses’ moral courage, and is there an association between moral courage and demographic and work characteristics? what is the level of nurses’ moral reasoning and moral considerations, and familiarity and is there any association between nurses’ moral reasoning and demographic and work characteristics? and finally, do nurses’ moral reasoning, practical considerations, familiarity with moral dilemmas, and khatiban m., et al. 3 j med ethics hist med. 2021(december); 14: 20. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e demographic and work characteristics predict professional moral courage? methods we used a descriptive-correlational design and conducted the study in five hospitals affiliated with the hamadan university of medical sciences located in the west of iran during 2018. the target population consisted of nurses employed in one of these hospitals with at least one year of clinical nursing experience in the same hospital. the researchers personally distributed the questionnaires among the nurses working the morning, evening and night shifts, and asked them to fill them out in their free time within 3 days. they also instructed the nurses to manually return the completed questionnaires in an envelope to the researchers. considering a two-tailed significance level of 95%, a test power of 0.90, and 20% probability of receiving incomplete questionnaires, 223 nurses were selected using proportional, stratified random sampling. lists of nurses with one year of clinical nursing experience were obtained from the “nursing management office” in each hospital. the target population (n = 1270) was stratified by hospital, and random samples were taken in proportion to the hospital size. potential participants were selected from the lists using the numbers generated by the random number generator. there were 74 participants from besat hospital (%33), 40 from shahid beheshti hospital (17.9%), 44 from farshchian heart hospital (19.6%), 34 from sina hospital (15.2%), and 32 from fatemieh hospital (14.3%). the research questionnaires in this study were: 1the demographic and work characteristics questionnaire: this questionnaire assessed the nurses’ demographic and work characteristics with validated items. the items were related to age, gender, marital status, nursing degree, university, work experience, work shifts, and service area. 2the nursing dilemma test (ndt) developed by crisham (21): the nurses’ moral reasoning, decision-making, practical considerations, and familiarity with moral dilemmas were measured by this questionnaire. the ndt contains six scenarios addressing health-care ethical dilemmas concerning 1) a newborn with anomalies, 2) forcing medication, 3) an adult’s request to die, 4) new nurse orientation, 5) medication errors, and 6) an uninformed terminally ill adult. the “newborn with anomalies” dilemma reflects the concern about describing and promoting the quality of life in neonatal nursing. the issues of “forcing medication” in the psychiatric-mental ward and “an adult’s request to die” in the critical care unit consider the patient’s right to autonomy. the “new nurse orientation” and “medication errors” scenarios focus on maintaining professional and organizational standards and equitable distribution of nursing resources in pediatric and surgical wards. finally, the “terminally ill adult” dilemma professional moral courage and moral reasoning among nurses in clinical environments … 4 j med ethics hist med. 2021(december); 14:20. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e emphasizes the concern over the client’s right to receive personal health-care information in the internal ward. as seen below, the three parts of ndt produce four scores assessing decision-making, practical considerations, moral reasoning (principled thinking), and familiarity with moral dilemmas. ndt part a assesses moral decisionmaking (dm). in each of the six scenarios, participants are asked to imagine themselves in the position of the nurse and answer this question: "what should the nurse do?" the participants may choose "should act", "cannot decide", or "should not act". the nurse who decides to act has made a moral decision. moral dm is shown by the percentage of the nurses' action choices in each scenario. ndt part b assesses moral reasoning, moral development, and practical considerations. in this part there are six statements that express the reasons for participants’ action choices regarding each of the six moral scenarios. of the six statements for each scenario, five measure the stages of moral reasoning which represent 2, 3, 4, 5 , 6 of kohlberg's levels of moral development, . the statement 5 and 6 measure the highest level of moral reasoning (principled thinking). the remaining option measures practical considerations that have a major effect on nurses’ decision-making, for instance time allotment, health team availability, institutional rules, and the physical structure of the setting. given that each statement represents one stage of the three levels of moral development, the respondent’s first priority shows his/her level of moral development. each level contains two stages: pre-conventional (stages 1 and 2), conventional (stages 2 and 3), and post-conventional (stages 5 and 6) (21, 22). in the pre-conventional level, an individual’s moral reasoning is externally controlled by the rules set by the experts and is mainly focused on the external consequences of the actions. in the conventional level, an individual’s moral reasoning is based on the rules, norms and expectations of the society, and the fairness of a rule is rarely probed. in the postconventional level, an individual’s moral reasoning is linked to more abstract principles and values, for instance basic human rights such as life, liberty and justice (23). nurses are asked to think of the factors they took into consideration when responding to the question on moral decision making, and to rank the statements from the most important (score of 6) to the least important (1). the total score is calculated as the sum of the items’ ratings, and ranges from 6 to 36, with lower scores indicating a higher level of “practical considerations” (such as institutional rules, time and resource availability) and a lower level of moral reasoning when making moral decisions. the total score for moral reasoning is calculated according to the formula proposed by the tool developer and varies from 11 to 66, with high scores indicating high levels of moral reasoning. ndt part c assesses nurses’ familiarity (f) with similar moral dilemmas in each scenario by using a 5-point scale including khatiban m., et al. 5 j med ethics hist med. 2021(december); 14: 20. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e “i have made a decision in a similar dilemma” (score = 1), “i know someone else in a similar dilemma” (2), “i do not know anyone in a similar dilemma, but the dilemma is conceivable” (3), “it is difficult to imagine the dilemma as it seems remote” (4), and “it is difficult to take the dilemma seriously as it seems unreal” (5). a total score of 6 17 indicates familiarity, and a score of 18 30 indicates unfamiliarity with moral dilemmas in ndt. for an easy understanding of the familiarity variable in our model, we reversed the scores, so in our model, higher scores show more familiarity. the nursing dilemma test was translated into persian, and back-translated and validated by zirak et al. (2011). we obtained permission to use the persian version of the ndt in our study from zirak et al (24). the translated ndt was given to 10 nursing students and its reliability was found to be desirable using the test-retest method with a pearson’s correlation coefficient of 0.73 (p < 0.05), and a cronbach’s alpha of 0.82 (25). we examined cronbach's alpha to assess the internal consistency of 30 ndts completed by nurses. moreover, the coefficient alpha was equal to 0.76 for moral reasoning in the ndt. 3the professional moral courage questionnaire (pmc): the pmc consists of 15 questions reflecting five themes: 1) moral agency, or the tendency to act as a moral agent, 2) multiple values, that is, the ability to employ various value sets to recognize the right action, 3) threat endurance, which helps nurses to take the right action despite threats, 4) going beyond compliance, which means nurses will consider the rules but decide to go beyond them to do what is right, and 5) moral goal, or the drive to accomplish tasks without taking self-serving interests into account. participants have answered the questions in the context of their work based on a 7-point scale, ranging from “never true” to “always true”. higher scores indicate greater levels of moral courage (26). the professional moral courage questionnaire is openly available for non-commercial and research purposes. the pmc was translated into persian, and back-translated and validated by mohammadi et al. (2014). based on their experts’ feedback, the response scale was modified to a 5-point scale, ranging from “never true” (1) to “always true” (5). the internal consistency of the pmc was attained in their study (cronbach's alpha of 0.85) (20). in our study, the coefficient alpha of 30 completed questionnaires was equal to 0.90, which showed suitable reliability. the data were analyzed using the spss software version 20 at 0.05 p level. the kolmogorov-smirnov normality test showed that differences in the study variables of demographic and work characteristics did not have normal distributions, and therefore non-parametric tests were applied. a multivariate regression model with the backward stepwise method was used to determine the most significant predictors of moral courage. the approval of the research ethics committee (id number: irprofessional moral courage and moral reasoning among nurses in clinical environments … 6 j med ethics hist med. 2021(december); 14:20. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e umsha.rec.1395.486), as well as the research and technology vice-chancellor at the hamadan university of medical sciences (id number: 9511056842) were were obtained prior to the conduct of the study. anonymity and confidentiality were guaranteed. all the respondents signed an informed consent. result of the 239 eligible nurses, 224 returned a fully completed questionnaire, yielding a 93.7% response rate. on average, the participants were 30 ± 6.65 years of age (range: 22 46). most were women (66.1%), had a bachelor’s degree (95.5%), were employed in internal wards (44.6%), worked the morning shift (45.5%), and had 6.96 ± 6.25 years of work experience (range: 1 22). the percentages of participants’ responses for the variables measured by the ndt across the six scenarios are presented in table 1. table 1scores on the nursing dilemma test across scenarios scenarios a scenario 1 scenario 2 scenario 3 scenario 4 scenario 5 scenario 6 total b decision-making n (%) cannot decide 84 (37.5) 38 (17.0) 75 (33.5) 58 (25.9) 53 (23.7) 56 (25.0) 364 (27.1) should act 125 (55.8) 149 (66.5) 123 (54.9) 154 (68.8) 159 (71.0) 142 (63.4) 852 (63.4) should not act 15 (6.7) 37 (16.5) 26 (11.6) 12 (5.4) 12 (5.4) 26 (11.6) 128 (9.5) moral development n (%) preconventional 66 (29.5) 96 (42.9) 62 (27.7) 84 (37.5) 52 (23.2) 27 (12.1) 387 (28.8) conventional 50 (22.3) 20 (8.9) 47 (21.0) 58 (25.9) 91 (40.6) 48 (21.4) 314 (23.4) postconventional 108 (48.2) 108 (48.2) 115 (51.3) 82 (36.6) 81 (36.2) 149 (66.5) 643 (47.8) practical considerations m ± sd 3.38±1.44 2.96±1.52 3.63±1.51 3.87±1.52 2.96±1.48 3.19±1.55 19.97±4.01 moral reasoning m ± sd 6.78±2.11 7.37±1.70 7.36±2.38 7.00±2.36 7.27±1.98 7.42±1.99 43.21±5.98 familiarity with moral dilemmas m ±sd 2.35±1.46 2.24±1.06 2.59±1.11 2.38±1.13 2.25±1.00 2.14±1.01 13.93±4.85 a a newborn with anomalies (scenario 1); forcing medication (scenario 2); an adult’s request to die (scenario 3); new nurse orientation (scenario 4); medication errors (scenario 5); and an uninformed terminally ill adult (scenario 6) b total scores in the 6 scenarios of the nursing dilemma test (ndt) these indicate that most nurses made the decision to act in all scenarios (364 responses out of 1344 possible responses for the six scenarios, equaling 63.4%), and were in the post-conventional level of moral reasoning. overall, participants reported moderate levels of practical considerations (19.97 ± 4.01), a high level of moral reasoning (43.21 ± 5.98), and familiarity with similar moral dilemmas (13.93 ± 4.85). the mean score on the pmc was above the midpoint of the scale (56.16 ± 10.18). the mean scores on the pmc subscales were high, as shown in table 2. khatiban m., et al. 7 j med ethics hist med. 2021(december); 14: 20. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e table 2mean scores of the professional moral courage questionnaire (n = 224) scale mean ± sd total scale professional moral courage (possible scores 15 75) 56.16 ± 10.18 sub-scales moral agency (possible scores 3 15) 12.18 ± 2.66 moral goal (possible scores 3 15) 11.46 ± 2.71 multiple values (possible scores 3 15) 11.31 ± 2.67 going beyond compliance (possible scores 3 15) 10.78 ± 2.27 threat endurance (possible scores 3 15) 10.42 ± 2.28 the bivariate associations among study variables are shown in table 3 as the mean (standard deviation) scores on moral courage, moral reasoning, practical considerations, and familiarity with moral dilemmas across participants’ demographic characteristics. significant correlations (all p’s < 0.05) were found for some demographic characteristics. table 3study variables by demographic and work characteristics (n = 224) demographic variables n% professional moral courage moral reasoning practical consideratio familiarity age, year 22 – 27 122 (54.5) 56.65 (±9.61) 43.32 (±5.73) 20.30 (±4.28) 14.53 (±4.59) 28 – 33 43 (19.2) 58.79 (±10.03) 45.44 (±5.69) 19.54 (±2.90) 14.67 (±5.02) 34 – 39 36 (16.1) 57.66 (±9.80) 40.81 (±6.45) 20.67 (±4.15) 13.28 (±5.17) 40 – 46 23 (10.3) 46.26 (±8.80) 42.17 (±5.83) 18.00 (±3.59) 10.44 (±3.85) kruskal-wallis test h=23.44, p = 0.000 h=9.97, p = 0.020 h=9.75, p = 0.021 h=17.47, p = 0.001 nursing job experience, year 1-7 142 (63.4) 57.16 (±10.01) 43.54 (±5.54) 20.10 (±4.11) 14.44 (±4.90) 8-14 51 (22.8) 56.63 (±9.31) 43.04 (±7.23) 19.84 (±3.54) 14.43 (±4.24) 15-21 24 (10.7) 52.29 (±12.10) 41.75 (±5.67) 20.17 (±4.51) 10.96 (±4.22) 22-29 7 (3.1) 45.86 (±2.67) 42.57 (±6.19) 17.71 (±3.30) 10.14 (±5.49) 1-7 142 (63.4) 57.16 (±10.01) 43.54 (±5.54) 20.10 (±4.11) 14.44 (±4.90) kruskal-wallis test h=11.32, p = 0.010 h=1.85, p = 0.605 h=1.68, p = 0.642 h=16.04, p = 0.001 gender women 150 (67.0) 56.34 (±10.23) 43.81(±5.86) 19.44 (±3.97) 13.98 (±4.92) men 74 (33.0) 55.80 (±10.15) 41.97 (±6.09) 21.05 (±3.89) 13.84 (±4.73) mann-whitney test z=0.36, p = 0.717 z=-1.95, p = 0.051 z=-2.57, p = 0.010 z=-0.95, p = 0.951 marital status never married 92 (41.1) 60.02 (±9.48) 43.32 (±5.16) 20.70 (±4.23) 15.21 (±4.73) married a 123 (54.9) 53.47 (±9.82) 42.13 (±6.52) 19.47 (±3.78) 13.05 (±4.74) mann-whitney test z=-4.62, p = 0.000 z=-0.25, p = 0.804 z=-2.39, p = 0.017 z=-3.58, p = 0.000 nursing degrees bachelor 214 (95.5) 55.65 (±9.93) 43.08 (±5.98) 19.86 (±4.02) 13.92 (±4.83) master 10 (4.5) 66.90 (±10.03) 45.80 (±5.71) 22.50 (±2.68) 14.20 (±5.51) mann-whitney test z=-3.54, z=-1.24, z=-2.33, z=0.34, professional moral courage and moral reasoning among nurses in clinical environments … 8 j med ethics hist med. 2021(december); 14:20. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e demographic variables n% professional moral courage moral reasoning practical consideratio familiarity p = 0.000 p = 0.216 p = 0.020 p = 0.732 types of university b public 144 (64.3) 57.96 (±9.71) 43.33 (±6.17) 20.47 (±4.03) 13.83 (±4.97) private 80 (35.7) 52.93 (±10.71) 42.98 (±5.67) 19.08 (±3.83) 14.13 (±4.64) mann-whitney test z=-3.54, p = 0.000 z=-0.20, p = 0.842 z=-2.58, p = 0.010 z=-0.52 p = 0.602 employment status permanent 151 (64.7) 57.34 (±10.03) 43.60 (±5.88) 19.32 (±4.28) 14.14 (±5.52) impermanent 73 (36.3) 55.59 (±10.25) 43.01 (±6.04) 20.29 (±3.84) 13.83 (±4.50) mann-whitney test z=-1.34, p = 0.180 z=-0.43, p = 0.667 z=-1.68, p = 0.094 z=-0.78, p = 0.438 most work schedules c day shifts 102 (45.5) 57.40 (±10.44) 43.07 (±6.10) 20.11 (±3.56) 13.09 (±5.03) evening shifts 46 (20.5) 59.24 (±8.18) 43.41(±6.53) 21.48 (±5.24) 14.52(±4.79) night shifts 76 (33.9) 52.63 (±10.05) 43.26(±5.55) 18.88 (±3.40) 14.71(±4.50) kruskal-wallis test h=14.73, p = 0.001 h=0.36, p = 0.836 h=10.46, p = 0.005 h=7.54, p = 0.023 service areas internal wards 100 (44.6) 56.51(±10.48) 43.71 (±6.12) 19.43 (±3.88) 14.72 (±4.65) surgical wards 44 (19.6) 61.64 (±6.84) 45.02 (±5.15) 20.13 (±3.78) 14.34 (±4.51 ) emergency wards 45 (20.1) 49.51(±8.55) 41.22(±4.92) 20.49 (±4.76) 12.20 (±5.38 ) pediatrics wards 24 (10.7) 62.08(±7.48) 43.04(±7.80 ) 20.63 (±3.75) 13.58 (±4.67 ) critical care wards 11 (4.9) 45.36(±5.56) 39.82(±4.40) 20.71 (±3.10) 13.00 (±4.75) kruskal-wallis test h=53.25, p = 0.000 h=14.51, p = 0.006 h=2.48, p = 0.453 h=7.89, p = 0.096 a married: married, remarried, divorced, and widowed b type of university: public (local or national public medical education university); private: (local private university) c day (7:30 am – 2:30 pm), evening (2:00 pm – 8:30 am), night (8:00 pm – 8:00 am) as shown in table 4, there were positive correlations between moral courage and moral reasoning (p < 0.001). nurses with fewer practical considerations had more moral courage (p < 0.05). also, participants were more likely to apply moral reasoning if they had fewer practical considerations, or had lower familiarity with moral dilemmas. table 4correlation between moral courage, moral reasoning, practical considerations, and familiarity with moral dilemmas (n = 224) moral courage moral reasoning practical considerations moral reasoning ρ 0.24** 1.00 p 0.000 _ practical considerations ρ 0.15* 0.35** 1.00 p 0.026 0.000 _ familiarity with moral dilemmas ρ 0.04 0.24** 0.05 p 0.509 0.000 0.499 ** spearman’s correlation (rho) is significant at the 0.01 level (2-tailed). * spearman’s correlation (rho) is significant at the 0.05 level (2-tailed). khatiban m., et al. 9 j med ethics hist med. 2021(december); 14: 20. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e multiple regression analysis was applied to determine how well the combination of the studied independent variables explains the variance in professional moral courage using a backward stepwise method. the results (table 5) indicated that moral reasoning, marital status (never married vs. married), the university where the participants graduated (public vs. private), service environment (emergency or critical care, vs. other wards) and work shift (night vs. evening or day shift) were significantly associated with moral courage. however, practical considerations and working in pediatric wards (vs. other service environments) were barriers to the nurses’ moral courage. these predictors accounted for 42.1% of the variables affecting moral courage (r2 = 0.421, f = 19.51, p < 0.001). table 5predictors of moral courage b se β t p (constant) 5.13 0.46 11.23 < 0.001 moral reasoning 0.02 0.01 0.20 3.53 0.001 practical considerations 0.03 0.01 -0.16 -2.70 0.007 marital status (ref = never married) married 0.31 0.07 -0.22 -4.12 < 0.001 universities (ref = public) private 0.23 0.08 -0.16 -2.99 0.003 service area emergency (ref = 0) 0.57 0.09 0.33 6.09 < 0.001 pediatric (ref = 0) 0.33 0.12 0.15 2.80 = 0.006 critical care (ref = 0) 0.68 0.17 0.21 3.90 < 0.001 work schedules night shifts (ref = 0) 0.36 0.08 0.25 4.60 < 0.001 note: r2 = 0.42, f = 19.51, p < 0.001. predictors: (constant), moral reasoning, marital status (never married = 0, married = 1), type of university (public = 0, private = 1), service area: emergency ward, critical care ward, pediatric ward, work schedules (day = 0, 0, 0; evening = 0, 1, 0; night = 0, 0, 1). excluded variables: familiarity with moral dilemmas; age; nursing job experience (years); gender; nursing degree; employment status; most work schedules: day shift and evening shift; service area: medical and surgical wards. discussion the results of this study supported associations among nurses’ moral courage, moral reasoning, practical considerations, familiarity with moral dilemmas, and demographic and work characteristics. this study is innovative in that it is the first one to examine the association between moral courage and moral reasoning in clinical environments. professional moral courage and moral reasoning among nurses in clinical environments … 10 j med ethics hist med. 2021(december); 14:20. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e in this study, most nurses responded that they would take the actions planned in the six scenarios presented in the ndt, and their responses were consistent across scenarios. although in iran nurses have a legal obligation to carry out physicians’ written orders, most participants decided to do what they thought was right in the context of the scenarios. these findings differ from those in other countries. in a study in turkey, a small percentage (25.5%) supported a decision to give terminally ill adults information on their prognosis, and about half (49.7 %) were willing to orient a new nurse to her/his responsibilities (27). most nurses who participated in this study were at the post-conventional level of moral development. this is similar to the findings of other studies, indicating that most iranian nurses (28), turkish nurses (29) and american nurses (30) were in the postconventional level of moral development. however, the result of a meta-analysis showed that only expert nurses were at the post-conventional level, and that most nurses followed a uniform pattern of conventional ethical reasoning and practice (31). when nurses are at the post-conventional level, they recognize and mainly agree to follow the society’s rules, norms and expectations, but their agreement is based on framing and accepting the general moral principles such as human rights that underlie these conventions. attaining the post-conventional level, the highest level of kohlberg’s moral development, may be important to acting as a responsible professional (21, 23). in this study, nurses achieved an aboveaverage score in moral reasoning. this is comparable to the findings of other studies about nurses working in a universityaffiliated hospital in the central (32), and another one in the northwest regions (33) of iran, as well as a university hospital in turkey (27). however, the nurses in the present study scored slightly lower than the nurses who participated in studies conducted in korea (34). this closeness in nurses’ moral reasoning across different cultures may come from the similarity in the ethical dilemmas they are faced with, which may be the reason why they consider the same solution as morally excellent. in our study, although the 28 34 years old nurses showed the highest level of moral reasoning, no correlation was found between moral reasoning and years of nursing job experience. this can be due to the differences in nurses’ experience of potential moral conflicts in different situations and not to the job experience itself. however, a negative association between moral reasoning and years of experience was found in another study (34). nurses who worked in surgical wards had a significantly higher level of moral reasoning than those in other service environments. these nurses provide care for patients undergoing a wide range of surgical procedures, and therefore need to manage post-operative complications including pain management, wound care and self-care needs. it should be mentioned that pain management was cited as the ethical dilemma most frequently encountered by nurses (35). our participants reported taking practical khatiban m., et al. 11 j med ethics hist med. 2021(december); 14: 20. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e issues into consideration when making ethical judgments in different situations. these practical considerations included time allotment, health team availability, and the physical structure of the situation (21). the mean level of practical considerations reported in our study was similar to that of turkish nurses (27), but lower than another study on iranian nurses (28). our results indicated that practical considerations were higher in men and in nurses who had a master’s degree, had graduated from a public university, or worked evening shifts. these nurses were more dependent on hospital rules than moral reasoning in ethical decision-making. our study findings showed that nurses had a fairly high familiarity with moral dilemmas. in the same way, most turkish (27) and american nurses (21) were familiar with the ethical dilemmas assessed by the ndt. these consistent results may be due to the nature of the nursing profession rather than the cultural and health-care context where nurses practice. it was not surprising that nurses in the highest age group and those with the most experience were more familiar with similar dilemmas. scores of familiarities with moral dilemmas were higher in nurses who worked day shifts than those in other groups. this difference may be due to the fact that older nurses with more experience work the day shifts. nurses who participated in this study reported a fairly acceptable level of professional moral courage. by creating a balance between rashness and fearfulness, moral courage makes a person act correctly in an ethical dilemma (36). having fairly acceptable moral courage would enable a person to challenge unacceptable practices and policies (37). persons who lack the moral courage to oppose poor standards of care or unaccepted policies will experience moral distress (8, 9, 18, 37). it seems that the nurses who participated in our study were able to perform ethically when faced with moral dilemmas. nevertheless, even the most morally courageous nurse may be afraid to speak up when the organization does not support the nurses and react correctly to their concerns about standards of care (37). in our study, a significantly positive association was found between moral courage and moral reasoning. moreover, moral reasoning was the most important predictor of moral courage. accordingly, it may be claimed that moral nursing practice depends on two important components: moral reasoning (principled thinking) and moral courage (acting). moral reasoning and the ability to recognize the right decision are not enough for ethical practice, as courage is needed to take action (36). moreover, courageous nurses do not act impulsively, but apply effective reasoning skills and seek moral resolution (38). our findings revealed a negative correlation between practical considerations (pc) and moral courage, and in the regression model, pc was a significant barrier to moral courage. the association between moral courage and pc had not been investigated in previous studies, and should be further examined in future research. the bivariate professional moral courage and moral reasoning among nurses in clinical environments … 12 j med ethics hist med. 2021(december); 14:20. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e correlation between moral courage and familiarity with moral dilemmas was not significant in our study, but some researchers found that moral courage can be improved by familiarizing nurses with strategies to address moral dilemmas through training (8, 39). our bivariate correlation showed that both age and work experience had a negative relationship with the nurses’ moral courage, but in the regression model, neither was recognized as significant predictors of moral courage. other researchers found that nurses who were older or had more work experience had more moral courage (19). our results suggest that age or experience alone is not enough to develop moral courage, and additional strategies should be integrated into nurses’ academic and professional life to promote moral courage in their confrontations with moral conflicts (12, 39). through an intensive ethics education, nurses who experienced a moral dilemma were able to reflect on the experience, reason about the experience, then act and show behaviors that they had just learned (40). in our study, participants who had a master's degree in nursing exhibited more moral courage than those who had a bachelors’ degree, but this may have been due to the insufficient number of participants with a master’s degree, which made it difficult to draw a robust comparison. therefore, it can be concluded that education is not an important predictor of nurses’ moral courage. moreover, in another study in iran, nurses with master’s and bachelor’s degrees were similar in terms of moral courage, which confirms our results. (19). we also found that moral courage was higher in never married nurses. given that some researchers found no association between moral courage and marital status, further research is needed in this area (19, 20). nurses who had graduated from public universities had more moral courage than those from private universities. since this was a significant predictor of moral courage, more research is needed to further understand how moral courage is developed or strengthened in different types of universities (11). findings of the present study also revealed that nurses with permanent employment status demonstrated almost the same degree of moral courage as temporary nurses. in the regression model, permanent employment was not a significant predictor of moral courage, but other researchers found that nurses with permanent employment status had more moral courage than temporary nurses (19). it is possible that nurses with temporary employment cannot do the right thing because of the negative consequences and the risk of losing their job or social status (15). in clinical settings, the negative consequences of moral courage such as stress, fear of corrective measures, colleague isolation and losing the respect of the healthcare team, and other barriers such as organizational culture can keep a nurse from exhibiting moral courage (41). however, further research seems to be necessary in this area. khatiban m., et al. 13 j med ethics hist med. 2021(december); 14: 20. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e working in environments such as the emergency room and critical care (as opposed to the pediatrics ward) and working the night shift was directly related to the nurses’ pmc. the critical condition of patients increases the incidence of lifethreatening and end-of-life events, and nurses need more moral courage to make ethical decisions in these situations (36, 42). as these stressful events are common in the emergency and critical care environments and during night shifts, having more courageous nurses in these situations can promote the quality of ethical nursing practice. moral reasoning and moral courage initially develop in the undergraduate and graduate nursing curriculums, but current nursing education programs cannot adequately equip nurses to deal with ethical dilemmas in stressful environments (9). as knowledge and training can help nurses to cope with moral dilemmas in ethically distressing situations (43), adequate education is needed to promote the moral courage of nurses working in these clinical environments. one positive feature of this study was that it was the first study to focus on nurses’ moral courage and moral reasoning using a multivariate model. many factors including nurses’ demographic and work characteristics, their moral reasoning, familiarity with moral dilemmas, and clinical considerations were studied as the predictors of moral courage for the first time. another strength of this study was the random sampling and high response rate which led to less biased sampling. however, a cross-sectional study does not offer a study of the cohort effects, and it is therefore recommended to conduct a study on how these factors develop over time. it should also be mentioned that although we recruited nurses in all hospitals, the sample may not be representative of the nursing population throughout the community and/or outpatient clinics. conclusion most participating nurses made the decision to act in situations involving moral dilemmas and were therefore in the postconventional level of moral development. they had a moderate level of moral reasoning, practical considerations, and familiarity with moral dilemmas. they also demonstrated a reasonable degree of professional moral courage. the nurses’ moral courage was positively associated with moral reasoning, and negatively with practical considerations. however, more moral courage was found in nurses who had never been married, had graduated from a public university, had been employed in the emergency room and critical care ward, and had worked the night shift. there are shortcomings in the undergraduate nursing curriculum as well as the continuing professional development in terms of moral courage and moral reasoning education. the role of nursing leaders is to boost and support professional moral courage and enhance nurses’ powers of clinical reasoning and promote these professional values, which will consequently improve the ethical professional moral courage and moral reasoning among nurses in clinical environments … 14 j med ethics hist med. 2021(december); 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16: 132-42. 41. lamiani g, borghi l, argentero p. when healthcare professionals cannot do the right thing: a systematic review of moral distress and its correlates. j health psychol. 2017; 22(1): 5167. 42. thorup cb, rundqvist e, roberts c, delmar c. care as a matter of courage: vulnerability, suffering and ethical formation in nursing care. scand j caring sci. 2012; 26(3): 427-35. 43. comrie rw. an analysis of undergraduate and graduate student nurses' moral sensitivity. nurs ethics. 2012; 19(1): 116-27. hhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh copyright © 2022 tehran university of medical sciences. this work is licensed under a creative commons attribution-non commercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. original article abstract media is an opportunity for health professionals; however, it is not free of threats. fixing the threats requires professional systematization through developing practical guidelines, which brings us to the goal this study was designed to achieve. the study was conducted qualitatively through literature review, semi-structured interviews, and a focus group discussion with health and media experts, as a result of which 486 codes were extracted and classified into 4 groups. the first group was addressed to media professionals and contained 126 codes in 5 categories: seeking and reporting the truth, harm minimization, integrity, independence, and respect for the rights of others. the second and third groups were addressed to health professionals, the former (150 codes) dealing with formal media, and the latter (190 codes) dealing with cyberspace. these groups were both categorized into 6 categories: scientific demeanor, beneficence, harm minimization, *corresponding author hamidreza namazi address: no. 23, 16 azar st., keshavarz blv., tehran, iran. postal code: 1417863181 tel: (+98) 21 66 41 96 61 email: hrnamazi@sina.tums.ac.ir received: 29 jan 2022 accepted: 8 mar 2022 published: 15 mar 2022 citation to this article: kiasalar m, shokrkhah y, nedjat s, namazi h. media codes of ethics for health professionals and media professionals:a qualitative study. j med ethics hist med. 2022; 15: 2. integrity, maintaining the dignity of the profession and professionals, and respect for the rights of others. the fourth group was addressed to the public audience and contained 20 codes categorized into 2 categories: ethics of belief, and ethics of (re-)publishing. since the study was conducted during the pandemic/infodemic, the proposed codes can help reduce possible conflicts in similar future situations. keywords: media ethics; codes of ethics; media professional; health professional; covid-19 pandemic. media codes of ethics for health professionals and media professionals: a qualitative study 1. phd candidate of medical ethics, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran; department of medical ethics, school of medicine, tehran university of medical sciences, tehran, iran. 2. assistant professor, department of european studies, faculty of world studies, university of tehran, tehran, iran. 3. professor, department of epidemiology and biostatistics, school of public health, tehran university of medical sciences, tehran, iran. 4. assistant professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran; department of medical ethics, school of medicine, tehran university of medical sciences, tehran, iran; department of history of medicine, school of persian medicine, tehran university of medical sciences, tehran. mohammad kiasalar1, younes shokrkhah2, saharnaz nedjat3, hamidreza namazi4* media codes of ethics for health professionals and media professionals… j. med. ethics. hist. med. 2022 ( march); 15: 2. 2 introduction in the 21st century, which is called the era of mediacracy (1), confrontation with media seems inevitable (2). many theorists have examined this issue by using different methods (3). james lull (1982), for example, demonstrated how the electronic media frames the daily lives of families (4). albert borgmann explained this concept by proposing the theory of "focal things and focal practices" from another perspective (5). many professions and professionals are also struggling with this confrontation. the more prominent the social role of professions and the more vital the function of professionals in the society, the more unavoidable this confrontation becomes (6). the covid-19 pandemic has highlighted the importance of this issue (7). during the pandemic, the world health organization (who) has issued numerous warnings about the infodemic, factcheck, and information diet (8). the development of social media has doubled the importance of this confrontation for health professionals (9). informal medicine is a term coined in this regard following the influence of social media on the physicians’ personal and professional lives (10). the relation between health and media has grown so rapidly and convergently that clarke (2003) has identified it as the most influential reason for medicalization in the contemporary world (11). some have warned of harm in this convergence; however, many other health professionals have accepted that the increasing influence in the market, culture, politics and society goes through this interaction (12). media professionals likewise shape the tastes of their audiences according to this convergence and take advantage of the market. but in this media-health win-win game, the one that often loses is morality. this is the point where media ethics and medical ethics can redefine and declare their necessities (11). in short, health and media in today's world have an inevitable relation that can be convergent and synergistic, but despite the opportunities that media provides to the field of health, it is not threat-free (6); the nature of these threats is such that they can occasionally mislead and disturb the public audience, and undermine the moral and professional dignity of professionals (table 1). kiasalar m., et al. 3 j. med. ethics. hist. med. 2022 ( march); 15: 2. table 1. the most prominent media opportunities and threats for health professionals opportunities threats dissemination of information in order to promote public health dissemination of misinformation, fake news or lay knowledge reducing the burden of diseases through public education promoting the medicalized and advertised aspects of medicine in the public sphere desirable presence of the professionals in the media increasing people's trust and enhancing the prestige of the profession and professionals in the public sphere undesirable presence of the professionals in the media causing negative reflections for the profession and professionals in the public sphere complying with ethical codes and clarifying the challenges of public health in order to attract public participation and promote public health violating ethical codes and undermining the status of the profession and professionals in the society fixing the above-mentioned threats requires ethical and professional systematization. one of the most tried and tested mechanisms of organizing such professional relations is the development of local and practical codes of ethics and encouraging the professionals to adhere to the maximum level of these procedures (13). the literature review reveals no comprehensive and integrated study covering both the target audience (health and media professionals) and the public audience (public sphere) simultaneously in terms of both separate (external) and yet relevant (internal) codes of ethics/conduct. an integrated holistic view of these scattered yet relevant audiences is missing in the literature. the absence of such a view is also evident in iranian interdisciplinary literature, which is doubly important, considering the goal of the present study, that is, the compilation and development of comprehensive local and practical codes of ethics to optimize the health-media professionals’ encounter. methods qualitative approach the study was conducted from april 2020 to july 2021 through literature review, semi-structured interviews, and a focus group discussion (fgd) with interdisciplinary health and media professors, policy makers and professionals. researcher characteristics one of the 4 members of the research team was female. at the time of and during the study, mk was md, ph.d. candidate in medical ethics, and a media professional. sn and hn were academic members of the school of medicine at a local university, the former teaching methodology and media codes of ethics for health professionals and media professionals… j. med. ethics. hist. med. 2022 ( march); 15: 2. 4 the latter teaching medical ethics and philosophy of ethics. ys was an academic board member of the center for media studies teaching mass communication at the faculty of world studies, university of tehran. all researchers were involved in all phases of the study except for conducting the interviews, which were performed by mk. the research team aimed at de-threatening and optimizing the health-media professional’s encounter through compiling and developing local and practical media codes of ethics/conduct. sampling strategy the interviewees were selected by multi-stage purposive sampling through homogeneous, typical and snowball methods. in the first stage, a group of professors and professionals in the field of media and medical ethics who were involved in healthoriented media were selected using the homogeneous method. in the second stage, prominent figures were chosen for in-depth interviews (typical method). finally, through their introduction (snowball method), more professionals and policy makers who were expected to raise new discussions on the subject were added to the interviewees. ethical issues informed consent was obtained at the beginning of the interviews verbally. given that the interview questions were accompanied by up-to-date examples of recent events (esp. about the pandemic), and since most of them featured specific individuals in the media, health and politics, interviewees were assured of confidentiality. participants were also informed that the purpose of the study was not to criticize specific acts or individuals in the pandemic period or in the health-media relations. in this regard, the objectives of the research were clarified for the interviewees. they were also told that they could not be informed of other interviewees’ opinions and only the final results of the study would be communicated to them. the study was approved by the research ethics committee of the school of medicine, tehran university of medical sciences, tehran, iran (ir.tums.medicine.rec.1398.963). data collection instruments mk searched the relevant literature by using keywords including media ethics, photojournalism ethics, cyber journalism ethics, ethical journalism, digital media ethics, cinematic ethics, media codes of ethics, media scandal, media literacy, infodemic, health literacy, health journalism, health communication, open science, and science communication, on pubmed, scopus, cochrane, proquest, google scholar, iranmedex, and irandoc kiasalar m., et al. 5 j. med. ethics. hist. med. 2022 ( march); 15: 2. databases. after filtering 3108 documents, 379 were finally selected for the literature review, but the interview questions were mainly derived from the same study. the research team brainstormed 15 open-ended questions as the in-depth interview framework. in this way, the interviewees would be encouraged to think aloud about the topics brought up in the questions accompanied by up-to-date examples of recent events in the field of healthmedia encounter, especially during the pandemic. table 2 provides a summary of the content and domain of these questions. data collection methods following the literature review, the semi-structured interviews were conducted until data saturation was obtained after 20 interviews. an fgd was conducted subsequently with the participation of 7 out of the 20 health and media experts and medical ethicists interviewed previously. the average interview duration was about 90 minutes and all the interviews were recorded through note-taking and verbatim transcription. the fgd was conducted for 120 minutes to ensure further validation and confirmation of the generated codes, categories and subcategories. units of the study 20 participants were engaged in semi-structured interviews, of which 6 were professors of medical ethics and mass media or communications, 4 were policy makers in the field of health or media, 2 were prominent filmmakers with a history of making popular films in the field of public health, 2 were experienced public health journalists, 1 was a documentarist, 1 was a public health tv programmer, 1 was a physician with a past history of managing a popular news agency, 1 was the chair of the department of health communication in a research institute, 1 was the chair of the department of philosophy of science in a research institute, and 1 was the owner of a well-known journal in the field of public health (table 3). the fgd was performed by 7 participants who had raised innovative discussions in the interviews. media codes of ethics for health professionals and media professionals… j. med. ethics. hist. med. 2022 ( march); 15: 2. 6 table 2. domains and topics of the interview questions domains topics about health professionals *evaluating the media activity of health professionals during the pandemic *considering the ethical norms threatened by health professionals in the media *explaining the circumstances under which the interaction of health professionals with the media can harm the position of the profession and professionals in the public sphere *suggesting solutions to prevent or manage the threats hidden in the professionals’ encounter with the media *pointing out the most important opportunities and threats for health professionals dealing with the media about media professionals *pointing out the most important issues in publishing health news and information *assessing the professional activity of the iranian media during the pandemic *explaining the circumstances under which the media help maintain and promote the health level of the society about health and media professionals *explaining the circumstances under which the transmission of health messages can lead to the spread of anxiety in the society *explaining the circumstances under which the transmission of health messages can lead to the formation of an induced demand in the society *explaining the circumstances under which the media can encourage unjustified medicalization in the society about the public audience *pointing out the most important issues in sharing or republishing health news *explaining the best ways to deal with misinformation or fake news in the public sphere *explaining the best ways in which the public audience can validate health news in the media *pointing out the most important messages derived from religious teachings to spread health information and to prevent the spread of misinformation table 3. demographic data of the interviewees interviewees (n: 20) n % age (year) (mean ± sd) 55.08 ± 10.425 professor of medical ethics 3 female 1 33 male 2 67 professor of communications or mass media 3 female 1 33 male 2 67 health policy maker 2 female 1 50 male 1 50 media policy maker 2 female 1 50 male 1 50 health professional 5 female 2 40 male 3 60 media professional 5 female 2 40 male 3 60 work experience 5 years > 1 5 5 10 years 2 10 10 20 years 4 20 20 years < 13 75 kiasalar m., et al. 7 j. med. ethics. hist. med. 2022 ( march); 15: 2. data processing, analysis and confirmation data analysis was performed using a general deductive approach. the graneheim and lundman method was used for content analysis (14). data analysis began at the same time as data collection in the second phase of the study, so that the findings of each interview could be used to reconstruct and improve subsequent interviews with subsequent interviewees to achieve more successful performance and more accurate results in the process of data collection. in order to make full use of all the findings and not to omit inconsistent findings, the interviews were reread several times, and the data were matched with the findings of the literature review so that no heterogeneous data would be ignored. in labeling, while extracting the initial code, an attempt was made not to ignore any of the heterogeneous findings. audio files of the in-depth interviews were carefully listened to and transcribed. microanalysis was performed by analyzing and interpreting the data line by line, and finally, 486 open codes were extracted and classified in 2 stages:1. according to the audience all codes were divided into 4 groups (table 4). 2. according to the content the codes of each of the 4 groups were categorized separately (tables 5, 6, 7, 8). finally, 19 categories, 54 subcategories, and 486 codes were extracted. table 4. the audience-oriented classification of codes codes focused on the health-oriented media (486 items) codes addressed to the public audience (20 items) codes addressed to the target audience (466 items) codes addressed to media professionals (126 items) codes addressed to health professionals (340 items) codes dealing with formal media (150 items) codes dealing with informal media (190 items) techniques to enhance trustworthiness member checking (15), prolonged engagement (16), thick description (17), data source triangulation (18), and optimal use of tables (19) were done to enhance trustworthiness. reporting this study is reported according to the “standards for reporting qualitative research (srqr) guideline (20). results the literature review revealed that the link between health professionals, the media and the public media codes of ethics for health professionals and media professionals… j. med. ethics. hist. med. 2022 ( march); 15: 2. 8 audience seems obvious and superficial at the first glance; however, in the depth of this linear and simple relation that exists between the 3 spheres (health, media, and public sphere), there is a complex and close connection that indicates the common roots of moral systems (figure 1). this internal bond can be better understood in the numerous references that exist between the codes of conduct in the 3 spheres of the study. the field study was carried out using questions derived from the literature review through 20 semi-structured interviews and an fgd with 7 interdisciplinary health and media experts whose characteristics were mentioned earlier (tables 2 and 3). after coding the interviews and drawing the content analysis tables, 486 codes were extracted and classified in 2 stages: in the first stage, according to the audience (table 4), and in the second stage, according to the content (tables 5, 6, 7, 8). figure 1. the concept map of the relations between media, health and ethics kiasalar m., et al. 9 j. med. ethics. hist. med. 2022 ( march); 15: 2. 1. codes addressed to media professionals codes of conduct addressed to media professionals (126 codes) are categorized into 5 categories and 15 subcategories (table 5) 1.1. seeking and reporting the truth media professionals must be accurate, fair and impartial in gathering and publishing news and information. this category consists of 3 subcategories (accuracy / fairness / impartiality). "news media are crazy about speed, and the first thing that falls victim to speed is accuracy. but in health news, the accuracy of the message is usually more important than speed." [participant no. 1] 1.2. harm minimization media professionals are required to remember that information dissemination cannot be a license to inflict unnecessary sufferings on individuals or the society. this category includes 4 subcategories (considering health anxiety / avoiding stereotypes, stigma and social discrimination / caring for the vulnerable / facing sensitive topics). "i think one of the reasons why the suicide rate increased significantly in iran during the pandemic was that social media covered the suicide news contrary to international guidelines." [participant no. 8] 1.3. integrity what motivates media professionals to prioritize the well-being of the society over personal and professional interests is their integrity. this category is divided into 2 subcategories (honesty and transparency / responsibility and accountability). "in the hospital, a filmmaker has no right to point his or her camera in any direction he or she wants. when patients are your subjects, you must know that they are vulnerable and you are responsible for them." [participant no. 9] 1.4. professional independence media professionals are expected to be the voice of the voiceless by demanding and declaring their needs boldly and transparently. professional independence is the premise of such courage and transparency. this category consists of 3 subcategories (managing conflict of interests / facing ads / professional excellence). "in the midst of the pandemic, one institution that had its own vested interest in a specific vaccine held a press conference about its vaccine, which had not even received the code of ethics license in research yet. but the media easily published the news. what that institution did was immoral and so were the reports of those media outlets. clearly one media codes of ethics for health professionals and media professionals… j. med. ethics. hist. med. 2022 ( march); 15: 2. 10 of them did not mention this conflict of interests and just published those unproven claims." [participant no. 5] 1.5. respect for the rights of others media professionals are expected to recognize and take into account the privacy and human dignity of individuals, including their subjects and sources as well as their colleagues and audiences. this category includes 3 subcategories (considering privacy / obtaining informed consent / observance of social norms). "patients' privacy has been ignored in our national tv several times during the pandemic, because we have never had a clear-cut guideline to follow in this regard.” [participant no. 15] table 5. categorization of 126 codes for media professionals categories subcategories number of codes seeking and reporting the truth accuracy 16 23 fairness 4 impartiality 3 harm minimization considering health anxiety 12 51 avoiding stereotypes, stigma and social discrimination 3 caring for the vulnerable 14 facing sensitive topics 22 integrity honesty and transparency 8 19 responsibility and accountability 11 professional independence managing conflict of interests 7 14 facing ads 5 professional excellence 2 respect for the rights of others considering privacy 4 19 obtaining informed consent 12 observance of social norms 3 2. codes addressed to health professionals dealing with formal media codes of conduct addressed to health professionals in their interviews and interactions with the formal media (150 codes) were categorized into 6 categories and 17 subcategories (table 6). 2.1. scientific demeanor the statements of health professionals in the media should be scientific, evidence-based and in the area of their expertise and/or responsibility. this category is divided into 2 subcategories (scientific expression / commenting in the area of expertise and responsibility). "many of the contradictions in the pandemic period were due to the fact that some health professionals kiasalar m., et al. 11 j. med. ethics. hist. med. 2022 ( march); 15: 2. who did not have the expertise or responsibility made ill-considered populist statements or claims that were soon proven to be fake or false." [participant no. 12] 2.2. beneficence in each media interaction, health professionals are expected to assess the benefits that their media activities will bring to their audience. this category consists of 2 subcategories (effectiveness / patient and community health care). "if you, as a doctor, have a medical message that really benefits your community but you do not know when and how to communicate it, according to the media language, your message will be martyred."[participant no. 6] 2.3. harm minimization health professionals are expected to assess in each media interaction whether the benefits of their media activity outweigh the harms. this category includes 3 subcategories (considering health anxiety / avoiding stereotypes, stigma and social discrimination / caring for the vulnerable). "perhaps you remember that the minister of health said we will not allow our nation to become the lab mice for the covid-19 vaccine. from my point of view, that was a typical example of stereotyping or stigmatization to all participants in scientific research, which was both immoral and unprofessional." [participant no. 5] 2.4. integrity what persuades health professionals to prioritize the interests of the society over personal and professional interests is, above all, their integrity, the codes of which can be divided into 2 subcategories (transparency and honesty/ accountability and responsibility). "if you, as a health professional, say something in the media today that will come out to be false tomorrow, you have to accept the responsibility and seek compensation and correction in the media. this is your duty and the right of your audience." [participant no. 19] 2.5. maintaining the dignity of the profession and professionals health professionals are expected to beware of any act in their media activities that could damage the reputation of themselves or their colleagues or profession. this category includes 4 subcategories (managing conflict of interests / facing ads / organizational commitment / respect for the profession and colleagues). "we must adopt a clear stance on medical advertising, that is, we either have to accept the essence of the issue and set a framework for it, or media codes of ethics for health professionals and media professionals… j. med. ethics. hist. med. 2022 ( march); 15: 2. 12 announce that advertising is absolutely forbidden. right now we have a situation of indecision and uncertainty, and, from time to time, an ill-advised advertisement damages the reputation of the profession and health professionals." [participant no. 5] 2.6. respect for the rights of others respect for the patient’s autonomy is the first of the four principles of medical ethics, but respect for the rights of others in the media is broader and includes media audiences, as well as media subjects and professionals. this category is divided into 4 subcategories (considering privacy / obtaining informed consent / confidentiality / observance of social norms). "in a live tv program, for example, the doctor does not have the right to ask the patient any question he or she may ask in his or her office. the meaning of privacy is different at the office than in the media." [participant no. 17] table 6. categorization of 150 codes for health professionals dealing with the formal media categories subcategories number of codes scientific demeanor scientific expression 13 19 commenting in the area of expertise and/or responsibility 6 beneficence effectiveness 15 23 patient and community health care 8 harm minimization considering health anxiety 16 31 avoiding stereotypes, stigma and social discrimination 4 caring for the vulnerable 11 integrity transparency and honesty 11 24 accountability and responsibility 13 maintaining the dignity of the profession and professionals managing conflict of interests 8 27 facing ads 7 organizational commitment 4 respect for the profession and colleagues 8 respect for the rights of others considering privacy 7 26 obtaining informed consent 11 confidentiality 4 observance of social norms 4 kiasalar m., et al. 13 j. med. ethics. hist. med. 2022 ( march); 15: 2. 3. codes addressed to health professionals dealing with cyberspace codes of conduct addressed to health professionals in cyberspace, especially social media (190 codes) are categorized into 6 categories and 20 subcategories. (table 7) 3.1. scientific demeanor this category consists of 4 subcategories (understanding cyberspace / keeping the personal and professional life separate / scientific expression / commenting in the area of expertise and responsibility). "the first principle in understanding cyberspace is to know that nothing is ever lost here. that is, every piece of content that you publish and every trace that you leave behind will eventually remain in this space, and one day this digital footprint may cause you trouble." [participant no. 7] 3.2. beneficence this category includes 2 subcategories (effectiveness / patient and community health care)."believe it or not, many health professionals have used social media to get likes and followers and become celebrities during the pandemic, instead of using the cyberspace to care for public health." [participant no. 13] 3.3. harm minimization this category is divided into 3 subcategories (considering health anxiety / avoiding stereotypes, stigma and social discrimination / caring for the vulnerable). "coronavirus was first associated with a specific country, and in iran with a specific city, but the stigma and social consequences of this stigma were so great that the who tried to eliminate this stigma from cities and countries in the news, and so did the ministry of health in iran." [participant no. 3] 3.4. integrity this category consists of two subcategories: (transparency and honesty / accountability and responsibility). "the least amount of honesty that can be expected of someone in social media is that they present their expertise exactly as it is. but because there is no special supervision over social media, many health professionals pretend to be much more knowledgeable than what they really are in the virtual sphere." [participant no. 5] 3.5. maintaining the dignity of the profession and professionals this category is divided into 5 subcategories (managing virtual interaction / managing conflict media codes of ethics for health professionals and media professionals… j. med. ethics. hist. med. 2022 ( march); 15: 2. 14 of interests / facing ads / organizational commitment / respect for the profession and colleagues). "it is against the dignity of the medical profession to follow one’s patient on instagram or send him or her private messages. if the message has a content outside of the medical framework, it is also immoral." [participant no. 4] 3.6. respect for the rights of others this category consists of 4 subcategories (considering privacy / obtaining informed consent / confidentiality / observance of social norms). "during the covid crisis, the spokespersons of the ministry of health or the medical council have no right to insult critics using personal rhetoric on the same page that they publish the posts of the ministry or the council. it is apparent that many people associate such remarks with that organization, not that person. this is against the norms of the society and it is also unprofessional." [participant no. 2] table 7. categorization of 190 codes for health professionals dealing with cyberspace (esp. social media) categories subcategories number of codes scientific demeanor understanding cyberspace 5 29 keeping personal and professional life separate 5 scientific expression 13 commenting in the area of expertise and/or responsibility 6 beneficence effectiveness 14 22 patient and community health care 8 harm minimization considering health anxiety 15 30 avoiding stereotypes, stigma and social discrimination 4 caring for the vulnerable 11 integrity transparency and honesty 11 24 accountability and responsibility 13 maintaining the dignity of the profession and professionals managing virtual interaction 9 48 managing conflict of interests 10 facing ads 9 organizational commitment 6 respect for the profession and colleagues 14 respect for the rights of others considering privacy 12 37 obtaining informed consent 12 confidentiality 9 observance of social norms 4 kiasalar m., et al. 15 j. med. ethics. hist. med. 2022 ( march); 15: 2. 4. ethical statement regarding the public audience this statement contains 20 ethical recommendations to the public audience dealing with media messages, all of which can be classified into 2 categories. (table 8) table 8. categorization of 20 ethical recommendations for the public audience categories number of ethical recommendations ethics of belief 16 ethics of (re-)publishing 4 4.1. ethics of belief some ethicists consider believing to be voluntary (or at least semi-voluntary) and, on this basis, consider it immoral to accept claims without sufficient evidence. "an iranian celebrity in one corner of the world said if you blow a hair dryer up your nose, you will not get covid-19. this misinformation was spread on social media so fast that many people burned their noses! did the media do that? no! had the doctors confirmed the message? no! but the public users’ beliefs matter in social media, and can turn misinformation snowflakes into avalanches." [participant no. 1] 4.2. ethics of (re-)publishing covid-19 pandemic (in the world) and the ensuing infodemic (in cyberspace) showed people’s role in the dissemination of misinformation or fake news. "think twice for a few minutes before republishing anything and ask yourself, “is this content really true? what is my intention in republishing this? what are the consequences of publishing this content?” these simple questions can sometimes prevent the republishing of misinformation or fake news." [participant no. 12] table 9 visualizes all of the prementioned classifications in a holistic framework. this framework is a conceptualized format that provides a helicopter view of the subject so that while avoiding the confusion caused by the mass of codes, we can organize our minds and, at a macro level, understand the relevance of the ethical codes and principles. in the same way, this study tried to pay attention to both ethical codes and principles in order to aim at discourse-building (through ethical principles), and taking serious action (through developing codes of ethics) for media and health professionals in their interdisciplinary activities. according to the interviews, if we want to compare media experts’ perception of health and health experts’ perception of media, it seems that media experts have a better understanding of health, while health experts’ understanding of media seems more media codes of ethics for health professionals and media professionals… j. med. ethics. hist. med. 2022 ( march); 15: 2. 16 limited and is mainly focused on formal media. also, media experts not only consider the quality of the presence in the formal media, but also pay attention to how health professionals appear in the informal media and how they interact with the public audience in order to evaluate their media activities. table 9. a framework covering all codes of ethics and target groups of the study groups and categories media professionals health professionals vs. formal media health professionals vs. social media the public audience harm minimization considering health anxiety considering health anxiety considering health anxiety ethics of publishing / republishing caring for the vulnerable caring for the vulnerable caring for the vulnerable avoiding stereotypes, stigma and social discrimination avoiding stereotypes, stigma and social discrimination avoiding stereotypes, stigma and social discrimination facing sensitive topics beneficence effectiveness effectiveness patient and community health care patient and community health care respect for the rights of others considering privacy considering privacy considering privacy obtaining informed consent obtaining informed consent obtaining informed consent observance of social norms confidentiality confidentiality observance of social norms observance of social norms integrity transparency and honesty transparency and honesty transparency and honesty accountability and responsibility accountability and responsibility accountability and responsibility professional independence / maintaining the dignity of the profession and professionals managing conflict of interests managing conflict of interests managing virtual interaction managing conflict of interests facing ads facing ads facing ads professional excellence organizational commitment organizational commitment respect for the profession and colleagues respect for the profession and colleagues seeking and reporting the truth / scientific demeanor accuracy scientific expression scientific expression ethics of belief impartiality commenting in the area of expertise and responsibility commenting in the area of expertise and responsibility fairness understanding cyberspace keeping personal and professional life separate kiasalar m., et al. 17 j. med. ethics. hist. med. 2022 ( march); 15: 2. the categories of interest of these two groups were also different in most interdisciplinary issues. for example, when analyzing the subject matter of filming patients and vulnerable groups (e.g., sexual victims), most health professionals were focused solely on rasterizing the victims’ faces; most media professionals, however, considered this superficial, saying that the victims’ privacy should be maintained more fundamentally and by using a more appropriate technique. some filmmakers even believed that pixelating the faces of victims is not a good solution as it might lead to revictimization or labeling, causing a sense of rejection and despair among vulnerable subjects (esp. sexual victims and children). these filmmakers found adjusting the camera angle and specific filming techniques more suitable alternatives. while many health professionals considered the above-mentioned subject to be the most important topic in health-oriented media issues most media professionals found the contradictions in health professionals’ expressions during the pandemic to be of great significance. in this regard, some media professionals believed that health professionals should demonstrate a degree of intellectual humility, expecting that this humility would find its way into the tone and expression of health professionals and gradually improve the public view of science. one point that most media and health professionals agreed on was the emphasis on the lack of a systematic dialogue between the two groups, which was referred to as the weakness of interdisciplinary discourse. most of them believed that healthoriented media issues should be included in university curriculums, and some considered the basics of media literacy and health literacy as absolutely necessary even for school students. discussion an integrated guideline containing 486 codes of conduct for optimizing the ethical-professional relations of media-health professionals can be considered as the most important result of the present study. the literature review revealed no comprehensive study covering both the target audience (health and media professionals) and the public audience (public sphere) in term of integrated codes of ethics; therefore, the novelty of the study may be that it attempted to achieve an interdisciplinary comprehensiveness in the research topic through an integrative approach. also, the integration of health humanities concepts (e.g., medical ethics) into the field of health media codes of ethics for health professionals and media professionals… j. med. ethics. hist. med. 2022 ( march); 15: 2. 18 communication is another achievement of the present study. a scrutiny of the most inclusive media codes of ethics shows that ‘harm minimization’, ‘reporting the truth’, and ‘independence’ are the most common themes available in well-known valid guidelines; for example, the society of professional journalists (spj) (21), and the united nations communications group (uncg) (22) agree on the 3 themes mentioned above; however, both of them neglect an important category, that is, ‘respect for the rights of others’, and its subcategories including ‘considering privacy’ and ‘obtaining informed consent’. the unicef has paid attention to these subcategories in its codes for reporting child abuse (23), but has ignored the important subcategory of ‘observance of social norms’ in the relevant category. in the present study, both of the above shortcomings are overcome. in other words, the category of ‘respect for the rights of others’ is included and comprises of 3 subcategories (considering privacy, obtaining informed consent, and observance of social norms) and separate codes of conduct are assigned to each of them. accountability is another common theme in the media codes of ethics that spj (21) and uncg (22) have taken into account; however, the uncg, unlike the spj, has added ‘transparency’ to ‘accountability’. nevertheless, neither of them has paid attention to the semantic differences between ‘accountability’ and ‘responsibility’ (24). in the present study, this shortcoming is also eliminated by the inclusion of ‘integrity’ as a distinct category comprised of two subcategories: ‘accountability and responsibility’, and ‘honesty and transparency’, with differentiated codes of conduct assigned to each of them. despite its richness, iranian media literature does not concern itself with the subject of ethical codes, and the few works written in this field often lack a native color. one of the best is the book "professional and applied ethics in the islamic republic of iran media: concepts and examples" which has distinctive features; among all, it has targeted media professionals based on their specific duties and has developed different ethical codes for each particular professional group. nevertheless, this work is mainly aimed at the formal and traditional media (esp. radio and television), while the tendency of the public sphere is increasingly moving away from the formal and traditional media and approaching modern and digital media (25). the present study has tried to cover this gap by dedicating a special part to the cyberspace. the aforementioned lack is also evident in iranian kiasalar m., et al. 19 j. med. ethics. hist. med. 2022 ( march); 15: 2. medical ethics literature. although the studies conducted in this field have a desirable diversity, none have examined a set of ethical codes that cover both the target audience (health and media professionals) and the public audience. some of the best works in this area are: "a general guide to the professional ethics of medical professionals and affiliates of the general medical council of the islamic republic of iran" (26), "a guide to professional behavior in cyberspace for the professionals of tehran university of medical sciences" (27). special attention to social media can be found in the australian medical association (ama) and its council of doctors in training (amacdt) codes of conduct, which categorizes all codes in 6 categories: confidentiality, privacy, advertising, professional reputation, managing online comments, and using social media for advocacy (28, 29). however, it neglects important issues such as considering health anxiety, avoiding stereotypes, stigma and social discrimination, caring for the vulnerable, scientific expression, and commenting in the area of expertise and/or responsibility. the latter topic is covered in one of the oldest guidelines for health professionals dealing with the media (keith spiegel and koocher's codes of conduct), which, due to the time of its publication (1985), is mainly focused on printed media (12, 30). the present study tried to cover all the above-mentioned defects by compiling clarified themes and sub-themes, and assigning distinct codes of conduct to each while dedicating a separate section to health professionals' exposure to cyberspace (esp. social media). leaving aside the integrative approach to reach interdisciplinary comprehensiveness and the novelty of the present study, we must turn to the concept of news values, a criteria used by media professionals to determine which events are worthy of being reported in the news (31). the present study has tried to observe some of these values, including: timeliness since the study coincided with the covid-19 pandemic/infodemic, we were able to obtain the opinions of interdisciplinary media and health experts on the encounter between the two areas through semi-structured interviews and fgd. impact the covid-19 pandemic significantly increased media attention to health professionals in iran. the dramatic increase in the number of health professionals’ followers in cyberspace (e.g., instagram) and the emergence of unprecedented media codes of ethics for health professionals and media professionals… j. med. ethics. hist. med. 2022 ( march); 15: 2. 20 issues such as some health professionals establishing fan clubs and disclosing the medical records of celebrities suffering from covid-19 on social media and similar issues brought about updated questions, which could be debated through semi-structured interviews and fgd. magnitude compiling 486 codes of conduct through studying 379 documents including books and original articles, and conducting 20 semi-structured interviews with health and media experts can be considered as examples of numerical magnitude in the study. prominence the participants of the study are all authorities and prominent figures in the field of media or health and their fame is rooted in their knowledge, skills and expertise. proximity since the significant works in this field rarely have native color, the field study tried to cover this gap by focusing on the challenges faced in iran during the pandemic/infodemic period. hence, the examples and solutions expressed during the interviews, not only made the study up-to-date, but could also help solve problems in this field, and following the proposed codes can help reduce potential contextual problems in similar future situations. since our study was conducted during the pandemic, we faced a serious limitation, especially at the beginning of the field study, which required in-depth and lengthy face-to-face interviews with interdisciplinary health and media experts. in order to turn this challenge into an opportunity, we used video call interviews to find out the opinions of some well-known iranian health and media experts living outside of iran and learn how these two fields interact in other countries during the pandemic. selfcensorship was another limitation the pandemic imposed on this study. since many of the pandemic media outlets in iran were challenged and criticized, some of the participants censored their own answers to questions about current examples of media weaknesses obvious in the health system or health authorities of iran. to overcome this limitation, all participants were assured of confidentiality. on the other hand, since the significant works in this field rarely had native color, the study tried to focus on the health-media challenges in iran, especially during the pandemic period. hence, timeliness and proximity can be considered as two of the most important strengths of the study that can be seen in the experts’ kiasalar m., et al. 21 j. med. ethics. hist. med. 2022 ( march); 15: 2. opinions about the health-media encounter during the pandemic. member checking, prolonged engagement, thick description, and data source triangulation were also done to overcome the limitation of generalizability that threatens most qualitative studies. to take a step towards interdisciplinary comprehensiveness, the study tried to cover both the target audience (health and media professionals) and the public audience with 4 separate sets of codes of ethics. bringing the concepts of health humanities into the field of health communication has been another attempt at coming closer to one of the initial goals of the study, which was interdisciplinary comprehensiveness. conclusion the study achieved 486 integrated codes of conduct to optimize the health-media encounter through an integrative approach that is missing in the literature. to cover both the target audience (health and media professionals) and the public audience (public sphere) with relevant codes of ethics, the study integrated health humanities concepts (e.g., medical ethics) into the field of health communication and used a holistic view to predict and evaluate the professional and ethical behavior of each group of research audiences from different perspectives in various situations. that is why health anxiety, stigmatization, social discrimination and similar issues have been highlighted in the ethical codes of health professionals from the public audience’s perspective, and effectiveness is emphasized from the media point of view. the study also revealed the differences between media professionals' and health professionals' views on existing interdisciplinary challenges. the findings show that while media professionals' approach to such issues is mainly consequential and pragmatic, health professionals have a dutybased and virtue-based view of these matters. given the weakness of the interdisciplinary discourse and the increasing convergence of media and health, it seems that conducting complementary studies to evaluate the codes proposed in this study can be helpful. launching the field of media and health research in the areas focused on media-oriented and health-oriented studies can provide a suitable platform for such research. also, analysis of these codes in relevant institutions (such as the high council of medical ethics, the cinema organization, etc.) as well as the formation of a "media and health council" in organizations in charge of public health and/or media codes of ethics for health professionals and media professionals… j. med. ethics. hist. med. 2022 ( march); 15: 2. 22 media can monitor how the proposed codes are implemented and evaluated. building a discourse can take place in the public sphere through media promotion, and incorporating the proposed codes in school and university curricula can be beneficial. funding this study was part of a phd thesis that was financially supported by the school of medicine, tehran university of medical sciences, tehran, iran. acknowledgements the authors gratefully acknowledge the participants of this study. conflict of interests the authors declare that they have no known competing financial interests or personal relationships that could have influenced the work reported in this paper. references 1. phillips k. mediacracy: american parties and politics in the communications age. new york: doubleday; 1975. 2. meraz s. the fight for ‘how to think’: traditional media, social networks, and issue interpretation. journalism. 2011; 12(1): 107-27. 3. hampton m. understanding media: theories of the press in britain, 1850-1914. media, culture & society. 2001; 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[cited march 2022]; available from: https://www.unicef.org/afghanistan/media/2136/file/afgpublication_un%20ethical%20guidelines%20for%20journalists%20-%20english.pdf%20.pdf 23. anonymous. denouncing sexual exploitation. [cited march 2022]; available from: https://photos.unicef.org/guidelines-childrights-denounce-exploitation 24. anonymous. standards and guidance. scope of nursing and midwifery practice framework. [cited march 2022]; available from: https://www.nmbi.ie/standards-guidance/scope-of-practice.aspx 25. zahir a, khojasteh h. professional ethics in the islamic republic of iran media: concepts and examples. ethics. 2020; 10(39(61)): 41-65. 26. shamsi-gooshki e, parsapoor a, asghari f. developing "code of ethics for medical professionals, medical council of islamic republic of iran". arch iran med. 2020; 23(10): 658-64. 27. anonymous. [rahnamaye raftare herfey dar fazaye majazi]. 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[cited march 2022]; available from: https://www.ama.com.au/articles/guide-social-media-and-medical-professionalism 30. koocher gp, spiegel pk. ethics in psychology and the mental health professions: standards and cases, 4th ed. uk: oxford university press; 2016. 31. brighton p, foy d. news values. usa: sage publications ltd; 2007. ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ 1 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e original article volume 13 number 17 november 2020 copyright © 2020 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. nurses' perspectives regarding the relationship between professional ethics and organizational commitment in healthcare organizations *corresponding author camellia torabizadeh community-based psychiatric care research center, 2nd floor, building no.3, fatemeh pbuh school of nursing and midwifery, namazi teaching hospital, namazi square, shiraz, iran. postal code : 71936-13119 tel : (+98)71 36 47 42 55 : 221 email : torabik@sums.ac.ir received: 18 april 2020 accepted: 1 oct 2020 published: 8 nov 2020 citation to this article: torkaman m, heydari n, torabizadeh c. nurses' perspectives regarding the relationship between professional ethics and organizational commitment in healthcare organizations. j med ethics hist med. 2020; 13: 17. mahya torkaman1, naval heydari1, camellia torabizadeh2* 1.phd candidate in nursing, department of nursing, school of nursing and midwifery, shiraz university of medical sciences, shiraz, iran. 2.associate professor, community based psychiatric care research center, shiraz university of medical sciences, shiraz, iran. abstract nurses' professional and ethical performances are influenced by the health organizations' environment, and high quality and holistic care can only be provided by observing the principles of professional ethics and organizational commitment. therefore, this study aimed at investigating the relationship between professional ethics and organizational commitment in nurses. this descriptive-analytic study was conducted in hospitals affiliated to shiraz university of medical sciences (sums) in 2019 in iran. the study participants included 210 public ward nurses selected using the stratified random sampling method. data were collected using petty professional ethics and allen-meyer organizational commitment questionnaires, and then analyzed by spss v.25. both the mean score of the nurses' professional ethics (102.21 ± 10.89) and the mean score of the nurses' organizational commitment (95.30 ± 16.54) were at high levels. moreover, a direct and significant relationship was found between professional ethics and organizational commitment (p= 0.009, r = 0.179). in other words, a positive correlation was found between professional ethics and organizational commitment. considering the relationship between professional ethics and organizational commitment in nurses, managers should enhance nurses' level of adherence to ethical principles, organizational commitment and organizational attachment. additionally, training courses can help improve nurses' professional capabilities, and hence enhancing the quality of providing healthcare services. keywords: organizational culture; ethics; organizational commitment; nursing. nurses’ perspective regarding the relationship between professional ethics and … 2 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 17 november 2020 introduction human resources are the most important asset of organizations. nurses, the largest and most important human resources in healthcare organizations, play a major role in providing continuous high quality care (1). the current rapid developments in healthcare organizations have raised concerns about necessity of caring based on the professional ethics' principles. professional ethics is a set of basic human principles and standards governing the individuals and groups' behavior. moreover, professional ethics is a rational thinking process that targets at determining values of an organization (2), and disregarding it can question the organization's legitimacy and actions. empowerment and adherence to principles and codes of ethics are among the concerns of human resource management in the healthcare organizations worldwide (3). according to the international council of nurses (icn), nurses not only promote public health and well-being, but also protect themselves against ethical dilemmas in healthcare organizations by emphasizing on ethical planning and practicing (4). the healthcare organizations' negligence of the professional ethics and their failure in adhering to ethical principles can create problems for nurses that question their measures and reduce their teamwork, job satisfaction, and appropriate relationships with colleagues (5). however, results of various studies indicated that nurses' adherence to professional ethics was not high. bah et al. (2018) showed that nurses' adherence to ethical values was at a low level, and they did not observe the codes of ethics (4). in other words, nurses encounter conflicts between their personal and professional values by ignoring ethical considerations, thereby resulting in their distance from patients and indifference to care provision (4). professional ethics and adherence to its principles can influence individual's commitment to the organization. organizations can rarely succeed without adhering to professional ethics and institutionalizing the organization's ideals and values (6). organizational commitment is defined as believing in the organization's values and goals, feeling loyal to the organization, as well as feeling ethical requirements, heart desires, and needs to stay in the organization. organizational commitment is a type of emotional dependence on the organization; highly committed employees take their identity from the organization, participate in the organization, and enjoy membership in the organization (7). employees with organizational commitment can create an efficient atmosphere to improve organizational ethics, motivation, and efficiency (2). organizational commitment, as an employee evaluation criterion, affects nurses' intention to change their occupation, leave their occupation, absenteeism, conflicts, job stress, and clinical performance (8). to have efficient human resources in the health sector, employing nursing staffs with high organizational commitment is extremely challenging as nurses' low organizational commitment can decrease their performance and quality of care (9, 10). safari and yoosefpour in their study in iran showed that enhancing nurses ‘organizational commitment improved their quality of care (11). torkaman m., et al. 3 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 17 november 2020 researchers of the present study consisted of clinical educators, and nurses who have frequently observed the weaknesses of healthcare organizations in adhering to ethical principles and organizational commitment. in addition, they have closely experienced the consequences of ignoring professional ethics and organizational commitment. both professional ethics and organizational commitment can influence the quality of healthcare staff’s work-life and nursing care, and to the best of our knowledge, this is the first study to investigate the relationship between professional ethics and organizational commitment on nurses. method this descriptive-analytical study was conducted from july to october 2019 in hospitals affiliated to shiraz university of medical sciences (sums) in shiraz, one of the largest cities in the south of iran. participants, selected using stratified random sampling method, were 210 nurses working in sums’ affiliated hospitals. the sample size was calculated as 210 based on a similar study (12), and the sample size formula using r = 0.192, confidence level of 0.95, and test power of 0.8 by medcalc software. inclusion criteria were as follows: being employed as a nurse, having at least a bachelor's degree in nursing, and consenting to participate in the study. participants were excluded if they refused to continue attending or fully complete the questionnaires. the ethics committee affiliated with sums approved this research (medical ethic no: ir. sums. rec.1398.1086), and introduction letters were sent to the hospitals' managers for necessary coordination. prior to the study, all participants were provided with a cover letter explaining the study’s purpose and data collection procedure. then, informed written consent was obtained from all participants, and they were guaranteed the confidentiality of the data, anonymity as well as their voluntary participation in the study. to collect data, petty professional ethics and allen-meyer organizational commitment scales were administered along with the demographic information questionnaire. the professional ethics questionnaire, developed by petty in 1993, includes four dimensions: interest in work, perseverance in work, healthy human relationships at work, and participation in work. attainable scores on this questionnaire ranged from 23 to 115 such that higher scores indicate higher professional ethics. scores within the range of 23-46, 47-69, and 70-115 indicated low, moderate, and good levels of the professional ethics, respectively. content validity of this questionnaire was confirmed by an expert panel of professionals, and its construct validity was corroborated by factor analysis method. cronbach's alpha value to measure the total internal consistency of this tool was 0.96. interest in work, perseverance in work, healthy human relationships at work, and participation in work had cronbach's alpha values of 0.85, 0.79, 0.87, and 0.74, respectively (13, 14). moreover, sheikhzakaryaie and atashzadeh-shoorideh showed that the total reliability of this tool was nurses’ perspective regarding the relationship between professional ethics and … 4 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 17 november 2020 85%. for the following four dimensions, healthy human relationships at work, perseverance in work, interest in work, and participation in work, the reported reliability indices were 79%, 91%, 84%, and 86%, respectively (15). the allen-meyer organizational commitment questionnaire (1990) contains 24 items with three main dimensions of affective (indicating the individual's emotional dependence on the organization), continuance (including costs of leaving the job), and normative commitment (showing the obligation and sense of duty to stay in the organization). the respondents' scores could range from 24 to 168. respectively, a score within the ranges of 120190, 60-90, and 0-60 showed high, moderate, and low organizational commitment. reliability coefficients of the affective, continuance, and normative commitment dimensions were 0.86, 0.79, and 0.75, respectively. validity of this questionnaire was also confirmed by 15 experts, and its structural validity was verified by confirmatory factor analysis (16, 17). in the study by nabizadeh et al., the internal consistency was assessed using cronbach's alpha coefficient (18). based on their findings, (α = 0.87) for the total tool, (α = 0.82) for the emotional commitment, (α = 0.89) for the continuous commitment, and (α = 0.75) for the normative commitment dimension were obtained. the tool's stability was evaluated using the retest method at 14day intervals for all the organizational commitment tools (r = 0.89) as well as the continuous commitment (r = 0.93), emotional commitment (r = 0.93), and normative commitment (r = 0.87) dimensions (18). using spss software version 25, descriptive statistics (percentage, mean, and standard deviation) and analytical statistics (t-test and pearson and spearman correlation coefficient) were used to analyze the data. according to kolmogorov-smirnov test, data had a normal distribution, and the level of significance was considered at 5%. results demographic characteristics from 210 nurse participants, 156 were female (74.3%), 129 were married (61.4%), and 189 had a bachelor's degree (90%). the mean age of nurses was 31.11 ± 6.74 years, and their mean work experience was 7.46 ± 5.89 years (table 1). table 1participant’s demographic information variable number (percentage %) marital status single married 81 (38.6) 129 (61.4) gender male female 54 (25.7) 156 (74.3) education level bachelor's degree master’s degree 189 (90) 21 (10) type of employment permanent employment contractual employment temporary to permanent employment conscription law's employment corporate employment 60 (28.6) 40 (19) 29 (13.8) 72 (34.3) 9 (4.3) based on the independent t-test results, mean scores of the professional ethics and torkaman m., et al. 5 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 17 november 2020 organizational commitment were not significantly diverse in different gender and marital status groups. however, a significant difference was found between the participants' organizational commitment and level of education, and organizational commitment was higher in nurses with a bachelor's degree (table 2). table 2nurses' demographic information as well as its relationship with organizational commitment and professional ethics (n = 210) variables organizational commitment professional ethics *age r = 0.129 p = 0.062 r = 0.047 p = 0.501 *years of working r = 0.051 p = 0.459 r = 0.02 p = 0.777 **gender male 96.51±16.00 r= -0.001 p=0.988 102.61±12.34 r = 0.055 p =0.425 female 94.89±16.75 102.07±10.38 p-value 0.535 0.757 **marital status single 93.50±17.89 r = 0.56 p=0.451 101.91±13.01 r = 0.043 p = 0.538 married 96.44±15.59 102.40±9.37 p-value 0.211 0.752 **academic level bachelor 96.37±15.60 r = 0.125 p =0.071 102.31±10.60 r = 0.003 p =0.965 master 85.76±21.54 101.28±13.48 p-value 0.005* ** 0.682 *pearson correlation coefficient was used, and significance level was considered at 0.01. **spearman correlation coefficient was used, and significance level was considered at 0.01. ***independent t-test was used, and significance level was considered at 0.05. participants' professional ethics and organizational commitment the professional ethics' total mean score was high (102.21 ± 10.89) in nurses. the highest and lowest scores were attributed to the perseverance in work (27.41 ± 3.11) and relations in work (23.00 ± 2.30) dimensions, respectively. the participants' mean scores in dimensions of interest in work and participation in work were )24.46 ± 5.32 ( and )27.32 ± 3.03(, respectively. mean score of the total organizational commitment was high (95.30 ± 16.54). the highest mean score was related to continuance commitment dimension (37.76 ± 9.80), while the lowest mean score was attributed to the normative (30.61 ± 6.63) and affective commitment (31.92 ± 6.49) dimensions. correlation between professional ethics and organizational commitment professional ethics had a direct correlation with interest in work. in addition, organizational commitment had a very weak nurses’ perspective regarding the relationship between professional ethics and … 6 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 17 november 2020 correlation and weak correlation with affective and normative dimensions, respectively. organizational commitment also had a direct and very weak relationship with professional ethics and normative dimension, respectively (table 3). table 3. correlation between professional ethics and organizational commitment in nurses variable professional ethics interest in work perseverance in work human relations at work participation in work total organizational commitment r=0.179 p=0.009* r=0.304 p<0.001* r=0.123 p=0.076 r= -0.028 p=0.681 r=0.006 p=0.926 affective commitment r=0.228 p=0.001* r=0.413 p<0.001* r=0.071 p=0.308 r= 0.025 p=0.724 r=0.038 p=0.583 continuance commitment r=0.047 p=0.497 r=0.065 p=0.352 r=0.056 p=0.420 r= 0.007 p=0.918 r=0.004 p=0.954 normative commitment r=0.154 p=0.025* r=0.257 p<0.001* r=0.154 p=0.026* r= 0.036 p=0.600 r= -0.027 p=0.695 pearson correlation coefficient was used, and significance level was considered at 0.01. discussion this study aimed to investigate the relationship between professional ethics and organizational commitment in nurses. according to the findings of this work, which are consistent with those of a study by dehghani et al. (19) in iran, the mean score of nurses' total professional ethics was at a high level, showing that observing professional ethics was a part of the nursing profession's intrinsic nature. however, a study in uganda indicated that nurses had a poor knowledge of basic ethical concepts (20). another study in iran showed that nurses' knowledge and attitudes were at a moderate level towards ethical codes, implying that nurses did not use various and available related resources appropriately (e.g., international and national codes of ethics in the nursing profession) (21). the discrepancy between our findings and other studies can be due to the differences in participants' characteristics and tools used for measuring professional ethics. in addition, professional ethics is a multidimensional phenomenon influenced by nursing education system, system's views and attitudes toward nurses, as well as social and cultural factors. in professional ethics, the highest and lowest mean scores were related to the perseverance in work and human relations dimensions, respectively. the nurses' high level of perseverance in work can be justified by nursing profession nature, in which nurses should render high quality services to patients despite all shortcomings, many overtime hours, and shortage of the healthcare staff. the low scores in the human relations torkaman m., et al. 7 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 17 november 2020 dimension can be due to nurses' lack of sufficient motivation, burnout, job dissatisfaction, and lack of professional interest as well as low nurse-patient ratio. in this regard, nursing managers can significantly help improve the relationships in workplace and serve as role models for other healthcare system personnel by adhering to the ethics' principles and appropriate human relationships (22). the mean score of total organizational commitment was high among the participants; this finding was also confirmed by many studies in iran and other countries (23-25). staff with higher levels of organizational commitment usually have better performance with less absenteeism and delay to work, which are significantly important in sensitive occupations such as nursing (26). organizational commitment enables the employees to interact emotionally with the organization, feel satisfied to work for the organization, and make endeavor to reach the organization's goals (24). the results of other heterogeneous studies reported an average level of organizational commitment among nurses (27, 28). in our study, the highest mean score of commitment was related to continuance commitment dimension as individual’s continuance commitment can be enhanced by increasing the number and length of training programs (e.g., in-service courses) (27). continuous commitment appears when an individual analyzes positive and negative aspects of leaving the organization. with high levels of continuance commitment, the employees remain loyal to the occupation because they think that starting a new job would destroy the experiences gained in the organization. however, such thought may put the organization in a position facing employees who are not motivated, creative and innovative (6). the present study’s participants seemed to adapt to the current situation to avoid financial costs of leaving the organization, possibly due to low nurses' salaries and economic problems in iran. the lowest mean score of organizational commitment was related to normative commitment dimension, which was confirmed by another study in iran on nurses (18). in normative commitment, employees are faced with the situation of staying in the organization because they think it is a right and proper action. the following approaches can be effective in improving employees' normative commitment: in-service training, labor division based on the individuals' abilities and competences, as well as continuous evaluation of the personnel's performance, abilities, and capabilities (26). this study’s results showed a significant relationship between professional ethics and organizational commitment. many studies also confirmed the relationship of professional and ethical empowerment with nurses' organizational commitment (25, 29). inconsistent with the present study, a research in iran on nurses showed no significant relationship between professional ethics and organizational commitment (2). based on the literature, ethical work environment can be considered to be a main factor affecting the performance and nurses’ perspective regarding the relationship between professional ethics and … 8 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 17 november 2020 competence of the staff (4, 30). in this regard, karami et al. stated that hospital managers need to extensively plan to improve nurses' professional performance and organizational quality (7). the present study showed a significant relationship between the nurses' organizational commitment and the bachelor's degree. this finding was in line with the results of a study by nabizadeh et al. (18), but contradicted those of a study by sheikhzakaryaie and atashzadeh-shoorideh (15). usually, nurses with master's and doctoral degrees are employed in universities and research centers in iran. moreover, nurses with a bachelor's degree have fewer job opportunities, and hence they have to work in clinical settings and are more dependent on the healthcare organizations. given that various factors affect nurses' professional ethics and organizational commitment, managers should consider factors such as delegating authority, clarifying responsibilities, and evaluating staff performance properly. the authorities should enhance nurses' commitment to ethics and organizational attachment through training courses to empower the nurses, thereby improving their quality of health care services. a limitation of this study was administration of the self-report questionnaires, and hence future work can use other data collection methods such as interview and observation to increase data validity. conclusion according to the study findings, nurses had high levels of professional ethics and organizational commitment, and a significant relationship was observed between these two factors. considering the priority of high-quality care provision by nurses, nursing managers should seriously consider the effect of nurses' professional ethics and organizational commitment on organization's development. moreover, providing a precise definition of ethical codes as well as in-service training courses for nurses can encourage them to practice on ethical principles and improve their organizational commitment. acknowledgments this study was derived from an approved research project in shiraz university of medical sciences, iran with registration number: 19773. the authors thank and appreciate all nurses who participated in this research. conflict of interests the authors declare that they have not competing interest. torkaman m., et al. 9 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 17 november 2020 references 1. esmaelzadeh f, abbaszadeh a, borhani f, peyrovi h. ethical sensitivity in nursing ethical leadership: a content analysis of iranian nurses experiences. open nurs j. 2017; 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26(86): 29-38. 28. lim t. relationships among organizational commitment, job satisfaction, and learning organization culture in one korean private organization. asia pacific education review. 2010; 11(3): 311-20. 29. weng q, mcelroy jc, morrow pc, liu r. the relationship between career growth and organizational commitment. journal of vocational behavior. 2010; 77(3): 391-400. 30. lu cs, lin cc. the effects of ethical leadership and ethical climate on employee ethical behavior in the international port context. journal of business ethics. 2014; 124(2): 20923. ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ 1 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e original article volume 13 number 16 october 2020 copyright © 2020 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. white lies in pediatric care: a qualitative study from nurses’ perspective *corresponding author alireza nikbakht nasrabadi no.1, school of nursing and midwifery, doctor mirkhani st., tohid sq., tehran, iran. tel: (+98) 21 61 05 41 28 email: nikbakht@tums.ac.ir received: 29 mar 2020 accepted: 1 sep 2020 published: 18 oct 2020 citation to this article: shali m, joolaee s, navab e, esmaeili m, nikbakht nasrabadi a. white lies in pediatric care: a qualitative study from nurses’ perspective. j med ethics hist med. 2020; 13: 16 mahboobeh shali1, soodabeh joolaee2, elham navab3, maryam esmaeili4, alireza nikbakht nasrabadi5* 1.reseacher, department of critical care nursing and management, school of nursing and midwifery, tehran university of medical sciences, tehran, iran. 2.professor, nursing care research center, iran university of medical sciences, tehran, iran; researcher, center for health evaluation & outcome sciences (cheos), university of british columbia (ubc), vancouver, bc, canada. 3.associate professor, department of critical care nursing and management, school of nursing and midwifery, tehran university of medical sciences, tehran, iran. 4.researcher, nursing care research center, school of nursing and midwifery, tehran university of medical sciences, tehran, iran; associate professor, department of critical care nursing and management, school of nursing and midwifery, tehran university of medical sciences, tehran, iran. 5.professor, department of medical surgical nursing, school of nursing and midwifery, tehran university of medical sciences, tehran, iran. abstract communication and sharing information with ill children are challenging. to protect a child from the bitter reality, sometimes use of well-intended untruths, or white lies is necessary. this research aimed at studying the experiences of nurses about the use of white lies in in pediatric clinical setting. in this qualitative, content-analysis study, 24 on-duty pediatric nurses were interviewed in 2019. data were collected through purposeful sampling using semi-structured interviews, and the collected data were analyzed according to granheim and landman’s method using maxqda-10 software. eighteen female and six male nurses with the mean age of 42 ± 3/7 years and mean work experience of 16 ± 4/1 years were selected to participate in this study. data analysis showed that use of white lies depends on both situation and several other factors classified into five general categories: nature of data, childhood characteristics, family norms, treatment team’s capabilities and organization policies. treatment team members need to improve their communication skills to convey therapeutic information to the ill child’s family appropriately. to do so, special guidelines should be prepared for healthcare staff in pediatric clinical setting. keywords: ethics; pediatrics; truth-telling; content analysis. mailto:nikbakht@tums.ac.ir white lies in pediatric care: a qualitative study from nurses' perspective 2 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 16 october 2020 introduction implementation of therapeutic measures for children can be an undesirable experience for parents and caregivers (1). statistical data show that three percent of the children have been hospitalized at least once during their childhood, and nearly five percent of them have been admitted to the therapeutic centers for treatment (2). due to clinical differences between children and adults, special skills are required in pediatric care (3). the importance of pediatric nurses' vital role is becoming more prominent, and hence the significance of educating pediatric caregivers and clinical practitioners about promoting child health is becoming more highlighted in order to provide child care at the highest standard (4). in pediatric setting, caring for children involves effective communication with children and their families to deliver highquality care during hospital stay or even after discharge (2). communication methods are influenced by various factors such as child’s age, parents’ needs and cultural norms (5). some parents oppose or resist the disclosure of bad news to protect their child, which is common in asian culture (6, 7). review of literature and research on this topic in iran, pakistan, israel, jordan, lebanon, palestine, turkey, united arab emirates and saudi arabia showed that viewpoints of middle eastern regarding disclose of truth is different and varied (8). in middle eastern culture, concealing truth is considered protection against the bitter truth, and hence medical and care staff are forced to disclose bad news in distorted, indirect, changed ways, typically called white lies (9, 10). a white lie can be considered an ethical decision made in certain circumstances (e.g., facing a bitter truth) to protect the patient from predictable harm without personal motivation or self-interest. (11). james et al. (2006) in their research showed that white lie can be seen in all levels and 96.4% of clinicians use it as a communication strategy (12). deciding on the following options is an ethical challenge requiring knowledge of ethical principles, disclose truth, conceal truth, or use white lie (13). nurses should have an understanding of ethical reasoning to preserve their patients’ rights without compromising their own moral conscience (14). otherwise, in complicated clinical situation, wrong decisions followed by inappropriate interventions may result in undesirable consequences for the patients, their families, or even the nurses. according to the researchers' experience in nursing care and other available studies, white lies are frequently used in children care process (5, 15). since nurses’ perceptions and experiences are formed through continuous encounters with real world situations, studying their state of mind, feelings, emotions, as well as their experiences leading to white lies in childcare domain is extremely important. to do so, the qualitative study method was an appropriate research methodology capable of searching through such states and experiences. to the best of our knowledge, no qualitative study has been conducted on the use of white lies in children care so far, and hence this study shali m., et al. 3 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 16 october 2020 was the first to review nurses' experiences of white lie in pediatric care setting. methods this qualitative study with content analysis approach was designed and conducted in 2019. in this study, purposeful sampling was used to select the samples from on-duty nurses working in pediatric medical, surgical, critical and emergency wards of four teaching hospitals affiliated to tehran university of medical sciences. the criteria for entering the study include the followings: at least a bachelor’s degree in nursing, willingness and consent to participate, at least one year of work experience in pediatric ward, and capability of expressing personal experiences regarding the study’s subject. nurses with managerial position or with no experience in childcare were excluded from this study. data were collected using semi-structured one-to-one interviews scheduled at participants’ preferred time and location. each interview lasted between 45 to 60 minutes. data analysis was performed based on conventional content analysis approach suggested by granheim and lundman (16). initial interview questions included the followings: have you ever experienced a situation where you did not want to tell the truth or could not tell the truth to your patient? under what circumstances, did you use a white lie during patient care? then, depending on the dynamics of the interview, more detailed questions were asked to gain a deeper understanding of the participants' experiences. after carefully listening to the recorded interviews, they transcribed verbatim. after reviewing the transcripts and mentorship’s notes, the words, sentences and paragraphs were considered as the conceptual units, which later were assigned specific codes. data management was done using maxqda software version 2010. the codes were compared to find similarities and differences, and then classified into several categories. data validity and reliability were assessed using guba and lincoln method (17). credibility of the data was assured using two methods: (i) checking the collected data by members and peers having prolonged engagement with the related topics, and (ii) considering maximum variation during sampling with cases purposefully as different from each other as possible. transferability of the findings was attained by rich descriptive data collection and analysis to allow readers match findings with their context. in addition, detailed and descriptive data analysis as well as use of experts’ experiences were utilized to achieve dependability. conformability and consistency of the analysis were confirmed through discussions among the research team members and resolving disagreements. this research was conducted under the supervision of ethical committee of tehran university of medical sciences with ir.tums.vcr.rec.1397.568 code of ethics. all participants were asked to sign written consent forms after being informed about the study’s objectives and method. confidentiality of the data was maintained, and the possibility of early withdrawal was provided to the participants. white lies in pediatric care: a qualitative study from nurses' perspective 4 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 16 october 2020 results in this study, 24 nurses with the mean age of 42±3/7 years and the mean work experience of 16±4/1 years were participated. all participants were married and had no managerial or executive position. they were exclusively caring for children under the age of 12 (table 1). table 1participants' characteristics characteristics number gender female 18 male 6 education level bachelor’s degree 13 master’s degree 5 doctoral degree 3 ward medical/surgical (m/s) 11 operating room(or) 2 intensive care unit (icu) 4 emergency department (ed) 4 data analysis on 454 initial codes showed that the use of white lies depends on situation. the initial codes were classified into five main categories: nature of data, childhood characteristics, family norms, treatment team’s capabilities, and organization policies. shown in table 2, each main category had several subcategories. table 2categories & sub-categories categories subcategories nature of data bad news technical data childhood characteristics fear and insecurity continues questioning family norms culture child protection decision-making responsibility treatment team’s capabilities respect of values ethical reasoning communication skills organization’s policies organization’s principles organization’s instructions nature of data technical terms in medical news are difficult to understand even for adults. however, participants believed that patients should receive comprehensive information that is concise and appropriate to their level shali m., et al. 5 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 16 october 2020 of understanding and literacy. otherwise, if information cannot be conveyed in this way, use of harmless or white lies become inevitable. therefore, nature of medical data was defined as one of the main categories of this study that led to the use of white lie in pediatric care setting. this category had two subcategories: bad news and technical data. bad news based on the participants' experiences, families and caregivers tend to hide unpleasant news and facts. instead, they tend to convey more appropriate and hopeful news out of compassion, and white lies can make difficult situations such as delivering bad news easier. a participant stated, “children are too young to be told that they have an incurable and dangerous illness unlikely to be healed. telling the bitter truth is not possible. such news is even difficult for adults and they cannot accept it.” [participant no. 6]. technical data conveying technical information (e.g., diagnostic tests, treatments, medications, and care), especially in incurable diseases, to children is difficult if not impossible. nevertheless, informing children is essential to attracting their cooperation and participation in the care process. a post intensive care unit (icu) nurse with 14 years of work experience stated, “it is not possible to talk to the child using technical terms. even if we could explain medical information in a very simple language, not all information would be transferable. we have to simplify or change the information, so sometimes we need to use lie.” [participant no. 9] childhood characteristics the aim of informing patients is to respect patients’ autonomy, to gain their trust to participate in care and treatment process, and to allow them to have complete awareness of the situation to make informed decisions. due to various factors such as children’s age, their inability to do self-care, and their lack of legal responsibility for decision-making, healthcare staff sometimes are reluctant to deliver all correct clinical information to patients. the children’s ability to interpret and use such information is different from that of adults due to their childhood characteristics, which can become an obstacle in disclosing truth. this category had two sub-categories: (i) fear and insecurity, and (ii) continuous questioning. fear and insecurity answering children’s continuous questioning and coping with their fear, insecurity and restlessness, when isolated from their families or caregivers, are among the reasons for the use of white lies. a participant said, “parents are not allowed to accompany their children to the icu. when children want to see their parents, we tell them that their parents are waiting behind the icu door, and if you allow us to inject the medicine or if you are a well-behaved child, we let them into the room to visit you. but, in fact, at that time, parents are often not in the hospital.” [participant no. 11] continuous questioning white lies in pediatric care: a qualitative study from nurses' perspective 6 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 16 october 2020 according to the participants, the caregivers' fear and frustration over children's constant questioning forced them to use white lies. one participant stated, “we tell the child that he will have surgery. he begins to ask about the type of surgery. in response, we say, for example, that you will have abdominal surgery. the child then asks where the abdomen is located and where in the abdomen will be operated on. we answer, for example, that the stomach will be operated on. then the child asks what is the stomach and where it is located. can't i eat chocolate if you operate on my stomach? can i go to school without a stomach? may i die of surgery? did the patient next to my bed who had died recently had a stomach and did he die because of it? these questions go on and on. “[participant no. 20] family norms despite different cultures, all families seek to support and protect their children. in addition, the legal decision-maker for the children is usually their guardian or one of their parents. this category had three subcategories: culture, child protection, and decision-making responsibility. culture according to the participants, in some cultures, families do not disclose the illness or eminent death to their children, and hence at the request of the family, the medical team are forced to use white lies. an on-duty nurse in children surgical ward with six years of work experience shared her findings,” she was a little girl and had problems with her perineal region. her parents did not want to tell her anything about the disease and asked us to tell her that she was going to have a tummy operation. they did not allow us to use specific terms related to this region.” [participant no. 12] child protection parents use white lies to protect their children against bad news and ask the treatment team to do the same. a participant said, “the parents thought that if she knew, she would be very upset. her younger sister died of the same disease last year, so she should never know that she was suffering from the same disease.” [participant no. 1] decision-making responsibility although respecting patient autonomy is a principle of ethical care, children are less involved in decision making related to their care process. intricate parents-child communication as well as ill child's dependence, fragility, and immature decision-making capability make the parents the final decision-makers in care process. a participant stated, “the parents sign all consent forms and make decisions in all situations. they ask us not to tell the children what is happening so that they do it themselves. when the children ask us, we do not tell them the truth because their parents have asked us not to do so.” [participant no. 3] treatment team’s capabilities treatment team members’ various opinions and outlooks on the appropriateness of different methods as well as their lack or absence of basic skills are among the reasons for using white lies. acquiring necessary skills or enhancing them promotes shali m., et al. 7 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 16 october 2020 treatment team’s capabilities in children care according to medical ethics principles. treatment team’s capabilities had three subcategories: (i) respect of values, (ii) ethical reasoning, and (iii) communication skills. respect of values in children’s care process, the participants have experienced situations where they have decided to conceal the truth and use white lies based on their personal values. an onduty nurse in pediatric oncology ward with 10 years of work experience stated,” my nephew suffered from cancer, and we did not tell him until his death. we knew that he would die, but we liked to see him happy. now, i do not tell my patients that they have cancer, or at least i do not want to be the person telling them what is going on.” [participant no. 15] ethical reasoning according to participants, the ability of ethical reasoning to evaluate different angles of truth-telling can help caregivers decide whether to use white lies or not. a participant stated, “i look at the situation and sometimes it is impossible to tell the truth. telling the truth in inappropriate situations may frustrate and frighten sick children, which may eventually stop them from cooperating. we have to wait for the right time.” [participant no. 18] communication skills communication is a fundamental concept in nursing care. the following skills are required in pediatric care: (i) understand child’s feeling, (ii) assess the need to disclose some or all of the information, (iii) effectively communicate with the child in a friendly way, (iv) provide information to the children according to their level of understanding, and (v) realize suitability of time and place to communicate with the child. absence or lack of the abovementioned skills may force the caregivers to use white lies. a participant said, “working with children is difficult. you should know how much they know, what they know, what experiences they had, how much they know about death at this age, and what information their parents has given them. you also need to reassure them because they may be afraid of the treatment team. you need to make them feel safe and speak to them in a language they can understand, and be prepared to respond appropriately to their requests and questions.” [participant no. 9] organization’s policies as a health care organization, hospitals pursue their goals of providing the most appropriate care with the best quality; however, they focus more on medical care and less on other aspects of care (e.g., availability of information to the patients, especially the children). integrity of the organization’s principles in valuing all healthcare and medical aspects as well as developing guidelines in line with these principles can facilitate delivering information to children. the organization’s policies category had two subcategories: organization’s principles and organization’s instructions. organization’s principles white lies in pediatric care: a qualitative study from nurses' perspective 8 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 16 october 2020 if the organization provides the principles of telling the truth to children in a comprehensive guidebook accessible to all staff, the treatment team can use that guide in delivering information to patients, thereby minimizing inconsistencies and resolving conflicts. without providing such guidebook for all on-duty caregivers, they employ their personal and preferred approaches where white lies can be part of them. a participant said, “to fulfill patient’s rights, precise and true information should be presented to the patients. however, if their physicians, their supervisors, or their families oppose, what should we do? if i follow the rules, then who will answer these opponents?” [participant no. 2] organization’s instructions according to the participants, instructions for truth disclosure to patient is more adultoriented, and no clear set of instructions exists for the children. an on-duty nurse with 14 years of work experience in pediatric operating room stated, “recently, to break bad news to adults, some instructions have been provided, which are not so practical. for children, however, no instructions have been prepared. a set of instructions would be very useful for the children since they are completely different from adults.” [participant no. 17] discussion the research aimed to study nurses’ experiences regarding the use of white lies in pediatric care setting. the findings of this study were summarized into five main categories: nature of data, childhood characteristics, family norms, treatment team’s capabilities, and organization’s policies. nature of data is a common reason for the use of white lies as breaking bad news or delivering highly technical information to children is challenging. although disclosing bad news to children is frustrating, the way the news is presented can help alleviate stress (18-20). disclosure of information should be done gradually, systematically, in smaller sections with proper control and management. family and the ill child should be involved in the care process with full support of treatment team, even if they are not eager to hear all the information. furthermore, childhood characteristics are also among the reasons for filtering information and using white lies (18, 21). children’s age and their needs should be considered in information disclosure. kelly et al. stated that adolescents tend to receive filtered information from their family (22). information disclosure causes confusion and fear among children in some instances. healthcare staff frequently perform the duty of disclosing information to the families. after information disclosure, answering ill child’s continuous questions are challenging. according to the participants, white lies were used to manage such questions or to conceal information to keep ill child happy without answering numerous sad questions; our findings are in line with those of sadathoseini and aramesh (23). nevertheless, children should be kept informed on what is happening around them, because if they attribute their pain and sadness to various wrong causes (e.g., punishment of god, not being a well-behaved child), the shali m., et al. 9 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 16 october 2020 circumstances would be intolerable to them. to cope with such circumstances, families should help relieve distress and anxiety of their children (24). various parents has their own parenting styles (25), and these styles are affected by different factors (e.g., culture, ethnicity, language, gender and socioeconomic status). hence, when interacting with healthcare team, such styles affect the interpretation of clinical data, decision making and treatment process (26). according to our findings, since parents’ contribution in child’s care is inevitable, healthcare team, especially the nurses, should understand their cultural differences, and their cultural sensitivity should be considered in interactions. parents to protect their ill child ask the healthcare team to filter information or even use white lies (27). however, intentional truth concealment even benevolently can have negative consequences. parents are their children’s decision-makers, so they cannot make informed decision about their child’s treatment if being deprived from information of diagnosis, treatment process, and prognosis. additionally, without such information, parents may have unrealistic requests during treatment process or follow therapeutic measures that are futile, unreasonable, useless and unprotective (28, 29). parents with realistic perspective of ill child’s condition experience less regret after making a decision (5). the use of white lies in pediatric care also depends on the abilities of the treatment team to communicate. competent treatment team with effective communication skills can mutually cooperate with parents and facilitate information disclosure to the ill child. according to valizadeh and ghasemi, although nurses seem to have a positive attitude towards parents’ involvement in caring for sick children, in practice, nurses’ attitude is negative or neutral, especially in emergency cases or in implementation of specialized procedures (30). furthermore, to comply with the rules and ethical principles, nurses should not only know their personal values, but also respect patients’ values. nurses are caring for patients with cultural varieties and are obliged to provide comfortable clinical environment for their patients (31). therefore, they should effectively communicate with their multicultural patients to reach a mutual understanding. nurses in their professional activities and duties should consider patients’ values and beliefs, and they should be able to deliver healthcare services to patients irrespective of their cultural background. lack of knowledge and cultural competence cause the nurses to care for the patients without considering their culture and religious beliefs (32). healthcare organization’s policies about use of white lies in clinical setting can facilitate disclosing information to children; however, no definite organizational protocol, guide, or instruction set has been provided. according to culley et al., no formal instructions have been provided to disclose or conceal the truth; no precise or technical definition for white lie has been presented; when to use while lie and how to use white lie have no clear guidelines (33). in line with our findings, jouybari et al. stated that nurses use indirect methods for disclosing white lies in pediatric care: a qualitative study from nurses' perspective 10 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 16 october 2020 information and no special instructions have been provided on how to tell the truth about treatment to patients and their families. for information disclosure, different nurses have their own ways derived from several factors (e.g., values, beliefs, mindset, and cultural context) (34). in grassi et al. study, healthcare staff highlighted their need for guidelines and instructions to disclose disease-related information (i.e. diagnosis and prognosis) (35). this study was based on the experiences of pediatric nurses regarding white lies. further qualitative studies on this subject with other approaches and situations are recommended. in addition, further comprehensive investigations on corrective measures in different educational, social, and organizational settings can elaborate nursing promotions in ethical care and methods of information disclosure to children. conclusion regarding children’s expediency, social structure and culture together with customs and traditions may prioritize the principle of “no harm” over “individual discretion” and “justice” in information disclosure to children. however, in defining child's best interests, or expediency, real sources of children's harm should be realized and distinguished from illusionary sources. enhancing healthcare team’s skills in information disclosure and communication as well as providing special guidelines for information disclosure are requirements for truth-telling to children to preserve their fundamental rights. as an ethical principle, disclosure of information to children should be performed considering their special needs and level of understanding with the least possible harm. acknowledgements authors would like to thank all nurses who participated in this study. this study is part of the correspondent author’s phd dissertation at tehran university of medical sciences (project number: 9421199004), and the authors would like to thank the university for supporting this project financially. conflict of interests all authors declare no significant competing interests that might have influenced the performance or presentation of the work described in this article. shali m., et al. 11 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 16 october 2020 references 1. birnie k, noel m, parker j, et al. systematic review and meta-analysis of distraction and hypnosis for 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800-1. 13. hekmat-afshar m, jooybari l, sanagou a, kalantari s. study of factors affecting moral distress among nurses: a review of previous studies. j educ ethics nurs. 2013;1(1): 0-0. 14. fazljoo e, borhani f, abbaszadeh a, dadgari a. assessment of moral reasoning ability of the nurses in dealing with moral dilemmas. medical ethics. 2016; 10(36): 47-54. 15. hudson n, spriggs m, gillam l. telling the truth to young children: ethical reasons for information disclosure in paediatrics. j paediatr child health. 2019; 55(1):13-7. 16. graneheim uh, lundman b. qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. nurse educ today. 2004; 24(2): 105-12. 17. hsieh hf, shannon se. three approaches to qualitative content analysis. qual health res. 2005;15(9):1277-88. 18. mack jw, joffe s. communicating about prognosis: ethical responsibilities of pediatricians and parents. pediatrics. 2014;133(suppl.1): s24-30. white lies in pediatric 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communication about prognosis between parents and physicians of children with cancer: parent preferences and the impact of prognostic information. j clin oncol. 2006; 24(33): 5265-70. 30. valizadeh f, ghasemi s. medical staff attitude toward parents’ participation in the care of their hospitalized children. hayat. 2008; 14(1): 69-76. 31. kourkouta l, papathanasiou iv. communication in nursing practice. mater sociomed. 2014; 26(1): 65-7. 32. ardoin kb, wilson kb. cultural diversity: what role does it play in patient safety? nurs womens health. 2010; 14(4): 322-6. 33. culley h, barber r, hope a, james i. therapeutic lying in dementia care. nurs stand. 2013; 28(1): 35-9. 34. mahasti jouybari l, ghana s, sarrafi kheirabadi s, sanagoo a. the nurses' experiences of breaking bad news to the patients and their relatives. medical ethics. 2013; 7(24): 1131. 35. grassi l, giraldi t, messina eg, magnani k, valle e, cartei g. physicians' attitudes to and problems with truth-telling to cancer 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____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ 1 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e © 2019 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. original article volume 12 number 5 april 2019 lived experiences of nursing students about ethical concerns regarding mobile learning in educational and clinical contexts *corresponding author nayereh baghcheghi department of nursing, school of nursing, saveh university of medical sciences, saveh, iran. tel: (+98) 86 42 24 25 96 email: baghcheghinayereh@gmail.com received: 23 june 2018 accepted: 18 apr 2019 published: 29 april 2019 citation to this article: koohestani hr, baghcheghi n, karimy m, hemmat m, shamsizadeh m. lived experiences of nursing students about ethical concerns regarding mobile learning in educational and clinical contexts. j med ethics hist med. 2019; 12: 5. hamid reza koohestani1, nayereh baghcheghi2*, mahmood karimy3, morteza hemmat4, morteza shamsizadeh5 1.assistant professor, department of medical education, school of medicine, saveh university of medical sciences, saveh, iran. 2.assistant professor, school of nursing, saveh university of medical sciences, saveh, iran. 3.associate professor, social determinants of health research center, saveh university of medical sciences, saveh, iran. 4.assistant professor, department of health information management, school of medicine, saveh university of medical sciences, saveh, iran. 5.instructor, chronic diseases (home care) research center, hamadan university of medical sciences, hamadan, iran. abstract the field of education has experienced a profound change following the introduction of mobile technology over the last decades, and nursing education is not an exception. this study explored the experiences of nursing students about the ethical concerns regarding the use of mobile devices for learning purposes, that is, mobile learning, in educational and clinical contexts. a qualitative phenomenological study was carried out on nursing students (n = 19) in saveh university of medical sciences of iran between december 2017 and april 2018. data were collected through semi-structured interviews with openended questions. data analysis was done using colaizzi’s 7-step method, revealing four themes and nine sub-themes including: 1) preserving professional dignity (in front of the patient, and the teacher, and preserving academic virtual identity); 2) securing informed consent and respecting personal (the patient’s and teachers) autonomy; 3) proper and efficient use (observing the regulations and codes, and making educational use); and 4) avoiding harm (responsible  use of  class and patient data). it was revealed that using mobile technology in education could raise ethical concerns for nursing students, and this should be emphasized in nursing educational programs. keywords: mobile learning; smartphone learning; ethical concerns; nursing student; education; clinical setting lived experiences of nursing students about ethical concerns … 2 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 5 april 2019 introduction mobile devises have emerged as new learning tools with a notable potential both in classrooms and outdoor learning environments (1). mobile learning (mlearning) refers to using mobile electronic devices for educational purposes (2). in short, it means using a mobile handheld electronic device for learning without time or place limitations (3, 4). portable devices are rightfully considered as powerful and interconnected handheld computers that among other things are used as efficient tools for learning and delivering targeted and curated content (5). m-learning has gained a more important role in improving the outcomes of learning and education (6). mobile technology as a learning tool can add a new level of experience and significantly improve electronic learning (e-learning) appeal (7). mobile devices such as smartphones can be integrated into health profession education (8, 9). studies at the international level indicate that in general, university students have a positive attitude about using mobile devices for educational purposes (10, 11). the findings of a systematic review showed that using an m-learning strategy in medical education can have positive effects on learning in all three domains of bloom’s taxonomy, that is the cognitive, effective, and psychomotor domains (12). there is a growing demand in medical science education programs for m-learning, since it is more convenient and readily accessible than traditional lectures (13). gallegos and nakashima (2018) reported that allowing the students to use mobile devises benefited the learning experience, and proper use of technology for educational purposes could enhance student interaction and engagement (14). every day a new technological innovation is introduced in the field of higher education. the advancements have also affected nursing education. the integration of mobile technology has revolutionized learning over the past decades and it is widely incorporated into nursing education (15). m-learning has not only brought about deep changes in education, but it has also created new issues in the field of ethics. with the expansion of various aspects of nursing education, the dimensions of ethical concerns have also expanded. use of mobile technologies by students in the educational context is not free of ethical concerns. while some studies have concentrated on ethical issued in m-learning, there is a paucity of studies to recommend ethical ways of using m-learning (16). the diversity of the usages of m-learning in nursing education also increases complexity of the issues. although several studies have been conducted to determine the effectiveness of m-learning in students’ academic achievements, there are no published study on the lived experiences of students about the ethical concerns surrounding the issue. there are universal ethical principles and values such as trustfulness, veracity, intrinsic dignity, respecting others’ privacy, freedom, honesty and the like; however, these concepts have different definitions in each situation. for instance trustfulness in business is different from trustfulness in education. koohestani h.r., et al. 3 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 5 april 2019 all research projects start with a clear question that dictates the path and stages of the study. thus, the research method is a function of the question. in this work, the question was “how do nurses experience the ethical concerns related to using m-learning in educational and clinical contexts?” as the question indicates, methodology should represent the nature of the phenomenon in a natural context along with the structures and factors that affect its development. indeed, the authors expected to find the reality in its natural form as experienced by the students. in other words, the authors tried to perceive the experience instead of measuring it. thereby, a qualitative method was the best option to illustrate the nature of the phenomenon in its natural context. there has been a paucity of qualitative studies on the lived experiences of nursing students about the ethical concerns regarding m-learning in educational and clinical contexts. thus, the present study was an attempt to examine nursing students’ lived experiences about the ethical concerns related to the use of mobile devices for learning purposes in such contexts. methods a qualitative study was carried out using the phenomenological method of inquiry in saveh university of medical sciences in iran between december 2017 and april 2018. purposive sampling was used to identify and choose well-informed individuals in order to select the participants. study inclusion criteria consisted of being an undergraduate nursing student, having passed at least two academic terms, and willingness to participate in the study. given that nursing students entered the clinical setting starting the 2nd semester, all participants had at least 20 days of clinical experience. nursing students with different demographic characteristics and clinical experiences (maximum variation) were included in the research for enhancing transferability of the results. however, to make sure that the participants were familiar with mobile technology, the research population was limited to undergraduate nursing students. these students were mostly at the same age group and could be recognized as the “digital native” generation. on the other hand, adding graduate nursing students could create unique landscapes. sampling was continued until data saturation was achieved and no new code was found. data gathering was done using semistructured interviews with open-ended questions (e.g. “can you tell me about a situation where you used mobile phone for learning purposes?”, or “tell me about your ethical concerns in m-learning experience”. the interviews were performed at the university campus (classroom, office, and any place of convenience). given that the author is a research instrument in qualitative studies, guided questions were also obtained from the interview texts and used in subsequent interviews. probing questions were used based on the information offered by the participations to gain deeper insight into the issue. to improve trustworthiness and rigor of the data, guba (1981) was followed including the four criteria for lived experiences of nursing students about ethical concerns … 4 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 5 april 2019 credibility, transferability, conformability, and dependability (17). to ensure creditability, the authors tried to create an intimate interaction with the subjects, win their trust by creating a relaxed and unstressed environment, and assign adequate time for data collection. in this way, the authors made sure that the participants could recount their experiences without tension. in addition, field notes, memos, member-check, and reviewing codes and themes by external reviewers (extended check) were used to guarantee the credibility of the data. to ensure conformability of the study, details of the study procedure including data collection, analysis, and extraction of codes and themes were elaborated so that the readers could form a judgment by reading the report. to support dependability, the whole procedure was extensively described to make it easy for readers to audit the study. with regard to transferability, a detailed account of the location of the research, interactions, and the processes observed during the study was also provided to facilitate judging the transferability of the study. the results were analyzed using colaizzi’s 7-step method (18). at first, the statements in the interviews were transcribed verbatim, and the transcriptions were read several times to obtain a common perspective with the participants. at the second stage, the key meanings and concepts were extracted and critical points were determined. at the third stage, the important themes were formulated and the authors tried to find the meaning of each extraction and the related concepts. the themes were clustered at the fourth stage, and the concepts were studied in detail and classified based on their similarity to the subject categories or the main concepts. as the fifth step, the results were used to achieve a comprehensive explanation of the subject. at this point, different subject categories of the same meaning were placed in larger categories to find the concepts of the main description. afterward and as the sixth stage, the explanation of the intrinsic structure of the phenomenon under study was presented as an explicit statement of its basic structure. as the final step, creditability of the findings was ensured by carrying out a private interview with each participant. in the interview, each participant was asked to comment on the findings, and the results were then finalized. in observance of ethical codes, the subjects were informed at the start about research objectives, interview method, and confidentiality of their information, and were also assured that they could leave the study whenever they wanted. in addition, they were asked to sign an informed letter of consent. to ensure convenience of participation, the interviews were arranged in a way so as not to interfere with the daily routines and educational programs of participants. the author secured a permit from the ethics committee of saveh university of medical science as well (ir.savehums.rec1396.33). the students expressed their consent to participate in the study both orally and in written form. they were informed about the study purposes, interview method, confidentiality of information, and their right to participate in or leave the research at any point. koohestani h.r., et al. 5 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 5 april 2019 results among the 19 subjects in this study, 63.15% (n = 12) were female, and the average age of the participants was 20.57 ± 0.53. moreover, three students were in the 3rd, five in the 6th, and six in the 8th semester. data analyses yielded 352 primary codes, which were then truncated based on overlaps and merged into 167 primary codes. after comparing the codes and their similarities, nine sub-themes and four themes were extracted (table 1), which are presented below. table 1the main themes and sub-themes themes sub-themes preserving professional dignity preserving professional dignity in front of the patient preserving professional dignity in front of the teacher academic virtual identity securing informed consent and respecting personal autonomy securing informed consent and respecting the patient’s autonomy securing informed consent and respecting the teacher’s autonomy proper and efficient use observing the regulations and codes making educational use avoiding harm responsible use of class data responsible use of patient data 1.preserving professional dignity preserving professional dignity in front of the patient the findings showed that it was very important for the students to preserve their professional prestige before patients. for this reason, while interviewing the patient or providing care, they would try to keep eye contact and refrain from using their mobile phones in any way that might be construed as disrespectful. in addition, some of the respondents said that using phones during care provision might interrupt the nursepatient relationship and negatively affect the quality of rapport. one participant said: [“using any technology entails a specific code of conduct; for instance, i would never use my mobile phone while interviewing a patient, not even for educational or academic purposes. if i do so, it might be interpreted as disrespectful, and would be degrading to my professional prestige.”] (participant no. 11) another one said: lived experiences of nursing students about ethical concerns … 6 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 5 april 2019 [“i would rather not use my phone while i interview the patients or provide care to them, because i think it is wrong and might lower my professional prestige. there are times when i try to take notes while interviewing or taking case history. in such situations i would ask for the patient’s permission beforehand to avoid any misunderstanding.”] (participant no. 8) preserving professional dignity in front of the teacher in this study, the participants’ concern about preserving their dignity before their teacher was also examined. observing the codes of good conduct and decorum based on humanistic and professional values throughout academic and non-academic activities is a generally accepted standard among academicians. using mobile phones in the presence of a teacher in clinical and educational environments, especially in a respectful manner, was one of the experiences mentioned by the participants. in observance of this rule, the students would limit the use of mobile phone for educational purposes to specific places and situations. one participant stated: [“there is no doubt that mobile phones offer many possibilities regardless of time and place, but i do not use them everywhere. for instance, i would never check my phone while i am talking to my teacher, because it is unethical.”] (participant no. 12) another student said: [“not all teachers are familiar with the advantages of smartphones for educational purposes. many of them are aged and follow traditional methods so they reject the idea of using mobile phones for educational purposes. respecting the teacher’s way is important for me and i would rather not use my phone before these teachers even for educational purposes.] (participant no. 2) academic virtual identity accepting a role brings responsibilities and fulfilling them entails observing specific ethical codes. being a student also requires observing specific ethical principles and codes. among the students’ ethical concerns in the field of information technology was adopting a virtual identity. one participant said: [“as a student, i try to have a proper online presence because i think the society has specific expectations from a student. for instance, i do not join just any channel or group in social media nor do i post careless messages or comments. before forwarding a message or post, i make sure that it fits my professional prestige.”] (participant no. 4) another student stated: [“like all other forms of socialization, online socialization has its own codes and ethics. although there is no direct physical contact in the virtual world, people still need to follow certain moral codes. i choose the words and stickers i use in social media very carefully because i believe prestige in the online world is even more important than the real world.”] (participant no. 19) 2. securing informed consent and respecting personal autonomy securing informed consent and respecting the patient’s autonomy informed consent is one of the main concepts in the field of medical ethics and koohestani h.r., et al. 7 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 5 april 2019 patients’ rights worldwide. similarly, patient autonomy is a basic element of healthcare, and respecting it is an accepted ethical principle. respecting patients’ autonomy means acknowledging their right to accept or reject care. entering patients’ private zone without permission is an unethical action. smartphone features like recording film or voice make it much easier to neglect this ethical code, and failure to deal with this issue may lead to serious ethical challenges. one student said: [“i always ask for patients’ permission before taking a picture of them, their file, or medical report. for instance, once there was a patient with diabetic foot. i asked him if i could take a picture of his foot and he accepted.”] (participant no. 17) another student said: [“once i asked a patient for permission to film a grade 3 burn on his hand and the debridement process on the scar tissue for class conference, but he did not allow it. i totally understand why he did not; he was in a bad situation and had the right to refuse my request.”] (participant no. 9) securing informed consent and respecting the teachers’ autonomy recording the teacher’s lecture for later use is very advantageous, since the student can listen or watch the lecture several times at a more convenient place. the practice, however, is not free of risk. most of the participants said that voice recording in the class without permission is unethical; still, they had witnessed their classmates do so. one noted: [“i think teachers have full autonomy whether or not to allow students to record their voice or image. once one of the teachers was really upset that a student had recorded his voice and image in the classroom even though he had banned it.”] (participant no. 14) 3. proper and efficient use the participants’ experiences indicated that making good and fruitful use of mobile technology for learning purposes in the educational context was one of the ethical principles of m-learning. this theme is comprised of two sub-themes including observing the regulations and codes, and making educational use. observing the regulations and codes educational regulations are deemed as organizational guidelines within the educational context that guarantee discipline order and discipline. failure to observe the laws or breaching them for personal benefits shows lack of respect for educational environments and neglect of ethical organizational principles. one student noted: [“i always try to respect the laws concerning mobile use in educational environments. like the real world, the virtual world should be used based on specific rules and regulations. failure to respect these rules and regulations results in harm to oneself and others. for instance, according to the regulations, we must put our mobile phones on silent mode in the classroom, and that is what i always do.”] (participant no. 13) lived experiences of nursing students about ethical concerns … 8 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 5 april 2019 another participant said: [“the laws in this respect are very important for me; for instance, if a teacher does not let the students use their mobile phones in the classroom or during a training course, i will not disobey. i will not use my mobile phone if it is not allowed, since it is illegal and unethical to do so.”] (participant no. 6) making educational use the main feature of mobile learning that is generally emphasized in the literature is the learning possibility regardless of place and time. using m-learning, students can access educational material of any kind in classrooms and clinical contexts. making fruitful and educational use of mobile phones in class or while providing care to patients was one of the ethical considerations mentioned by the participants. one student said: [“for example, if the teachers allow using mobile phones to search for academic material in the class, i will use my phone only for that purpose and on that occasion. i think it is unethical to make other uses of your phone in the classroom.”] (participant no. 1) another student said: [“if i use my mobile phone while interviewing a patient, it will be only for educational purposes.”] (participant no. 3) 4. avoiding harm responsible use of class data recording lectures and class audio creates a valuable educational resource for students that provides better understanding on a personal level, and can also be shared with other students and audiences. observing ethical codes in terms of using and sharing videos and voices of teachers or other students, however, was another concern for the participants. the majority of the participants believed that sharing content is ethical only when recipients of a recording personally attended an event. therefore, it is unethical to share it with others and it might harm those who participated in the event. the students’ experiences indicated that they were faced with certain ethical challenges in this field. one participant said: [“a friend of mine once shared part of a video on youtube in which our teacher asked a question and another student gave a rather irrelevant and somewhat funny answer. this action created a quarrel, and i think it was quite unethical.”] (participant no. 11) another participant said: [“following a disagreement with the teacher, one of my friends played an audio file that he had recorded at the beginning of the semester for the education department to prove that the teacher was not doing what he had promised before. i found it quite unethical and personally would never do it.”] (participant no. 18) responsible use of patient  data a key element of observing patient’s rights is to respect their privacy, and in terms of information, confidentiality of patient data is of particular importance. the patients’ rights charter puts special emphasis on protecting patients’ information. sharing koohestani h.r., et al. 9 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 5 april 2019 patients’ information can be interpreted as violation of their rights, whether it is a lab report or a video file. as stated by one participant: [“films and pictures taken from patients or their medical files should be treated with care. i will never publish films or pictures that i have taken with the consent of the patient on the internet. if i share a photo of a patient’s chest or electrocardiogram, i will make sure that the identity of the patient remains unknown.”] (participant no. 5) another student said: [“unfortunately and in some cases, irresponsible use of mobile phones has turned the private issues of patients into a public matter. my friend once filmed an interview and the medical history review process for educational purposes with the permission of a cardiac patient. later he published that film publicly, which i believe was unethical.”] (participant no. 10) discussion while new technologies, including mobile technology, can act as a positive force to facilitate change, they can also be a source of new ethical challenges. the findings showed that using mobile technology in clinical and educational contexts causes ethical issues, and it is critical for nursing students all around the world to ponder on these issues in their daily education. the rapid growth of mobile device use over the recent years has led to conflicts with the accepted standards of behaviors (19). still, the wide diversity of contexts where mlearning can be used adds to the complicacy of the issue for nursing students. the participants mentioned complicated and dynamic experiences while using their mobile devices. learning in the hospital context also creates another layer of complexity for individuals about how and when they are ethically allowed to use their devices before patients and teachers. four themes were extracted from the students’ experiences with regard to the ethical concerns associated with m-learning: preserving professional dignity, securing informed consent and respecting personal autonomy, proper and efficient use, and avoiding harm. to the best of the authors’ knowledge, the present research was the first qualitative study on the lived experiences of nursing students about the ethical concerns related to m-learning. it is notable, however, that m-learning has been qualitatively and quantitatively examined in some studies as a general issue to determine the effective factors in accepting the technology or its learning effect on students. for instance, xiao et al. (2017) reported that nursing students had a positive attitude and understanding about m-learning. they concluded that the use of m-learning by students should be promoted by providing suitable conditions (20). iqball and qureshi (2012) studied students’ perception of mlearning adaptation and reported that “practicality, convenience, and accommodating settings” were significant factors in the students’ desire to use mlearning (21). yoo and lee (2015) illustrated that mobile applications may render as highly effective simulators which may provide an exactly precise image of human lived experiences of nursing students about ethical concerns … 10 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 5 april 2019 patients for the purpose of teaching cardiopulmonary assessment skills (22). however, the ethical concerns related to mlearning in nursing education have been neglected by researchers. developing one’s knowledge is an essential part of learning, and in clinical settings, students tend to use mobile devices for rapid acquisition of information. still, some of the participants said that they did not use their phones before patients, as they perceived it a rude action. this concern was also mentioned by patients and hospital personnel (23). respecting patients’ autonomy and gaining their informed consent was another theme extracted from the students’ experiences. capturing digital content about patients without prior consent (for instance picturing embarrassing situations and neglecting their intellectual property) and sharing it on the internet may create serious ethical challenges, even if done unintentionally. the purpose of securing permission beforehand is to make sure that the patient or surrogate is given the chance to accept or reject the action or treatment under no duress. otherwise, autonomy and dignity of the subjects is neglected (24). therefore and as mentioned by the majority of the students, recording information and content about patients should be done only after obtaining their free and informed consent. irresponsible use of patients’ electronic information and digital educational content was another ethical concern extracted from the experiences of the participants. one ethical concern with regard to the risk of information accessible only for a limited audience was public distribution of that information. although most of the participants agreed that publishing such information without permission was unethical, some had experienced ethical challenges in this regard. other studies have demonstrated that irresponsible and unethical use of information and educational materials may be an ethical concern with regard to m-learning (25). the findings indicated that one consequence of using patients’ information irresponsibly was rooted in capturing and disseminating videos that might go viral. some students film their teachers or classmates and publish the videos on the web, which in most of the cases is done to humiliate them. therefore, along with providing a supportive environment for mobile phone use in class, teachers should play as ethical role models to prevent cyber-bullying. mobile learning is widely practiced in universities as a sort of educational method (2, 8); however, the results of this study showed that some students do not respect the professional ethics associated with the use of mobile technology and find the cyber world a place to act beyond ethical limits. one probable problem is the lag between the rapidly advancing technology and the slow evolution process of the rules on its use. mobile devices have become a part of students’ daily lives, nursing students included. teachers are required to adapt to the technology and modify their teaching techniques to facilitate ethical m-learning. likewise, students should be equipped with koohestani h.r., et al. 11 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 5 april 2019 the knowledge that using mobile devices may have negative effects on their professional prestige before teachers and patients. ethics is an ambiguous concept (24) and the results of this study indicated that many students have a poor understanding of the ethical way to use mobile devices in teaching and learning contexts. as a result, one may conveniently slip into a sort of ethical relativism and choose to follow one’s own path (19). lack of training, which is the case in many situations, makes it hard for the students to find an ethical way to manage their use of mobile devices for educational purposes. in our path toward a more ethical approach to m-learning, our focus must be shifted from mobile devices to the issues that are the real concerns. the main question is how to use mobile devices in learning. therefore, rather the prohibiting their use, we need approaches to limit bad behaviors and empower the students with efficient ways to deal with inappropriate behaviors of others. like other fields of education, improvement of student-teacher-patient relationship in terms of observing the ethics of m-learning leads to an enhanced quality of nursing education. by relying on the principles of ethics and extending their knowledge in this regard, students can use m-learning in a more intelligent, purposeful and informed manner. university teachers also need to pay special attention to ethical codes on using mobile devices both in the real and online world. as a qualitative research, the findings cannot be generalized to a larger population, but may be transferable to similar environments. however, our research was the first of its kind to explore nursing students’ experiences regarding the ethical concerns related to using mobile devices for learning purposes in educational and clinical contexts. future studies with different students, schools and countries are needed to investigate the role of additional constructs in the issue. conclusion using mobile technology in clinical and educational contexts can raise ethical concerns for nursing students. rather than prohibiting the use of mobile devices, we must devise approaches to restrict unacceptable behaviors and help the students develop strategies to deal with others’ inappropriate behaviors. this should be emphasized in nursing educational programs. additionally, it is necessary to adjust teaching and education and allow the students to use their mobile devices in a more appropriate manner. acknowledgements this study was a research project approved under license ir.savehums.rec1396.33 by the saveh university of medical sciences. we are very grateful to the university for their financial support. the authors would also like to thank all the students who took part in this study. conflict of interests none declared. lived experiences of nursing students about ethical concerns … 12 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 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learning in educational contexts. in: yu s, ally m, tsinakos a, eds. mobile and ubiquitous learning. berlin: springer; 2018, p. 81-93. 17. guba eg. criteria for assessing the trustworthiness of naturalistic inquiries. et r&d. 1981; 29: 75. koohestani h.r., et al. 13 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 5 april 2019 18. colaizzi pf. psychological research as the phenomenologist views it in: valle rs, king m. existential– phenomenological alternatives for psychology. uk: oxford university press; 1978, p. 48-71. 19. dyson le, andrews t, smyth r, wallace r. toward a holistic framework for ethical mobile in: berge zl, muilenburg l, eds. handbook of mobile learning. abingdon: routledge; 2013, p. 405-16. 20. xiao q, zhang q, wang l, wang y, sun l, wu y. mobile learning in nursing undergraduates in china: current status, attitudes and barriers. stud health technol inform. 2017; 245:1314. 21. iqbal s, qureshi ia. m-learning adoption: a 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professor, department of philosophy, school of literature and human sciences, shahid beheshti university, tehran, iran. 3bsc candidate in nursing, school of nursing & midwifery, shahid beheshti university of medical sciences, tehran, iran. corresponding author: lida nikfarid address: sbmu school of nursing & midwifery, vali asr ave., ayatollah hashemi rafsanjani cross road, niayesh complex, tehran, iran. postal code: 1985717443. email: l.nikfarid@sbmu.ac.ir tel: (+98) 2188655366 received: 23 dec 2017 accepted: 15 april 2018 published: 22 may 2018 j med ethics hist med, 2018, 11: 6 © 2018 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract metaparadigm concepts comprise the central issues in a discipline. fawcett has named person, health, environment and nursing as the four main concepts of nursing that need to be comprehensively defined. the human caring theory is significant because of its focus on the spiritual dimension of human beings. the aim of this study was to comparatively explain three of the main metaparadigm concepts of nursing in the human caring theory and persian mysticism, and find the similarities and differences that can help develop the theory and its application in societies with a theistic point of view. this comparative documentary study was done in two phases. first, a concept analysis was performed to find the attributes, antecedents and consequences of the concepts of human being, environment and health in the two fields of persian mysticism and jean watson’s human caring theory. then they were apparently and deductively compared with each other. in spite of some similarities between the two perspectives, persian mysticism was found to provide more comprehensive conceptualizations of the three main concepts of nursing. keywords: mysticism, nursing theory, human caring theory mailto:l.nikfarid@sbmu.ac.ir j med ethics hist med 11: 6, may, 2018 jmehm.tums.ac.ir lida nikfard et al. page 2 of 9 introduction based on the literature, after experiencing the worldviews of theism and naturalism, modern nursing has adopted a kind of postmodern worldview: a pantheistic monism (1). in new nursing theories terms such as soul, energy, source and divine have been used in the three perspectives mentioned above, though with different meanings in each one (2). in the latter, they have found a more personal ontological place, which is related to creating one’s own reality (3). most recent theories of nursing are affected by the philosophical ideas of existentialism and humanism, and far east philosophies such as taoism, buddhism and hinduism (1, 4), which are properly matched to the secular modern ideology of the west. as a result of the attempts to find a unique and distinct identity between other medical disciplines, the definitions of the main nursing concepts in these theories are holistic, subjective and transcendence-based (5). jean watson is a theorist in nursing who has persistently disseminated her “theory of human caring” by publishing many articles and books, and providing lectures in professional seminars (6). she critiques the current trend of giving more attention to the expansion of solid and accurate knowledge in nursing through developing more specific theories. she cautions against the risk of ignoring the development of a theoretical basis for the main concepts in nursing, such as caring, which are needed for the humanistic face of the discipline (7). the human caring theory has received attention because of the importance it places on the concept of caring as the essence of nursing (8). this theory has been developed over the past thirty years and is greatly influenced by theories of consciousness, existentialism, cognition sciences, quantum physics, interpersonal psychology, taoism and feminism (9). the human caring theory gives much importance to the spiritual, rather than the physical, dimension of human beings, and emphasizes the selftranscendence and self-actualization of the nurse in caring experiences. this is what makes this theory different from others that focus only on patients and do not notice spirituality as the preferable aspect (6, 9). in spite of the theorist’s attempts to provide a comprehensive worldview for nurse-patient encounters, there are some critiques on its theoretical philosophy and the definitions for its main concepts. the definitions of the concepts of person, health and environment are vague since they are abstract terms derived from multiple west and far east philosophical thoughts (4, 6). some concepts that are used in the definition of health and need to be briefly explained include: self-healing, harmony of mind, body and soul, and conciseness-transcendence (10). the concept of environment is defined as the internal and external factors effecting a person (8), which creates the need to answer questions about the existence of the world without considering the human factor. the indirect effects of global issues such as ethnic wars, terrorism and the ecological problems on every human being living in the world are ignored in this subject-based point of view. affected by the thoughts of existentialism and humanism, the concepts of human being, nature, transcendence and even that energy-giving source (whether it is referred to as god, the divine power, or a similar title) are defined based on humancentrality. an evaluation of the current worldviews shows the need to seek another perspective on nursing, which may still be unknown in nursing literature. one possible perspective that has not been explored in nursing literature may be persian mysticism. mysticism is to reach the truth through intuition, revelation and alliance, which is an old creed in many cultures and nations (11). despite some differences in the forms and manners, all types of mysticism have common points (12). according to henry corbin, an islamist researcher (1978 1903), the non-secular persian mysticism has a rich and comprehensive theoretical basis that is notable in the modern world (13). alive, dynamic, and tremendously affected by islam, persian mysticism covers a range of worldwide themes and has the potential to be matched with many human science theories (14). most nursing theories borrow their theoretical basis from other disciplines, and many nursing concepts are well conceptualized in persian mysticism. to see the nursing concepts from a celestial mystical perspective is a new approach that can be used for the development of nursing grand theories. any new approach in nursing should provide clear and precise definitions for the four nursing concepts of person (human being), environment, health and nursing. jean watson’s theory has a mystical nature; moreover, it is important to see things in the light of a recent and frequently studied theory. the aim of this study was to comparatively explain the concepts of person, health and environment in the human caring theory and persian mysticism. methods in this comparative documentary analysis research, first we used the concept analysis method introduced by walker and avant (15) to identify, clarify and find definitions for three of the main concepts of nursing, that is, person, environment and health, in texts related to persian mysticism and the human caring theory. the walker and avant method consists of eight steps (box 1), and was chosen as it is widely used and was highly related to the aim of the study. j med ethics hist med 11: 6, may, 2018 jmehm.tums.ac.ir lida nikfard et al. page 3 of 9 box 1walker and avant’s (2005) steps of concept analysis actions steps select a concept 1 determine the purpose of the analysis 2 identify all uses of the concept 3 determine the defining attributes 4 construct a model case 5 identify antecedents 6 identify consequences 7 define empirical referents 8 the steps in the present study were: 1) determining the purpose of analysis, 2) finding all definitions and uses of the concepts, 3) identifying the characteristics or attributes, and 4) determining antecedents and consequences. for this aim, we searched related keywords in multiple steps in electronic databases such as google, google scholar, noor, sid, magiran and pubmed, guided by experts in persian mysticism. at the start, the first author read 2 textbooks and 3 articles on the history of persian mysticism to achieve a general understanding of the subject. next, papers on the works of mulla sadra, avicenna, suhrawardi, attar and rumi were examined due to the consensus of experts on their comprehensiveness and admissibility in explaining metaphysical concepts in a logical manner. at the concept analysis stage, 12 books, 48 articles and 4 theses were selected based on the creditability of the authors and journals. qualitative content analysis was used to determine the attributes, antecedents and consequences of the concepts. expert debriefing, long term involvement of the researcher with the subject, and concise reporting of the process of the study were used to increase the trustworthiness of the findings. considering the aim of the study, we needed to find the similarities and differences between the attributes of the three concepts and provide a thick description for the philosophical foundations, so we did not construct any case models. in the second part of the study, we used a recommended method of comparison for religious and spiritual studies by gharamaleki (16), and proceeded with the steps below: 1. statement of the problem: this part focused on the question “what differences and similarities exist between the perspectives of persian mysticism and the human caring theory regarding the main concepts of nursing: person, health and environment?” 2. limiting the scope of the comparison: in the present study, the ontological outlooks on the main concepts were explored in the two fields. additionally, the attributes, antecedents and consequences driven for each of the concepts in the first part of the study were compared in both fields. 3. providing a hypothesis: at this stage we formulated the hypothesis that “the theoretical foundations for the main concepts of nursing in the two fields of the human caring theory and persian mysticism have a lot in common, although the former could be more meaningful if explained from the non-secular perspective of persian mysticism. 4. listing differences and similarities: here we found the differences and similarities between the concepts in both fields based on their obvious characteristics and what could be perceived thorough comparing appearances (tables 1 3). table 1-comparison between the concept of “person” in persian mysticism and human caring theory persian mysticism human caring theory creation of the world and humans as a result of the love of the divine essence emerging antecedents a human being: has dimensions of body-soul is an existence on its way to becoming is an embodied soul deserves respect and is valuable has authority to choose can actualize his or her potentials, which are the divine attributes has an existential gradation has certain faculties in each grade of existence may evolve to the upper steps of gradation or not a human being: has dimensions of mindbodysoul is an existence on its way to becoming is an embodied soul deserves respect and is valuable has authority to choose can actualize his or her potentials attributes love of the divine essence is the motivation to transcendence consequences j med ethics hist med 11: 6, may, 2018 jmehm.tums.ac.ir lida nikfard et al. page 4 of 9 table 2comparison between the concept of “environment” in persian mysticism and human caring theory persian mysticism human caring theory creation of the world and the human being was the result of the love of the divine essence creation has gradations that end in the natural world (the environment of humans) the ten caritas processes can be used to provide a healing environment antecedents there are forces to help or inhibit the evolution of a person pantheistic monism may be seen between creatures (as the unified essence and plural manifestations) there is an active intelligence that can be connected to partial human intelligence creatures and meanings are various types of the divine essence attributes there are internal and external factors surrounding human beings there are factors that affect self-healing the human conscience can be connected to through caring experiences attributes creatures are interrelated for each other’s evolution the formularized regulation governs the world can be positive or negative for the harmony of mind-body-soul consequences table 3comparison between the concept of “health” in persian mysticism and human caring theory persian mysticism human caring theory disease and suffering may be regarded as opportunities to develop the spiritual dimension (or not) the caritas processes antecedents the harmony of soul and body to help one move upward in the spiritual dimension to evolve through existential gradation to know and move in step with the ethical, physical and social rules of the materialistic world the harmony of mind-body-soul a higher level of psycho-physical and social function, freedom from any form of disease, or an attempt to be from disease the metaphysical potential for selfhealing attributes the ability to move to the upper grade (or not) emergence of attributes of the divine essence or exhibiting attributes pertaining to the lower grades to self-heal through disease and suffering (or not) consequences addressing real positions of differences and similarities: to do this, we used a systematic reasoning approach to provide a deep, meaningful explanation for the results. considering the historical, theoretical and philosophical contexts and frameworks of each of the fields, we used a deductive approach to answer the central question posed in this study. 5. explanation of the real positions of differences and similarities: based on the ontological outlook derived from the literature and the experts’ standpoints, an explanation was provided for the results of the comparison between the concepts in each of the fields. results in this section, the metaparadigms of nursing will be compared in the two fields of human caring theory and persian mysticism. the aim is to present a brief explanation for each metaparadigm in the two fields, and then proceed to provide a comparison. 1) person / human being a) the human caring theory: according to watson, a person has three dimensions of mind, body and soul, and is in fact an embodied soul on its way to becoming (17). therefore, the spiritual dimension of a person has a higher value in the human caring theory. a person is a being whose wholeness is valuable and deserves respect, assistance and care (4). from this perspective, soul is the higher sense of self and is similar to the psychological concept of self-actualization. here, watson’s existentialistic/humanistic ontological point of view shifts to a mystical one as she points out that a person can expand his or her inner healing power and reach an intuited mystic and even miracle-like experience through caring moments (4, 18). b) persian mysticism: according to persian mysticism, the world of creation began with the love of the divine essence (god) and emerged from two of his attributes: beauty and majesty. in persian mysticism, a human being is a two-dimensional existence consisting of j med ethics hist med 11: 6, may, 2018 jmehm.tums.ac.ir lida nikfard et al. page 5 of 9 body and soul who is higher than all other creatures, being the only one who bears all the divine attributes and knowledge of the divine essence (god) as inherent potentials (19). the body is the lower dimension of the human existence: it has needs to serve, but will help the soul on the way to transcendence and actualization, that is, the emergence of the attributes of the divine essence through acts and thoughts (20). the human being is the only creature blessed with free will, empowered by intelligence and the faculty of speech. in addition, there is a gradation in existence with the sequence of solid-plant-animal-human, where each creature has the faculties to evolve and rise to the next grade (figure 1). the ultimate perfection of a human being is to actualize the potentials of his or her grade (21). humans can choose to ascend through their existential gradation toward being perfect human beings and gain more divine attributes, or stay in the lower grades and show attributes of those who are not evolved, for instance violence against others (an extreme manifestation of wrath, which belongs in the animal grade of humanity) (19). intrinsic divine attributes such as mercy and grace inspire a kind of love for perfection in a human being, and are nurtured through everyday life practices such as caring, which can lead to self-actualization and selfhealing (21). rumi says: "half made of water and clay half soul and half solar ray half on the shallow beaches lay half from the oyster's pearly play" (22). c) comparing the concept of person in the two fields (table 1): watson’s perception of the human being as an embodied soul, whose spiritual dimension is more significant, is close to the standpoint of persian mysticism. nevertheless, the philosophical foundation of her theory is derived from an existentialistic/humanistic phenomenology, which is the center of everything in human beings (4). in this theory, the growth of a person and the actualization of his or her potentials are mentioned, but these potentials need to be well defined. from the celestial standpoint of persian mysticism, affected by religious thoughts, god is the center of everything and the evolution of human beings is measured based on the extent of actualization of their divine attributes, which are their inherent potentials. a j med ethics hist med 11: 6, may, 2018 jmehm.tums.ac.ir lida nikfard et al. page 6 of 9 person is valuable in the human caring theory, but the reason for this value is unclear. additionally, it is not understandable why a person should be respected and valued when his or her acts are far from what is called humanity. in persian mysticism, the faculties of each grade of humanity act for the maturity of that grade: from the time one is like a plant in the embryonic stage, or an animal before gaining the whole power of reasoning at the age of adolescence, until they gradually move far from their physical dimension to leave it at the age of seniority. watson propounds the high value and spirituality of human beings (23), which is compatible with islamic persian mysticism. in persian mystical thought, human beings are referred to as “caliphs of allah” (24), since they bear all the divine attributes as potentials. these attributes bear divine names, are the whole knowledge of the truth, and can emerge through willingly chosen, everyday human acts. according to watson, there are possibilities to grow and excel. nevertheless, from such a standpoint, the human being should be seen as a bi-dimensional existence that can move forward and backward in gradation, since an endless movement toward an unknown ultimate goal, like what is drawn in existential-based philosophies, does not make sense. in the human caring theory, a source or god is inevitable, and is the empowering agent for human beings. it is introduced as a kind of metaphysical connection that can happen to a person. thus, a mystical description of the human being can support nursing theories such as the human caring theory. 2) environment a) the human caring theory: in watson’s theory, there is great emphasis on a caring and healing environment, which can be provided by a nurse according to the existing literature. the internal and external factors that can help a person actualize his or her inner power of selfhealing are called the environment. a nurse is considered an external factor that can offer assistance and care to a person through the ten caritas processes including love, empathy, trust and teaching/learning experiences. thus, a unity of the nurse and that person and self-transcendence of both will happen in such enchanted moments. it is notable that watson only describes a caring environment and how it is provided by a nurse, and does not elaborate on the surroundings of a person in general in her theory. b) persian mysticism: from the perspective of persian mysticism, the world and everything around a person are manifestations of god. the ultimate goal of creation is the emergence of divine attributes in humans through perfection of each level of their existential gradation, so the external and internal factors can be either inhibitors or facilitators in the process. in the natural world where physical, social and ethical issues are governed by formalized rules, people need to be in harmony with the ultimate goal of creation, or suffer. according to persian mysticism, there is gradation for the worlds of existence as well, which are in agreement with the various levels of human perception (figure 2). c) comparing the concept of environment in the two fields (table 2): it seems that both perspectives are mindful of how environmental factors may affect the evolution of a person positively or negatively. it is understandable that a nursing theory should acquire a practical point of view, but considering the complicated and challenging modern societies, there is need for a more holistic worldview. from a mystical perspective, the environment is more than just what surrounds us. in fact, man is living alongside an enormous set of material and nonmaterial creatures, is whole but has a unified essence, is one of the manifestations of god, and is moving toward a determined aim. human beings are the only creatures who are free to choose the way to perfection or stay away from it. human beings and all other creatures make a unit where all are interrelated to one another, although they may belong to different grades of existence, and the acts of everyone affect this unified whole, themselves and others. 3) health a) the human caring theory: watson defines health as harmony of the body, mind and soul; as a high level of physical, mental and social performance; and absence of or an attempt to eliminate diseases (9). healing means regaining wholeness, which is a new, different and better state than the one in which the patient was previously. it is moving toward transcendence, as well as physical, mental and spiritual wellness. healing is defined as finding a new meaning for the disease and the recent condition (25). identifying healing as a spiritual function, watson believes in human beings’ potential metaphysical ability to self-heal and achieve supreme consciousness (26). she also supports a unique way of making meanings for illness/wellness experiences by each person, and the possibility of perceiving these meanings during the moments of care by the nurse (27, 28). j med ethics hist med 11: 6, may, 2018 jmehm.tums.ac.ir lida nikfard et al. page 7 of 9 figure 2diagram illustrating the bi-dimensional humankind, the substantial gradation and faculties of each grade in the world of matter, according to persian mysticism (figure drawn by the authors) b) persian mysticism: although the spiritual dimension is preferred and its perfection is the aim of the creation of human beings, spirit is confined by the physical dimension in material life. as the spirit does not belong to this structure and is a divine essence, living in the natural world and enduring its attributes cause pain and suffering. over the centuries human beings have unsuccessfully tried to conquer everything that made them suffer. furthermore, if the soul begins to move away from its earthly dimension, it can find a way to join the divine spirit and achieve peace or what is considered a healthy state in mysticism. therefore, human beings choose to move downward or upward in this continuum of soul-body dimensions. the farther one moves from the end pertaining to the soul, the more suffering one will experience. c) comparing the concept of health in the two fields (table 3): watson sees health from a phenomenological perspective, in terms of what it means to people in their illness-wellness experiences, and a state that should be improved in caring moments. like other cognitivists, she believes the human being is an existence that gives meaning to concepts and entities, and one that needs to rise to perfection through life events. during caring moments, the caritas processes help nurses improve the mentality of patients toward their illness. although according to watson a caring moment can lead to a spiritual/mystical experience for both the care-giver and the care-provider, the philosophical stances do faculties of each grade nourishment reproduction growth giving stimulant (wrath/desire) apparent senses inner senses (common sense, imagination, memory) -theoretical intellect practical intellect gradations of substance in humankind human animal plant divine essence embodied spirit leaving body spiritual dimension physical dimension birth to the world of matter death and leaving the world of matter j med ethics hist med 11: 6, may, 2018 jmehm.tums.ac.ir lida nikfard et al. page 8 of 9 not give any additional information about it. health is a spiritual concept in the persian mystical perspective too. it is regarded as an intuitive movement toward perfection, i.e., the emergence of divine attributes, in spite of limitations that are of a sensual nature. thus, health is possible to achieve even in the presence of disease, and may even be considered as an opportunity for spiritual growth (29). "hafiz do not complain for union try put up with the pain whenever it comes by" (30). nevertheless, both of these perspectives are similar in terms of addressing the spiritual dimension and potential of individuals for healing by the use of their metaphysical power. one approach to treating many physical and psychological problems in modern psychology is changing perceptions. while this viewpoint does not specify what humans should think about incurable diseases and pains in order to reach a state of transcendence and well-being, in persian mysticism it is recommended to view them as the mercy of god, as a way to begin to move toward spirituality and feel closer to god (which watson calls the source). watson interestingly applies a mystical meaning to the spiritual linkage of two persons (a nurse and a patient) engaging in a caring experience. in an islamic mystical context, this experience serves to help both oneself and other people acquire more divine attributes. healing happens when a new meaning of life and its events are gained through interpreting pain as an opportunity for growth and getting closer to the spiritual dimension. while one of the critiques of the human caring theory is that it cannot explain the relationship between the physical and spiritual aspects of human nature, persian mysticism has rich theoretical bases that can help interpret the role of the physical dimension. persian mysticism considers the human being as a gradational existence with certain faculties for each grade, and proposes to keep equilibrium in the function of each faculty to gain more health. for instance when a person in the plant grade has problems in the faculty of nourishment, this can lead to health issues like obesity. conclusion nursing is a caring profession, and since care is defined as the process of helping others grow, it is necessary to provide a theoretical basis that can demonstrate how to help all the bio-, psycho-, socio and spiritual potentials of a human grow. as a preliminary phase to find a more comprehensive theory for nursing, we compared one of the current theories with a theistic point of view. our findings showed some common points between definitions for the main concepts of nursing in the human caring theory and persian mysticism, even though the former has a human-centered structure, and the latter a god-centered one. through this comparison, one can find the main similarities and differences between the two perspectives toward the main central concepts of nursing. nursing has begun to experience conceptualization in a way as to examine concepts from a metaphysical perspective. the lack of empirical support is a limitation, but it seems that for a holistic standpoint it is impossible to set aside the person-centered lens. acknowledgements the present studyfunded by shahid beheshti university of medical sciences (66001044-95/7/24). conflict of interests all authors declare that they have no significant competing financial, professional, or personal interests that might have influenced the performance or presentation of the work described in the manuscript. j med ethics hist med 11: 6, may, 2018 jmehm.tums.ac.ir lida nikfard et al. page 9 of 9 references 1. salladay sa. healing is believing: postmodernism impacts nursing. scientific review of alternative medicine. 2000; 4(1): 39-47. 2. pesut b, fowler m, taylor ej, reimer‐kirkham s, sawatzky r. conceptualising spirituality and religion for healthcare. j clin nurs. 2008; 17(21): 2803-10. 3. jankowski pj. postmodern spirituality: implications for promoting change. counselling and values. 2002: 47(1): 69-79. 4. alligood mr. nursing theorists and their work, 9th ed. missouri: elsevier (usa); 2018. 5. butts jb, rich kl. philosophies and theories for advanced nursing practice. burlington: jones & bartlett publishers; 2013. 6. meleis ai. transitions theory: middle range and situation specific theories in nursing research and practice. new york: springer publishing company; 2010. 7. gulnar a, wattis j, snowden m. why are spiritual aspects of care so hard to address in nursing education:a literature review (1993-2015). international journal of multidisciplinary comparative studies. 2015; 2(1): 731. 8. masters k. nursing theories: a framework for professional practice. burlington: jones & bartlett publishers; 2014. 9. rafael arf. watson's philosophy, science, and theory of human caring as a conceptual framework for guiding community health nursing practice. ans adv nurs sci. 2000: 23(2): 34-49. 10. watson j. caring knowledge and informed moral passion. ans adv nurs sci. 1990: 13(1): 15-24. 11. spencer s. mysticism in world religion. london: oneworld publications; 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1975. 21. abrahamovb. divine love in islamic mysticism. the teachings of al-ghazali and al-dabbagh. london: routledge; 2011. 22. levis fd. rumi past and present, east and west: the life, teachings, and poetry of jalal al-din rumi, 2th ed. london: oneworld publication; 2007. 23. mckenna h. nursing theories and models. abingdon: routledge; 2006. 24. arkoun m. rethinking islam today. the annals of the american academy of political and social science; 2003: 588:18-39. 25. hood l. leddy & pepper's conceptual bases of professional nursing, 8th ed. philadelphia: lippincott williams & wilkins; 2014. 26. watson j. intentionality and caring‐healing consciousness: a practice of transpersonal nursing. holis nurs pract. 2002: 16(4): 12-9. 27. watson j. caring theory as an ethical guide to administrative and clinical practices. nurs adm q. 2006: 30(1): 48-55. 28. favero l, meier mj, lacerda mr, mazza va, kalinowski lc. jean watson's theory of human caring: a decade of brazilian publications. acta paul enferm. 2009: 22(2): 213-8. 29. ridgeon l. morals and mysticism in persian sufism: a history of sufi-futuwwat in iran. new york: routledge; 2014. 30. ghorbani n, watson pj, aghababaei n, chen z. transliminality and mystical experience: common thread hypothesis, religious commitment, and psychological adjustment in iran. psych relig spirit. 2014: 6(4): 268. ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ 1 commentary volume 13 number 9 august 2020 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e copyright © 2020 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. ebola, quarantine, and the need for a new ethical framework corey benjamin moore school of public health and community medicine, university of new south wales, sydney, australia. abstract quarantine is a broad public health strategy used to control infectious diseases outbreaks. an arguably most aggressive public health intervention, quarantine limits the asymptomatic individuals’ liberty and can result in significant harm. quarantine was used in an attempt to control several ebola outbreaks during the ebola epidemic in west africa in 2014. the most concerning quarantine intervention occurred at west point, a slum of 75,000 people in the capital liberian capital, monrovia. this work critically reviews present ethical frameworks in public health for the examination of outbreaks in west africa. this work utilizes the nine public health ethical principles described by kerridge, lowe and stewart to argue that the quarantine at west point was not ethically justified; and, it concludes that a new ethical framework for quarantine is required to address future outbreaks in the west african context. keywords: quarantine; ethics; ebola virus. *corresponding author corey b moor school of public health and community medicine, university of new south wales, sydney, nsw, 2052, australia tel: (+68) 409314222 email: coreybmoore@hotmail.com received: 18 may 2019 accepted: 7 june 2020 published: 26 aug 2020 citation to this article: moore cb. ebola, quarantine, and the need for a new ethical framework. j med ethics hist med. 2020; 13: 9. ebola, quarantine, and the need for a new ethical framework 2 volume 13 number 9 august 2020 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e introduction quarantine is a broad public health strategy attempting to contain disease outbreaks by stopping communicable diseases’ transmission chain through limiting, isolating and monitoring contact of individuals who have been or who may be exposed to the disease (1, 2). quarantine is one of several public health strategies to prevent the communicable diseases’ spread. it originates from general moral obligations to prevent harm to others; and, it is arguably the most aggressive public health measure as it limits the asymptomatic individuals’ liberty (3). quarantine raises conflicting ethical values as it creates and worsens unequal burdens and benefits among individuals and groups. both ethical values and decisions reflect and are influenced by cultural differences and political pressures. ebola virus disease (evd) is a communicable disease transmitted through direct contact with bodily fluids. it was first raised in 1976 and it has caused ten outbreaks since then (4, 5). no vaccine or pharmacological treatment exists for evd (6). in march 2014, who declared an evd outbreak in west africa, a public health emergency of international concern (7). the main affected countries were liberia, sierra leone and guinea. these countries have a history of unstable government, political violence, civil war, social disadvantage, and weak public health infrastructure (8-10). these conditions contributed to a rapid spread of outbreak (11) and made military-enforced quarantine inevitable (8). the most concerning quarantine intervention was at west point, a slum of approximately 75,000 people in the liberian capital, monrovia. military troops were employed to restrict movement (2, 8). the quarantine, however, was not effective in the outbreak control (12) and ended after ten days of civil unrest (13). rapid changes imposed on quarantine during crisis although international law supports the right to freedom of movement (14), all legal systems and international human rights permit quarantine (15). the specifics and use of quarantine vary by country; however, public health officials are allowed to use measures to protect public health (16). while few countries have ethical frameworks to guide difficult decision-making for epidemics (17), the existing legislation and guidelines of democracies reflect their citizens’ ethical values (18). public health interventions such as quarantine should be exercised according to the law and with appropriate evidence; however, during a crisis these laws can change quickly and be enforced arbitrarily, often based on community fear and political pressure (13, 19). for example, during the evd epidemic, canada denied visas to individuals from countries with evd outbreaks, against international health regulations (20). in usa, quarantining of healthcare workers who had worked in west africa was inconsistent and politically motivated (21). during the avian flu pandemic, australia stockpiled $192m on an antiviral with questionable efficacy (22), and the fear caused by the evd epidemic contributed to the creation of a $300m centre to manage future epidemics (23). moore cb. 3 volume 13 number 9 august 2020 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e public health ethical frameworks to study quarantine a number of public health frameworks exist that address ethical issues of public health interventions. however, the broadness of the issues that public health need to address makes achieving a generalizable ethical framework difficult (24). the application of such frameworks to quarantine is even more difficult given the quarantine’s potential in limiting autonomy, causing harm, targeting vulnerable people and exacerbating inequalities. some public health frameworks need to justify the effectiveness of an intervention. for example, the ethical framework described by kass states that in case of a lack of evidence, the intervention is questionable and should be terminated (25). however, at the beginning of an outbreak, often insufficient information is available to determine if a quarantine will be effective (1). such frameworks may prevent action due to a lack of evidence, which could lead to worse outcomes. for the abovementioned reasons, ethical frameworks have been developed specifically for quarantine (13, 26, 27); however, these as well as others can suffer from ideological and cultural biases. for example, kass gives increased weight to liberty (25), baum argues for less emphasis on autonomy (28), calman and downie for increased utility (29), and gostin et al. states the importance of individual principles and is not sensitive to cultural traditions (26,30-32). such liberal views may not be relevant for addressing issues in africa (30). therefore, ethical principles that are flexible, less prescriptive and have less western biases are more appropriate for addressing public health interventions in an african context. the public health ethics’ principles described by kerridge et al. have been derived from many ethical discussions on the appropriateness of public health interventions (31). they do not put weight or bias on any single principle, and thereby reduce western values’ influence (31). hence, they are considered appropriate in analysing the quarantine ethics at west point. necessity for a feasible and effective quarantine quarantine has been successfully used as a public health strategy in preventing the disease spread in past outbreaks (e.g., influenza (33), measles (34) and sars (35)). however, at the time of an outbreak, evidence for the effectiveness of quarantine is often quite limited (36). therefore, the level of evidence required to justify quarantine must be much lower than that of other public health interventions due to the potential harm of the disease to the public. hence, precautionary principle, beliefs and ethical recommendations are utilized to justify the use of quarantine in the absence of quality evidence (24, 26). however, feasibility, an important aspect of effectiveness, can be overlooked, and may be known with some certainty at the beginning of an outbreak. if a quarantine is not feasible, it does not meet the principle of effectiveness, described by kerridge et al. (31). hence, feasibility needs to be considered in evaluating the effectiveness of a quarantine. ebola, quarantine, and the need for a new ethical framework 4 volume 13 number 9 august 2020 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e conditions triggering disease outbreaks such as socioeconomic inequality and weak health infrastructure have been used to justify the extreme public health intervention of quarantine (5, 18). however, these conditions also limit the surveillance capacity, contract tracing, public trust and health education, which are all critical to maintain stability during a quarantine, and to identify and isolate the infected individuals (6, 37). quarantine, imposed under these conditions, would not only do require people to give up their liberty, but would also put them at increased risk of infection harm and further inequalities. despite this, a consequentialist argument could justify such harm if containing a disease outbreak and preventing harm to the greater community were possible. however, under such inadequate conditions, an intervention is unlikely to prevent harm to the greater community because those quarantined are unlikely to support and comply with quarantine measures. such circumstances was the case at west point. military-enforced quarantine did not benefit the greater community, thereby resulting in increased harm to those quarantined and creating civil unrest leading to breaches and the eventual abandoning of the intervention (13). few public health interventions with weak public health infrastructure quarantine may be justified if public health is threatened and less restrictive strategies (e.g., education, monitoring, decreased social mixing and increased social distancing) cannot achieve an appropriate outcome (31). in the case of evd, symptoms develop in individuals before they become infective (38); hence, anyone with symptoms could potentially be identified and isolated before becoming a risk to others. that is, given appropriate resources and procedures, measures less restrictive than quarantine can achieve the same goal of preventing evd spread. however, in liberia, a lack of public health infrastructure meant that these less restrictive measures were not an option, thereby effectively limiting initial public health options to nothing or quarantine. who had recommended against quarantine (2); however, considerable local and international pressures demanded the politicians and public health officials to stop the epidemic in some way (4, 39). similar pressures also resulted in quarantine in western neoliberal countries as well (8). counter-productivity of excessive infringement public health interventions should be implemented with the least infringement (24). in the case of quarantine, measures range from voluntary movement restriction to military-imposed restriction. this principle respects individuals’ and community’s liberties, rights, interests and needs (39). this is crucial as those most affected by quarantine are at risk of misappropriation of restrictive measures, thus requiring special efforts to protect them (39, 40). the use of the military to implement quarantine in resource-poor countries with weak public health structures is often inevitable (8). strong coercive measures are rationalized because voluntary compliance is unlikely considering the lack of public consultation, acceptance, and reciprocity. in moore cb. 5 volume 13 number 9 august 2020 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e addition, public health infrastructure limits the ability to implement less restrictive measures, such as using web-cameras to monitor for symptoms as was done in the quarantine in singapore during the sars pandemic (41). the military-enforced quarantine in beijing during sars saw 250,000 flee the city overnight (42) and the quarantine in taiwan was counter-productive due to the panic it created (18). at west point, the use of the military to enforce quarantine resulted in distrust, decreased compliance, worse health outcomes and increased stigma. hence, the quarantine did not meet the least infringement principle. necessity for community consultation public health decisions should be justified through discussion with the community (31, 43). these discussions and subsequent decisions should be made without political interference and with fair representation (24) while concerning transparency, due process and fairness factors (42). however, this is difficult due to the social and political relationships of power existing within communities (37). it is also difficult during public health emergencies because such consultation consumes already-limited public health resources especially in low-income, developing countries. the authoritarian history and culture of some countries such as liberia also make it challenging. nonetheless, public health actions need to be understood by the affected people and consistent with local values. interventions also need public trust as they require individuals to follow orders that are counter-productive to their personal benefit (18). this trust should be built during good times, and then maintained and protected during interventions (31). mistrust of government and public health officials at the beginning of an epidemic are also worsened with the use of military (21). at west point, this distrust was counter-productive to the interventions’ intentions. the use of humanitarian organisations to enforce restrictive measures created a perceived conflict of interests, resulting in further distrust (8). people were afraid of reporting symptoms and preferred to remain under their families’ and friends’ care, thereby spreading the disease (9); individuals thought public health measures were being made by foreigners in exchange for increased personal wealth of officials (10); a screening centre was destroyed because people believed that the government was bringing sick people into their community; soldiers were bribed to leave the quarantine area and citizens were shot (13). after ten days; these actions and civil unrest resulted in the quarantine cancellation (13). quarantine reflecting community core values and culture public health interventions need to be aligned with community values to maintain social structures during and after quarantine (13, 31, 44). ethical questions and their answers are subject to cultural differences (37). quarantine has been argued to be less tolerable in liberal states assigning a greater weight on liberty (13). however, quarantine measures can contradict deep cultural beliefs, thus making it an intolerable measure in societies with more communitarian values. in ebola, quarantine, and the need for a new ethical framework 6 volume 13 number 9 august 2020 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e addition, quarantine can question and stigmatize cultural practices. cultural practices in west africa involve the family and community of the dying being included in their care and intimate traditional customs in the preparation of the dead for the afterlife (6). the liberian government did not respect such practices; they denied contact of those identified as infected and enforced cremation of the dead. consequently, people did not report if they had symptoms and preferred to stay at home under their families’ and friends’ care (9). such attitude created stigma of cultural practices and reduced social cohesion. since the intervention was not aligned with the community values, individuals’ moral obligation to report and comply with the quarantine remains questionable. community’s moral obligation to protect affected individuals those under quarantine are more likely to be the community’s vulnerable members and are at the greatest risk of harm from public health interventions. they are asked to relinquish their liberty and face hardship to benefit the greater public good (13). the unaffected part of community then has a responsibility to prevent further exacerbation of hardship and allocate resources to compensate for loses. during the sars epidemic, taiwan provided fixed sum compensation (45), canada provided income replacement (46), and singapore provided criminal immunity to increase public health orders’ compliance (41). furthermore, to compensate for immediate and direct harm, protecting against stigmatization and its sequel is necessary (1). stigma, a major social determinant (47), resulted in job losses and rejection from community in west africa (48, 49). in nigeria, psychosocial teams held meetings in communities to reduce stigma (49). in canada, during the sars quarantine, legislation prohibited discrimination against those quarantined (50). the quarantine in west point targeted the vulnerable, and a lack of reciprocity (21)(i.e., those quarantined had no moral obligation to comply with the quarantine) resulted in worse health outcomes, starvation, financial losses and stigmatization’s long-term consequences. summary this paper has argued that the west point quarantine was not ethical because it did not meet the nine ethical principles outlined by kerridge et al. (31) due to the followings: 1. considering the outset, the quarantine was not effective since the outbreak had spread outside of the quarantined area (e.g., a lack of public health infrastructure made it infeasible), and since those quarantined were unlikely to comply with quarantine measures. 2. the quarantine failed the proportionality test as it caused harm to those quarantined and did not protect the majority of population. 3. the lack of infrastructure meant unavailability of less invasive public health interventions. hence, the quarantine was not justified based on the principle of necessity because doing nothing would have been less invasive and less harmful. moore cb. 7 volume 13 number 9 august 2020 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e 4. the restrictive infringement involving use of military force was likely to have been counter-productive. 5. insufficient evidence of any or adequate community consultation. 6. the taken actions exacerbated high mistrust levels. 7. the intervention targeted a vulnerable population and did not respect community and cultural values. 8. inadequate support was provided for the individuals under quarantine, people exposed to worse health conditions, suffering financial hardship, facing increased stigma and exacerbated inequality. the intervention did not allow for appeal, due practice or evaluation, and only ceased under political pressure after civil unrest (13). discussion necessity for a new framework this paper used the principles of public health ethics outlined by kerridge, lowe and stewart (31) to examine the quarantine at west point because no existing ethical framework addresses quarantine as a special public health intervention and in the unique context of west africa (34). previous work have used existing public health ethical frameworks to examine the quarantine at west point and have concluded that the quarantine was unethical (8, 39, 51); in more marginal cases, biases or omissions in existing ethical frameworks may be important. inevitability of future outbreaks in west africa, the unavoidable use of quarantine to attempt to contain outbreaks, and similarities among the west african countries’ values (52) make attaining such a framework specific to quarantine and west africa both necessary and feasible. such a framework would address the influence of groups outside of the community, including other countries. many of the issues requiring public health interventions in west africa exhibit global injustice symptoms, and hence sharing the burden is an ethical responsibility of other countries. a new framework would consider the principle of proportionality on a more global level and consider sharing the burden of epidemics with other nations. while other nations did contribute to the control of the evd epidemic in west africa, this contribution was largely due to self-interest and did not result in fair reciprocity to the people directly affected by evd. the original ethical considerations made by who were on questions of experimental pharmaceuticals since they were, arguably, more relevant to the donor nations’ interests (8). finally, frameworks have been created around more communitarian values and social solidarity as a result of recent epidemics (e.g., (13, 27)); nevertheless, they do not adequately address differences across and between communities, weak or non-existent public health infrastructure’ implications, or cultural practices that are important for social cohesion and support, but contrary to quarantine measures. all of the abovementioned factor are major issues in west africa. ebola, quarantine, and the need for a new ethical framework 8 volume 13 number 9 august 2020 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e conclusion the existing ethical frameworks for considering and designing a quarantine intervention in west africa do not adequately address the west africa’s social and cultural values. furthermore, they fail to consider the responsibilities of other communities that have contributed to the need for public health interventions. since future outbreaks are inevitable, developing new ethical public health frameworks is required. the endorsement of such frameworks may encourage research and investment to prevent the conditions contributing to such outbreaks. moore cb. 9 volume 13 number 9 august 2020 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e references 1. upshur r. the ethics of quarantine. virtual mentor. 2003 nov 1;5(11): virtualmentor.2003.5.11. msoc1-0311. 2. koch t. ebola, quarantine, and the scale of ethics. disaster med public health prep. 2016;10(4): 654-61. 3. harris j, holm s. is there a moral obligation not to infect others? 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[cited on 2020 august]; available from: https://stacks.cdc.gov/view/cdc/11429 42. gostin lo, berkman be. pandemic influenza: ethics, law, and the public's health. administrative law review. 2010; 59(1). moore cb. 11 volume 13 number 9 august 2020 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e 43. gutmann a, thompson d. deliberating about bioethics. hastings cent rep. 1997; 27(3): 38-41. 44. anonymous. who: global alert and response, guiding principles for international outbreak alert and response. [cited on 2020 august]; available from: http://www.who.int/csr/outbreaknetwork/guidingprinciples/en/ 45. cdc. use of quarantine to prevent transmission of severe acute respiratory syndrome-taiwan, 2003. mmwr. 2003; 52(29): 680-3. 46. anonymous. sars assistance and recovery strategy act 2003. [cited on 2020 august]; available from: https://israelfoulon.com/2003/05/14/sars-update/ 47. hatzenbuehler ml, phelan jc, link bg. stigma as a fundamental cause of population health inequalities. am j public health. 2013; 103(5): 813-21. 48. davtyan m, brown b, folayan mo. addressing ebola-related stigma: lessons learned from hiv/aids. glob health action. 2014; 7: 10.3402/gha. v7.26058. 49. maduka o, odia o. ethical challenges of containing ebola: the nigerian experience. j med ethics. 2015; 41(11): 917-9. 50. sandora m, hartocollis a. in new york, protections offered for medical workers joining ebola fight. new york times. 31 october 2014. 51. pomerantz a. ethics of ebola quarantines. sound decisions. 2015;1(1): 5. 52. tangwa gb. the traditional african perception of a person. some implications for bioethics. hastings cent rep. 2000; 30(5): 39-43. hhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh copyright © 2022 tehran university of medical sciences. this work is licensed under a creative commons attribution-non commercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. original article abstract ethical decision-making and professional behavior are essential skills in nursing profession, hence educational programs should be designed to enable future nurses to tackle problems related to ethical decision-making. this descriptive, correlational and analytical study aimed at determining the ability of iranian nursing students to make ethical decisions as well as relationship between such decisions and professional behavior. the present study used census to select 140 freshmen from the school of nursing and midwifery of tabriz university of medical sciences, tabriz, iran. data collection tools included a demographic questionnaire, the nursing dilemma test (ndt) comprising two indices of “nurse’s principled thinking” and “practical consideration”, as well as the nursing students professional behaviors scale (nspbs). *corresponding author mozhgan behshid address: medical and surgical nursing department, faculty of nursing-midwifery, southern shariati st., tabriz, iran. postal code: 5138947-977 tel: (+98) 41 34 79 67 70132 email: behshidm@tbzmed.ac.ir received: 27 feb 2022 accepted: 28 may 2022 published: 10 aug 2022 citation to this article: molaei tavani f, behshid m, rahmani a, mousavi s, seif farshad m, rahmani p. relationships between ethical decisionmaking and professional behavior in iranian nursing students. j med ethics hist med. 2022; 15: 4. the mean scores obtained were 41.3±5.7 for “nurse’s principled thinking”, 21.3±3.7 for “practical consideration”, and 119.07±11.79 for professional behavior. relationships of professional behavior with “nurse’s principled thinking” and “practical consideration” were insignificant (p>0.05). according to the present study’s findings, nursing students’ weakness in applying ethical concepts to decisions and professional behaviors was due to a gap between scientific material learned and clinical practice. hence, novel training strategies and programs should be designed to reduce such theorypractice gap. keywords: professionalism; decision-making; students; nursing; professional practice. relationships between ethical decision-making and professional behavior in iranian nursing students 1. student research committee, tabriz university of medical science, tabriz, iran; medical and surgical nursing, msc student faculty of nursing-midwifery, tabriz university of medical sciences, tabriz, iran. 2. assistant professor, medical education research center, health management and safety promotion research institute, tabriz university of medical sciences, tabriz, iran. 3. assistant professor, medical surgical department, nursing and midwifery faculty, tabriz university of medical sciences, tabriz, iran. 4. assistant professor, department of statistics and epidemiology, faculty of health sciences, tabriz university of medical sciences, tabriz, iran. fatemeh molaei tavani1, mozhgan behshid2*, azad rahmani3, saeid mousavi4, mehran seif-farshad2, parvin rahmani1 relationships between ethical decision-making and professional behavior in iranian nursing students j. med. ethics. hist. med. 2022 (aug); 15: 4. 2 introduction advancements in science and technology have growingly made ethical patient care difficult (1). compared to other professions, nursing profession faces more ethical challenges and problems (2). properly managing these problems in patient care requires a proper understanding of ethical principles and ethical decision-making (3). failing to comprehend these ethical challenges and situations can cause ethical distress (2). creating and developing ethical decision-making skills in the nursing profession improve creative thinking and ensure the provision of care based on ethical principles (3). ethical decision-making is defined as a logical process that involves making optimal ethical decisions through systematic reasoning in situations including contradictory choices. nurses and nursing teachers constitute role models for nursing students in clinical activities and ethical decision-making in patient care (4). research suggests that 97% of nursing students face at least one ethical and clinical challenge, and 48% experience unsolved ethical problems (5). in turkey, ethical problems were reported for 46.7% of intensive care unit (icu) nurses and unsolved problems for 35.7% (6). timely ethical decisionmaking by nurses is essential for providing patients with necessary services (7) as well as can accelerate patient recovery and reduce healthcare costs (8); hence, failure in such decision-making results in unprofessional behavior and inadequate patient care (7). professionalism refers to measures and skills that reflect the habits, attitudes, beliefs and values defined by a profession. ten principles of the professionalism charter include commitment to the following items: having professional competency, being honest with patients, preserving patient’s confidentiality, maintaining appropriate relationship with patients, improving quality of care, enhancing access to care, distributing finite resources fairly, having scientific knowledge, maintaining trust by managing conflicts of interest and upholding professional responsibilities (9, 10). commitment to the principles of nursing ethics and professional behavior encourages nurses to prioritize patient health by adhering to professional standards, to enhance their position from following the instructions of others to independent decisionmaking, and to promote their professional behavior (11). nursing students must be aware of the principles of professional behavior and ethical theories, as acquiring knowledge of ethical codes, molaei tavani f., et al. 3 j. med. ethics. hist. med. 2022 (aug); 15: 4. principles and standards helps them make appropriate decisions and provide optimal care for patients (12). specialized scientific resources have rarely addressed professional ethics in the field of nursing (13). research on the professional behavior of nursing students and nurses suggests contradictory results, ranging from low (14, 15) to moderate (16) and high (17, 18) levels of professional behavior. lack of studies on nursing students’ ability to make ethical decisions and investigation of relationship between such decisions and professional behavior motivated the present study. moreover, the likelihood of nursing students’ weakness in making ethical decisions in clinical practice due to their lack of experience also made such investigation essential. before teaching nursing ethics as a course, this investigation helps nursing teachers identify the existing educational gaps and assess students’ ability to make ethical decisions. moreover, designing effective programs can productively enhance their learning outcomes in professional nursing such as the ability to make ethical decisions. this study was conducted to determine the skill of ethical decision-making and its relationship with professional behavior in iranian nursing students. in line with educational policies, the present findings can help create and develop appropriate educational programs as well as promote ethical decision-making and professional behavior in nursing students as future nurses. methods the present descriptive, correlational and analytical study was conducted in 2021 to determine the ability to make ethical decisions and its relationship with professional behavior of nursing students in the northwest of iran. the study population comprised of all the students of the school of nursing and midwifery of tabriz university of medical sciences. the inclusion criteria were being a second-semester student of the aforementioned university and not passing the ethics course. the participants who completed the questionnaire more than once or returned incomplete questionnaires were excluded. after obtaining permission from the school officials and the research ethics committee of tabriz university of medical sciences (ir.tbzmed.rec.1398.1261), census was used to select 140 eligible candidates. an online questionnaire was developed that included explanation about the study objectives and methods. then, the students were provided with instructions on how to complete the relationships between ethical decision-making and professional behavior in iranian nursing students j. med. ethics. hist. med. 2022 (aug); 15: 4. 4 questionnaire and were asked to sign informed consents. the participants were ensured about the confidentiality of their data and their right to withdraw from the study. the questionnaires were distributed among the participants using porsline as the data collection system. the data collection tools comprised a demographic questionnaire, the nursing dilemma test (ndt) for measuring the ability to make ethical decisions and the nursing students professional behaviors scale (nspbs). demographic details included age, gender, marital status, knowledge about the principles of nursing ethics and the resources used to gain information about professional ethics. the ndt was developed by crisham through interviewing 130 graduate nurses at the university of minnesota in 1981 based on kohlberg’s theory of moral development. the hypothetical scenarios of this questionnaire used to measure ethical dilemmas facing the nurses included newborn with anomalies, forcing medication, adults’ request to die, new nurses’ orientation, medication error, and terminally-ill adults. three questions were asked at the end of each scenario, and the choices selected as the response to the first question on the nurse’s reaction to the hypothetical situation comprised “right”, “wrong” and “i do not know” options. the second question presented six common views on the scenario based on stage two to stage six of kohlberg’s theory of moral development. two options in each scenario suggested principled thinking. the respondents selected these two options as their priorities received a score of six for one item and five for the other one. the total score of principled thinking ranged from 18 to 66 given that the maximum and minimum score of each scenario was 11 and 3, respectively. the higher the total score, the higher the ability to make ethical decisions. a score of one to six was also received from an option associated with clinical considerations depending on the priority given to this item by the respondent. the total score of clinical considerations in all the scenarios was therefore six to 36. this score negatively related to the ability to make ethical decisions. the third section measured the experience of similar situations on a likert scale. receiving a score of six to 17 from this section suggested the familiarity of the subjects with similar problems, and a score of 18 to 30 showed their unfamiliarity and lack of similar experience. the reliability of ndt was 95% using cronbach’s alpha test in a study by zirak et al. in tabriz university of medical sciences (19). ten academic staff of tabriz school of nursing and midwifery and experts in medical ethics at tabriz university of medical sciences molaei tavani f., et al. 5 j. med. ethics. hist. med. 2022 (aug); 15: 4. confirmed the validity of this questionnaire based on the content validity index. the 27 items of the nspbs, used for measuring nursing students’ professional behavior, were scored based on a five-point likert scale (always: 5; often: 4; no comments: 3; sometimes: 2; never: 1). scores of 27-63 were categorized as low, 64100 as moderate and 101-135 as high (20). heshmati nabavi et al. confirmed the reliability of this questionnaire in mashhad university of medical sciences by calculating a cronbach’s alpha of 0.76 (21). the validity of this tool was also approved by ten faculty members of tabriz school of nursing and midwifery and experts in ethics in tabriz university of medical sciences. the data was analyzed in spss-25 using descriptive statistics, i.e. frequency, relative frequency, mean and standard deviation (sd), and analytical statistics such as the pearson correlation coefficient. the level of statistical significance was adjusted at p<0.05. results out of 140 freshmen with a mean age of 20.32±1.77 years included as undergraduate nursing students at tabriz university of medical sciences; 50% (n=70) were female, and 96.7% were single. from 140 freshmen, 56.4% (n=79) admitted their familiarity with the principles of nursing ethics through experiences at school and educational centers (25.1%), reading books (22.6%) and using media (16.2%). table 1 presents the demographic characteristics of the students. table 1: demographic characteristics of nursing students demographic information frequency percentage gender male 70 50 female 70 50 marital status single 137 97.9 married 3 2.1 familiarity with ethics yes 79 56.4 no 61 43.6 resources used to gain information about professional ethics book 81 22.6 co-worker 40 11.1 participate in conferences 12 3.3 media 58 16.2 regulations 21 5.8 educational centers 90 25.1 personal reasoning 57 15.9 relationships between ethical decision-making and professional behavior in iranian nursing students j. med. ethics. hist. med. 2022 (aug); 15: 4. 6 table 2 presents the results of analyzing the students’ responses to the first section of ndt, suggesting that the highest frequency of correct responses (90.7%) pertained to medication error and the lowest (26.4%) to terminally-ill adults and new nurse’s orientation. table 2: nursing student’s responses to section a of ndt (n=140) dilemmas ‘what should nurse do?’ n % newborn with anomalies should resuscitate the newborn 58 41.4 cannot decide 27 19.3 should not resuscitate the newborn 55 39.3 forcing medication should forcefully give the medication 86 61.4 cannot decide 13 9.3 should not forcefully give the medication 41 29.3 adults’ request to die should provide assistance for artificial respiration 121 86.4 cannot decide 13 9.3 should not provide assistance for artificial respiration 6 4.3 new nurse’s orientation should allocate time for orientation of the nurse 37 26.4 cannot decide 28 20.0 should not allocate time for orientation of the nurse 75 53.6 medication error should report the medication error now 127 90.7 cannot decide 10 7.1 should not report the medication error now 3 2.1 terminally-ill adults should answer the patient’s questions 37 26.4 cannot decide 22 15.7 should not answer the patient’s questions 81 57.9 according to table 3, the mean score of the professional behavior of the nursing students was 119.07±11.79, and high levels of professional behavior were observed in 94.3% of the cases as per the likert scale. moreover, the scores of nurse’s principled thinking and practical consideration were obtained as 30-65 and 13-30 with mean levels of 41.3±5.7 and 21.3±3.7, respectively. table 3: nursing students’ minimum, maximum, mean and sd in professional behavior and ndt variable minimum maximum mean±sd professional behavior 77.0 135.0 119.07±11.79 principled thinking 30 65 41.3±5.7 practical consideration 13 30 21.3±3.7 according to the pearson correlation coefficient, the relationships of the total scores of nurse’s principled thinking and practical consideration with the score of the professional behavior of the students were statistically insignificant (p>0.05) (table 4). molaei tavani f., et al. 7 j. med. ethics. hist. med. 2022 (aug); 15: 4. table 4: relationship between ndt and nursing students’ professional behavior variables professional behavior p-value r principled thinking 0.89 0.01 practical consideration 0.06 -0.15 investigating the relationship of demographic characteristics with the main variables showed that gender, knowledge about the principles of nursing ethics and facing ethical challenges were not significantly related to professional behavior and ethical decision-making (p>0.05). the mean scores of professional behavior and nurse’s principled thinking were, however, higher in the females and those familiar with the principles of nursing ethics or with the experiences of facing ethical challenges. discussion reaction to the hypothetical dilemmas, nurse’s principled thinking and practical consideration were used based on the ndt to evaluate the ability to make ethical decisions in the nursing students. selection of “wrong” or “cannot decide” response options to the majority of scenarios in the first question of the ndt indicated nursing students’ inability to make right ethical decision, and hence, they were unable of making ethical decisions. the highest frequency of correct responses was related to “medication error”; the lowest to “new nurse’s orientation” and “terminally-ill adults”. the low frequency of correct responses to “new nurse’s orientation” can be explained by heavy workload, stressful environment and patients’ poor health status. furthermore, the low frequency of correct responses to “terminally-ill adults” can be explained by the unwillingness of the nursing students to inform the patients of their disease status and progress to prevent their psychological damage, as requested by the physicians or patients’ family. according to sari et al., most students preferred to use the physician paternalism model to preserve the patients’ well-being, autonomy and quality of life. this model introduced the physician as the sole decision-maker on the treatment process (4). as an indicator of steps five to six of kohlberg’s ethical level (22), the mean score of nurse’s principled thinking derived from the ndt was estimated at 41.3±5.7, which was below the average of 42. similarly, koohi et al. reported this score as 40.81±6.72 in nurses (23). in contrast, above average scores were reported in literature for nurse’s principled thinking in nursing students (4, 24) and nurses (25, 26). zirak et al. reported the relationships between ethical decision-making and professional behavior in iranian nursing students j. med. ethics. hist. med. 2022 (aug); 15: 4. 8 mean score of nurse’s principled thinking in nursing students (48.9±6.5) that significantly exceed that of nurses (46.6±6.7) (27). given the major responsibility of nurses and the key role of their decisions, laying foundations for their ethical development and principled thinking is crucial. the lower-than-average score of nurse’s principled thinking in the majority of the nursing students suggested their inability to make ethical decisions. the discrepancy observed in the score of nurse’s principled thinking between the present research and other studies can be explained by differences in culture, workplace atmosphere, as well as knowledge of ethical problems, level of education in ethics, and type of study groups. practical consideration reflected the importance of environmental factors, including the numbers of patients and available resources, institutional policies, nurses’ perceptions of governmental support, and supervision by physicians when deciding on ethical problems (22). the higherthan-average score of practical consideration obtained in the present study (21) was inconsistent with literature reports associated with nursing students (4, 28) and nurses (22, 26, 29). this finding suggests the effect of environmental factors on the nursing students when making decisions on ethical problems. crisham found nurses to be stressed in the face of ethical dilemmas that required ethical decisions under environmental conditions such as organizational policies in conflict with the concepts of justice in nurses, obeying physicians, time constraints, conscientiousness, loyalty to the nursing profession, patients and hospital, uncertain professional responsibilities, information overload and difficulty in finding the most efficient way of benefiting from this information (22). the lower score of principled thinking than that of practical consideration can be explained by students’ unfamiliarity with similar ethical challenges and problems. familiarity with ethical challenges helps students discuss and select optimal solutions to ethical dilemmas and make ethical decisions. unfamiliarity with ethical dilemmas makes ethical decision-making difficult and causes nursing students to use practical consideration rather than principled thinking (4). in line with the results obtained by fattahi-bafghi and barkhordari-sharifabad (18), khajavi et al.(17), mousaviasl et al. (12) and khachian et al. (30), the present findings suggested high levels of professional behavior in the nursing students with a mean score of 119.07 out of 135. in contrast, dikmen et al. (31), çelik and hisar (32), demir and yildirim (33), koştu and arslan (34) and cerit molaei tavani f., et al. 9 j. med. ethics. hist. med. 2022 (aug); 15: 4. and dinc (14) reported low levels of professional behavior among nurses. this discrepancy in the professionalism of nurses can be explained by differences in the education levels of nurses and community’s perception of nursing as a profession, as well as the hierarchical structure of hospitals, heavy workload, long working hours, lack of staff and equipment, job insecurity, low income and weak organizational workforce (31). tanaka et al. (35) and hisar et al. (36) reported higher mean scores for the professional behavior of nurses with postgraduate education and more work experience than those of other nurses. investigating the relationships of demographic factors with the indicators of ethical decisionmaking and professional behavior in the participants showed insignificant associations of the total scores of professional behavior, nurse’s principled thinking and practical consideration with age, gender, knowledge about the principles of nursing ethics and experience of facing ethical challenges. similarly, zirak et al. (25), koohi et al. (23) and ham (37) reported insignificant relationships of nurse’s principled thinking with education level, age and gender. these scores were, however, higher in the nurses familiar with the principles of nursing ethics and females, which is consistent with the findings of khajavi et al. (17) and jahanbazi and lotfizadeh (16). higher sensitivity of females to ethical issues than that of males helps females make more rational decisions in the face of ethical challenges. in line with the present findings, khajavi et al. (17) and heshmati nabavi et al. (21) observed the insignificant relationships of in-service training courses and knowledge about the patients’ rights charter with the scores of professional behavior and ability to make ethical decisions (23). despite the key roles of teaching ethics and familiarity with and experience of ethical challenges in ethical development and making appropriate decisions in the face of ethical challenges, the gap between scientific material learned and clinical practice can counteract the effect of ethical concepts on the decisions and professional behavior of nursing students. moreover, professional regulations, norms and responsibilities prevent nursing students from independently making ethical decisions during their education based on their own principles and practice. professional behavior was found to insignificantly relate to practical consideration and nurse’s principled thinking (p>0.05). to the best of the authors’ knowledge, cerit and dinc were the only researchers who investigated ethical decisionmaking and professional behavior in nurses, and relationships between ethical decision-making and professional behavior in iranian nursing students j. med. ethics. hist. med. 2022 (aug); 15: 4. 10 they reported insignificant and positive relationships between professional behavior and nurse’s principled thinking (14). in line with the present study, lim and kim reported a gap between thinking and practice in ethical decision-making, as well as failures to direct thinking toward ethical practice given the obstacles to the implementation of ethical decisions despite the continuity of ethical decision-making (38). according to ashuri, ethical reasoning and moral behavior positively and significantly relate to ethical metacognition. furthermore, positive and significant relationships were observed between moral reasoning and moral behavior. that is, the stronger the reasoning, the greater the ability to thoroughly and accurately examine ethical challenges and make ethical decisions. improving this ability, therefore, promotes ethical metacognitive skills and moral behavior (39). ethical reasoning is required for making ethical decisions in nurses (23). amiri et al. reported positive relationships of ethical reasoning with caring and professional behaviors in nurses (40). despite the indirect associations of the cited results with the present findings, the discrepancy in results can be explained by differences in individual characteristics, communication challenges, research setting, and educational systems. given the need for integrating academic education into nursing practice, laying foundations for turning ethical decisions into ethical and professional behavior is essential for providing ethical and professional care. the gap between theory and practice causes crises in nursing care and lack of appropriate professional behaviors in the face of ethical dilemmas. eliminating this gap, thus, enables nurses of making more appropriate ethical decisions and ultimately improves their professional performance. the present study’s limitations included the use of self-report tools for the variables of ethical decision-making and professional behavior, which might have affected the responses of the participants and the results. conclusion the findings obtained, respectively, showed lowerthan-average and higher-than-average scores of 42 and 21 for nurse’s principled thinking and practical consideration in the nursing students, whose professional behavior was also high. the insignificant relationship between ethical decisionmaking and professional behavior suggested the effect of environmental factors on the students in the face of ethical challenges, their weakness in turning ethical decisions into professional actions and behaviors, and their uncertainty about their molaei tavani f., et al. 11 j. med. ethics. hist. med. 2022 (aug); 15: 4. ability to provide quality care. the gap between theoretical and practical education should be bridged by laying accurate educational plans, adopting modern educational strategies, synchronizing clinical education with recurring ethical dilemmas and simulating the clinical environment. comprehensive training programs should also be designed to help students improve and enhance their ethical decision-making ability both theoretically and practically, and direct their ethical decision-making toward professional behaviors. authors’ contribution fatemeh molaei tavani and parvin rahmani collected the data. saeid mousavi provided and analyzed the data. mozhgan behshid and fatemeh molaei tavani provided the data and prepared the manuscript. mozhgan behshid, azad rahmani and mehran seif farshad conceived the study’ idea, prepared the manuscript, and edited the final version of the manuscript. funding the deputy of research and technology of tabriz university of medical sciences financially supported this study. acknowledgements this article was extracted from a master’s dissertation and a project approved by the ethics committee of tabriz university of medical sciences (ir.tbzmed.rec.1398.1261). the authors would like to express their gratitude to the authorities of school of nursing and midwifery and the participating students. conflict of interests the authors declared no conflicts of interest regarding the publication of the present article. relationships between ethical decision-making and professional behavior in iranian nursing students j. med. ethics. hist. med. 2022 (aug); 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15: 8. two hundreds and forty-two codes, five sub-categories, two categories, and a theme entitled "reciprocal accountability in ipp” were extracted. the barrier category was named “weakness in accountability to team-based values" and the facilitator category was called "responsibility of maintaining empathetic relationship within the ip team". development of ipp and professional values (e.g., altruism, empathetic communication, and accountability to individual’s and team’s roles) can facilitate collaborative processes among different professions. keywords: interprofessional; professionalism; values; collaboration; team; semi-structured qualitative study. interprofessional professionalism as a motivating force in interprofessional collaboration 1. associate professor, medical education department, education development center, shahid sadoughi university of medical sciences, yazd, iran. 2. instructor, department of operating room, school of allied medical sciences, qom university of medical sciences, qom, iran. fatemeh keshmiri1, azam hosseinpour2* interprofessional professionalism as a motivating force in interprofessional collaboration j. med. ethics. hist. med. 2022 (oct); 15: 8. 2 introduction professionalism has been recognized as an essential component of inter-professional collaboration (ipc) (1). inter-professional professionalism (ipp) has been introduced as an integrated concept in professionalism and interprofessional (ip) care fields (2). ipp focuses on respecting professional values in ipc process through maintaining an atmosphere of mutual respect and shared values (3) that should be considered by providers in all fields involved in providing healthcare services to improve individual’s and team’s competencies as well as to develop an educational atmosphere (4). in the definition of ipp principles and values such as respect, communication, excellence, altruism, and accountability in ipc process have been emphasized (4). for example, surgery teams should acquire ipc competencies as they are required in complex and sensitive situations in the operation room (or) environment. developing ipp and respecting team-work values can facilitate ipc (3,5). ipp aimed at defining professionalism aspects of teamwork rather than just the concept of experts in various profession working together as a team (1). thus, viewpoints of those with ipp experiences on various dimensions of ipp can help perceive it. ipc is a multi-dimensional and complicated concept affected by various factors, including personal, professional, and cultural factors (6). however, factors affecting the facilitation of ipc and the development of professional values in various fields can be different, and hence a qualitative approach should be used to explain the factors affecting diverse cultural contexts. although recent studies on professionalism and ipc as two separate fields have been conducted, few have been focused on professionalism in the ip team. moreover, recent studies on education and ipc have been mainly quantitative, and hence qualitative research has been recommended to be conducted in this field (6). regarding the importance of understanding the ip values influencing ipc in or environment, as criticallysensitive clinical settings, the present study aimed at exploring or team members' experiences on ipp’s facilitators and barriers in surgery team. methods qualitative approach this qualitative study had been designed and conducted from 2019 to 2021. content analysis in keshmiri f., et al. 3 j. med. ethics. hist. med. 2022 (oct); 15: 8. qualitative research is a systematic method to describe the depth and breadth of a phenomenon (7). researcher characteristics all members of the research team were female. at the time of and during the study, ah was msc candidate in surgical technology. fk were faculty members of education development center at ssu. all authors were involved in all steps of the study. fk conceptualized and designed the study. a.h collected the data, and f.k and a.h analyzed and interpreted data. sampling strategy the purposive sampling method was used in the study. as inclusion criteria, the team members had worked in the surgery team for at least four months and had attended the ip meetings. to obtain maximum diversity within the samples, the participants included from both genders and various age groups (young, middle-age, and older adults) and experience levels (novice, advanced beginner, competent, proficient, expert), with diverse professions and education levels (b.sc, m.sc, m.d, specialists). ethical issues the interviews were audio recorded after obtaining informed consent to participate in the study. principles of information confidentiality and obtaining informed consent were ensured in interviewing participants, interviews’ recording, and offering the right to withdraw from the study. to increase result accuracy, the findings were presented to the participants to reconfirm, which was among the ethical considerations observed in this study. this study was approved by the ethics committee of the national center for strategic research in medical education, tehran, iran (ir.nasrme.rec.1400.094). data collection methods data was collected through semi-structured interviews. the research team members prepared interview questions. the interview guide and questions were reviewed and approved by experts with experiences in the fields of professionalism, ip education and ipc and health professions’ education. according to the interview guide, interviews initiated with open-ended questions: how are you collaborating with different professions? what professional principles do you or other team members comply with to improve ipc? what professional behaviors have facilitated your ip relationship and ipc? which unprofessional issues have disrupted your collaboration in an ip team? probing was conducted to facilitate participants’ explanation of interprofessional professionalism as a motivating force in interprofessional collaboration j. med. ethics. hist. med. 2022 (oct); 15: 8. 4 their experiences. interviews’ place and time were scheduled considering participants’ preferences. the interviews lasted 40 to 60 minutes. the data collection was continued until data saturation when no new code emerged. units of the study participants were selected from the surgery teams including surgeons, anesthesia nurses, and surgical technology-nurses of hospitals affiliated with shahid sadoughi university. fifteen participants contributed in semi-structured interviews, of which six were surgeon, four were anesthesia nurses, and five were surgical technology nurses. seven male and eight females were participated in our study (table 1). data processing, analysis and confirmation all interviews were transcribed verbatim, and audio files were reviewed several times to ensure transcripts’ accuracy. then, all interviews were coded and extracted according to the content analysis method based on the lundman and graneheim approach (7). the data analysis process was performed in several stages, including transcribing the interviews, extracting semantic units and classifying them under the compact unit, summarizing and classifying the compact units and selecting appropriate labels for them, and sorting subcategories based on their similarities and differences. content analysis was performed on the data based on qualitative content analysis. meaningful segments of data were identified and labeled as open codes. the extracted codes were compared considering their differences and similarities. then, the categories and subcategories emerged after sorting the extracted codes. the themes were extracted through comparing the extracted categories. the researchers conducted the analysis process. in cases of disagreement over the coding, the researchers discussed until reaching a consensus. techniques to enhance trustworthiness to obtain credibility criteria, the extracted codes and categories were examined and confirmed by the participants (member checking). furthermore, the research team members (peerchecking) examined the extracted results. two experts in the qualitative field reviewed and validated the correlations of the extracted results to achieve confirmability and dependability (expertchecking). the suggestions for changing the extracted findings have been discussed until reaching a consensus. moreover, field notes, memo writing, and prolonged engagement with the participants were conducted. the participants and the context of the study were described to reach transferability criteria. keshmiri f., et al. 5 j. med. ethics. hist. med. 2022 (oct); 15: 8. reporting this study is reported according to the “standards for reporting qualitative research (srqr) guideline. results table 1 presents participants’ demographic and background characteristics. two hundreds and forty codes, five sub-categories, two categories, and a theme were extracted. table 1 – participants’ demographic and background characteristics study participants n (%) gender male 7 (46.66) female 8 (53.33) age (mean ± sd) 40±7 work experience (mean ± sd) 8±4 profession surgeons 6 (39.99) anesthesia nurses 4 (26.66) surgical technology nurses 5 (33.33) this study explored a theme of "reciprocal accountability in ipp" (table 2). in this study, two categories, including "weakness in accountability to team-based values" and "responsibility of maintaining empathetic relationship within ip team", were also explored. the category of "weakness in accountability to team-based values" includes ignoring human and professional values and team-based challenges. the second category, "responsibility of maintaining empathetic relationship within ip team" includes empathy in ip team’s communications, accepting and responding to team roles, and maintaining mutual and respectful relationships. table 2the participants’ experiences regarding ipp’s elements theme category subcategory reciprocal accountability in ipp weakness in accountability to team-based values ignoring human and professional values team-based challenges responsibility of maintaining empathetic relationship within ip team empathy in ip teams communications accepting and responding to team roles mutual and respectful relationships interprofessional professionalism as a motivating force in interprofessional collaboration j. med. ethics. hist. med. 2022 (oct); 15: 8. 6 1.weakness in accountability to team-based values in this category, the challenges of cooperation among surgery team members were included. team members believed that ignoring human and professional values would create unfriendly atmosphere in or and decrease team members' performance. lack of commitment to professional values such as disrespecting team members' personal and professional status, disregarding altruism and individualism, and disrespectful communication disrupts ipc. 1.1. ignoring human and professional values in this category, team members' lack of commitment in adhering to professional principles and human values prevents ipc. several inappropriate behaviors, such as undermining others for self-aggrandizement and appearing imperative as well as demeaning others in the eyes of the leader or team leader, are significant barriers to cooperation. ignoring or team members, disrespecting other team members’ personality or profession, and disregarding the altruism principles were among personal barriers inhibiting initiating an appropriate team atmosphere. a participant stated: "we should all respect each other, but the physicians consider us their slaves". [participant no. 3] "a significant characteristic of hospital nurses and staff is pulling the rug under colleague’ feet". [participant no. 6] communication was introduced as a core element in ipc process. in this study, disrespectful communication was stated as a cooperation barrier. a participant stated: “some hospital wards have harsh attending physicians that humiliate chief resident who in a row act similarly with freshman residents, and they also do the same with scrub or circular nurses. who can work in such teams?" [participant no. 4] lack of empathy among team members was another barrier. a participant stated: "altruism is not respected in the workplace. some staff do nothing in one room while a critical operation is underway in or where help is needed". [participant no. 9] feeling superior in terms of the field of the study, work experience, and administrative hierarchy prevents empathy in team. a participant stated: "more experienced staff mistreat us. for example, i had been in the hospital from morning to afternoon and in different ors. a senior staff sent keshmiri f., et al. 7 j. med. ethics. hist. med. 2022 (oct); 15: 8. me to or again in the afternoon instead of another senior just because i was recently employed". [participant no. 7] 1.2. team-based challenges this category included ipc barriers such as professional discrimination and injustice, professional irresponsibility, ignoring team members' decision-making process, and disregarding their opinions. the individualism among members and ambiguity in professional responsibilities hinders ipc. discrimination among different professions, professional antagonisms, and discrimination due to the hierarchy prevent ipc. income discrimination was identified as a significant barrier contributing to social class gap. furthermore, involving hierarchy and discriminatory aspects makes team members feel ignored and dissatisfied with ipc. discrimination due to physician dominance in hospitals was mentioned as another barrier. according to participants, physicians are always responsible for decision-makings and may judge with bias and support their physician colleagues. therefore, the right of other professions can be disregarded. regarding physician dominance and understanding of the hierarchy in different professions, a participant stated: "we are constantly experiencing physicians' commanding tone, humiliating look, and behavior”. [participant no. 4] a staff member referred to income discrimination: "there is a negative attitude regarding physicians’ salary, leading to hatred of novice staff towards medical team without even knowing them. it is an initiation and determining behavior in other interactions among them”. [participant no. 11] regarding the understanding of ip discrimination, a participant stated: "the decision is always made by a doctor; even if the anesthesia nurse makes a mistake, one from the paramedic group is not allowed to fix the problem. rather, the decision is made by the medical team. unfortunately, doctor dominance has been a disaster for years and affects our interactions and behaviors”. [participant no. 5] regarding ambiguity in professional responsibilities, personnel stated: "defining and assigning tasks are important. almost all my colleagues do not know what to do or not to do. we studied anesthesia for four years and were taught about its principles. but, we do not know what each of us needs to do". [participant no. 13] regarding individualism and excellence in ip team, a participant stated: “power in a team is a interprofessional professionalism as a motivating force in interprofessional collaboration j. med. ethics. hist. med. 2022 (oct); 15: 8. 8 determining factor that is a function of the level of knowledge and money. physicians see themselves as having more money and more knowledge than others, while they just play a different role. since physicians do not know the importance of others’ duty, they consider themselves superior and maybe even leaders”. [participant no. 1] disorder in individual behaviors and team planning has been explained as barriers to ipc. a staff stated: "fatigue and boredom affect our behavior. there is an excessive workload, and without planning, inappropriate ethical conflicts occur between surgeon and or manager". [participant no. 2] regarding the staff's misbehavior, a participant stated: "i do not know why there are no specific working hours for the attending physician and others. personnel is present, the patient is present, but the attending physician is not. there is no obligation for the physician to be on time”. [participant no. 8] 2. responsibility of maintaining empathetic relationship within ip teams this category introduced a commitment to professional values and empathetic implementation of ip responsibilities as essential factors in facilitating ipc. 2.1. empathy in ip teams communications in addition to accountability, empathy among team members of different professions in achieving ipc is vital. mutual understanding and helping among team members to provide quality services are essential. a participant stated: "now i am a resident, and i need the staff to help me when the attending physician is not present. they have more experience, and later when i become an attending physician, i can train the staff with less work experience”. [participant no. 14] 2.2. accepting and responding to team roles believing in teamwork in providing services in or, accountability in professional and team activities, and respecting all professions facilitate ipc. regarding the commitment to the team roles and responsibilities, a participant stated: "we are all like interconnected chains; if a team member does not do well, the whole team faces difficulties. now, if we want to cooperate effectively, first we need to admit teamwork concept”. [participant no. 15] 2.3. making mutual and respectful relationships participants considered contributors to respectful behavior and team interactions as essential factors in creating closeness and ipc atmosphere. respectful relationship helps making a comfortable atmosphere, that plays a significant role in service quality. in this regard, a participant stated: “team members are human beings not keshmiri f., et al. 9 j. med. ethics. hist. med. 2022 (oct); 15: 8. robots, and we need a peaceful workplace to do our best, to provide best services, which is not achievable without good relationships and respectful interactions”. [participant no. 6] regarding the interaction with team members, a participant stated: "when attending physicians enquire residents’ opinion, they are respecting the residents and they feel valuable and appreciated, which in row affect their behavior and push them towards excellent outcomes”. [participant no. 10] discussion this study explored theme of "reciprocal accountability in ipp”. present findings confirm the accountability in ip team function as a facilitator, and weakness in accountability to the team-based values as a barrier to ipc; weakness in accountability to respect team-based values, including respectful communication, empathy, altruism, and not adhering to human and professional values among team members, were barriers to ipc in or. the participants complained about the weaknesses of team members in respecting altruism and commitment to professional values. moreover, situational abuses of team members based on feeling superior in terms of several factors (e.g., education level, age group, or social class) make the abusers self-gormandize, show off, or seek less suffering and hardship at work, thereby leading to unfavorable relationships among team members. the feeling of being abused by the exercise of power by the abusers, as well as disrespecting the personality and professional values of other team members, were major obstacles in ip activities. value-contradictory behaviors of some members towards their colleagues to conceal their mistakes or negligence, or showing their abilities and highlighting incapacity of others, may cause a deviation of the team's attitude towards others and even other professions. such behaviors may disrupt cooperative relationships and effective communication among different professions. the dominance of individualism and the priority of selfinterest can adversely affect ip relationships and ipc (8). according to a cohort study conducted at asian universities, altruism and empathy were two attributes that the students disregard as professional behaviors (9) that may be due to the individualistic attitude in their cultural context. in the category of team-based challenges, defections in team responsibility, disruption in ipc, and ip discrimination were highlighted. accountability in healthcare team involves accepting responsibilities and diverse roles as well as meeting requirements and activities affecting interprofessional professionalism as a motivating force in interprofessional collaboration j. med. ethics. hist. med. 2022 (oct); 15: 8. 10 patients, team outcomes, and community’s health needs (10). participants regarded role ambiguity as an excuse for some colleagues’ failure to do their responsibilities and delegate their duties to others due to conflicts and superiority. ambiguity of roles, lack of accountability, as well as creation of ip challenges and conflicts may lead to personal and professional abuse and disrupt ip relations. moreover, disorder and disorganization disrupted ipc in teamwork and stressful environments such as ors. deficiency of work discipline among team members, such as physicians' unpunctuality, lack of coordination for the timely presence of all members, and non-compliance with the organizational rules in individuals, especially in physicians, were among individual problems disrupting ipc. the lack of planning for service management and the large number of patients causes chaos and increases the workload for some employees, especially new employees. furthermore, lack of empathy, altruism, and discrimination frustrate team members. participants believed that lack of evaluation system and constant monitoring of the performance on compliance with organizational rules and professional principles creates challenges in ipc. according to schot et al., ipc should be implemented through bridging professional and social gaps and removing the slacks among the professional duties, negotiating overlapping roles and responsibilities, and creating opportunities to understand members' professional duties and roles (11). the present findings showed that ip discrimination is perceived as unfair behavior and prevents the formation of cooperative relationships among healthcare team members. the paramedic personnel highlighted class antagonisms in the teams, resulting in various payment levels for equal effort of the healthcare team members. these differences make physicians underestimate other professions. such feeling of superiority has rendered administrative and decision-making positions extending and making everything in favor of physicians. therefore, in personal, professional and legal disputes, everything is in favor of physicians, that weakens the rights of other professions, as well as leads to inappropriate conduct and professional judgments and reduces the motivation of other professions for ipc. moreover, physicians believe that they deserve higher salaries, and lack of motivation in other professions is because of their incapacities and indolence. feeling superior makes the physicians forget that they are members of teams and consider themselves the team head. this attitude poses a keshmiri f., et al. 11 j. med. ethics. hist. med. 2022 (oct); 15: 8. significant challenge in collaborative relationships. the class-income antagonisms and professional discriminations lead to negatively competitive surroundings among team members and prevent cooperative relationships. in the targeted context, discrimination, the culture of physician dominance, and the hierarchy system among different professions deepen the boundaries and fail to realize team-based services (8). consistent with the present findings, shohani's results showed that the experience and perception of the discrimination in the organization is an essential factor influencing how individuals work together, the lack of motivation to cooperate and work in the clinic, and even the decision to leave the service (12). observing discrimination leads to the team member's disobedience to the leader, failure to perform assigned responsibilities for the member, and failure to cooperate in requested tasks (13). in line with the present findings, discrimination is an important factor leading to irresponsibility and lack of obligation in accepting and fulfilling professional, personal, ipc and ip roles (13). tsou et al. emphasized on the need for integrity and maintaining justice as well as the need to include ip framework. the adherence to integrity and maintaining justice among team members prevents unprofessional actions such as discriminating, undermining, and disabling colleagues (10). consistent with the present findings, in another study on understanding ipc mechanisms, the "support and value" mechanism, as an underlying mechanism, highlighted team members’ support of each other and respect for their skills, capabilities, and values (14). in the second category, “responsibility of maintaining empathetic relationship within ip team” as a facilitator of ipc was explained. respectful interactions and exchanging ideas among team members make them feel relieved and not ignored. empathy and mutual understanding among team members disrupt the boundaries among different professions and create closeness among them. altruism, helping others, and teamwork spirit were explained as significant ways to initiate ipc. similar to the present findings, in a grounded theory study by sur, empathy in ipc is considered a critical component in team making, ipc, and ip interactions. in the category of empathy as a collaborative engagement, mutual respect, understanding and assisting others, and team communication are facilitators of ipc (15). adamson et al. introduced ip empathy as a factor affecting the well-being of ip team members, leading to team cohesion and ipc (16), inconsistent with the present results. according to the present interprofessional professionalism as a motivating force in interprofessional collaboration j. med. ethics. hist. med. 2022 (oct); 15: 8. 12 findings, accountability to the team responsibilities facilitates cooperation among team members. when members accept team responsibility and team membership, they need to be able to respond to other team members' requests, help them, teach them, as well as strive for individual and team excellence. hewitt et al. introduced efficient, open, and equitable communication, shared responsibility, and team behavioral norms as team members’ accountability approaches for ipc (17), consistent with the present findings. respectful relationships, empathy, and accountability to team roles are essential elements to improve ipc, in line with other studies’ findings (18, 19). stephenson and bliss suggested that ip learning provides situations for understanding, practicing professional values, and ipp improvement among learners and staff (20). considering that the present study is qualitative, generalizing the results to other contexts with different cultures involves limitations. implementation details cannot be controlled by the researchers. conclusion the present study explored "reciprocal accountability in ipp" as a theme, and two categories, "weakness in accountability to teambased values" and "responsibility of maintaining empathetic relationship within ip team", were considered. the development of ipp and professional values such as altruism, empathetic communication, and accountability to individual and team roles can facilitate collaborative processes among diverse professions. lack of commitment to ip values leads to ineffective communication, unprofessional practice, and ipc challenges. moreover, the rejection of team-based values and responsibilities disrupts the realization of ipc. therefore, educational and practical opportunities in ip teams should be created and culture of team-based service should be launched in the target context. funding this project was funded by the national agency for strategic research in medical education. tehran. iran. grant no. 992000. acknowledgements we would like to thank the participants who contributed to the study. conflict of interests the authors report no conflict of interest. keshmiri f., et al. 13 j. med. ethics. hist. med. 2022 (oct); 15: 8. references 1. hammer d, anderson mb, brunson wd, et al. defining and measuring construct of interprofessional professionalism. j allied health. 2012; 41(2): e49-53. 2. holtman mc, frost js, hammer dp, mcguinn k, nunez lm. interprofessional professionalism: linking professionalism and interprofessional care. j interprof care. 2011; 25(5): 383-5. 3. bainbridge l, nasmith l, orchard c, wood, v. competencies for interprofessional collaboration. j. phys. ther. educ. 2010; 24(1): 6-11. 4. frost js, hammer dp, nunez lm, et al. the intersection of professionalism and interprofessional care: development and initial testing of the interprofessional professionalism assessment (ipa). j interprof care. 2019; 33(1): 102-15. 5. barnard d. “joining the healing community”: images and narratives to promote interprofessional professionalism. j allied health. 2015; 44(4): 244-8. 6. reeves s, fletcher s, barr h, et al. a beme systematic review of the effects of interprofessional education: beme guide no. 39. med teach. 2016; 38(7): 656-68. 7. graneheim uh, lundman b. qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. nurse educ today. 2004; 24(2): 105-12. 8. vafadar z, vanaki z, ebadi a. barriers to implementation of team care and interprofessional education: the viewpoints of educational managers of iranian health system. iranian journal of medical education. 2015; 14(11): 943-56. 9. guraya sy, sulaiman n, guraya ss, et al. understanding the climate of medical professionalism among university students; a multi-center study. innovations in education and teaching international. 2021; 58(3): 351-60. 10. tsou p, shih j, ho mj. a comparative study of professional and interprofessional values between health professional associations. j interprof care. 2015; 29(6): 628-33. 11. schot e, tummers l, noordegraaf m. working on working together. a systematic review on how healthcare professionals contribute to interprofessional collaboration. j interprof care. 2020; 34(3): 332-42. 12. shohani m. the consequences of nurses' endeavors to overcome inter-professional discrimination. nurs ethics. 2019; 26(7-8): 2058-70. 13. shohani m. strategies of iranian nurses to overcome professional discrimination: an explorative qualitative study. nurs ethics. 2019; 26(1): 235-47. interprofessional professionalism as a motivating force in interprofessional collaboration j. med. ethics. hist. med. 2022 (oct); 15: 8. 14 14. hewitt g, sims s, harris r. using realist synthesis to understand the mechanisms of interprofessional teamwork in health and social care. j interprof care. 2014; 28(6): 501-6. 15. sur d. interprofessional intentional empathy centered care (ip-iecc) in healthcare practice: a grounded theory study. j interprof care. 2021; 35(2):175-84. 16. adamson k, loomis c, cadell s, verweel lc. interprofessional empathy: a four-stage model for a new understanding of teamwork. j interprof care. 2018; 32(6): 752-61. 17. hewitt g, sims s, harris r. evidence of communication, influence and behavioral norms in interprofessional teams: a realist synthesis. j interprof care. 2015; 29(2):100-5. 18. rotz me, duenas gg. "collaborative-ready" students: exploring factors that influence collaboration during a longitudinal interprofessional education practice experience. j interprof care. 2016; 30(2):238-241. 19. peu md, mataboge s, chinouya m, et al. experiences and challenges of an interprofessional community of practice in hiv and aids in tshwane district, south africa. j interprof care. 2014; 28(6): 547-52. 20. stephenson a, bliss j. supporting the development of professionalism in the education of health professionals. in: clinical education for the health professions: theory and practice. singapore: springer, 2020. jmehm-11-7 journal of medical ethics and history of medicine original article evaluation of informal payments to health care professionals and the influential factors in urmia city hospitals, iran abdolvahed khodamoradi1*, arash rashidian2, reza daryabeygi‐khotbehsara3, siamak aghlmand4 1researcher, department of health economics, social security research institute, tehran, iran. 2professor, department of health management and economics, school of public health, tehran university of medical sciences, tehran, iran. 3department of clinical nutrition, school of nutritional sciences and dietetics, tehran university of medical sciences, tehran, iran. 4associate professor, department of public health, school of public health, urmia university of medical sciences, urmia, iran. corresponding author: abdolvahed khodamoradi address: no. 20, 10th st., bokharest ave., argentina square, tehran, iran. email: khodamoradi84@gmail.com tel: (+98) 21 88753245 received: 23 jan 2018 accepted: 17 jun 2018 published: 11 july 2018 j med ethics hist med, 2018, 11: 7 © 2018 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract informal payments refer to sums that patients may pay to individual or organizational health care providers outside of the official payment channels or approved fee schedules. the aim of the current research was to investigate informal payments and related influential factors in urmia city hospitals. the present study was a cross-sectional survey conducted among post-discharged patients from all urmia city hospitals during one iranian calendar month (january 21 to march 19, 2013). simple random sampling was used to recruit 265 patients to undergo assessment via phone call interviews and complete a questionnaire. data analysis was performed using spss software for descriptive reports, and eviews software for determination of factors affecting informal payments. eleven percent of the patients had made informal payments to physicians (mean amount: 503,000 tomans, equivalent of $412), 5% to nurses (mean amount: 20,000 tomans, equivalent of $16), and 17% to other employees (mean amount: 16,000 tomans, equivalent of $13). hospital ownership, patients’ place of residence, education and income significantly influenced the payments. most substantially, patients receiving surgical care were 100 times more likely to make informal payments compared to those who had received non-surgical inpatient care. the present study showed that although informal payment is illegal in iran, it is a common practice among hospitalized patients, and has now become a challenge for the health system. considering the high prevalence of informal payments and their severe impacts on equity and justice, policymakers have focused on this phenomenon to reduce and eliminate it. keywords: out-of-pocket payment, informal payment, health care professionals, iran mailto:khodamoradi84@gmail.com j med ethics hist med 11: 7, july, 2018 jmehm.tums.ac.ir abdolvahed khodamoradi et al. page 2 of 9 introduction many countries around the world have suffered the consequences of informal payments for health services, which is one of the important issues in health care systems. the extent and importance of informal payments for health care services have been discussed in various sectors, especially after the reform attempts of the former soviet union and increased focus on the health care systems of economies facing transition (1). informal payments are made to individual or organizational health care providers by patients outside of the official payment channels (2), and may take various forms. instances include cash, kind (goods and services such as drugs, food, nursing care, blood supply, laboratory tests), and gifts (chocolate, juice, cookies, flowers) (3 5). from an economic perspective, informal payments fall in the category of out-of-pocket (oop) payments, as they have the same effect on the financial burden for patients and their access to care (6). due to their negative consequences, informal payments have become a common policy concern in low-, middle-, and occasionally high-income countries since three decades ago (5). there are various reasons and causes for informal payments, including: a) the culture of gift giving in certain countries; b) the low income of medical staff; c) the lack of resources and supplies in provider organizations where an informal payment might result in better care; d) the bargaining power of the medical staff with the patients; e) inadequate supervision of the health system; and h) a shortage of regulations and law enforcement (7 9). informal payments may have many negative consequences, including decreased access to and utilization of care; increased inequity in care provision and instigating a sense of hopelessness among the poor; decreased motivation for delivering quality services at authorized costs among health care providers; increased corruption in the health sector resulting from secrecy and unhealthy financial relationships; provision of incorrect information about the costs of patients’ illnesses; and an increase in the patients’ share of costs. finally, informal payments may provide false information about real costs, which may lead to incorrect decisions and policies resulting in impaired performances and hinder the required reforms in health systems (1, 10, 11). on the other hand, some authors have suggested that a portion of informal payments can be regarded as the participation fee to ensure that the employees receiving the payments will remain in their workplace and continue to provide care (12). informal payments vary largely in different countries: 55, 81 and 96 percent of users in cambodia, vietnam and pakistan incurred informal payments, respectively. lower levels of such payments have been reported in other countries, for instance in thailand and peru it affected less than three percent of the users. similarly, low or high levels of informal payments have been reported in other regions (2). furthermore, the prevalence of informal payment is higher in inpatient (hospital) services than outpatient (13). iran is a higher middle-income economy with a population of over 80 million. total expenditure on health is estimated to be 6.2% of gross domestic product (gdp) in 2008 (based on world bank; 7.1% in 2014) (14). the government and private section’s proportion of health expenditures are 55.1% and 44.9%, respectively. ninety-five percent of private section’s health expenditures are out-of-pocket (15), although the majority of the population is covered by health care insurance funds, estimated at 83% of the population in 2010 (16), and over 90% presently. it has been argued that a former policy of “hospital autonomy” across the public sector in iran might have resulted in a transfer of a portion of the health care costs to users. limited evidence from the city of tehran suggests that the rate of informal payments to physicians in public hospitals was close to zero, but these studies did not include the private sector, or public hospitals not affiliated with the ministry of health (moh) entities (e.g. social security organization hospitals (ssoh)) (17). informal payments increase out-of-pocket payments; in addition, they may exacerbate health catastrophic expenditures and poverty among the poor, and have negative effects on equity and health outcomes. considering the scarcity of accurate information about the extent of informal payments and limitations of comprehensive studies in this field in iran, we decided to conduct a study on the issue. we set out to estimate the frequency and extent of informal payments and their determinants so that the information could be used in policymaking geared toward reducing informal payments and out-ofpocket expenditures. in recent years, some studies have been performed on informal payments in iran. a number of these studies have assessed physicians’ attitudes and experiences toward informal payment (18), and some have targeted teaching hospitals affiliated with the ministry of health (17, 19). moreover, some other studies have assessed influential factors, reasons and outcomes of informal payment (20 24). the current study is different from the research mentioned above in that it has assessed the issue in non-teaching hospitals (including private and social security hospitals). additional strength to the present study is the investigation of informal payment through j med ethics hist med 11: 7, july, 2018 jmehm.tums.ac.ir abdolvahed khodamoradi et al. page 3 of 9 patients’ viewpoint, which is eventually assessed for influential factors by an econometric model. in this study, we measured informal payments according to frequency, mean, type, nature, and the patients’ motivation in making these payments to three groups of medical staff (physicians, nurses, and other staff), in three different types of hospital ownerships: moh teaching hospitals (affiliated with universities of medical sciences and health services at the provincial level under the supervision of the ministry of health and medical education); nonmoh public hospitals (affiliated with governmental organizations other than the ministry of health and medical education, such as the social security organization or petroleum industry health organization); and private hospitals. we also identified factors influencing informal payments to physicians. method in this cross-sectional study, we surveyed informal payments across all inpatient admissions to the hospitals located in urmia, the capital of west azerbaijan province in the northwest of iran. the province shares borders with azerbaijan, iraq and turkey. according to the 2012 census, urmia had a population of 1,265,721 (700,000 households), and the population of the whole province was 3,080,576 in the same year. the hospitals in urmia offer specialized secondary and tertiary care services, serving the west azerbaijan province, and occasionally the neighboring countries. the study population included all patients who were discharged in one iranian calendar month (jan 21 to march 19, 2013) from urmia hospitals. hospitals that were eligible for inclusion in the study included: five moh teaching hospitals affiliated with the urmia university of medical sciences, one hospital affiliated with the social security organization (public non-moh), and three private hospitals, with a total number of 1727 beds. the calculations indicated that a sample size of 265 would suffice. in total, 10791 patients were discharged from the hospitals during the study period. as the first step in sample selection, the list of all the patients discharged during the specified period were obtained from the hospitals and collated into one sampling frame, and were subsequently numbered from 1 to 10791. considering the possibility of missing samples and non-responses, 500 discharged patients were selected using a random number table and the simple random sampling approach. in the next step, the list of the 500 patients was ordered so that the first person on the sample list was the first person selected through the random number table; and the last person on the list was the last (500th) patient selected through the random number table. for data collection, we contacted patients starting at the top of this list and continued until the required sample size of 265 was obtained. the target sample size was reached after contacting the 332nd patient on the list, giving us a response rate of about 80%. the data were collected via discharge lists and telephone conversations with the patients or their informed families. the data collection tool contained 40 questions in five sections: the first section contained questions about provider and hospital care characteristics, total out-of-pocket payment to the hospital, and whether any informal payment had occurred. the following three sections focused on the details of informal payments, if any, to physicians, nurses and other hospital staff. the last section consisted of the socio-economic and demographic characteristics of the patients. a preliminary tool was prepared using a review of the literature. next, each member of the research team gave feedback on the tool in terms of its completeness and face validity. the tool was finalized after group discussions among the research team. based on consensus across literature, the current definition of informal payment covers various forms such as cash, kind and gift, each reported separately. however, in iranian culture, informal payments specifically refer to cash, whereas gifts are usually a means of acknowledgement (22). hospital professions were divided into three groups: physicians, nurses and other staff (e.g. office workers, housekeeping crew, watchmen, midwifes and other clinical staff). data were included in a data sheet and were analyzed using univariate (e.g. mean and frequency) and multivariate (i.e. logistic regression) analytical techniques. the latter was conducted to identify influential factors on informal payments to physicians, and the significance level was set at 0.05. the model was specified as: logit y = b0 + b1x1 + b2x2 + ... + bnxn. y was a dummy variable, so that y = 1 if any informal payment had occurred and, y = 0 if no informal payments had been made. we used the hosmer and lemeshow statistics and wald test, which indicated adequacy of goodness of fit for the models. the study was approved by the ethics committee of tehran university of medical sciences, tehran, iran, november 2013. results of the 265 patients in this study, 149, 69, and 47 were hospitalized in teaching, private and social security hospital, respectively. distribution of respondents is presented in table 1 as below. j med ethics hist med 11: 7, july, 2018 jmehm.tums.ac.ir abdolvahed khodamoradi et al. page 4 of 9 table 1descriptive statistics of respondents variable n % gender female male 149 116 56.2 43.8 patient residing in urmia (site of hospitals) other towns or cities a village 132 57 76 49.8 21.5 28.7 household head education illiterate primary school high school college/university graduate 71 114 48 32 26.8 43 18.1 12.1 income i (the lowest) ii iii iv v vi (the highest) not clear 30 62 70 40 23 26 14 11.3 23.4 26.4 15.1 8.7 9.8 5.3 hospital type teaching private social 149 69 47 56.2 26.1 17.7 treatment type surgery medical therapy (excluding surgery) natural childbirth caesarean operation 118 111 14 22 44.5 41.9 5.3 8.3 frequency, size and nature of informal payments of the total 265 respondents in the study sample, 79 (29.8%) of the patients reported informal (cash or non-cash) payments to hospital staff. this figure varied depending on the type of hospital; for example, in private and social security hospitals, informal payments were more than twice the amount reported in teaching hospitals. among these, 30 (11.3%) patients made informal payments to physicians (mean amount: 503,000 tomans, equivalent of $412), 14 (5%) to nurses (mean amount: 20,000 tomans, equivalent of $16), and 45 (16.9%) to other hospital staff (mean amount: 16,000 tomans, equivalent of $13). the amount of cash paid informally to non-physicians was insignificant, and some patients had made informal payments to two or three groups of staff in one hospital admission. informal payments to physicians, nurses and other staff also varied depending on the type of hospital. for example, 34% of the patients in the social security hospitals and 15% of the patients in the private hospitals reported informal payments to physicians, but only 2% of the patients admitted to teaching hospitals reported informal payments to physicians (table 2). table 2frequency, percentage and mean amounts of informal payments by hospital type hospital type no. of patients mean out-of-pocket payments* (ci) $ mean informal payments (ci) $ proportion of patients who made informal payments to physicians nurses other staff all teaching 149 128 (106-181) 7 (1-13) 3 (2%) 9 (6%) 22 (14.7%) 29 (19.4%) private 69 785 (602-1096) 71 (13-129) 11 (16%) 5 (7%) 17 (24.6%) 29 (42%) social ecurity 47 230 (115-363) 153 (52-254) 16 (34%) 0 6 (12.7%) 21 (44.6%) total 265 317 (265-423) 50 (25-74) 30 (11.3%) 14 (5%) 45 (16.9%) 79 (29.8%) * including informal payments exchange rate (april, 2013): 1$ = 1220 tomans the findings indicated that informal payments comprised 15.5% of the total out-of-pocket expenses that patients had to meet, which was $49 (ci: 24 71) out of $317 (ci: 241 393) for each patient. the amount of informal payments in the social security hospital was considerably higher than those made to physicians in the private or teaching hospitals (two and 22 times higher, respectively). in this study, the largest part of informal payments had been made in cash. we classified informal payments in two categories of cash and non-cash payments. the results showed that 67% of the payments were in cash, while 28% were non-cash, and 5% were both cash and non-cash. most non-cash payments (90%) consisted of flowers and gifts, and 10% were in the form of goods. this was true for all types of hospitals, and the total amount of cash payments was higher than non-cash ones. in terms of personnel, payments to physicians (87%) and to other staff (64%) were mainly in cash, while payments to nurses (64%) were mostly non-cash. we also assessed mandatory payments (requested by staff) and voluntary payments (offered by patients) and found that 70% of the payments were voluntary and 30% were mandatory. it should be mentioned that more than 90% of the payments to nurses and other staff were voluntary, but 83% of the payments to physicians were mandatory and had been requested by physicians as extra payment. payments to physicians were all in cash and requested by the physicians. most (80%) of these payments were made before hospital admission, 16.7% were made in the hospital, and an additional 3.3% occurred after discharge. in the case of nurses and other staff, the payments were all made in the hospitals. j med ethics hist med 11: 7, july, 2018 jmehm.tums.ac.ir abdolvahed khodamoradi et al. page 5 of 9 the respondents were asked to choose the “best” response among the choices shown in table 3. in the majority of the cases (73.4%), the patients made the payment at the request of the physician. acknowledging the physician’s efforts or receiving high-quality services (the fear that if they did not pay, they would not receive appropriate services) were mentioned as other reasons for payments. the scenario was different for nurses and other staff, in that the majority of the payments (71.4% and 64.4 respectively) were made to acknowledge the efforts or show gratitude, or as gifts and presents (table 3). table 3reasons for informal payments to physicians and nurses reasons for informal payments physician nurse other staff acknowledgement, gratitude, gifts and presents 4 (13.3%) 10 (71.4%) 29 (64.4%) high-quality service (without provider request) 4 (13.3%) 3 (21.4%) 12 (26.6%) provider request 22 (73.4%) 1 (7.2%) 4 (8.8%) we also identified the type of personnel (for staff other than physicians and nurses) who received informal payments. most of the payments were made to the housekeeping crew (71.1%) followed by watchmen (2.2%). the rest of the payments were made to a group of personnel or a ward (such as labor or pediatric ward). factors influencing informal payments among physicians, general surgeons received the most informal payments at 42%, followed by ophthalmologists, otorhinolaryngologists, and maxillofacial surgeons (24%), internists, neurologists, and hemato-oncologists (10%), orthopedic surgeons (7.1%), urologists (6.2%), and obstetricians and gynecologists (5.5%). cardiologists and pediatricians received no informal payments. however, in general, the logistic regression model showed no significant correlation between the physician’s specialty and probability of receiving informal payments. moreover, the percentage of informal payments to physicians was 20% in surgical patients (29 out of 140 persons) and 0.8% in nonsurgical patients (1 out of 125 persons). the current study model showed that surgery had a significant positive effect on the occurrence of informal payments (p-value = 0.00). informal payments to nurses and other staff were negligible in size and mostly in the form of gifts to show gratitude, but in the case of physicians, they were mandatory and in most cases much higher than their official fees. therefore, we assessed the factors that influence informal payments to physicians. the results are shown in table 4 below. table 4the results of the logistic regression model (logit) prob. z-statistic std. error marginal effect coefficient variable 0.05 0.00 1.94 4.05 0.47 0.35 2.50 4.18 1 0.92 1.43 hospital type teaching private social security 0.55 0.59 1.09 0.52 0.65 supplemental insurance (yes, no) 0.00 0.06 3.56 1.85 0.85 1.00 20.84 6.42 1 3.04 1.86 patient residing in urmia other towns or cities a village 0.54 0.61 0.72 1.56 0.44 male gender 0.00 3.21 1.44 103.11 4.65 surgery (yes, no) 0.28 0.19 0.37 0.13 0.16 1.06 1.30 0.89 1.49 1.40 0.86 1.15 2.50 1.48 1.05 2.52 4.49 0.11 0.11 0.23 1 0.92 1.51 2.23 2.21 1.47 physician specialties general surgeon maxillofacial surgeons hemato-oncologists nephrology or urology orthopedic surgeon obstetrics and gynecologist 0.00 0.00 0.02 2.62 2.58 2.26 1.47 1.52 1.66 47.51 51.06 43.24 1 3.86 3.93 3.77 household head education illiterate primary school high school college/university graduate 0.02 2.25 0.07 1.18 0.16 income 0.00 4.30 2.08 8.98 c goodness of fit of the model: h-l value: 14.30, p-value: 0.07; wald’s chi-squared: 8.06, p-value: < 0.01; mcfadden r-squared: 0.60 j med ethics hist med 11: 7, july, 2018 jmehm.tums.ac.ir abdolvahed khodamoradi et al. page 6 of 9 logistic regression showed that the probability of informal payments to physician was 4.1 times higher in patients hospitalized in the social security hospital compared to teaching hospitals. additionally, informal payments were more likely to have occurred in the private hospitals than the teaching hospitals, but the difference was not statistically significant. we could also find no significant relationship between the occurrence of informal payments and the variables of complementary medical insurance, specialty of the physician, and the patient’s gender. logistic regression also showed that the probability of informal payments was 20 times higher if the patient’s place of residence was different from the city in which the hospital was located. moreover, the occurrence of informal payments to surgeons was on average 103 times more than physicians in nonsurgical roles. in other words, surgery increased the probability of informal payments by over 100 times. another factor that positively affected informal payments was literacy of the household head. the logistic model also demonstrated that a higher income increased the probability of informal payments (table 4). discussion this was one of the few studies that have assessed the potential impact of hospital ownership (e.g. public, private, etc.) on informal payments in hospitals in lowand middle-income countries. our findings indicate that 30% of the hospitalized patients in any type of hospital had made informal payments to various members of staff, and 11% had made informal payments to physicians. patients admitted to teaching hospitals were substantially less likely to make informal payments to physicians as compared with those admitted to social security and private hospitals. the present study findings were similar to the results of studies from greece and prereform turkey, where informal payment rates were 36% and 31%, respectively (5, 25). lewis reported an increase in informal payments from 3 to 96 percent worldwide (2). they also revealed informal payments to be higher in the inpatient sector compared to outpatient. results from stepurko et al. showed that prevalence of informal payment ranges from less than 10% to more than 70% (26). this wide range of payments may be prominently influenced by methods of data collection. gaal et al. have discussed the underlying reasons for informal payments and provided four issues that account for diversity of the reported informal payments: a) sampling selection bias; b) incorrect classification of health care costs; c) inability to identify informal payments; and d) recall period (10). in addition, lewis believes that data sources are varied, studies are undertaken in different area levels (regional, municipal, state or national), conducted on diverse populations (households, health care providers, or health centers), or pursue corruption (2). a published study in iran assessed informal payments in teaching hospitals only in tehran and the authors observed no informal payments to the physicians (17). this was in line with the current study results in which only 2% of the patients admitted to teaching hospitals had made informal payments to physicians. in a study by vafaei najar et al. conducted in two educational hospitals in mashhad, results revealed that the prevalence of informal payment was approximately 6% and mainly for acknowledgement purposes to health care providers (19). also, parsa et al. demonstrated that acceptance of informal payments was higher among physicians working in private sector compared to the public sector (18), which is in a similar vein to current results. it should be mentioned that informal payments to physicians were different in type and magnitude from payments to nurses and other staff. the physicians (specifically those providing surgical care) received payments that had higher amounts, were mandatory, and were more likely to be made in response to the direct requests of the patients, whereas 93% of the payments to nurses and 98% to other staff were voluntary. these findings showed that physicians were more likely to ask for informal payments, even though their formal earnings were higher than other members of the staff. the reason might be physicians’ higher income expectations that are not satisfied via their formal earnings (27), and may be further assessed in future studies. a study in greece showed that of the 36% informal payments to physicians, 19% were mandatory and at the physicians’ request, and 17% were voluntary (25). we also observed that informal payments to physicians were more likely to occur in the social security hospital rather than teaching and private hospitals. this was interesting, since in iran, social security hospitals have official zero co-payment policies, while teaching and private hospitals employ different rates of co-payment (28). as a result of the informal payments, patients were spending higher total out-of-pocket payments in social security hospitals than in the teaching hospitals. such policies only focus on reducing user charges without adequate regulatory mechanisms and might result in lowered benefit to patients (1). we also found few studies that compared informal payments across hospitals with different ownerships. liaropoulos et al. showed that the probability of informal payments to nurses was higher in private hospitals than governmental ones (25). moreover, a study by j med ethics hist med 11: 7, july, 2018 jmehm.tums.ac.ir abdolvahed khodamoradi et al. page 7 of 9 ozgen et al. in turkey showed that the type of ownership of the service provider had a significant correlation with informal payments (5). in the present study, the place of residence was significantly associated with informal payments. people from surrounding cities were more likely to make informal payments compared to those living in the city where the hospital was located. congruent to our findings, studies conducted in albania, turkey, serbia, hungary, greece and russia found a positive association between the place of residence and informal payments (9, 29 33). moreover, informal payments were positively correlated with the educational level of the head of household. illiterate patients made the lowest, and patients with academic education made the highest payments. one reason could be that people with higher education generally have larger incomes. in a similar vein, a number of studies (30 32, 34 36) identified the effect of education on informal payments. furthermore, the probability of making informal payments was higher in households with larger incomes. a number of studies have also showed that household expenditure or income have a significant correlation with informal payments (5, 9, 31-38). informal payment does not exist or is barely seen in successful health systems throughout the world such as great britain, denmark, germany, sweden, netherland, norway, finland, belgium, portugal, switzerland, france, italy, iceland, and so on (39). the present study showed, however, that in iran, it is common practice among hospitalized patients and has now become a challenge for the health system. as a result and considering the high prevalence of informal payments and their severe impacts on equity and justice, policymakers have focused on this phenomenon to reduce and eliminate it. since payments to physicians vary in different types of hospitals and different specialties, health managers should take measures that can address the problem of informal payment appropriately (40, 41). health experts believe that informal payments are harmful to the health sector, the government, and the society, and should therefore be prevented. some studies have proposed strategies to deal with the issue of informal payments. however, few studies have attempted to assess the effects of implementation programs aiming at elimination or reduction of informal payments, and have recommended policies against it instead. examples of successful practical programs include universal health coverage, complementary private insurance, ratification of acts against informal payment, and promotion of public awareness via media (9, 36, 42). conclusion with regard to specificities of the medical profession and the importance of public trust in physicians, it is essential to protect and reclaim the public faith in medical staff. informal payment is among the most critical stimulators of public distrust that tarnishes the physician-patient relationship. in addition, the medical community is responsible for the well-being of the general public (including vulnerable populations) by ensuring that extra expenses are not imposed on people through under-the-table payments. moreover, health system policymakers must outline felicitous strategies to reduce and eliminate informal payments. in this respect, experiences of other countries can be beneficial and should therefore be taken into consideration. recognizing the structure and processing of health care systems of countries where informal payments are uncommon would be helpful for countries struggling with this issue, especially in terms of financial investment to eliminate class distinction. it should also be noted that there is no universal approach to elimination of informal payment, and formulation of a set of policies commensurate with the country’s condition 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policy. 1998; 43(3): 203-18. 41. vian t, burak lj. beliefs about informal payments in albania. health policy plan. 2006; 21(5): 392-401. 42. balabanova d, mckee m. understanding informal payments for health care: the example of bulgaria. health policy. 2002; 62(3): 243-73. jmehm-7-6 journal of medical ethics and history of medicine health care practices in ancient greece: the hippocratic ideal christos f. kleisiaris1, chrisanthos sfakianakis2, ioanna v. papathanasiou3 1clinical professor of nursing, nursing department, technological educational institute of crete, greece; 2nursing department, technological educational institute of crete, greece; 3clinical professor of nursing, nursing department, technological educational institute of thessaly, greece. corresponding author: ioanna v. papathanasiou address: nursing department, technological educational institute of thessaly, greece. email: iopapathanasiou@yahoo.gr tel: +302410684446 fax: +302410613986 received: 07 aug 2013 accepted: 18 feb 2014 published: 15 mar 2014 j med ethics hist med, 2014, 7:6 © 2014 christos f. kleisiaris et al.; licensee tehran univ. med. sci. abstract asclepius and hippocrates focused medical practice on the natural approach and treatment of diseases, highlighting the importance of understanding the patient’s health, independence of mind, and the need for harmony between the individual, social and natural environment, as reflected in the hippocratic oath. the aim of this study was to present the philosophy of care provision in ancient greece and to highlight the influence of the hippocratic ideal in modern health care practices. a literature review was carried out using browser methods in international databases. according to the literature, “healthy mind in a healthy body” was the main component of the hippocratic philosophy. three main categories were observed in the hippocratic provision of care: health promotion, interventions on trauma care, and mental care and art therapy interventions. health promotion included physical activity as an essential part of physical and mental health, and emphasized the importance of nutrition to improve performance in the olympic games. interventions on trauma care included surgical practices developed by hippocrates, mainly due to the frequent wars in ancient greece. mental care and art therapy interventions were in accordance with the first classification of mental disorders, which was proposed by hippocrates. in this category music and drama were used as management tools in the treatment of illness and in the improvement of human behavior. the role of asclepieion of kos was highlighted which clearly indicates a holistic health care model in care provision. finally, all practices regarded detailed recordings and evaluation of information within the guidelines. the hippocratic philosophy on health care provision focused on the holistic health care model, applying standards and ethical rules that are still valid today. keywords: hippocratic medicine, ancient greek medicine, health care provision, health care interventions mailto:iopapathanasiou@yahoo.gr j med ethics hist med 7:6 march, 2014 jmehm.tums.ac.ir christos f. kleisiaris et al. page 2 of 5 (page number not for citation purposes) introduction it is widely accepted that the foundations of science and the study of physiology, anatomy and psychology in ancient greece were developed in order to find the sources of diseases and to promote health status (1). moreover, there were the moral obligations of individuals who were working in health and other fields of science (2). with the increasing developments in medical science, different perceptions were created as to the exercise of medical practice as a consequence of the formation of different medical schools. among the most famous is that of knidos physicians, where philosophy focused entirely on the disease that cumbered the patient (3). however, the most dominant philosophy thus far has been that of the methodists (medical thinking), which was founded by asclepius, and which focused on maintaining health and the importance of understanding the whole consideration of patients’ health and health status (4). following the asclepius paradigm, hippocrates focused on the "natural" treatment to approach the disease (5). this approach is widely accepted even today, and thus hippocrates is considered to be the founder of ancient greek medicine. according to kristen et al., the focal point of hippocratic medicine is the belief that medicine should be practiced as a scientific discipline based on the natural sciences, diagnosing and preventing diseases as well as treating them (6). also, hippocrates believed that the physician should study anatomy, in particular that of the spine and its relationship to the nervous system, which controls all functions of the body. in addition, he was the first who believed that this observation helps recognize the symptoms of each disease (7). moreover, the hippocratic tradition emphasized environmental causes and natural treatments of diseases, the causes and therapeutic importance of psychological factors, nutrition and lifestyle, independence of mind, body and spirit, and the need for harmony between the individual and the social and natural environment (8). furthermore, the "hippocratic" physician above all made sure the patient was healthy as the practice of medicine so required (9). surprisingly, the hippocratic ideal is reflected in the hippocratic oath (the oath required for obtaining a medical license in greece), which focuses on the integrity of the professional, benevolence and human dignity in the practice of medicine (7, 10). the aim of this paper is to present the philosophy of health and the provision of care at a physical and mental level in ancient greece and to highlight the influence of the hippocratic ideal in relation to modern health care practices. method literature review was held using the browsing method in international databases (medline, scopus and proquest) during the period june 2011 to may 2012. one hundred and eighty five articles on the topic were browsed. in this literature review only seventeen reviews, eight original researches and nine general articles, met the inclusion criterion of medical interest, whereas a total of 151 references were excluded due to philosophical or archaeological reasons. results physical exercise: the key to maintain health the ancient greeks believed that mental and physical health were interrelated as they had found that the body and mind should be in harmony. aristotle believed that sports and gymnastics were essential to the development of the human body to optimize functional capacity and harmony between mind and body, hence the famous phrase "healthy mind in a healthy body" (11). this ascertainment has been confirmed by several recent studies reporting that students with mile run/walk times beyond california fitness gram standards, or those whose body mass index (bmi) were higher than the sexand age-specific standards suggested by centers for disease control (cdc), performed less satisfactorily in academic tests than students with healthier bmi or better fitness level, even after taking parent education and other covariates into consideration (12). another finding indicates that single, vigorous sessions of moderately intense aerobic exercise such as walking may boost cognitive attention control in preadolescent children. moreover, moderate intensity exercise may serve to improve attention and scholastic performance. this data suggests that single sessions of exercise affect certain underlying processes that are beneficial to cognitive health and can be essential for satisfactory performance during a person’s life (13). additionally, girls taking part in longer sessions of physical education (70 -300 minutes per week) scored slightly but significantly higher in mathematics and reading (referent: 0-35 minutes per week). however, no such differences were observed among boys, whose academic achievement did not seem to be positively or negatively affected by longer sessions of physical education (14). health promotion physical activity was a necessary part of the training done in schools primarily to promote physical and mental health (15). health promotion appeared during the olympic games since the care of athletes and prevention of injuries were specialist services provided by instructors called "paidoj med ethics hist med 7:6 march, 2014 jmehm.tums.ac.ir christos f. kleisiaris et al. page 3 of 5 (page number not for citation purposes) trivai" (16). according to hippocrates’s study "on food", for the exercises that were done by athletes, olive oil was used to increase body temperature, warm up and for muscles to be flexible so as to avoid sport injuries (17). also, figs and other fruits with high glucose concentration that provide energy were offered to athletes to improve performance (18). interventions on trauma care wars were a common phenomenon in ancient greece. there are records that indicate treatment practices on wounds during the trojan war and even treatment of infected wounds. for such treatments medicinal preparations were taken from nature, such as seawater, honey, vinegar, rainwater and medicinal plants in the form of powder (18). in homer’s “iliada” injuries and amputations that reflect the actual care of wounds are described in wars in ancient greece, and hippocrates noticed the separation of limb gangrene and made incisions between dead and alive tissue to treat the condition (19). hippocrates’s views were highly innovative for their time as he suggested chest tube output for possible liquid in external fixation and traction when aligning broken bones. he believed that in order to properly and quickly heal the wounds they must be kept dry, after being taken care of using pure water or wine (20). in addition, the formation of pus was considered a positive factor for the reduction of wound complications because of the frequent occurrence of infections. as a consequence, the combined findings of hippocrates and galen had an influence on surgical care practices of injuries and wounds until the middle ages (21). mental care interventions and art therapy the first classification of mental disorders proposed by hippocrates was: mania, melancholy, phrenitis, insanity, disobedience, paranoia, panic, epilepsy and hysteria. some of these terms are still used today (22). psychological and mental illnesses were viewed as the effect of nature on man and were treated like other diseases. hippocrates argued that the brain is the organ responsible for mental illnesses and that intelligence and sensitivity reach the brain through the mouth by breathing. hippocrates believed that mental illnesses can be treated more effectively if they are handled in a similar manner to physical medical conditions (23). according to hippocrates, the diagnosis and treatment of mental and physical diseases is based on observation, consideration of the causes, balance of theory and on the four liquids, blood, phlegm, yellow bile and black bile (22). interestingly, plato’s theory mentions that the healing of body and soul may be either true or false, and medicine and gymnastics are classified as true treatments while in true healing of the soul we have the legislative and the judiciary. the role of music and theater in the treatment of physical and mental illnesses and the improvement of human behavior was essential. it was believed that healing the soul through music also healed the body, and there were specific musical applications for certain diseases. for instance, the alternating sound of the flute and harp served as a treatment for gout. asclepius was the first to apply music as therapy to conquer "passion" (24). aristotle claims that in some, the effect of religious melodies that thrill the soul resembles those who have undergone medical treatment and mental catharsis (25). the ancient tragedies acted as psychotherapy for patients (26). the theater of epidaurus at the ancient temple of epidaurus was the place where "catharsis" or the release of emotions through performance took place. moreover, "quiet rooms" were designed in which patients would go to sleep so that they could dream of being mentally healthy, and it was believed that this would help them to improve their mental health (27). the concept of “physis” was first proposed by hippocrates, who changed hieratic or theocratic medicine into a rational discipline. the basic structure of the asclepieion in kos points to the fact that hippocrates believed in a holistic health care model, and in his school science met with drug therapy, diets, and physical and mental exercise, as well as divine solicitation (28). furthermore, the asclepieion of kos offered all patients general treatment that included physical exercise, massage and walks considered necessary to restore health, well-being of the soul and the inner peace of man, and using dreams both for diagnostic and for therapeutic reasons (5, 29). to achieve the desired therapeutic result, the therapist should have prior understanding of the concept of soul and its distinction from the body according to the platonic trisection of the soul (30). the hippocrates evidence-based knowledge another great contribution of hippocrates to medicine is the professional ethics and standards that are respected and observed even today (28). according to miles, hippocratic medicine is founded on the available evidence based knowledge, as hippocratic physicians were required to give complete and detailed medical histories, and this reminds us of the current research protocol in existence today (31). specifically, in their diagnoses of syndromes or diseases, greek physicians were instructed to note the geographical location, climate, age, gender, habits and diet. also rational mood swings, sleep duration, dreams, appetite, thirst, nausea, location and severity of pain, chills, coughing, sneezing, belching, flatulence, convulsions, nosebleeds, even menstrual changes were recorded. the physical examination required great attention to be given to fever, respiration, paralysis and color of the limbs, pain on palpation, stool, urine, sputum and vomit. the overall assessment of these recordings interpreted the final diagnosis and determined the type of treatment of the disease. j med ethics hist med 7:6 march, 2014 jmehm.tums.ac.ir christos f. kleisiaris et al. page 4 of 5 (page number not for citation purposes) moreover, schiefsky mentions that the key area of hippocratic medicine was the precision or the details of prognosis and the reliability of prognostic signs (32). according to a recent greek review, the hippocratic physician had to examine a patient, observe symptoms carefully, make a diagnosis and then treat the patient (33). therefore, hippocrates established the basics of clinical medicine as it is practiced today. he introduced numerous medical terms universally used by physicians, including symptom, diagnosis, therapy, trauma and sepsis. in addition, he described a great number of diseases without superstition. their names are still used in modern medicine, for instance diabetes, gastritis, enteritis, arthritis, cancer, eclampsia, coma, paralysis, mania, panic, hysteria, epilepsy and many others. accordingly, hippocrates greatly contributed to modern medicine by declaring that medicine should depend on detailed observation, reason and experience in order to establish diagnosis, prognosis and treatment. obviously, after hippocrates there was no longer a mixture of superstition, magic, religious views and empirical treatments examined by priest-physicians, and medicine became a real science through accumulating experience (34). conclusion given that the ancient greeks had understood long ago that "healthy mind in a healthy body" was the key for the physical and mental 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____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ original article copyright © 2021 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. journal of m edical ethics and h istory of m edicine challenges of hospital ethics committees: a phenomenological study *corresponding author mir sajjad seyyed mousavi address: paramedical school, university of tabriz, university street, tabriz, iran. tel:( +98) 41 31 77 59 90 email: mousavi@tbzmed.ac.ir received: 1 aug 2021 accepted: 15 nov 2021 published: 11 dec 2021 citation to this article: raoofi s, arefi s, khodayari zarnaq r, azimi nayebi b, seyyed mousavi ms. challenges of hospital ethics committees: a phenomenological study. j med ethics hist med. 2021; 14: 26. samira raoofi1, seddighe arefi2, rahim khodayari zarnaq3, bashir azimi nayebi4, mir sajjad seyyed mousavi5* 1.phd student in health care management, department of health care management, school of health management and information sciences, iran university of medical sciences, tehran, iran. 2.phd student in health education and health promotion, department of health education and health promotion, faculty of medical sciences, tarbiat modares university, tehran, iran. 3.associate professor, department of health policy and management, school of management and medical informatics, tabriz university of medical sciences, tabriz, iran; tabriz health service management research center, tabriz university of medical sciences, tabriz, iran. 4.phd student in health policy, student research committee, school of management and medical informatics, tabriz university of medical sciences, tabriz, iran. 5.assistant professor, department of basic sciences, faculty of paramedicine, tabriz university of medical sciences tabriz, iran. abstract medical ethics committees play an important role in examining and resolving ethical problems in hospitals by developing ethical guidelines and making ethical decisions. this study aimed at investigating the challenges that these committees typically face. this qualitative phenomenological study was conducted in 2020. data was collected through semi-structured interviews with purposive sampling and participation of 19 ethics committees’ members in tehran hospitals. then, data were analyzed by the content analysis method using maxqda-10 software. challenges of hospital ethics committees were classified into three main themes including external factors, intraorganizational factors, and ethics committee structure, in addition to six sub-themes including inadequate supervision, lack of instructions, organizational culture, human resources, nature of the committee, and ineffectiveness of committees’ decisions. since many challenges are faced by ethics committees, plans should be developed and implemented to fulfill the following purposes: (i) strengthen the position of these committees in hospitals, (ii) continuous supervision over the formation and holding of the committees, (iii) their operation process, (iv) their decision-making process, and (v) process of sharing committees’ decisions with all hospital stakeholders and staff. keywords: ethics committees; medical ethics; professional ethics; ethical issues; qualitative research. challenges of hospital ethics committees: a phenomenological study 2 j med ethics hist med. 2021(december); 14:26. journal of m edical ethics and h istory of m edicine introduction hospital committees peruse several purposes: (i) improving the performance and solving the problems of hospitals, (ii) increasing the awareness and participation in decision-making, and (iii) easy communication with multiple units, and (iv) creating development opportunities for staff at all levels and gaining experience in supervisory skills. the committees are also involved in the process of improving hospital services as well as regular and continuous evaluation of hospital activities. according to the ministry of health and medical education, hospital committees are necessary for achieving the optimal quality in healthcare service provision. the medical ethics committee, as one of the top ten priorities of medical ethics, is among the essential hospital committees to improve medical service quality (2, 3) and is the primary mechanism for reviewing ethical problems faced in the hospital. ethical guidelines (4, 5) and these committees also play an important role in regulating patientphysician relationships, maintaining their mutual rights, promoting health, and creating mutual trust between healthcare service recipients and providers. these committees provide organizational guidance to help healthcare providers against legal issues, reduce moral tensions, maintain ethical performance, and achieve patient safety (6). the latest guidelines for the ethics committee and other hospital committees are related to the fourth generation of accreditation criteria, notified to hospitals in 2019, according to which hospitals should draft internal regulations for all their committees at the beginning of the year; in addition, according to the schedule of the committees, the documents of the committees should be regularly sent to the vice-chancellor of the relevant university for supervision (7). the medical ethics committee has been referred by various titles such as "clinical ethics committee", "patient care advisory committee", "institute ethics committee", and "health care ethics committee", and it has been active in hospitals since the early 1980s (4, 8). in iran, according to the standard instructions for evaluation of public hospitals in the country from 1997, all hospitals are required to implement an ethics committee in the hospital (9). the structure and members of this committee are almost similar in different countries and include both medical and non-medical members as well as social workers, spiritual care providers, and legal advisors, whose membership is voluntary and, in some cases, appointed. the participation of various groups in the committee is required to examine all ethical aspects of the emerging problems and provide improved care to patients and their families. this committee is usually formed on a monthly basis in all hospitals, interacts closely with other hospital committees, as well as implements the standards of patient rights, controls compliance regulations, and provides facilities for religious rulings (10-12). various studies defined the functions of the ethics committee as follows: (i) developing guidelines, (ii) training healthcare providers raoofi s., et al. 3 j med ethics hist med. 2021(december); 14: 26. journal of m edical ethics and h istory of m edicine and patients, (iii) counseling and commenting on controversial medical issues, (iv) policy development, and (v) developing frameworks to assist in decision-making, (vi) solving hospital and patient problems, (vii) resolving ethical problems in the hospital, (viii) cooperating in the investigation of medical malpractice cases, (ix) following patient rights and fulfilling them, and (x) leading studies and research (13-17). lack of knowledge about the ethics committee, duties and role of the committee in the hospital, their activity, superficial and unplanned formation of hospital committees to acquire accreditation points, reasons for the committee’s inefficiency in changing physician-patient relationship, differences in the committee's activities in various countries, discussion of different cases, as well as not reporting committee's approvals are among ethics committees’ challenges (9, 18-21). these committees, as the hospital’s think tank, include advisors and decisionmakers of hospitals’ heads and managers. moreover, according to the ministry of health, to achieve the desired quality in providing hospital services, hospital committees are necessary and should participate in preparing the hospital’s strategic and operational plans. additionally, each plan must be evaluated and monitored to achieve the predetermined goals and to determine the executors. hence, this study aimed at investigating ethics committees’ challenges to improve performance or decision-making in the face of ethical issues in hospitals. methods in this study, a qualitative approach with content analysis method was used and data collection was through in-depth face-to-face interviews with participants chosen through purposive sampling. the participants were key informants of the medical ethics field at private and public hospitals in tehran as well as managers, nursing management, nurses, educational supervisors, accreditation experts, and patient safety experts. an official letter from the vice chancellor for research at tabriz university of medical sciences was previously sent to the key informants’ respective organizations for interviews. participants’ verbal consent was initially obtained, and interviews were conducted in a relaxing atmosphere. the purpose of the interview was fully explained to the interviewees, and, in each interview session, two interviewers asked questions, took notes, and recorded audios. each in-depth interview lasted for 50 to 90 minutes, and a semi-structured questionnaire was prepared to guide the interviews. the initial questions were developed based on the available literature and finalized through three pilot interviews. the questions were targeted at the "explaining the hospital ethics committee’ challenges" subject. the interview questions were open-ended and mainly focused on weaknesses and challenges of ethical committee in hospitals. the interview questions are listed in table 1. challenges of hospital ethics committees: a phenomenological study 4 j med ethics hist med. 2021(december); 14:26. journal of m edical ethics and h istory of m edicine table 1: interview guide data processing and analysis the interviews were transcribed verbatim, and initial content analysis was performed by inspecting transcripts and notes. after multiple reviews, three main themes were identified and entered into the maxqda10 software. then, subthemes were identified and reviewed by two experts in the field and then placed under subsets of the main themes in the maxqda-10 software. in case of no agreement between the two experts in the field for placing a sub-theme in a subset of the main themes, a third expert was consulted. to ensure the identification of all the sub-themes, the researchers reviewed the software implemented version. axial coding permitted the refined subthemes to be assembled to identify themes and relationships. during this process, the identification of the themes and sub-themes were validated by comparing the information provided by different respondents, obtained from the interviews, as well as observations and analysis of secondary documents (2). finally, using the themes and subthemes and the researchers’ interpretations of the interviews, a framework of relations was constructed, representing the hospital ethics committee’s challenges. to increase the consistency of the data and prevent prejudice, the researchers disregarded their presumptions about the subject during conducting interviews and data analyses (22). for the validity of the interview content and transparency of ambiguities, every interview was transcribed verbatim in the shortest possible time after the interview and then was sent to the interviewees for approval (23). result data saturation was reached after 18 interviews (table 2) with ethics committee members, including the hospital's internal manager, nursing management staff, committee coordination experts, patient safety experts, a secretary of the medical ethics committee, and accreditation experts. participants had doctoral, master’s, or interview guide 1. what do you know about the ethics committee in hospitals? 2. what are the structure and description of the duties of the ethics committee, its members, and its work process? 3. what are the challenges, barriers, facilitators, strengths, and weaknesses of the ethics committee in your hospital? 4. who can benefit from the ethics committee’s help? what are the ethics committee’s obstacles or facilitators? 5. what factors lead to challenges in the ethics committee’s activities? 6. are there any solutions to improve the hospital ethics committee’s performance? 7. can the ethics committee have an impact on the implementation and observance of ethics in the hospital? 8. if you have comments or suggestions regarding the hospital ethics committee, please mention them? raoofi s., et al. 5 j med ethics hist med. 2021(december); 14: 26. journal of m edical ethics and h istory of m edicine bachelor's degrees and were working in private hospitals. the ethics committees’ challenges in hospitals were identified and classified into three main themes and six sub-themes. the main themes were categorized into external factors, internal factors, and factors related to the structure of the ethics committee (table 3). table 2: characteristics of the participants characteristics of the participants (n = 18) qualitative variables frequency percentage gender male 2 11.11 female 16 88.89 age <30 2 11.11 30-50 15 83.33 <50 1 5.56 marital status married 15 83.33 single 3 16.67 educational level bachelor’s degree 1 5.56 master’s degree 10 55.56 doctoral degree 7 38.89 work experience 1-10 12 66.67 11-20 5 27.78 20-30 1 5.56 work place public hospital 3 16.66 private hospital 12 66.6 vice chancellor of treatment 3 16.6 job position management 2 11.1 head nurse and supervisor 4 22,2 nurse 4 22.2 responsible for hospital committees (hospital and university) 3 16.6 accreditation expert 5 27.7 challenges of hospital ethics committees: a phenomenological study 6 j med ethics hist med. 2021(december); 14:26. journal of m edical ethics and h istory of m edicine table 3: main themes, subthemes, and final codes external factors: lack of integrated instructions lack of transparency of the raised issues was a major challenge of the ethics or other hospital committees, which confused committee members and such ambiguity did not require them to discuss key significant subjects. all topics should be considered in the committee’s regulations, including committee members’ specifications, their assigned duties, meeting time, and schedule. these regulations should be compiled at the beginning of the year for all committees and communicated to the committee members. "the agenda of the ethics committee was wrong, and some people even think that it was accompanied by examining religious issues. but, according to the accreditation standards, the ethics committee has been used to fulfill patients’ rights, and its form has not been changed. national accreditation standards dealt with it broadly main themes, subthemes, and final codes maine themes subthemes final codes external factors poor and irregular monitoring lack of monitoring the effectiveness of committees’ approvals lack of integrated instructions failure to communicate the regulations of hospital committees by the ministry of health to hospitals internal factors organizational culture low and insufficient commitment of senior managers in the implementation of committees’ approvals lack of appropriate atmosphere in the organization to implement the standards human resources low awareness of the committee members about the description of the duties and purposes of the committee lack of awareness of the hospital staff about professional ethics standards lack of appropriate incentive and punitive system for the staff in enforcing committee approvals structure of the ethics committee the nature of the committee overlapping agenda of the medical ethics committee with other hospital committees uncertainty of the ethics committee’s scope of authority and executive power ineffective meetings of the ethics committee lack of transparency of the ethics committee’s mission and goals lower priority of the ethics committee’s formation process than other hospital tasks ineffectiveness of the committees’ approvals low impact of the ethics committees on the implementation of professional ethics lack of a clear and appropriate mechanism for the appropriate selection of committee members absence or low attendance of physicians and other committee members in committee meetings possibility of the ethics committee’s unfair judgments failure to fully implement committee’s approvals raoofi s., et al. 7 j med ethics hist med. 2021(december); 14: 26. journal of m edical ethics and h istory of m edicine and generally, and it did not comment on specific and well-defined tasks". (p.6) poor and irregular monitoring all committee meetings’ approvals should be sent to the vice-chancellor for treatment of the covered universities in due time, but no feedback was provided by the vicechancellor for treatment regarding the follow-ups of the committee approvals, the effectiveness of their implementation, or the corrective measures to be taken. the vicechancellor for treatment did not supervise the holding of the committees and the implementation of their approvals. "records are sent to the vice chancellor for treatment and the university at the end of the month. when i sporadically did not send the committees’ records, surprisingly no one cared or complained. no one also paid attention to whether the enactment had been implemented or not". (p.5) intra-organizational factors: human resources sometimes, the implementation of committee's approvals required several financial and human resources, which often led to delays in the implementation or nonimplementation of the approvals. organizational culture the organizational atmosphere and commitment of senior managers were important to make necessary follow-ups and to implement the committee's approvals. sometimes, the erring staff is a physician and should only be warned by the head of the organization or technical assistant, which was rarely done, or if it was done, the physician would not admit the mistake. "even in cases where the patient complains to the doctor, the relevant managers do not have necessary cooperation because they cannot say anything to the doctor. only complaint and incident records are documents, and such complaints can be repeated by another doctor “. (p.8) "a major challenge in hospitals, especially in private hospitals, is that, often, the judges themselves are to blame. self-judgment is difficult for them, which rarely happens. they do not judge honestly and fairly”. (p.10) moreover, committee members were often unaware of their job descriptions, which led to various issues and even their absence from the committee. the committee's primary mission was to deal with complaints, errors, and punishment, and the positive aspects and characteristics of staff work were not highlighted, leading to a negative view of the committee. "typically, committee’s physicians do not attend the meetings. committee members do not have a full understanding of the raised issues”. (p.2) structure of the ethics committee: the nature of the committee hospital committees, consisting of members appointed according to accreditation criteria in hospitals, should be formed according to a specific schedule. however, committees were often held superficially, ineffective in implementing approvals, as challenges of hospital ethics committees: a phenomenological study 8 j med ethics hist med. 2021(december); 14:26. journal of m edical ethics and h istory of m edicine well as inefficient in holding meetings and choosing committee members. the ethics committee's mission was often unclear to committee members and overlapped with other hospital committees, which led to noncompliance with standards in the hospital. “lack of regular formation of hospital committees according to a schedule can be a major problem, causing the committee' performance not to be assessed and their effectiveness not to be approved”. (p.1) ineffectiveness of the committee approvals all hospital committees output approvals that should be implemented while considering the organization’s problems and their effective implementation should be monitored by the committee members, especially the committee’s secretary. many members reported that the extent of their authority in the hospital, as a member of the committee, was not well defined for the implementation of the approvals, which discouraged them from monitoring and enforcing the approvals or had a significant impact on fulfilling the patient rights’ standards. moreover, committee approvals were not provided to other departments or wards so that they could be used as lessons learned to avoid repetition. "if the importance of this committee in the hospital is emphasized and its executive power is increased, like other hospital committees, it can supervise the implementation of professional ethics among the hospital staff”. (p.12) "the physicians participating in the committee, or even some other committee members, are not aware of these standards and do not take care of their full implementation, which leads to a lack of future attention and recurrence of many cases and problems”. (p.11) discussion this study aimed at identifying the challenges of the medical ethics committee in hospitals, where the challenges were classified into three main categories: external factors, organizational factors, and factors related to the committee’s structure. external factors related to the headquarters’ units and included supervisory roles and communication of integrated instructions. if such factors are communicated to the hospitals in a unified way, incoherency of the issues in the committee can be resolved. moreover, the hospital committee’s approvals should be monthly sent to the vice chancellor for treatment, but they did not provide feedback on the implementation or non-implementation of approvals. in contrary to the present study, a study titled "medical ethics committee in norway" showed that the ministry of health, in addition to developing and communicating training instructions to the ethics committee, specified the priority of the committee's activities (24). qarebaghian et al, (25) also stated that the regulations of the blood bank committee were communicated to hospitals by the ministry of health to discuss the optimal use of blood products and their application, which led to satisfactory results. in a study by haji beigi et al., blood bank committees in private hospitals were not as much of those of the public hospitals reported to upstream organizations; in public raoofi s., et al. 9 j med ethics hist med. 2021(december); 14: 26. journal of m edical ethics and h istory of m edicine hospitals, regulatory agencies’ role was relatively more significant (26). in that study, when public hospitals were compared against private hospitals, no significant difference was observed in the hospital committees’ performance and working conditions. extra-organizational challenges in the functioning of ethics committees in hospitals were pervasive, regardless of the hospitals’ type and ownership, mainly related to the healthcare system’s macropolicy. intra-organizational factors included organizational culture and the organization’s human resources. the present study’s results showed that the organization’s atmosphere did not support performing activities as a team, and major activities were not implemented considering their real priorities. lack of senior managers’ commitment and lack of enough budgets were the factors related to the nonimplementation of the committee approvals. moreover, the use of committee members with no training on medical ethics standards was a major committees challenge. a study by nasiripoor and kal in line with the present study, showed that although the hospitals’ national accreditation program emphasized that the training of the ethics committee members, the number and variety of members, and the way of selecting members were not appropriately done in hospitals (27), due to a lack of attention to the importance and position of such committees in hospitals. in line with this study, gaudine et al. concluded that the lack of commitment of senior managers in organizations was due to the non-implementation of the ethical committee’s approvals and caused the committees not to be held seriously in hospitals (28). du val et al and larcher et al also concluded that lack of standard regulations, lack of managers’ support, incompetence of committee members, lack of committees’ documentation, and non-implementation of committees’ approvals are among ethics committees’ challenges (29, 30). amini et al. (31) also pointed out that professional principles such as professional ethics of the residents of tabriz university of medical sciences were not at an acceptable level, demanding further inspection, formal training, and informal training. in other words, not enough investment was made to teach professional principles in universities, and at the hospital level, training in this area was not sufficient and effective. often, residents are involved in various ethical issues in the hospital, and in the future, they will become members of these ethics committees as physicians working in the hospital. in line with the present study, mousavi et al. stated that lack of formal and informal support of senior managers, lack of managers’ accountability regarding the raised issues, and sometimes their unjustified involvement in the committee led to ethics committee’ challenges (32). moreover, the uncertain position of the ethics committees in hospitals can contribute to these challenges. the ambiguity of the committee's position in challenges of hospital ethics committees: a phenomenological study 10 j med ethics hist med. 2021(december); 14:26. journal of m edical ethics and h istory of m edicine the hospital, the overlap of the ethics committee's outputs and agenda with those of other hospital committees, and the ineffectiveness of ethics committee in enforcing medical ethics standards have made ethics committees unproductive in hospitals, whereas mcgee et al. emphasized that a major task of the medical ethics committee in the hospital was policymaking. diversity in the selection of committee members is required to teach standards and ethics to the hospital staff as diverse groups of staff work at hospitals (33). according to the present study, the main reason for the non-implementation of approvals was the ethics committee’s low executive power and inefficiency in hospital’s policy-making, whereas younger et al. showed that the ethics committee had a positive impact on facilitating decisionmaking on the raised ethical problems, had been effective in providing legal protection to hospital and clinical staff, and had also shaped the hospital’s ethical policies (34, 35). as an advantage, the present research qualitatively studied the challenges of the professional ethics committees in public and private hospitals in tehran. a limitation of the present study was the lack of previous studies regarding ethics committees in iran, due to which further citation and comparison, as well as the preparation of a study guide were difficult or impossible. moreover, all interviewees were from the employees of the hospitals in tehran, and physicians did not participate in this study due to unwillingness and lack of time. conclusion given the identification of major challenges in the structure, development, and functioning of the hospital ethics committee, healthcare policymakers and senior managers should focus on the following factors: (i) facilitating committees’ activities, (ii) highlighting committees’ importance and purposes, (iii) strengthening committees’ position, (iv) supervising committees’ approvals, (v) obliging the implementation of committees’ approvals, and (vi) constantly monitoring committees’ activities. by promoting core tasks in organizations, organizational culture issues will be resolved. with the commitment of upstream organizations, guidelines and mechanisms can be developed to enhance the nature of ethical committees. moreover, higher authorities should apply more control over the selection of committee members, the process of holding committees, the importance and position of committees in the hospital, and implementation of committees’ approvals, as well as training for senior hospital managers, physicians, and other stakeholders. specific criteria should be developed and used for the selection of committee members, and an appropriate performance guarantee should be defined for the implementation of the approvals. furthermore, the ethics committee’s outputs should be provided to the hospital staff and the target groups as learned lessons to prevent the repetition of similar issues. ethics approval and consent to participate this study is part of a research project raoofi s., et al. 11 j med ethics hist med. 2021(december); 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doi:10.1177/1477750921994278 33. mcgee g, caplan al, spanogle jp, asch da. a national study of ethics committees. am j bioeth. 2001; 1(4): 60-4. 34. youngner sj, jackson dl, coulton c, juknialis bw, smith em. a national survey of hospital ethics committees. crit care med. 1983; 11(11): 902-5. 35. asgaripour f, mirrezaie s, hajibeigi b, chegini a, sadegh h. performance of hospital blood transfusion committees in tehran 2008-2009. the scientific journal of iranian blood transfusion organization. 2012; 9(2): 132-9. abstract introduction references hhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh copyright © 2022 tehran university of medical sciences. this work is licensed under a creative commons attribution-non commercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. original article abstract in intensive care units (icus), patient privacy is of particular importance due to the structure of the ward environment and the critical situation of the patients. the aim of this study was to identify the dimensions of patient privacy in icus. for this purpose, a descriptive-qualitative-exploratory study was performed. the data collection methods included observations and interviews, which were handwritten and analyzed using qualitative content analysis with a conventional approach. a total of 27 participants were selected based on purposeful sampling and with maximum diversity of health-care providers and recipients. the study environment was the icus of two selected hospitals affiliated to the medical sciences universities of isfahan and tehran, iran. the data were analyzed into 4 classes and 12 subclasses. the classes included physical, informational, psychosocial, and spiritualreligious privacy. *corresponding author alireza irajpour address: isfahan university of medical sciences, hezarjerib street, isfahan, iran. postal code: 8174673461 tel: (+98) 31 37 92 76 16 email: irajpour@nm.mui.ac.ir received: 3 apr 2022 accepted: 1 aug 2022 published: 25 oct 2022 citation to this article: tajdari s, irajpour a, shahriari m, saghaei m. identifying the dimensions of patient privacy in intensive care units: a qualitative content analysis study. j med ethics hist med. 2022; 15: 6. findings of the present study identified hidden layers of patient privacy as a multidimensional concept that is influenced by various factors. in order to provide holistic care, preparing the grounds for patient privacy and familiarizing the staff with its various dimensions seem necessary. keywords: patient rights; privacy; intensive care units; iran. identifying the dimensions of patient privacy in intensive care units: a qualitative content analysis study 1. phd candidate of nursing, student research center, school of nursing and midwifery, isfahan university of medical sciences, isfahan, iran. 2. professor, social determinants of health research centre, critical care nursing department, school of nursing and midwifery, nursing and midwifery care research centre, isfahan university of medical sciences, isfahan, iran. 3. professor, adult health nursing department, school of nursing and midwifery, isfahan university of medical sciences, isfahan, iran. 4. professor, anesthesiology and critical care research center, isfahan university of medical sciences, isfahan, iran. setareh tajdari 1, alireza irajpour 2*, mohsen shahriari 3, mahmoud saghaei 4 mailto:irajpour@nm.mui.ac.ir identifying the dimensions of patient privacy in intensive care units: a qualitative content analysis study j. med. ethics. hist. med. 2022 (oct); 15: 6. 2 introduction one of the basic human rights is respect for one’s privacy (1). privacy is a critical issue in the field of ethics and medical sciences (2, 3) and is very important in health-care centers (2, 4). the world health organization (who) has included this concept in the statement of patients’ rights as part of the principles of medical ethics (5). patient privacy has been emphasized as one of the main codes and basic principles of care standards of international organizations and associations (6). in iran, 1 of the 5 most important clauses of the patients' rights charter is dedicated to patient privacy. accordingly, the provision of health services to patients should be based on respect for their privacy and the principle of confidentiality (7). in recent years, numerous studies have been conducted in the field of patient privacy, and often, the level of patients’ satisfaction with the health team’s respect for their privacy has been reported as moderate or poor (8 10). additionally, in studies conducted with the aim of comparing the perceptions of patients and members of different groups of medical sciences about the level of patient privacy, significant differences have often been reported. despite the importance given to patient privacy by health system employees, including nurses, the level of compliance from patients' point of view and their satisfaction is very low (11 13). the results of studies performed in iran on patients' views about privacy during care are indicative of the undesirable privacy level (9, 11, 14). privacy has an indefinite and relative meaning for which several definitions have been proposed. this is due to the fact that the norms and cultural and religious values of each society and the specific positions of individuals within them are effective in defining and determining its scope (15, 16). privacy is of special importance in iran, where the official religion is islam (12), and has been mentioned many times in the holy quran (surah noor, verses 27, 28, 30, and 31). in order to provide appropriate health services and culturally suitable care, a qualitative study of the concept of privacy from the perspective of beneficiaries (providers and recipients of health services) is particularly important (11). in healthcare centers, intensive care units (icus) are considered as dynamic, complex and stressful care environments necessitating numerous ethical decisions. in these wards, professional staff with specific skills and expertise work together as a tajdari s., et al. 3 j. med. ethics. hist. med. 2022 (oct); 15: 6. team to provide the best health services to critically ill patients (17). some factors affecting patient privacy in icus include complexities of patients' clinical status, the ward’s physical structure, attitudes, beliefs and behaviors of health team members (18, 19), and even organizational factors such as the culture governing the relationships, interpersonal and interprofessional relationships, and management (20). in iran, most of the previous studies have addressed the level of patient privacy in general wards, although a few studies have investigated the conceptualization of patient privacy, especially in icus and with the participation of all stakeholders (8 10). qualitative studies seek to examine and deeply understand the studied phenomenon and identify it clearly and comprehensively by using different methods of data collection (21). therefore, the most reliable way to determine how to protect patient privacy is to directly examine events, experiences, values and norms (22). purposeful observation of the clinical field and reviewing the experiences of health-care providers and recipients can be effective in evaluating, maintaining and promoting patient privacy (23). since the concept of privacy is influenced by culture, religion and individual preferences (2), the researcher has directly identified and analyzed the participants’ beliefs and values by being in the field, observing events and interviewing all groups of stakeholders. this qualitative study was conducted to identify the dimensions of patient privacy in icus. methods this manuscript presents some of the findings of a phd dissertation. in the larger original study, the who clinical guidelines (24) were used to design and develop interprofessional patient territoriality clinical guidelines for icus. the present study was performed in 2021 in the form of a descriptivequalitative-exploratory study, using the content analysis method with a conventional approach. the study environment consisted of icus, coronary care units (ccus), and dialysis wards of two selected hospitals affiliated to isfahan university of medical sciences and tehran university of medical sciences, iran. data collection the data collection method included observations and semi-structured, in-depth interviews. during the 5 months of continuous presence in the study environment on different days and shifts and using various observation methods, the researcher recorded all her findings in the form of a field diary and its summary on paper, and later on the same identifying the dimensions of patient privacy in intensive care units: a qualitative content analysis study j. med. ethics. hist. med. 2022 (oct); 15: 6. 4 day prepared them for analysis by filling in the details. in-depth, semi-structured interviews were applied to assess patient privacy requirements. the study population included recipients and providers of health services in icus of two selected hospitals affiliated to the medical sciences universities of isfahan and tehran, iran. in order to select a small sample with maximum diversity of key informants, the purposive sampling method was adopted and sampling continued until data saturation. the health-care recipients included all patients hospitalized in icus of two selected hospitals affiliated to the medical sciences universities of isfahan and tehran, or patients with a history of hospitalization in icus of those hospitals and their families. patients who had been unconscious during hospitalization in intensive care units were often unable to fully recall the experiences and explain the details, and were reluctant to participate in the study and collaborate. in the case of patients admitted to the ward, only conscious patients could participate. the study inclusion criteria for health-care recipients included consciousness, being over 18 years of age, and having been admitted to the icus, and for family members, willingness to participate in the study, possessing time and place orientation, having no history of mental illness, and having the ability to communicate, express and recall information-rich experiences. the health-care providers included all professional and nonprofessional staff with at least 1 year of experience in the icus who were willing and free to participate in the study and had the required communication skills. in case of unwillingness of the participants or treatment/care-related factors prohibiting them from collaboration, they were excluded from the study. thus, 27 participants entered the study: 12 health-care providers from different professions, 3 patients, 2 family members, and 10 individuals who had relevant experience in different roles (for instance, health-care providers with a history of hospitalization in intensive care units). at the beginning of each interview, the researcher introduced herself and explained the purpose of the study. after gaining the trust of the participants, the researcher obtained their written informed consent to conduct and record the interviews and save their demographic characteristics, and by asking preliminary questions, provided the grounds for a better and easier interview. in order to conduct indepth, semi-structured interviews, the researcher began with general and open-ended questions. for example, the patients were asked, "what are your needs and expectations with regard to your privacy in the icu? tell me about your experiences.” tajdari s., et al. 5 j. med. ethics. hist. med. 2022 (oct); 15: 6. then, according to the stated issues and by asking progressive and clarifying questions, the interview was guided to cover the objectives of the study. the continuation of the interview process depended to some extent on the questions that arose spontaneously and as a result of the interaction between the interviewer and the interviewee. the in-depth, semi-structured interviews were conducted individually. initially, a preliminary interview was conducted in order for the researcher to be familiarized with possible and unforeseen issues and to formulate the arrangement of the questions and complete them. the interviews lasted 35 to 90 minutes. due to the occurrence of the covid-19 pandemic, the time, place and type of the interviews (face-to-face or non-face-toface/virtual) were determined by the participants. overall, 14 face-to-face interviews and 13 nonface-to-face interviews were conducted using the whatsapp messenger. data analysis in this study, the qualitative content analysis method with a conventional approach was employed to analyze the data. initially, all recorded observations and interviews were carefully typed and analyzed using the maxqda software (verbi gmbh, berlin, germany). then, the key words or phrases were identified, and code-naming was performed by continuing this process. the codes were then divided into subclasses that were more abstract than the original codes based on the similarities and differences among them. in order to create the classes, the subclasses extracted in the previous stage were combined according to the existing relationships and differences and similarities. rigor to ensure the validity and reliability of the study, lincoln and guba’s criteria were taken into consideration (25). to enhance the validity of the qualitative content analysis, the researcher used the strategies of continuous observation, continuous and long-term involvement in the desired phenomenon in the field and complete immersion in data, triangulation, peer review and transparency, and review by the participants. to ensure the credibility of the study, the researcher listened carefully to all interviews and then typed them verbatim. to verify the dependability of the study, the researcher tried to carefully record and report the research process in the course of the study to allow others to repeat the study if necessary. in order to ensure transferability, the researcher tried to provide the necessary grounds for judgment and evaluation by identifying the dimensions of patient privacy in intensive care units: a qualitative content analysis study j. med. ethics. hist. med. 2022 (oct); 15: 6. 6 others by accurately describing and explaining the study. moreover, participants of maximum diversity in terms of demographic characteristics were invited in a targeted manner. ethical considerations the ethics committee of isfahan university of medical sciences approved the research stages in terms of ethical considerations (ir.mui.research.rec.1398.424). the researcher explained the process of the observations and the research goals to participants. all participants gave verbal and written informed consent before each interview and observation, and were able to withdraw from the study at any time. the confidentiality and anonymity of the participants were preserved at all times, and their data were protected in accordance with the iranian regulations in force. results in this study, 5 months of clinical observation and 27 in-depth and semi-structured interviews were conducted with the associated beneficiaries. the participants included patients, patients' family members, nursing staff, physicians, clinical pharmacists, nutritionists and physiotherapists who met the study inclusion criteria. the majority of the participants (70%) were female, and their ages ranged between 28 and 78 years, with an average of 45.15. the minimum and maximum work experience of health-care providers in icus was 2 to 31 years, respectively, with an average of 11.75 (table 1). following the analysis of the observations and interviews, 374 primary codes, 12 subclasses and 4 classes (including physical privacy, information privacy, psychosocial privacy, and spiritual-religious privacy) were extracted (table 2). tajdari s., et al. 7 j. med. ethics. hist. med. 2022 (oct); 15: 6. table 1participant characteristics participants education work experience in icu, y job status marital status age, y gender number patient's family member master’s degree --bank manager married 52 male p1 patient's family member + staff phd candidate 4 faculty member married 40 female p2 staff phd candidate 3 nurse married 34 female p3 staff phd 2 faculty member + nursing manager at university married 57 female p4 patient's family member + staff bachelor’s degree 20 head nurse married 51 female p5 patient's family member + staff master’s degree 25 nurse single 49 female p6 staff bachelor’s degree 12 nurse married 38 female p7 patient's family member high school diploma --house worker married 53 female p8 staff phd 8 educational supervisor in hospital single 42 female p9 staff bachelor’s degree 20 nurse married 47 female p10 patient + staff master’s degree in critical care nursing 6 nurse single 36 female p11 staff fourth year resident of anesthesia 8 resident married 40 female p12 patient's family member + staff phd in nursing 4.5 faculty member married 47 female p13 patient + staff phd in nursing 10 faculty member married 41 male p14 patient's family member + staff phd candidate 10 nurse single 33 female p15 staff phd in nursing 16 academic member single 59 female p16 staff phd in nursing 31 faculty member married 60 male p17 staff anesthesiologist 32 faculty member married 61 female p18 patient's family member + staff diploma 10 nurse assistance married 40 male p19 patient diploma --businessman single 30 male p20 patient + staff bachelor’s degree 8 nurse single 29 female p21 staff phd in nutritional sciences 2 researcher single 31 female p22 staff bachelor’s degree 4 physiotherapist single 28 male p23 staff master’s degree 11 physiotherapist married 37 female p24 patient's family member + staff phd in disaster and emergency health 12 faculty member single 41 female p25 patient hnd --retired teacher married 78 female p26 patient high school diploma --retired military officer married 65 female p27 identifying the dimensions of patient privacy in intensive care units: a qualitative content analysis study j. med. ethics. hist. med. 2022 (oct); 15: 6. 8 table 2primary codes, subclasses and classes of qualitative content analysis classes subclasses primary codes physical privacy bodily privacy level of patient consciousness and dependence aggressive procedures providing service in the presence of others unnecessary touches gender conformity physical environment of the ward ward noise facilities and equipment common space human resources privatization of units absence of staff recruitment policy employment in other centers informational privacy confidentiality access to patients’ records and information patients’ ignorance unintentional disclosure of information professional and interprofessional rounds interviews in the presence of others patient’s awareness of his/her condition knowing about the progress of the disease knowing the diagnosis psychosocial privacy patient’s psychological status readiness to receive services preferences and priorities interpersonal interactions talking to the unconscious patient shyness distance from family cultural diversity refusing blood transfusion wearing local clothes spiritual-religious privacy religious values and beliefs tying the green cloth to the patient observing hijab facilities for performing religious duties helping patients to pray ritual bathing and ablution private space for religious practices spiritual care identification of spiritual needs class 1: physical privacy the physical privacy class comprised of 3 subclasses of bodily privacy, physical environment of the ward, and human resources. the researcher's observations and the experiences of the participants showed that physical privacy was one of the most important dimensions of patient privacy in icus. it is, however, affected by various human and environmental factors, for instance complex and critical disease status, level of patient tajdari s., et al. 9 j. med. ethics. hist. med. 2022 (oct); 15: 6. consciousness and dependence, gender conformity, number and composition of human resources, environmental conditions and facilities, and application of numerous and often aggressive procedures. with regard to patient privacy preservation, an icu physiotherapist said, "often when we dress a patient or change his/her position, we do not draw the folding screen. we forget, or think the patient is unconscious. sometimes, we do not even draw the folding screen for aggressive procedures, because it interferes with our work. well, conscious patients or the rest of the staff can see. we may be more careful when the patient is conscious, because he/she can tell us what he/she wants." [participant no. 23] on the subject of the need for protecting physical privacy in observation 17, the researcher wrote, "before visiting hours, one of the ward staff pulled a barrier tape in front of the door of each room so that patients’ companions could not enter the rooms. when the ward door opened, the visitors entered the main hallway of the ward and went to the room where their patient was. the folding screens were not drawn and the visitors could see all the patients. if their patient was awake, they would talk to him/her in a loud voice so that he/she could hear." based on the study findings, the gender composition and distribution of the employees in different shifts was such that it was not always possible to observe gender conformity. the participants cited the organization's policies on hiring, staff absenteeism and lack of appropriate replacements, the low number of male nurses, and their employment in other centers as the main reasons for non-compliance with gender conformity. with regard to the ward environment, a 65-year-old female patient said, "all the male and female patients are hospitalized in the same hall or room on beds next to each other or opposite each other, and there are patients who are unconscious, or critically ill. most of the time, the folding screens are not drawn, unless the staff want to clean or bathe the patient. patients who, like me, are conscious can see others and hear what the staff say." [participant no. 27] considering the findings, the privatization of some service units in the hospital was associated with a decrease in the recruitment of sufficient human resources in these units. this policy had an impact on providing high-quality services while respecting gender conformity in icus. in this regard, a participant stated, "due to the selfregulatory administration of the hospital, many identifying the dimensions of patient privacy in intensive care units: a qualitative content analysis study j. med. ethics. hist. med. 2022 (oct); 15: 6. 10 hospital wards have been privatized and few staff have been recruited. for example, we only have 1 male physiotherapist who cares for all our patients. he does not have enough time to provide adequate services to all patients. he gets tired too because many of our patients are unconscious or unable to cooperate." [participant no. 11] class 2: informational privacy the second class was informational privacy with 3 subclasses of confidentiality, unintentional disclosure of information, and patient’s awareness of his/her conditions. based on the study findings, employees' inattention when providing patients’ information to others and speaking loudly on professional/interprofessional rounds or in interaction with patients were the most common reasons for unwanted disclosure of patients’ information. the participants believed that in cases where patients had specific personal/health issues, the importance of paying attention to this dimension of privacy became more apparent. regarding the patient's health and personal information, which is considered a taboo, one of the participants said, "the patient does not want others to know his/her history. he/she does not like to be stigmatized. when we speak loudly on rounds, others hear us. i think guidelines in this regard must be observed, whether or not the patient is conscious." [participant no. 13] based on the results, sometimes the patient's family preferred their patient to be unaware of his/her illness. in this regard, one of the participants said, "my mother was a candidate for cardiac angiography. before the angiography, one of the nurses came to the front door of the ward and called me. he asked very quietly, "did you know that your mother has hepatitis b?" i was shocked. i said no and started to cry. i asked the nurse not to tell my mother anything about it, as i believed her condition would get worse. i decided we could tell her later, when the time was right." [participant no. 8] the findings also indicated that some colleagues expected to be provided with patient records and information. observation 56 was indicative of this: "during the visit, a young woman said to a resident standing at the door, 'i am a pharmacy student at this university and he is my uncle (pointing to her patient). can i take a look at his file?' the resident said, 'no, you are not allowed to.' the young woman continued, ‘so tell me what his problem is. they say he has a malignant tumor, is that true?’ the resident answered, ‘i’m not at liberty to discuss this with you. this information is only given to the patient or one of his first-degree relatives." tajdari s., et al. 11 j. med. ethics. hist. med. 2022 (oct); 15: 6. class 3: psychosocial privacy the third class was psychosocial privacy, consisting of the 3 subclasses of patient’s psychological status, interpersonal interactions, and cultural diversity. based on the study outcomes, failure to identify the psychosocial needs of unconscious patients or those with infectious and emerging diseases such as covid19 affected the provision of holistic care. in this regard, participant 12 stated: "a very important thing in hospitals is whether the patient likes to be visited or not. i really did not want anyone to come into the room. sometimes, patients are not in a good mood and these visits threaten their privacy. i think the conscious patient should at least be asked whether he/she wants to have a visitor and how long he/she would like the visitors to stay.” the findings showed that shyness, separation from family, readiness to receive services, and values, beliefs and preferences also affected social interactions and how psychosocial privacy was preserved. another finding of the study was related to the diversity of ethnic groups with different subcultures in the society and the need for employees to get acquainted with them. in this regard, one of the participants said, "we have many ethnic groups in our country, such as kurds, lurs, turks and arabs, each of whom have specific beliefs they are passionate about. we need to be familiar with these subcultures in order to be able to inspire satisfaction and peace in patients and their families." [participant no. 25] one thing that worried and upset conscious patients was the loud noise and fast movements of the staff during the resuscitation of patients. observation 20 confirmed this issue: "at 10 o'clock in the morning, the patient in bed number 4 had a cardiac arrest. his nurse said loudly, "guys, my patient had an arrest. bring the trolley". she opened the patient’s screen on one side. the screens of most of the patients were open, and the conscious patients who were awake were watching the events. the head nurse, 2 nurses and 2 doctors were talking at the patient's bedside. the equipment was moved quickly in the ward. at the same time, a conscious patient was crying, and another was murmuring prayers.” class 4: spiritual-religious privacy the fourth class was spiritual-religious privacy, which included the 3 subclasses of religious values and beliefs, facilities for performing religious duties, and spiritual care. the study findings emphasized identification of spiritual and religious needs and pointed out the necessity of facilities for ablution and ritual bathing as well as private environments for religious practices such as identifying the dimensions of patient privacy in intensive care units: a qualitative content analysis study j. med. ethics. hist. med. 2022 (oct); 15: 6. 12 praying, the role of spiritual care specialists, the attention of officials, and staff training. in this regard, one participant stated, "if a patient is awake and wants to pray, there’s no prayer hall, and no place to perform ablution. well, we must have tayammum soil or provide the conditions for patients to perform ablution. the patient wants to fulfill his/her religious duties even in the worst circumstances, to communicate with god so that he/she can calm down for a while." [participant no. 16] regarding the provision of spiritual care in icus, another participant said, "in my opinion, there is no spiritual care at the bedside at all. no one expects this from health personnel because we do not have the workforce trained for the purpose. in addition, the workload is so overwhelming that even if someone wants to provide spiritual care, there won’t be enough time. we have limited spiritual care to visitation by a cleric from a cultural institution every few months." [participant no. 18] discussion the present study was carried out with the aim to identify the dimensions of patient privacy in icus. based on the researcher's field observations and participants' experiences, patient privacy has 4 dimensions: physical privacy, informational privacy, psychosocial privacy, and spiritualreligious privacy. in several studies, physical, informational, psychological and social dimensions have been presented for the concept of patient privacy (2, 3). in the present study, hidden layers of the patient privacy concept appeared, which could be related to the type of study, different data collection methods, the diversity of participants, and the nature and extent of the study environment. the findings of the present study revealed that one of the most important dimensions of patient privacy is physical privacy, which is affected by human and environmental factors. an examination of the experiences of hospitalized patients regarding respect for patient privacy in iran showed that there are 2 dimensions of bodily and physical space privacy, and observing the patient's physical privacy creates a sense of calm and control and reduces anxiety in the patient (26). the results of a study in turkey showed that observing physical privacy is actually having respect for the patient's body. even if the patient is not able to express his/her thoughts and feelings, his/her body is valuable and respectable (27). in a study by nayeri and aghajani in the emergency department, more than half of the patients felt that their physical privacy had been violated. in this study, tajdari s., et al. 13 j. med. ethics. hist. med. 2022 (oct); 15: 6. unnecessary touching and exposure of patients’ body parts during the examination were the main causes of violation of physical privacy (11). based on the experiences of male nurses in australia, providing intimate care for female clients was a violation of patients' privacy and a major challenge for nurses (28). the study findings showed that the security and confidentiality of the patient's personal/health information is very important in the health system. in many areas today, technological capabilities have surpassed the legal privacy guidelines. there have also been significant changes in the type and speed of interpersonal communication, such as email, which has replaced traditional methods, but is inherently subject to interception and surveillance by others (29). a systematic review concerning the security and privacy of the electronic health record (ehr) focused on developing policies to ensure the confidentiality of patients’ information and control the access of others. accordingly, only members of the professional team who were in direct contact with the patient were given access to the patient's information (30). based on the results of a study in iran, patients expected information that was directly related to their health status to be used for care-treatment purposes only, and to determine the time and conditions of the provision of information to other individuals and organizations themselves (26). in this study, the third class that emerged from the data was psychosocial privacy. the findings suggested that some factors that promoted patients' feeling of comfort and relaxation included: identification and timely fulfillment of their needs, flexible visiting conditions, and familiarity of employees with the subcultures of the society. based on the results of a study conducted in iran, the patient visitor policy varied according to the environmental conditions of icus, culture and individual needs of patients. one of the predominant strategies for visiting patients in the icu was an observational visit that was performed remotely (through a window) without interacting with the patient. this study stated that individualized visits were the most appropriate strategy to enhance the positive effects of visiting on patients’ physical and mental recovery (31). the results of a qualitative study in canada suggested that patients had little knowledge of their rights, such as hospital privacy rules. patients' perspective on the concept of privacy, demographic characteristics, personality and culture were factors influencing privacy concerns (32). the results of another study conducted to evaluate patients' experience of privacy in the hospital demonstrated identifying the dimensions of patient privacy in intensive care units: a qualitative content analysis study j. med. ethics. hist. med. 2022 (oct); 15: 6. 14 that all patients, especially female patients, valued their privacy greatly and expected staff to be more sensitive in this regard. this did not mean that they demanded single rooms, but rather consideration for their individual, social and cultural characteristics (33). according to the findings of the present study, the fourth dimension of patient privacy in icus was spiritual-religious privacy. the findings showed that several factors were effective on patients’ spiritual-religious privacy in icus. in numerous studies, religion and spirituality have been identified as factors affecting the understanding of patient privacy (26, 34). based on the findings of a qualitative exploratory study in isfahan, iran, spiritual care had different dimensions and its provision required sufficient knowledge and expertise as well as close inter-professional cooperation. the participants in this study were patients, caregivers and health-care professionals, and mentioned empathy with patients, hope and comfort as effective factors in this regard (35). according to a review by timmins et al., regardless of cultural differences, patient privacy in the icu was an important issue for patients, their families and health personnel, and nurses in particular were the guardians of this aspect of humanity. the results of this study showed that the hospital environment was often considered disrespectful, and staying in the icu could be a dehumanizing experience for patients and their families. in this study, dignified death was identified as a policy priority of health-care organizations (36). the results of a qualitative study in canada revealed that patients and health-care providers had various definitions of spiritual care; in this study, empathy and companionship for the patient, active listening, and setting aside time to be with the patient were considered as spiritual care (37). the findings of a study conducted to explain the experiences of icu nurses regarding religious-spiritual care showed that adhering to religious principles and meeting the spiritual needs of hospitalized patients is a necessity. in times of sickness, religious beliefs are more important than ever in a person’s life and help him/her accept the illness. religious practices also give the patient hope for life and peace (38). the current study has several strengths. in order to conduct this qualitative study, observation and interview methods were used. the participants in the interviews were selected from different groups of stakeholders, and the research environment included the intensive care units of two selected hospitals of isfahan and tehran universities of medical sciences. however, the current research had some limitations. given the small number of tajdari s., et al. 15 j. med. ethics. hist. med. 2022 (oct); 15: 6. participants, the findings of this study cannot be generalized to all intensive care settings in iran or to all icu patients/staff. the covid-19 pandemic was an important factor in communication with professionals, patients and their families. additionally, since this was a qualitative study, some participants might have forgotten certain aspects of their experiences or been unwilling to express their true feelings. also, a number of patients did not want to be interviewed due to unpleasant memories of hospitalization in intensive care units. conclusion patient privacy is a very important component of patient rights in icus, and is a dynamic and multidimensional concept. the mentioned concept has physical, informational, psychosocial and spiritual-religious dimensions, all of which must receive sufficient attention to ensure provision of comprehensive and holistic care. based on the results of the present study, patient privacy is influenced by various human, environmental, cultural and religious factors. therefore, it is necessary to provide a suitable context in healthcare centers by emphasizing the observance of the basic rights of patients. the findings of this study provide a clearer and more comprehensive picture of the concept of patient privacy, and can be the basis for preparation and adjustment of programs, protocols and tools for measuring patient privacy, as well as more extensive investigations in this field. this study was the result of analyzing the qualitative content of the researcher's observations as well as experiences of health-care providers and recipients in the icus of two selected hospitals affiliated to isfahan university of medical sciences and tehran university of medical sciences, which also receive patients from other cities, provinces, and remote areas. in order to clarify the details of this concept in the social and cultural context of clinical settings, other studies with different methodologies and participants in iran and other countries are suggested. funding financial support for the research and/or publication of this article was provided by isfahan university of medical sciences, isfahan, iran (grant no: 398537). the authors are disclosing receipt of the above-mentioned financial support. acknowledgements this study was extracted from a nursing phd dissertation. the authors would like to thank isfahan university of medical sciences for supporting this research. identifying the dimensions of patient privacy in intensive care units: a qualitative content analysis study j. med. ethics. hist. med. 2022 (oct); 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emergencies, school of paramedicine, qom university of medical sciences, qom, iran. 2assistant professor, department of anesthesia, school of paramedicine, qom university of medical sciences, qom, iran. 3mentor, department of intensive care, school of nursing and midwifery, zanjan university of medical sciences, zanjan, iran. 4mentor, phd candidate, department of medical emergencies, school of paramedicine, qom university of medical sciences, qom, iran. 5mentor, spiritual health research center, departments of anesthesia, school of paramedicine, qom university of medical sciences, qom, iran. corresponding author: kourosh jodaki address: school of paramedicine, qom university of medical sciences campus, in front of yadegar emam stadium, ghadir blvd., iran. postal box: 3736175513 email: kuroshjodaki@gmail.com tel: :( +98) 9905514601 received: 11oct 2017 accepted: 17 feb 2018 published: 7 mar 2018 j med ethics hist med, 2018, 11:2 © 2018 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract moral distress is among the various types of distress that involves nurses and can lead to multiple complications. it is therefore rather important to identify the factors related to moral distress. the purpose of this study was to examine the relationship between futile care perception and moral distress among intensive care unit (icu) nurses. this cross-sectional study used a descriptive-correlation method and was conducted on 117 icu nurses of qom hospitals in 2016. data were collected using a 17item futile care perception questionnaire, and jameton’s moral distress questionnaire containing 30 questions. data analysis was performed using spss 16, descriptive statistics and univariate regression analysis. the results showed that the mean age of the participants was 34.99, and most (about 66.7%) were women. univariate regression analysis indicated that when icu nurses’ perception of futile care and work experience increased, their moral distress also increased significantly (p = 0.03 and p = 0.02, respectively). it can therefore be concluded that moral distress is associated with futile care and icu work experience. it seems that some interventions are necessary in future to place nurses in clinical situations involving futile care, and thus reduce their level of moral distress. keywords: futile care, moral distress, intensive care unit mailto:kuroshjodaki@gmail.com j med ethics hist med 11: 2, march, 2018 jmehm.tums.ac.ir hamid asayesh et al. page 2 of 6 introduction in nursing practice, burnout may be the result of various forms of distress. moral issues are among the major sources of distress in clinical situations and therefore need to be adequately addressed (1, 2). moral distress is a kind of pain or anger that affects the body, mind and communication, and is created in response to situations where the individual is aware of the existence of a moral problem (1). jameton believes that moral distress is caused by several factors, and can lead to complications such as anger, disappointment, anxiety, sadness, headaches, frustration, depression and moral mistakes (2). studies have shown that nurses may experience moral distress from once or twice a year to as often as once a week (3, 4). the results of various studies have indicated high (5), moderate (6, 7), or low (8) levels of moral distress among nurses. this type of distress can have many physical and psychological effects on nurses and influence their professional roles (9). therefore, it is important to recognize the effective factors through considering the frequency of moral distress and its complications among icu nurses (6). in her research, corley concluded that moral distress occurs in a variety of medical situations, including providing end-of-life care for patients experiencing prolonged deaths and caring for those less likely to survive, as a response to their families’ request (10). on the other hand, the aim of nursing is to care for all patients regardless of their conditions, even when chances of life and recovery are low (11). this view can put nurses at risk because they may consider certain therapeutic measures as futile, and the coercion of nurses to carry out these measures may have complications for them due to moral contradictions (12). the definition of futile care varies according to the patients’ circumstances as well as the individual values of nurses (13). futile care may be defined based on chances of survival or the quality of life afterwards (14). however, different perceptions of futile care as aggressive treatments or end-of-life care interventions pertain to patients whose life expectancies or chances of recovery are very low (15). according to this type of definition, if the therapeutic goals are not achievable or the success rate is too low, certain medical actions are considered ineffective (16), and will only impose additional costs on the medical system (17). one cause of moral distress among the medical team may be the various clinical situations that arise due to the advanced medical techniques; another cause is the increase in the number of elderly people, who are more likely to be exposed to futile care before they pass away (12). in such cases, the pain and discomfort of patients is untenable (1), and will give rise to moral distress in medical staff. several studies have investigated moral distress among iranian nurses and often have reported a considerable level among participants (18, 19). moreover, a quantitative study in icu has shown that futile action is one of the sources of moral distress (20). most studies have found a significant relationship between moral distress and futile care perception (15, 21, 22), but findings pertaining to the relationship between these issues and the demographic variables of nurses are contradictory. due to the nature of moral distress and futile care perception, and in order to better understand them in nursing care, they need to be investigated across the different regions of iran. therefore, the research team decided to examine the relationship between futile care perception and moral distress in icu nurses of the hospitals affiliated to qom university of medical sciences in iran. method this was a descriptive, cross-sectional study and investigated the relationship between futile care perception and moral distress among icu nurses of the hospitals affiliated to qom university of medical sciences (shahid beheshti, nekooie and kamkar hospitals) in 2016. research population consisted of the icu nurses of the above-mentioned hospitals, and samples were selected from among members of the research community who met the entry criteria and consented to participate in the study. the entry criteria included: 1) having a bachelor’s degree or higher in nursing, 2) having at least 6 months of icu experience, and 3) full-time employment. eventually, 117 full-time nurses participated in the study. data collection tool was a three-part questionnaire. the first part was a demographic questionnaire that included personal and professional characteristics such as age, sex, marital status, level of education, icu experience, and experience of caring for patients at the end of life. the second part was a futile care perception questionnaire developed by mohammadi and roshanzadeh (16) and included 17 statements. each statement presented a clinical situation that aimed to measure the nurses’ perceptions of futile care in terms of severity and frequency, designed based on corley’s moral distress scale. the questionnaire used a 6-point likert scale arranged in severity from 0 (not at all) to 5 (very high), and in frequency from 0 (never) to 5 (repeatedly). content validity and reliability of this questionnaire were reported by mohammadi and roshanzadeh to be 80% and 82%, respectively (16), and 82% and 85% respectively in a study by borhani et al. (21). the third part was jameton’s moral distress questionnaire that consists of 30 questions and has been verified by members of the nursing association of iran in 2008 (23). this questionnaire comprises three sections: patient’s ignorance (16 j med ethics hist med 11: 2, march, 2018 jmehm.tums.ac.ir hamid asayesh et al. page 3 of 6 questions), patient’s decision-making (8 questions), and professional performance competency of nurses (6 questions). the reliability of this questionnaire was determined through cronbach's alpha test for patient's ignorance, patient’s decision-making and professional performance competency at 93%, 86% and 80%, respectively. after obtaining the legal and ethical licenses from qom university of medical sciences, iran, the questionnaires were sent to research departments, and the participants were provided with instructions on how to complete the questionnaires. it should be noted that the participants were informed about freedom of research participation. data analysis was performed using spss 16, descriptive statistics and univariate regression tests. results of the 130 critical care nurses who received the questionnaire, 117 nurses completed it (response rate = 90%). the average age of the study participants was 34.99, with a standard deviation of 7.34. the results showed that 66.7% of the study subjects were female and 33.3% were male, and 47% had more than four years of icu experience (table 1). the mean score of moral distress among the participants was found to be 137.53, with a standard deviation of 23.14. in addition, the mean scores of futile care perception in the two dimensions of severity and frequency were 74.45 ± 11.08 and 76.48 ± 13.57, respectively (table 2). univariate regression analysis demonstrated a significant relationship between futile care perception and moral distress in the two dimensions of severity (or = 1.03, ci = 1.01 1.07) and frequency (or = 1.03, ci = 1.00 1.06). furthermore, the statistical analysis of the abovementioned test showed a significant relationship between icu experience (especially among the male participants) and moral distress (or = 3.06, ci = 1.14 8.19 and or = 2.30, ci = 1.04 5.05) (table 3). table 1demographic characteristics of the participants variables mean ± standard deviation age (years) 34.99 ± 7.54 gender (number, %) male female 39 (33.3) 78 (66.7) work experience in icu (years) less than 1 1 2 2 4 more than 4 17 ± 14.5 18 ± 15.4 27 ± 23.1 55 ± 47.0 educational level bachelor’s degree master’s degree 97 ± 82.9 20 ± 17.1 schedule permanent morning permanent night rotating day 12 ± 10.3 9 ± 7.7 96 ± 82.1 table 2mean and standard deviation of moral distress and futile care perception variables mean (sd) categories n (%) low moderate high moral distress 137.53 (23.14) 29 (24.8) 61 (52.1) 27 (23.1) futile care (severity) 74.45 (11.08) 32 (27.4) 60 (51.3) 25 (21.4) futile care (frequency) 76.48 (13.57) 32 (27.4) 58 (49.6) 27 (23.1) table 3univariate logistic regression results with moral distress as outcome variable p-value 95% ci or variables 0.15 0.98 1.06 1.03 age 0.03 1.04 5.05 2.30 1 gender male female 0.02 0.72 0.54 1 1.14 8.19 0.27 2.43 0.22 2.17 3.06 0.82 0.70 1 work experience in icu (years) more than 4 2 4 1 2 less than 1 0.03 0.11 0.93 0.32 1 educational level bachelor’s degree master’s degree 0.95 0.92 0.46 2.27 0.40 1.97 0.75 0.82 1 schedule permanent morning permanent night rotating day 0.03 1.01 1.07 1.03 futile care (severity) 0.03 1.00 1.06 1.03 futile care (frequency) discussion the results of this study showed that 75.2% of the j med ethics hist med 11: 2, march, 2018 jmehm.tums.ac.ir hamid asayesh et al. page 4 of 6 icu nurses who participated in this research had a moderate to high level of moral distress. in a study by borhani et al. performed on iranian icu nurses, moderate levels of moral distress were reported (21). findings of a hospital study conducted in italy by karanikola et al. were in accordance with the results of the present study as they reported a moderate to high level of moral distress among their icu staff (24). in a study conducted by lawrence in the united states during 2011, the level of moral distress among icu nurses was also reported at a moderate to high level (25), which is similar to the results of the present study. icu experience and moral distress the results of this study showed a direct relationship between moral distress and icu experience among nurses, that is, those with more than four years’ experience in icu exhibited a significantly higher rate of moral distress. one explanation for this may be that working in the intensive care unit entails futile care, which is related to certain challenges and other sources of moral distress. these results are in accordance with the findings of a 2009 study by epstein and hamric (26), as well as one by dodek et al. conducted in 2016 in canada (27). these studies discovered a relationship between moral distress and work experience, that is, the longer the nurses worked in the icu, the greater moral distress they would feel. in other words, having recurring experiences that cause moral distress leads to an exacerbation of primitive moral distress and the other anxieties that result from individuals’ previous experiences (26); in both cases, the level of moral distress will increase among nurses. additionally, mobley et al. believed increased moral distress among icu nurses over time to be due to a lack of adaptation mechanisms for moral distress situations as well as frequent exposure to futile care situations (15). in another study, elpern et al. found that moral distress is significantly associated with nursing experience (7). in their study of moral distress among iranian nurses, vaziri et al. noted that increased work experience significantly reduced job satisfaction among nurses, which affected their physical and mental health, self-image and spiritual life (18). they have believed these complications to be the outcome of intensified moral distress resulting from increased work experience. borhani et al. investigated the relationship between futile care and moral distress among iranian nurses and found that moral distress increased with work experience (21). they cited meltzer and huckabay, who repeatedly stated that this condition was a product of continuous exposure to moral distress; furthermore, they mentioned aging and mental and physical changes as some other factors that make nurses more vulnerable and more likely to be affected while providing endof-life care (22). futile care and moral distress the results of this study showed that the perception of futile care in its two dimensions of severity and frequency was at a medium to high level in 72.7% of the icu nurses. in two separate studies, piers et al. (28) and ferrell (29) also found a high level of futile care perception among nurses, which is in accordance with the present study results. these findings are different from those of rostami et al. (30) and mohammadi and roshanzadeh (16). in a 2010 study of the relationship between futile care and moral distress among icu nurses, dunwoody and danielle reported high futile care perception among nurses, which she considered to be a cause for moral distress (31). mobley et al. conducted a study on the relationship between futile care perception and moral distress in 2007 and reported moderate to high perception levels among nurses; they believed that one reason for moral distress among icu nurses was greater work experience and higher perception of futile care (15). in the present study, the univariate regression analysis demonstrated a positive correlation between futile care perception and moral distress, which is comparable with the results of the above-mentioned studies. the univariate logistic regression analysis also showed a higher likelihood and occurrence rate of moral distress among male nurses. however, ebrahimi et al. (32) and other studies (7, 23) discovered no significant relationship between sex and moral distress. conclusion the results of this study showed that icu nurses experience a high level of moral distress, which has a positive correlation with icu work experience as well as futile care perception. moral distress can lead to low collaboration with doctors, exhaustion and burnout. therefore, further studies are needed to identify other related factors. some recommended measures in this respect include training nurses in positive adjustment mechanisms in order to reduce the effects of this phenomenon, and adjusting the icu staff in a way that nurses with less work experience are used in this ward. one limitation of this research was that although approximately 90% of the icu nurses of qom hospitals affiliated to qom university of medical sciences participated in this research, the sample size was 117. acknowledgments this study was a research project approved under license no. 95729 by the research department of qom university of medical sciences. we are very grateful to the research department for their financial support, and to the managers of shahid beheshti, kamkar and nekooie hospitals. we would also like to express our appreciation to all nurses who helped us in this research. conflict of interests the authors declare no conflict of interests. j med ethics hist med 11: 2, march, 2018 jmehm.tums.ac.ir hamid asayesh et al. page 5 of 6 references 1. rushton ch, kaszniak aw, halifax js. a framework for understanding moral distress among palliative care clinicians. journal of palliative medicine. 2013; 16(9):1074-9. 2. ganske km. moral distress in academia. ojin: the online journal of issues in nursing. http://www.nursingworld.org/mainmenucategories/ethicsstandards/resources/courage-anddistress/moral-distress-in-academia.html (accessed on: 2015). 3. gutierrez km. critical care nurses' perceptions of and responses to moral distress. dimensions of critical care nursing. 2005; 24(5):229-41. 4. wiegand dl, funk m. consequences of clinical situations that cause critical care nurses to experience moral distress. nursing ethics. 2012; 19(4):479-87. 5. rabiee s, khatiban m, cheraghi ma. nurses distress in intensive care unit: a survey in teaching hospitals. iranian journal of medical ethics and history of medicine. 2012; 5(2):58-69. 6. attashzadeh sf, ashktorab t, yaghmaei f. the experience of moral distress in icu nurses: a qualitative study. daneshvar medicine journal. 2011; 19(95): 79-92. 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of medicine. 2013; 6(4):80-8. https://doi.org/10.1177/0969733017703694 microsoft word 7 journal of medical ethics and history of medicine effectiveness of the course of medical ethics for undergraduate medical students fariba asghari 1* , aniseh samadi 2 , taraneh dormohammadi 3 1.assistant professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. 2.researcher, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. 3.assistant professor, imam khomeini hospital complex, tehran university of medical sciences, tehran, iran. *corresponding author: fariba asghari address: no.21, 16 azar ave., keshavarz blvd., medical ethics and history of medicine research center, tehran, iran. tel: (+98) 21 66 41 96 61 e-mail: fasghari@tums.ac.ir received: 19 may 2009 accepted: 28 may 2009 published: 31 may 2009 j med ethics hist med. 2009; 2:7. © 2009 fariba asghari, aniseh samadi and taraneh dormohammadi; licensee tehran univ. med. sci. abstract keywords: medical ethics, ethics education, moral judgment test. judgment this study was done in order to evaluate the effectiveness of the revisions made in the course of medical ethics for undergraduate medical students. medical students of tehran university of medical sciences who took the course of medical ethics in a semester before the implementation of the revision and those who took the course after the implementation of the revision at the beginning and at the end of course responded to two questionnaires (one for evaluating knowledge and the other for assessing their moral judgment). response rate was between 70 to 93.1 percent. students’ knowledge was significantly higher in the semester after the course revision (mean ± sd: 6.12 ± 1.3) in comparison with the semester before the reform (mean ± sd: 3.63 ± 1.7) (p=0.001). students' knowledge after taking this course showed an increase of about 60% when compared with their knowledge level before starting the course (p=0.001). there was no significant difference in the level of moral judgment before and after taking the revised course of medical ethics while moral judgment level of students in two semesters [before (21.21± 4.0) and after 15.25 ± 2.87) reform] were significantly different (p=0.02). the revisions made in the course of medical ethics for medical students were effective in improving students' knowledge but could not improve their moral judgment. this could be due to the short length of this course and also the small sample size in this study. we suggest that this study should be repeated with larger sample size and also with other methods of a course evaluation. fariba asghari, aniseh samadi and taraneh dormohammadi j med ethics hist med 2009, 2:7 page 2 of 6 (page number not for citation purposes) introduction physicians encounter many different types of ethical dilemmas in their daily practice. problem based learning is expected to be helpful in providing competency for solving these ethical problems (1) which results in improvement of patient's care and patient’s satisfaction (2). medical ethics is a mandatory course in undergraduate medical education in iran but a few studies have been designed to evaluate its efficacy. strengths and weaknesses of a course of ethics could not be determined just through the assessment of students' knowledge. their attitude and moral judgment competency are much better criteria for assessing an educational methods (3) so a vast variety of assessment tools have been designed for evaluating the efficacy of this course (4, 5). many researches have been done to assess the effectiveness of educational methods on improving students' knowledge and skills. most of them have evaluated students' ethical judgment in response to ethical problems (6-8). some have used multiple choice questions or open questions for assessing participants' ethical knowledge (3, 9, 10). different tests which have been used for evaluating moral judgment (11) are based on the same principles but provide different indices. different researches have been done using tools such as moral judgment test (mjt) (12), moral judgment interview (mji) (13), vignette (14), sociomoral reflection objective measure-short form (srom-sf) (15) and defining issue test (dit) (16, 17) for evaluating medical students' moral judgment. some of them have evaluated students' moral improvement during their academic education (14) and some have compared student's moral competency between two or more universities (15, 18). the course of medical ethics in tehran university of medical sciences (tums) was basically revised in 2006 (19). before the revision, this course was offered in a teacher-centered and information gathering method while in this revision, we changed the course to be student centered and problem-based by adding case discussions in small groups and clinical ethics portfolios. this study was done in order to evaluate the efficacy of the revision in the course of medical ethics by comparing students' knowledge and moral judgment between the semesters before and after the revision and also at the beginning and at the end of the term when the revised course was offered. methods two groups of students entered the study: 1) fifth year medical students who had taken the course of medical ethics in the second semester of 2006. that semester was the last one in which the unrevised course was offered. this group is called "group a" hereafter. 2) fifth year medical students who took the revised course in the second semester of 2007. we call this group "b" henceforth. we used two types of questionnaires. knowledge questionnaire: this questionnaire consisted of seven multiple choice questions and two open questions. questions were developed by one of the authors based on the common contents of the unrevised and revised courses on the issues of informed consent, decision making capacity, confidentiality, ethical theories, medical error, euthanasia, conflict of interest and abortion. two faculty members who revised the course and one who taught this course before the revision evaluated contents and the face validity of the questionnaire. moral judgment test questionnaire: this test is an instrument for moral judgment competency evaluation (12), made by prof. lind. in this questionnaire, two moral dilemma scenarios are presented with 6 reasons for agreement and 6 others for opposition in each scenario. responders should mark their level of agreement with each reason. c-index, which is a multivariate analysis of variance, shows how much of a person's judgment in an ethical problem is based on his moral principles and values (20). this questionnaire has been translated to many languages including persian with an acceptable validity and reliability (21). at the top of both questionnaires, there was a text explaining the aim of this study and the voluntariness of participation and the fact that the result had no effects on students’ evaluation. using systematic random sampling, each student was given one of the questionnaires. students in the group a entered this study only at the end of the semester while group b took part at the beginning and at the end of the course. at the end of the semester in both groups, we distributed questionnaires in the final exam session and they responded them in the same session after the final exam. group b students also were given the questionnaires at the first session of the course. student's responses in groups a and b at the end of the course were compared with each other. we also compared responses of group "b" at the beginning and at the end of their ethics course. results of 160 students in group a, 149 answered the questionnaires (rr=93.1%) of whom 78 (52%) completed the knowledge questionnaire. of 95 students in group b at the beginning of course, 67 individuals participated in our study (rr=70%) out of whom 35 completed (52%) the knowledge fariba asghari, aniseh samadi and taraneh dormohammadi j med ethics hist med 2009, 2:7 page 3 of 6 (page number not for citation purposes) questionnaire. at the end of the course in groups b, 105 of 135 students (rr=76/6%) answered the questionnaires; 40 responses belonged to the knowledge questionnaire (40%). table 1 shows demographic data of the participants. table 1 – demographic characteristics of participants group sex age male female mean ± sd group a – end of term 35 (49.3%) 36 (50. 7%) 23.6±1.1 group b – beginning of term 32(47/8%) 35 (52.2%) 22.9±1.0 group b – end of term 54(45.8%) 64(54.2%) 23.7±1.2 results of knowledge evaluation: comparing before and after the course in group b: mean score of group b students (±sd) at the beginning of the course and at the end of the course was 3.98 (±1.9) and 6.12 (±1.3) out of 9, respectively, that showed a significant increase (p=0.001). students' knowledge regarding informed consent (p=0.008), competency (p=0.013) and confidentiality (p=0.002) was significantly more at the end of the course compared with the beginning of it (table 2). table 2 – proportion of correct responses to the knowledge questions of different ethical issues in paired cases at the beginning and the end of the course in group b students subject beginning of term mean ± sd end of term mean ±sd ethical theories 0.21 ± 0.4 0.43 ± 0.5 informed consent * 0.27 ± 0.3 0.65 ± 0.4 medical error 0.64 ± 0.5 0.79 ± 0.4 competency 0.29 ± 0.5 0.79 ± 0.4 abortion 0.71 ± 0.5 0.57 ± 0.5 confidentiality 0.36 ± 0.4 0.76 ± 0.2 euthanasia 0.71 ± 0.5 0.71 ± 0.5 conflict of interest 0.50 ± 0.5 0.79 ± 0.4 total mark 3.98 ± 1.9 6.12 ± 1.3 *the questionnaire consisted of one question on each ethical issue except for informed consent about which there were two questions. in this table, the mean score of those two questions are given. comparing the end of the course data between group a and b: mean score of group b students at the end of the term (6.12 ± 1.3) was significantly more than the mean score of group a student (3.63 ± 1.7) (p=0.001). students' knowledge about informed consent (p<0.001), decision making capacity (p<0.001), confidentiality (p<0.0001) and conflict of interest (p=0.001) was significantly higher in group b (table 3), while knowledge of the two groups were not significantly different on other issues such as medical error, ethical theories, abortion and euthanasia. table 3 – proportion of correct responses to the knowledge questions of different ethical issues at the end of course in group a& b students subject group a mean ± sd group b mean ±sd ethical theories 0.35 0.5 0.36 0.5 informed consent* 0.29 0.3 0.52 0.4 medical error 0.64 0.5 0.7 0.5 competency 0.28 0.4 0.77 0.4 abortion 0.42 0.5 0.39 0.5 confidentiality 0.32 0.3 0.58 0.3 euthanasia 0.53 0.5 0.63 0.5 conflict of interest 0.51 0.5 0.79 0.4 total mark 3.63 1.7 5.25 1.8 *the questionnaire consisted of one question on each ethical issue except for informed consent about which there were two questions. in this table, the mean score of those two questions are given. the mean score of students had no significant correlation with their age and gender. fariba asghari, aniseh samadi and taraneh dormohammadi j med ethics hist med 2009, 2:7 page 4 of 6 (page number not for citation purposes) moral judgment evaluation result: in this survey, 70 students of group a answered the mjt questionnaire. in group b students, 32 at the beginning of the semester and 63 at the end of semester completed this questionnaire. based on prof. linda's advice, cases with more than two missing data were excluded and for cases with one or two missing values, those missing data were replaced by the student's response to other questions (table 4). c-index in group a and b at the end of the course had a significant difference (p=0.02), however, pair test of c-index between student's responses at the beginning and at the end of the course in group b showed no difference (p=0.76). table 4 – changes in mjt, their demographic descriptions and c‐index t o ta l n u m b e r o f stu d e n ts c -in d e x o f a ll stu d e n ts (s e ) n u m b e r o f d e le te d c a se s (n ) n u m b e r o f c a se s w ith re p la c e d v a lu e s n u m b e r o f c a se s th a t e n te re d th e a n a ly sis m a le p ro p o rtio n m e a n o f a g e (s e ) m e a n o f c -in d e x (s e ) n u m b e r o f p a ire d c a se s m e a n c -in d e x o f c a se s th a t e n te re d p a ire d te st (s e ) group a end of term 70 20.71(1.7) 3 19 51 51.9 23.57(1.1) 21.21(2.0) group b beginning of term 32 20.11(3.1) 4 32 43.8 22.91(0.78) 20.09(3.1) 14 19.32(4.5) group b end of term 63 15.80(1.3) 6 7 46 54.3 23.64(0.9) 15.52(1.4) 14 20.63(3.0) there was no significant correlation between c-index of group a and b and age or gender. discussion in summary, the study results showed that the course had a great effect on knowledge improvement but we failed to find its positive effect on the students' moral judgment. other studies that have evaluated the influence of the course of ethics on student's knowledge of medical ethics have shown an improvement of 14 37% (3, 9, 10). our study also showed a knowledge improvement of 32% comparing with the beginning of the course and an improvement of 36% in comparison with the previous semester (group a), that seems quite prominent. moral judgment showed no difference before and after taking the revised course; however, the results showed that the students who took the unrevised course had a better moral judgment in comparison with those who took the revised course. it seems unlikely that the revision of a two unit course was the reason for this difference. many cases were deleted because of missing values and the comparison of the c-index of groups a and b before deleting the defective cases did not show a significant difference. the small sample size of the paired cases also reduced the power of the study to show the positive effect of our educational intervention. however, other studies that have used mjt have not shown a significant difference in students' moral judgment during their educational course (12, 22, 23). moreover, another study that used mjt to evaluate the improvement of medical students' moral reasoning over 3 years of education could not find any significant changes (13). the reason why this course is not effective on moral reasoning might be the impact of negative hidden curriculum in medical education (13, 24). on the other hand, medical students have a higher basic level of moral judgment in comparison with average people (25). small group discussions are effective for teaching high levels of cognitive goals such as analysis and decisions making (26). in this course of medical ethics, from the viewports of both, fariba asghari, aniseh samadi and taraneh dormohammadi j med ethics hist med 2009, 2:7 page 5 of 6 (page number not for citation purposes) students and faculty members, discussions on ethical dilemmas are preferred over lecture (6). the main reason for ineffectiveness of the course on students' moral judgment might be the short length of the course. furthermore, to be more effective on moral reasoning, teaching ethics should be integrated to the whole duration of medical education. this study had some limitations. one limitation was the low study power due to the small sample size, especially in the paired cases. in the knowledge questionnaire, the limited number of questions could not provide an acceptable content validity in each ethical issue so we could not interpret the significant differences shown in some ethical issues. moreover, since the study proposal was prepared at the end of the second semester of 2006, we were not able to evaluate student group a at the beginning of their course. course evaluation is an essential component of a course development and has a very critical role in its improvement. based on the result of this study, more researches with higher sample sizes and using different moral reasoning instruments is recommended for having a comprehensive course evaluation. acknowledgments according to contract number 132/2252 dated june 12, 2007, this study was funded by tehran university of medical sciences. the authors wish to thank prof. georg lind for providing the mjt questionnaire. we also thank dr fakhredin taghadosi nejad, dr kiarash aramesh and dr azim mirzazadeh for their assistance in reviewing the knowledge questionnaire. competing interests: none. fariba asghari, aniseh samadi and taraneh dormohammadi j med ethics hist med 2009, 2:7 page 6 of 6 (page number not for citation purposes) references 1. perkins hs, geppert cm, hazuda hp. challenges in teaching ethics in medical schools. am j med sci 2000; 319(5): 273-8. 2. musick dw. teaching medical ethics: a review of the literature from north american medical schools with emphasis on education. med health care 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purposes) 26. kern de, thomas pa, harward dm, bass ed. curriculum development for medical education: a six step approach. baltimore: john hopkins press; 1998. ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ case report copyright © 2021 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e when complementary and alternative medicine intervenes in the conventional treatment of cancer patients: ethical analysis of a clinical case mahboobeh saber assistant professor, department of medical ethics, school of medicine, shiraz university of medical sciences, shiraz, iran. keywords: neoplasm; complementary therapies; treatment refusal. introduction the use of complementary and alternative medicine (cam) is prevalent among cancer patients as they are known to use at least one type of cam (1, 2). in most cases, patients use cam treatments during the conventional treatment course to reduce the side effects of chemotherapy and improve their quality of life. however, in some cases, cam treatments replace conventional therapy immediately following the cancer diagnosis and after multiple conventional treatment stages and relapses (3). cancer patients visit traditional medicine practitioners despite the presence of conventional treatment options due to reasons such as fear, denial of illness, or death of close relatives following cancer (4). in the current study, two patients who chose to undergo traditional treatment after the cancer diagnosis was made are introduced. an ethical analysis of these cases will determine the existing ethical challenges in this area. case one miss s., a single woman of 38 years of age, felt pain in the area between her breasts and her armpit. as the ultrasound revealed a tumor in her right breast, the radiologist referred the patient to a surgeon. however, the patient decided to visit a traditional medicine practitioner (dr. a.). dr. a. started a warm conversation with miss s. and confidently convinced her that her disease can be treated with various medications and treatments such as leech or cupping therapy. after a few weeks of therapy under the supervision of dr. a., miss s. underwent another ultrasound that indicated tumor growth. *corresponding author mahboobeh saber address: block no.2, department of medical ethics and philosophy of health, school of medicine, zand ave., imam hussein sq., shiraz, fars, iran. tel: (+98) 71 32 34 89 80 email: saberma@sums.ac.ir received: 1 nov 2021 accepted: 5 dec 2021 published: 7 dec 2021 citation to this article: saber m. when complementary and alternative medicine intervenes in the conventional treatment of cancer patients: ethical analysis of a clinical case j med ethics hist med. 2021; 14: 22. when complementary and alternative medicine intervenes … 2 j med ethics hist med. 2021 (december); 14: 22. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e she worriedly informed dr. a. about the results, but was again convinced that the tumor cells have opened to get destroyed. after a few months of treatment, miss s. started to suffer from shortness of breath, making her unable to sleep without an oxygen tank. then, a lesion was found in her lung xray during a physician visit. once again, dr. a. stated that "they (the physicians) are trying to scare you. it is not a big deal, do not worry, i will cure you." meanwhile, the tumor had grown considerably and the patient started to experience daily bleedings from her wounded breast. nonetheless, dr. a. was still hopeful about the positive course of the treatment with great certainty. this traditional medicine practitioner explained all the symptoms as signs of recovery and prevented the patient from undergoing conventional treatments or visiting a surgeon. eventually, after 11 months when breasts were both wounded and the patient was experiencing secretion and bleeding, malodor, and shortness of breath, dr. a. finally told miss s. to go and visit a surgeon. case two miss f., a married woman of 42 years of age, visited a gynecologist with complaints about a burning sensation in her breasts. after physical examination, mammography was prescribed. after mammography and ultrasound, the radiologist detected a seemingly malignant tumor in the patient's breast; so, the patient was referred to a surgeon. after describing the situation, the surgeon explained the necessity of taking a tissue sample for an accurate diagnosis. the patient used her fear of the procedure and the fact that she was living alone as an excuse to refuse the doctor's diagnostic suggestion. the patient told none of her family members about her illness and did not visit the surgeon anymore. later, miss f. began traditional treatment and started taking the herbal medication. after 18 months, she started coughing and experiencing shortness of breath. the family doctor prescribed antibiotics, and as the symptoms persist, the patient was referred to a specialist. at this stage, cancer had spread to the lungs and other vital organs. this was two years after the first manifestation of the signs of disease. during this time, miss f. had only received herbal medicines from a traditional medicine practitioner. when the patient had not recovered after each treatment course, the practitioner had repeated the treatment and insisted on their efficacy in other patients. miss f. believed faith had guided her towards using traditional medicine and that the reason for failing to defeat the disease was herself, not having not enough serenity. she trusted that traditional medicine could cure and heal any patient. discussion cancer patients are often interested in complementary and alternative medicine; they, therefore, visit the cam providers. any interaction between practitioners and patients must be carried out by conventional methods and needs informed consent. while discussing the treatment goals, various types of available or alternative treatments, the benefits or effectiveness of the treatment, and saber m. 3 j med ethics hist med. 2021 (december); 14: 22. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e possible side effects must be explained. during this conversation, the type of treatment ought to be determined. patients talk to physicians when proper interaction for achieving shared decisionmaking is hardly possible due to the reasons such as fear of cancer, cancer in close relatives, and denial of illness, (5). often, patients expect the physician to talk about curative treatments with traditional medicine before getting engaged in conventional therapy. however, ethics must be concerned in another way. the best and most challenging approach is to reinforce the patient autonomy in determining the treatment goals and explaining the effectiveness of the recommended treatments realistically. in this way, the patient can freely decide based on a clear image of the possible future events and his or her preferences and concerns without any manipulation (6). traditional medicine practitioners promised to cure the illnesses of miss f. and miss s. using traditional treatment. the treatment methods, their side effects, and alternative options were not mentioned; besides the practitioner only referred to the successful results of the treatments. in this situation, not only the patient was not well informed but also her freedom in decision making was tempered by manipulation. miss f. and miss s. spoke of a lengthy hope-inspiring conversation with the traditional medicine practitioner that was desirable and calming; this conversation was the reason for their trust. such conversations repeatedly prevented the patients from visiting a surgeon; such interactions, therefore, are not considered professional behavior. manipulating a patient to make a confident decision while they are not well-informed is a clear example of impairing the patient's autonomy. in addition, providing the patient with a clear and unbiased explanation of the strengths and weaknesses of the treatments as well as their advantages and side-effects in accordance with ethical codes for the iranian medical professionals is the responsibility of the traditional medicine practitioners that has been violated in these cases. (7) the clinical procedure must be carried out based on professional standards. concerning her physical condition in the course of treatment, miss s. stated, "both of my breasts were wounded, they put leeches on them, and i was bleeding so much that i fainted and needed a serum infusion. this happened numerous times.” the repetition of this event during a treatment that failed to meet the minimum criteria for therapeutic effectiveness is a confirmation of causing harm to the patient. at later stages, the wounds became malodorous, and hence prolonged mental suffering was added to the pain and suffering without gaining any results. when performing diagnostic and therapeutic interventions, healthcare providers are obliged to adhere to the principles of nonmaleficence. if a procedure causes pain and tissue damage, there should be a clear and approved benefit (6). meanwhile, no evidence of benefit existed in this case. cam when complementary and alternative medicine intervenes … 4 j med ethics hist med. 2021 (december); 14: 22. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e approaches causing prolonged pain and suffering for the patient do not have any therapeutic effects such as increasing the lifespan or the quality of life (8). in the conventional treatment, the patient would receive chemotherapy and radiotherapy that are complex processes; they, however, recover to a definitive degree that lasts up to months or even years. for the reasons mentioned above, it can be stated that this type of treatment (traditional medicine) is in contradiction with the principle of nonmaleficence, as traditional treatment has led to increased pain and suffering in both patients. furthermore, the provision of health interventions outside the framework of clinical guidelines is also in contradiction with the iranian ethical codes. the treatments carried out by the traditional medicine practitioners were self-styled non-scientific therapies that violate the codes of professional ethics (7). cancer, or breast cancer in specific, was a known disease to ibn sina and al-razi, who used and recommended surgery and even a special drug with effects close to chemotherapy as the treatment (9, 10). however, the interventions performed for these two patients had no similarity to the approaches taken by these two persian scientists. nowadays, the traditional treatments offered to cancer patients result in reduced lifespan and quality of life (11). the professional behavior in such situations is to refer the patient who is interested in complementary medicine to an oncologist and prescribe the complementary treatments alongside chemotherapy and radiotherapy. agreeing to treat these two patients under such conditions contradicted the principle of beneficence and professional ethics, as these patients were not benefiting from the complementary medicine. there is a myth about traditional and complementary medicine which is adherence to such treatments is a sign of faith and even the idea that the patient's recovery is also connected to their beliefs. the impact of spirituality on an individual's health is a subject verified by substantial evidence. when a traditional medicine practitioner seduces the patient by the idea that specific treatments such as cupping or herbal medicine have more advantages than their known benefits, the desperate cancer patient and her religious beliefs in the effectiveness of such treatments are challenged. miss f. considered this type of treatment effective and associated the poor progress of her disease with not having enough serenity. traditional medical services are provided in a limited number of centers and through individualistic methods. therefore, if a patient starts doubting the quality of the services, there is no possibility of continuing the treatment elsewhere. this creates a barrier against supervising and developing care standards for cam practices. on the other hand, prescribing and providing therapeutic procedures and traditional products in the exact location is a clear example of a conflict of interest that is witnessed in most centers providing cam services. this often increases the cost of complementary medicine, and it is not possible to benefit from insurance services either. the use of saber m. 5 j med ethics hist med. 2021 (december); 14: 22. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e religious beliefs for attracting customers, the existence of individualistic styles, lack of professional standards, and the existing conflicts of interest present challenges to cam service provision concerning justice principle. the spread of cam services in the country increases the urgency of paying attention to the principles of professional ethics governing patient and physician interactions. although it is still a challenge to cite valid scientific evidence about adherence to the ethical rules governing the medical profession in traditional or modern medicine, the four principles of medical ethics, and the two medical approaches agreed (12). implementing the four ethical principles in cam can be achieved by paying attention to the seven-step framework known as the "risk-benefit analysis" (13). conclusion the inclination of the patients toward traditional treatment is accepted in the healthcare system. traditional medicine practitioners must display more sensitivity in providing traditional treatment to individuals with serious and acute illnesses. patient autonomy and collaborative decision-making are possible when the patient has valid and accurate information. all treatments applied by traditional medicine practitioners must meet the effectiveness criteria. in the case of acute and serious illnesses, traditional medicine should be used alongside the conventional treatments after investigating the drug interactions and not as an alternative to conventional treatments. paying attention to the faith and beliefs of the patients is essential for improving their spiritual health and their search for meaning although this should not be used as a method to advertise traditional medicine. adherence to the four principles of medical ethics and the ethical code of medical professionals is the proper route of interactions between the conventional and the traditional medical approaches to promote health in society. ethical consideration this article is a part of a qualitative study on cancer patients that has been approved by the research ethics board at shiraz university of medical sciences (ir. sums. rec. 1396. s1063). acknowledgments the authors are grateful and appreciate the two patients who participated in the interviews. when complementary and alternative medicine intervenes … 6 j med ethics hist med. 2021 (december); 14: 22. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e references 1. bernstein bj, grasso t. prevalence of complementary and alternative medicine use in cancer patients. oncology (williston park). 2001; 15(10): 1267-72; discussion 72-8, 83. 2. yates js, mustian km, morrow gr, et al. prevalence of complementary and alternative medicine use in cancer patients during treatment. support care cancer. 2005; 13(10): 806-11. 3. trinidade a, shakeel m, hurman d, hussain a. traditional and complementary and alternative medicines make for unwilling bedfellows in the management of cancer: a case report with a tragic outcome. j laryngol otol. 2011; 125(11): 1193-5. 4. saber m, khankeh hr, vojdani r, imanieh mh. patients’ experiences with the degenerative process of cancer: a content-analysis study in iran. middle east journal of cancer. 2019; 10(3) (39): 221-30. 5. tenner l, hlubocky fj, blanke cd, et al. let's talk about those herbs you are taking: ethical considerations for communication with patients with cancer about complementary and alternative medicine. j oncol pract. 2019; 15(1): 44-9. 6. beauchamp tl, childress jf. principles of biomedical ethics, 8th ed. usa: oxford university press; 2019. 7. shamsi-gooshki e, parsapoor a, asghari f, et al. developing "code of ethics for medical professionals, medical council of islamic republic of iran". arch iran med. 2020; 23(10): 658-64 . 8. sanford nn, sher dj, ahn c, aizer aa, mahal ba. prevalence and nondisclosure of complementary and alternative medicine use in patients with cancer and cancer survivors in the united states. jama oncol. 2019; 5(5): 735-7. 9. riddle jm. ancient and medieval chemotherapy for cancer. isis. 1985;76(3):319-30. doi:10.1086/353876 10. zarshenas mm, mohammadi-bardbori a. a medieval description of metastatic breast cancer; from avicenna's view point. breast. 2017; 31: 20-1. 11. johnson sb, park hs, gross cp, yu jb. complementary medicine, refusal of conventional cancer therapy, and survival among patients with curable cancers. jama oncol. 2018; 4(10): 1375-81. 12. stone j. ethical issues in complementary and alternative medicine. complement ther med. 2000; 8(3): 207-13. 13. cohen mh, eisenberg dm. potential physician malpractice liability associated with complementary and integrative medical therapies. ann intern med. 2002; 136(8): 596-603. ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ 1 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e original article volume 13 number 14 september 2020 copyright © 2020 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. clinical commitment and competence: a qualitative study *corresponding author narges shafaroodi no.4, school of rehabilitation sciences, iran university of medical sciences, maddadkaran st., mother sq., mirdamad blvd., tehran, iran. tel: (+98) 21 22 22 09 46 email: shafarodi.n@iums.ac.ir received: 29 mar 2020 accepted: 1 sep 2020 published: 28 sep 2020 citation to this article: zamanian jahromi s, shafaroodi n, lajevardi l. clinical commitment and competence: a qualitative study. j med ethics hist med. 2020; 13: 14. somaye zamanian jahromi1, narges shafaroodi2*, laleh lajevardi3 1.researcher, school of rehabilitation sciences of iran university of medical sciences, tehran, iran. 2.associate professor, occupational therapy department, school of rehabilitation sciences of iran university of medical sciences, tehran, iran. 3.assistant professor, occupational therapy department, school of rehabilitation sciences of iran university of medical sciences, tehran. iran. abstract commitment, a component of clinical competence, includes accountability and responsibility for professional roles and tasks; and, it has a positive correlation with job satisfaction and performance. this study aimed to elaborate on the concept of commitment in the field of occupational therapy using qualitative content analysis. the data was collected through interviewing 13 occupational therapists both in a focus group interview (including four participants) and in one-to-one interviews (nine other participants). the collected data was analyzed based on the grenheim method, and commitment concept was defined under three main themes: (i) commitment to patient (five subthemes), (ii) commitment to self (three subthemes), and (iii) commitment to profession (three subthemes). this study’s findings indicated that to acquire clinical competence, therapists should be committed to their patients, to themselves, and to their profession. future research is needed to further examine how and to what extent these commitment themes affect clinical competence as well as the interaction among them. keywords: occupational therapy; commitment; qualitative research; clinical competence. mailto:shafarodi.n@iums.ac.ir clinical commitment and competence: a qualitative study … 2 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 14 september 2020 introduction acquiring or enhancing competence, a significant concern in healthcare and therapeutic fields, has important implications for clinical practice, management, and education (1). however, competence is a controversial subject due to the complexity of its concept and difficulty of defining and evaluating it (2). clinical competence refers to proficient and constant use of technical expertise, communication skills, knowledge as well as clinical reasoning, emotional support and values in clinical settings (3). acquiring clinical competence includes a dynamic and complex process involving lifelong learning (4). as an element of clinical competence, commitment means accepting responsibility regarding the assigned tasks with satisfaction when conscientiously fulfilling professional obligations without any external supervisory system (5). previous studies show that commitment, related to conscious awareness of responsibility and obligations, involves effective use of knowledge and expertise, leading to improved clinical competence (6). considering that commitment concept is context-dependent, its definitions and interpretations depend on the followings: various environmental conditions, therapists with different specialties, patients with varied problems, professional duties and roles, as well as different laws and policies (7). therefore, different countries worldwide have various understandings of commitment concept, and hence descriptions for it. for instance, in canada, commitment is defined under the themes of "having professional responsibility", "formal appraisal process of performance", and "undertaking professional development" (8). in australia, in definition of clinical competence, commitment is addressed using the following themes: "behaviors and attitudes of a professional", "intervention”," professional responsibility"," professional development, and training" and "evaluating services" (9). in iran, hagbaghery et al. in a study on nurses' clinical competence addressed commitment in the context of medical ethics (5). while emphasizing on the importance of commitment, allami and mohammadi (10) stated that residences in residency training programs need to acquire competency of fulfilling expected professional commitments, including the followings: (i) sympathizing with patients, (ii) responding to patients’ needs, (iii) seriously considering patients' preferences, (iv) upgrading their scientific knowledge, (v) enhancing their clinical skills; as well as, (vi) taking responsibility of their patients, community, and medical profession. as an integral part of clinical competence, ethical commitment plays a key role in commitment enhancement, and being aware of this concept is imperative for occupational therapists (10, 11). despite its importance, commitment in the field of occupational therapy in iran has not received adequate attention and has not been clearly defined, and hence this study aimed to elucidate the concept of commitment as part of clinical competence through a qualitative study, involving semi-structured interviews with occupational therapists. zamanian jahromi s., et al. 3 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 14 september 2020 method in this study, the conventional content analysis approach was used to explore the concept of commitment as part of clinical competence from occupational therapists’ perspective. in qualitative content analysis, written content is subjectively interpreted via systematic classification of codes and the determination of themes and patterns. conventional content analysis is suitable in case of limited or sporadic literature on the under-study phenomenon. in this study, the researchers avoided the application of presupposed categories and managed to distill the categories from the data (12, 13(. setting and participants the participants were selected through purposive sampling. the inclusion criteria for occupational therapists were as follows: at least two years of clinical experience, at least a bachelor's degree, and consent to cooperate. from 13 occupational therapist participants, eight were women and five were men respectively, and they had three to 28 years of clinical experience. the interviews were held in a quiet room in participants’ workplaces at their preferred time and location. data saturation was achieved after ten interviews; however, three additional interviews were performed to reach certainty. respectively, four, one, and five of participants had doctoral, master’s, and bachelor's degrees, and five participants were doctoral students. in selecting participants, the researchers considered maximum diversity in work experience such as working in different settings (e.g., university, private clinics, and hospitals) and conditions (e.g., working with children and adults who suffer from physical or mental disabilities). data collection the data was collected through semistructured interviews both in form of a focus group interview and individual interviews. in the focus group interview, four occupational therapists participated, and nine interviews were performed on an individual basis. the interviews were started with open-ended questions (e.g., "what does clinical competence mean?", "what is the definition of commitment in this field?"), and continued with detailed questions. the interviews lasted between 60 and 120 minutes. ethical considerations the ethics committee of iran university of medical sciences approved this study through 1395.9411355003 code of ethics. the informed written and verbal consents were obtained from the participants. in addition, confidentiality of information was maintained, and the participants had the right to withdraw from the research at any time during the study as well as at the time of disclosure of the interviews and research results. data analysis the data was analyzed based on graneheim method (14). the interview transcriptions were thoroughly read several times, and the meaning units were extracted and condensed (i.e., the threads of meaning were found throughout the interview transcriptions). each meaning unit was conceptualized and clinical commitment and competence: a qualitative study … 4 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 14 september 2020 labeled with a code. the obtained codes were compared to extract similarities and differences. then, similar codes were grouped together as a subtheme and later similar subthemes generated a theme (14). credibility, transferability, dependability, and conformability of data was evaluated to assure data trustworthiness. to this end, the peer review method was used in which the researchers familiar with the qualitative research, concepts, classes, and extracted codes were asked to provide their perspectives on data accuracy. based on their comments, necessary modifications were made, and ongoing contact with the mentors and advisors was maintained over the course of the study. moreover, other data validation methods were employed as follows: (i) allocation of sufficient time for the research and interviews; (ii) active engagement of the researchers during this nine-month study; (iii) participant selection from different age groups with diverse academic and work experiences from various medical and educational centers; and, (iv) establishing good relationship with participants and effective communication. to ensure that the data were rich enough to provide answers to the research questions, the following methods were employed: (i) after data saturation, another three occupational therapists were interviewed; and (ii) following the interviews, audio files were transcribed and then transcripts were returned the participants to confirm that their words matches their intended beliefs. results the participants included 13 occupational therapists with three to 28 years of clinical experience (table 1). analysis of the highlights of interview transcripts regarding participants’ experiences of clinical commitment in occupational therapy resulted in 48 initial codes and then 20 after merging similar codes. finally, 3 main themes and 11 subthemes (sharing the same central organizing concept) were developed as summarized in table 2. based on data analysis, commitment of occupational therapists was classified into three abstract themes: "commitment to patients", "commitment to self", and "commitment to profession" (table 2). in following sections, these themes are explained and related excerpt from the interview transcripts are attached. table 1the characteristics of the study participants characteristics number gender male female 5 8 education level doctoral degree doctoral students master’s degree bachelor’s degree 4 5 1 3 zamanian jahromi s., et al. 5 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 14 september 2020 table 2emerged themes and subthemes themes subthemes 1.valuing patients' available time 2.providing information to patients 3. patient differences 4.judicious use of best evidence 5.confidentiality commitment to patients 1.enhancing teamwork 2.being up to date 3.considering self-health and selfcare commitment to self 1.accepting profession’s philosophy 2.believing in professional identity 3.acting within the paradigm commitment to profession commitment to patients according to the participants, competent therapists are committed to their patients by considering the importance of patients' time and providing the maximum possible and the most appropriate services in the patient's available time. a participant stated, “therapists easily devotes less than necessary time to patients; instead, they go to their offices and take more time to rest disregarding the importance of maintaining patients' trust”. [participant no. 10] providing information and advice on choosing treatment options to patients and their families are among indispensable routines in clinical practice. giving information and telling facts to patients help them and their families understand the circumstances better and realize the significance of treatment. awareness raising leads to effective collaboration and communication between the patient and the therapist and assists patients in making informed decisions. a participant stated, "the explanations by the therapists to families are important because families can persuade the patients to go home and exercise”. [participant no. 8] all patients deserve to receive treatment with no discrimination. factors such as social class, race, ethnicity, education level, occupation, and total wealth should not affect the patient-therapist relationship as well as clinical assessment, diagnosis, and treatment. in addition, therapists' treatment location (e.g., private clinics, public clinics, or patient’s home) should not affect their attitude and how they treat patients. a participant stated, " therapists can work in governmental settings, in private clinics, or in patients’ homes. in private clinics, therapists can apply long-term treatment plans for patients as well as can have specific purpose and direction. however, in public settings, customized individual treatment and providing advice are not routinely provided”. [participant no. 9] a subtheme of "commitment to patient” emphasizes on the use of best evidences to develop the most effective treatment plan, meaning that therapists need to consider each patient's specific conditions to develop the most suitable treatment for that particular condition. a participant mentioned, "effective treatment methods with shorter duration need to be used. committed therapists should explore best scientific methods in their field to adopt the most suitable treatments for their patients”. [participant no. 2] clinical commitment and competence: a qualitative study … 6 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 14 september 2020 maintaining confidentiality is another professional obligation for therapists; they should not share or disclose patients' information unless in emergency cases defined by laws and regulations. a participant stated, "therapists are required to keep their patients' information confidential, except in exceptional cases specified by law. such information is completely private and all details should not be disclosed". [participant no. 4] commitment to self occupational therapists are responsible not only for their patients but also for themselves. commitment to self includes "enhancing teamwork skills", "being up-todate”, and "valuing self-health and selfcare". in commitment to teamwork, therapists, regardless of their relations and connections and regardless of their workplace rules for teamwork, should know about the importance of teamwork and get involved to help choose the best treatment solution. a participant said, "individuals with cooperation and teamwork attitude can effectively communicate with their colleagues and easily exchange their information and opinions, which can improve both quality and result of treatments. everyone should increase opportunities for teamwork, regardless of the field of work and compulsory or voluntary presence in the team”. [participant no.13] competent therapists should be committed to being aware of innovative and recent therapies and employing them in their practice. according to the participants, they could keep themselves updated through the following approaches: (i) attending workshops as well as scientific and clinical conferences, (ii) studying or pursuing higher education, and (iii) staying connected with universities and research centers. a participant said, " to be an ethics-adhering therapist, when i do not know how to treat a specific patient, i need to study and look for a treatment solution. some therapists use outdated treatments for their patients for many years and not even update their obsolete isolated clinics. they are unaware of the new proposed treatment approaches, and they do not care and evaluate whether new approaches are worth trying ". [participant no. 9] the physical and mental health of therapists is another factor affecting their competence and performance. according to the participants, occupational therapists should take care of their health and maintain a healthy work-life balance. a participant said, "many therapists work at full capacity for a limited number of years and then their efficiency decreases due to burnout. some of them even have to change jobs. caring about personal health is very important and i always try to keep my work-life balance”. [participant no. 11] commitment to profession according to participants, competent therapists should understand the philosophical basis of a profession, referring to values, beliefs, facts, and principles that guide the therapist’s actions in their profession. the philosophy of a profession defines the nature of the profession, the theories, actions, reference framework, and zamanian jahromi s., et al. 7 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 14 september 2020 interventions functioning as compass in practicing that profession. knowing the philosophy of the profession leads therapists to design their goals and treatment plans to implement this philosophy. a participant said, "having perspectives regarding the philosophy of profession is very important. for example, occupational therapists should be aware of the occupational therapy philosophy to act according to it in their clinical practice and help patients enhance their quality of life. my view is based on a medical background and does not necessarily focus on occupational therapy, but is applicable to both areas.". [participant no. 6]. another participant stated, "first, i should believe in philosophy of occupational therapy, and then get involved in its context and enhance patients’ quality of life ". [participant no. 2] professional identity of therapists is defined through view of themselves in their profession and through being recognized as a member of that profession. professional identity consists of their beliefs, attitudes, understandings, values, motives, and experiences about their professional role; such view is formed though activities and duties involved in practicing of their domain of expertise and affects their professional growth and practice. according to participants, therapists should believe in their profession and perform their designated duties and roles based on that belief. a participant said, "during school years, the identity of the future profession should form the mindset of students of the related academic field of study. as a medical doctor, i am familiar with the identity of medical profession, and do my duties and responsibilities defined based on that identity. i am committed to do my professional role and related activities. similarly, the identity of the field of occupational therapy affects the occupational therapist's competence". [participant no. 7] competent therapist should act within the paradigm of professional expertise, where paradigm refers to framework within which the philosophy of profession is being implemented. the participants defined acting within the paradigm in terms of "being patient-centered", "being holistic" and "having a humanistic perspective". the participants identified patientcentered care in the following divisions: (i) involving patients and their families in treatment and decision-making processes, (ii) giving patients the right to choose, (iii) understand patients’ priorities and address them, and (ii) emphasizing on patient consent and satisfaction and empowering the patients to achieve satisfaction. a participant said, "occupational therapists should involve their patients in making decisions. patients should be considered as a source in information gathering and decision-making". [participant no. 12]. another participant mentioned, “therapists need to listen to their patients, understand their needs, and respect their values and beliefs". [participant no.13] according to the participants, occupational therapists with a holistic outlook could clinical commitment and competence: a qualitative study … 8 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 14 september 2020 evaluate patient’s problems from various perspectives, thereby avoiding treatment based on fragmental interpretations. a participant said, “we should have a holistic perspective and an extensive framework through which we can evaluate various causes of an effect from different angles “. [participant no. 2] a competent occupational therapist should have a humanistic perspective with a strong concern for human welfare, values, and dignity. a participant stated, “therapists as human beings need to have humanistic perspectives. when a pediatric patient goes to the therapist's office or is visited by the therapist at home, the first thing on the therapist mind is the financial situation of the child's father. such mindset contradicts the philosophy of occupational therapy as therapists behave differently depending on the father's job (e.g., a doctor or a worker). the treatment of the child based on biased views and such background information affects the provided treatment”. [participant no. 3 ] discussion this study’s findings showed that the occupational therapist participants refer to commitment as a key component of clinical competence and consider it an ethical concept within the context of occupational therapy. such commitment was defined in three major themes as commitment to patient, to self, and to profession, respectively. such commitment enables therapists enhance their knowledge and skills and effectively employ them in practice. many previous studies suggested that enhancing competence improves work performance. nonetheless, few studies stated that competence does not always lead to effective performance (15). however, the participants in this study referred to commitment as one of the influential factors in improving performance. therapists do their best to provide patients with the maximum and best medical services through various aspects of commitment, thereby earning patients' trust and leading to an effective therapeutic relationship between the therapist and the patient. establishing such relationship is important because rehabilitation is a lengthy process. the consequents of this study indicate some similarities to the articles have been performed in ethic fields which is stated in the following paragraphs. this study’s findings indicated that “commitment to patients” is a significant factor in clinical competence. studies in the field of occupational therapy in iran show that, due to lack of compassion, therapists often do not focus on providing the most and best services to the patient, or in other words, they do not provide the opportunity for patients to have the maximum possible benefits. vahidi et al. indicated that compassionate occupational therapists respect patients’ available time, give them essential information, use the best therapeutic methods; they also enhance their expertise, employ their potentials, and do not abuse their position or influence (16). according to the participants, providing information to the patients is also one of the most prominent obligations of the therapists. zamanian jahromi s., et al. 9 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 14 september 2020 the american occupational therapy association (aota) has addressed truthfulness under the title of “veracity” and defined it as conveying “comprehensive, accurate, and objective” information to the patients and promoting their comprehension of such information. veracity is necessary for establishing a therapeutic relationship between the patient and therapist, and decrease the possibility of misunderstanding and help occupational therapists avoid moral distress (12). maintaining confidentiality is another subtheme of “commitment to patients”. in a study regarding the invasion of privacy, the patients highlighted the following cases: (i) the invasion of personal territory, (ii) lack of privacy, (iii) insufficient or lack of attention and care from nurses and healthcare team, and (iv) not allocating enough time and patience. parsa yekta et al. found that among the causes of such invasion were the lack of awareness of patient rights and lack of care ethics, as well as lack of proper education on how to reserve patients' rights and observe care ethics (1). the study’s participants also emphasized on lack of professional ethics knowledge as another important factor in clinical competence, and they suggested learning and advanced levels training on related topics to compensate such lacks. brown et al. suggested that continuing education, including courses to develop knowledge and skills in a specific area, may be required to ensure evidence-based treatment and research utilization among pediatric occupational therapists (17). kalantari et al. indicated that ethics educational courses and workshops for iranian occupational therapists should be accommodated in curricula for students (12). in addition to “commitment to patients”, the participants highlighted “commitment to self” as another factor in clinical competence. committed therapists take on responsibilities and have valuable work experience (6). the participants also stated that occupational therapists should consider the importance of self-health and self-care as well as should maintain life-work balance. the participants believed that therapists constantly working at full capacity would experience early burnout, adversely affecting clinical competence. “commitment to profession” is another fundamental factor in clinical competence. according to santos and not-land, “commitment to profession” is part of professional identity, enhancing a sense of attachment to a job and increases the interest in engaging in that job (18). the participants also highlighted the importance of professional identity and commitment to the profession. professional commitment is typically discussed through social identity theory, where individuals are categorized into different social classes based on their profession, group membership, organization, and other factors (19). according to wallace, in “commitment to profession”, individuals are identified by their profession, a profession to which they adhere and have a high sense of clinical commitment and competence: a qualitative study … 10 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 14 september 2020 responsibility in performing designated tasks. furthermore, they emphasized on the importance of professional commitment in increasing clinical competency. they also believed that professional commitment enables individuals to increase their knowledge and skills to manage difficult or unforeseen situations, which means that professional commitment and ethical conduct are closely related to sense of responsibility (20). according to the participants, despite the importance of commitment as part of clinical competence, not all occupational therapists bind themselves to a course of actions required under that concept of commitment due to various organizational and individual reasons. one of the reasons is lack of courses in educational system’s curricula to teach ethics and professional commitment topics that raise awareness of future therapists in clinical practice. vanderkaay et al. also emphasized on the necessity of teaching ethics, including ethical theories and their clinical use, to occupational therapists (21). the participants also stated that individual factors, such as patience, self-esteem, altruism, honesty, generosity, motivation, and interest in the profession could affect clinical competence. several studies in the field of nursing have emphasized on the significance of the aforementioned factors (1, 5, 22). ghamari et al. conducted a research on motivational power of occupational therapy profession among occupational therapists considering volition factor. the low scores obtained in occupational therapy profession indicated that this profession itself did not provide sufficient motivation for practitioners and factors decreasing individuals’ volition were personal (e.g., inability of occupational therapists to perform clinical work) or organizational (e.g., lack of occupational therapy centers and lack of funding from departmental and organizational authorities). given that in occupational therapy, the term "profession" does not reflect its role and identity, the negative feedback of individuals and organizations on the term "profession" and the complicated concept of occupational identity adversely influence occupational therapists' attitudes towards this profession and reduce their job motivation. some of the factors involved in reducing job motivation in the occupational therapists are as follows: (i) higher recruitment rates in various branches of rehabilitation compared to that of occupational therapy, (ii) underestimation of occupational therapy in medical centers, (iii) reluctance of managers to set up occupational therapy centers; and, (iv) inequality in healthcare tariff in various fields (23). conclusion this study’s findings indicated that commitment to patient, commitment to self, and commitment to profession are integral components of occupational therapists' clinical competence. professional commitment and ethical conduct are closely related to sense of responsibility. hence, accommodating courses in curricula on ethics, covering customized topics for occupational therapy students at zamanian jahromi s., et al. 11 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 14 september 2020 undergraduate or higher education levels can enhance prospective occupational therapists’ commitment and improve the clinical competence. future research is needed to further examine how and to what extent these commitment components affect clinical competence as well as the interactions among these components. acknowledgments the researchers would like to thank all the participants for their sharing their valuable experiences. conflict of interests the authors declare no conflicts of interest in relation to this article. clinical commitment and competence: a qualitative study … 12 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 14 september 2020 references 1. parsa yekta z, ahmadi f, tabari r. factors defined by nurses as influential upon the development of clinical competence. journal of guilan university of medical sciences. 2005; 14(54): 9-23. 2. watson r, stimpson a, topping a, porock d. clinical competence in nursing: a systematic review of the literature. j adv nurs. 2002; 39(5): 421-31. 3. carr sj. assessing clinical competency in medical senior house officers: how and why should we do it? postgrad med j. 2004; 80(940): 63-6. 4. boyt schell ba, glen gillen g, scaffa m, cohn e. willard & spackman's occupational therapy, 12th ed. usa: lippincott williams & wilkins; 2014. 5. adib hagbaghery m, salsali m, ahmadi f. a qualitative study of iranian nurses' understanding and experiences of professional power. hum resour health. 2004; 2(1): 9. 6. memarian r, salsali m, vanaki z, ahmadi f, hajizadeh e. professional ethics as an important factor in clinical competency in nursing. nursing ethics. 2007; 14(2): 20314. 7. turner a, alsop a. unique core skills: exploring occupational therapists' hidden assets. british journal of occupational therapy. 2015; 78(12): 739-49. 8. anonymous. association of canadian occupational therapy regulatory organizations (acotro). essential competencies of practice for occupational therapists in canada. [cited 2020 sep]; available from: https://www.coto.org/docs/default-source/essential-competencies/3rd-essentialcompetencies_ii_may-2011.pdf?sfvrsn=2. 9. rodger s, clark m, banks r, o’brien m, martinez k. a comparison of international occupational therapy competencies: implications for australian standards in the new millennium. aust occup ther j. 2009; 56(6):372-83. 10. allami a, mohammadi n, shirazi m. faculty members experience about teaching of medical professionalism in qazvin university of medical sciences. research in medical education. 2015; 7(2):1-11. 11. thorner s. the essential skills of an occupational therapist. british journal of occupational therapy. 1991; 54(6): 222-3. 12. kalantari m, kamali m, joolaee s, rassafiani m, shafarodi n. perception of professional ethics by iranian occupational therapists working with children. j med ethics hist med. 2015; 8: 8. 13. barkhordari-sharifabad m, ashktorab t, atashzadeh-shoorideh f. obstacles and problems of ethical leadership from the perspective of nursing leaders: a qualitative content analysis. j med ethics hist med. 2017; 10: 1. 14. shafaroodi n, kamali m, parvizy s, mehraban ah, o’toole g. factors affecting clinical reasoning of occupational therapists: a qualitative study. med j islam repub iran. 2014; 28: 8. ecollection 2014. 15. kak n, burkhalter b, cooper m. measuring the competence of healthcare providers. operations research issue paper. 2001; 2(1):1-28. 16. vahidi h, shafaroodi n, joolaee s. occupational therapists’ perception of unethical practice in adults’ physical dysfunction field. scientific journal of rehabiliation medicine. 2015; 4(2): 70-8. 17. brown t, tseng mh, casey j, mcdonald r, lyons c. research knowledge, attitudes, and practices of pediatric occupational therapists in australia, the united kingdom, and taiwan. j allied health. 2010; 39(2): 88-94. zamanian jahromi s., et al. 13 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 14 september 2020 18. santos s, not-land e. factors related to commitment of extension professionals in the dominican republic: implications for theory and practice. journal of agricultural education. 2006; 35(3): 57-63. 19. mael, f.a. ashforth, b.e. loyal from day one: biodata, organizational identification, and turnover among newcomers. personnel psychology. 1995; 48(2):30933. 20. wallace je. organizational and professional commitment in professional and nonprofessional organizations. administrative science quarterly. 1995; 40(2): 22855. 21. vanderkaay s, jung b, letts l, moll se. continuing competency in ethical decision making: an interpretive description of occupational therapists’ perspectives. can j occupl ther. 2019; 86(3): 209-19. 22. ballard p, trowbridge c. critical care clinical experience for novice students: reinforcing basic nursing skills. nurse educ. 2004; 29(3): 103-6. 23. ghmari n, derakhshanrad sa, ghamari m. examining the motivational power of occupational therapy profession among occupational therapist in fars providence in 1390. journal of modern rehabiliation.2012; 6(3):5-12. microsoft word 3 journal of medical ethics and history of medicine a role for judges in assisted dying ana castelló 1 , francesc francès2, fernando verdú 1* 1.professor of legal medicine, department of forensic and legal medicine, faculty of medicine, university of valencia eg, spain. 2.assistant professor of legal, medicine department of forensic and legal medicine, faculty of medicine, university of valencia, spain. *corresponding author: fernando verdú address: facultad de medicina, u. d. medicina legal, av/ blasco ibañez, nº15, 46010 valencia, spain. tel: (+34) 96 38 64 165, (+34) 96 86 48 20 fax: (+34) 96 38 64 165 e-mail: fernando.verdu@uv.es received: 24 may 2009 accepted: 27 may 2009 published: 30 may 2009 j med ethics hist med. 2009; 2:3. © 2009 ana castelló, francesc francès and fernando verdú; licensee tehran univ. med. sci. abstract keywords: euthanasia, assisted suicide, end of life decisions, law. introduction medically provoked death, whether euthanasia or assisted suicide, is a common issue for discussion in various forums, participants coming from widely differing fields of knowledge, among who are, of course, doctors. a study carried out in france among a lay population found that the express request of the patient was the most important factor in either accepting or rejecting assisted suicide or euthanasia (1). this request would have to be made repeatedly so that it could be taken as a serious request, rather than one forced on the person in question by external circumstances. later, another study carried out in 12 european countries showed that the trend towards accepting euthanasia had grown over the last two decades by an average of 22%; the countries in which the increase in acceptance was greater were belgium, italy, spain and sweden. only germany presented results opposed to those of the rest of the countries studied (2). one important finding from that study is that a higher level of educational training was associated with a greater acceptance of provoked death. more recently, an excellent piece of work showed the substantial legal differences that exist in europe on this issue and also the discrepancies that can be perceived between the professional groupings of the countries studied (3). the authors of this paper have added to that the information by describing the state of affairs in spain (4). medically provoked death, whether euthanasia or assisted suicide, is a common issue for discussion in various forums, participants coming from widely differing fields of knowledge, among who are, of course, doctors. substantial legal differences exist in europe on this issue and in an ever‐wider europe, it is essential, for practical reasons, that legislation be standardised. we would like to propose possible regulations that would provide effective safeguards in the application of euthanasia or assisted suicide. mailto:fernando.verdu@uv.es j med ethics hist med 2009, 2:3 ana castelló, francesc francès and fernando verdú page 2 of 3 (page number not for citation purposes) in an ever-wider europe, it is essential, for practical reasons, that legislation be standardised. moreover, the thoughts and feelings of those who find themselves in a situation of approaching death must be borne in mind when it comes to tackling the issue of regulations, and particularly of those who fear the application of non-voluntary euthanasia (5). it is quite clear that a decision to request euthanasia or assisted suicide isshould bea fully self-conscious act. obviously, this is not the case when euthanasia is administered in the intensive care unit to a person who has suffered a cerebral injury (6). this, however, is not the ideal situation for freely taking decisions. neither is there any independent will involved in the application of euthanasia administered to babies born with spina bifida (7), a practice employed almost systematically in the netherlands. there is also evidence to show that non voluntary euthanasia (in non-competent patients) or involuntary euthanasia (when the patient is not consulted) does take place and that the authorities responsible for watching out for these cases are quite tolerant of these practices (8). a regulation proposal by making use of several fully effective legal situations –although in different territorial fields we would like to propose possible regulations that would provide effective safeguards in the application of euthanasia or assisted suicide. the first arises from a decision of the european court of human rights (echr) that declares that the judges of the united kingdom are the guarantors of an individual’s rights when decisions have to be taken on the possible terminating of a child’s life (9). the second is based on the existence of an article in the spanish penal code through which the sterilisation of incapacitated individuals is regulated (10). article 156 states the following: "however, the sterilisation of an incapacitated person who suffers a serious psychic deficiency shall not be punishable when that sterilisation, taking the greater interest of the incapacitated person as the guiding principle, has been authorised by the judge, either in the same incapacitation proceedings, or in proceedings of voluntary jurisdiction, following a request by the legal representative of the incapacitated person, and having heard the declaration of two specialists, the public prosecutors office and prior exploration of the incapacity”. taking this article as a basis, if we replace the concept of sterilisation with that of assisted suicide and the concept of incapacity with that of the petitioner, the text would read as follows: "however, assistance to the petitioner’s suicide shall not be punishable when that suicide, taking the greater interest of the petitioner as the guiding principle, has been authorised by the judge on the request of the interested party, having heard the declaration of two specialists, the public prosecutors office and prior exploration of legal proceedings”. hence, in our proposal and to ensure the greatest safeguards, it would be the judge who, having heard all the parties involved, would authorise that the person who wished to die could be assisted to do so. note that it is not only the judge who is responsible for making sure that legal proceedings are complied with, but that the public prosecutors office must also be involved. with regard to who is responsible for executing the order, another spanish law (similar to others in other countries) could be made use of, namely the law on juries (11). this regulation establishes that anyone may be named as a member of the jury (with certain legal exceptions) but that certain reasons can be cited for not participating in the very difficult task of judging the conduct of others. furthermore, given that there is between 60 and 70 percent of the population in favour of legalizing assisted suicide (12, 13), a list of voluntary assistants to suicide could be established who would be willing to fulfill the above mentioned legal authorisation. this list would be open and freely accessible to anyone, regardless of the profession. clearly, health personnel would be the most appropriate. however, just as first aid can be learnt with a certain amount of training, so could final aid. for greater judicial control, the volunteers list would be under the control of a judge responsible for civil registry offices. lastly, we still have to define who can apply for the application of assisted suicide. for this, we could also make use of article 143.4 of the spanish penal code (14), which considers extenuating circumstances for those who assist in the suicide of another and that demands that "the victim suffers a serious illness that would necessarily lead to his or her death, or that causes permanent and serious suffering difficult to sustain " in order to be applied. as can be seen, our proposal provides a solution with ample legal cover, so as to prevent possible abuses, and responds to the problems arising out of performing assisted suicide or euthanasia: who authorises it? who performs it? who requests it? j med ethics hist med 2009, 2:3 ana castelló, francesc francès and fernando verdú page 3 of 3 (page number not for citation purposes) a practical case the procedure is really quite simple and safe. if someone wishes to die voluntarily, he or she must take the following steps: 1. presentation of his or her application before the corresponding judge. the judge or magistrate, having examined the case and duly assessed it, authorises the practice of assisted suicide. 2. communication to the judge responsible for the list of volunteers, who, in the way established in the law on assisted suicide and euthanasia, will indicate to the corresponding person that he or she must comply with legal proceedings. this participation is not compulsory, but would deal with the moral objections of individual citizens. 3. the citizen designated will then go to the petitioner’s residence or to where he or she is living at that moment and proceed to undertake the necessary measures to directly or indirectly assist him or her in the exercise of his or her right to dispose of his or her own life. every one could recognize his own best interest much better than anyone else. but in some circumstances, i.e., when the patient is unconscious, we need an independent professional like a judge, to evaluate the best interest of patient, so that the procedure enjoys the greatest and most effective safeguards and legal protection, the figure of the guarantor judge could be created. his or her functions would be limited, in addition to checking that all legal requirements have been complied with in the prior procedure, to asking the petitioner if he or she wishes to persist with his or her death wish. in the event of an affirmative answer, the judge would exhort the designated volunteer with a simple “let the judicial authorisation be fulfilled”. given that assisted suicide and euthanasia is a social problem, it should be society as a whole, i.e., all its members, who contribute to providing a solution. j med ethics hist med 2009, 2:3 ana castelló, francesc francès and fernando verdú page 4 of 3 (page number not for citation purposes) references 1. frileux s, lelièvre c, muñoz sastre mt, mullet e, sorum pc. when is physician-assisted suicide or euthanasia acceptable? j med ethics 2003; 29(6): 330-6. 2. cohen j, marcoux i, bilsen j, deboosere p, van der wal g, deliens l. trends in acceptance of euthanasia among the general public in 12 european countries (1981-1999). eur j public health 2006; 16(6): 663-9. 3. bosshard g, broeckaert b, clark d, materstvedt lj, gordijn b, müller-busch hc. a role for doctors in assisted dying? an analysis of legal regulations and medical professional positions in six european countries. j med ethics 2008; 34(1): 28-32. 4. verdú f, castelló a. assisted dying in spain. http://jme.bmj.com/cgi/eletters/34/1/28 (accessed on 26.02.2009) 5. chapple a, ziebland s, mcpherson a, herxheimer a. what people close to death say about euthanasia and assisted suicide: a qualitative study. j med ethics 2006; 32(12): 706-10. 6. kompanje ej, de beaufort id, bakker j. euthanasia in intensive care: a 56-year-old man with a pontine hemorrhage resulting in a locked-in syndrome. crit care med 2007; 35(10): 2428-30. 7. de jong th. deliberate termination of life of newborns with spina bifida, a critical reappraisal. childs nerv syst 2008; 24(1): 13-28. 8. cohen-almagor r. non-voluntary and involuntary euthanasia in the netherlands: dutch perspectives. issues law med 2003; 18(3): 239-57. 9. english v, mussell r, sheather j, sommerville a. treatment decisions for children. j med ethics 2004; 30: 32930. 10. anonymous. spanish penal code. http://noticias.juridicas.com/base_datos/penal/lo10-1995.l2t3.html (accessed on 26.05.2009) 11. anonymous. spanish penal code. http://noticias.juridicas.com/base_datos/penal/lo5-1995.html (accessed on 26.05.2009) 12. guedj m, gibert m, maudet a, muñoz sastre mt, mullet e, sorum pc. the acceptability of ending a patient's life. j med ethics 2005; 31(6): 311-7. 13. teisseyre n, mullet e, sorum pc. under what conditions is euthanasia acceptable to lay people and health professionals? soc sci med 2005; 60(2): 357-68. 14. anonymous. spanish penal code. http://noticias.juridicas.com/base_datos/penal/lo10-1995.l2t3.html (accessed on 26.05.2009) hhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh copyright © 2022 tehran university of medical sciences. this work is licensed under a creative commons attribution-non commercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. original article abstract one critical tactic that leads to a better understanding of the ethical status of dentists is to assess their ethical attitude by using an appropriate scale. this study aimed to design and evaluate the validity and reliability of the ethical attitude of dentists scale (eads). this study was conducted based on a mixed‐method design. the first qualitative part of the study was conducted in 2019 and the items of the scale were produced from the ethical codes compiled in a previous study. in this part, the psychometric analysis was conducted. the reliability was evaluated by cronbach's alpha coefficient and intraclass correlation coefficient. factor analysis was used to assess the construct validity (n = 511), and the following three factors were extracted with a total variance of 48.03. 1) maintaining the standing of the profession in relationships. 2) providing dental services while maintaining trust in the profession, and 3) providing information for the benefit of the patient. *corresponding author azam khorshidian address: no. 12, dentistry research institute, qods st., enghelab st., tehran, iran. postal code: 1417614411 tel: (+98) 21 83 38 43 11 email: khorshidian_azam@razi.tums.ac.ir received: 18 apr 2022 accepted: 9 oct 2022 published: 28 dec 2022 citation to this article: ebadi a, shojaei a, larijani b, akhoundi ms, khorshidian a. the ethical attitude of dentists scale: development and psychometric properties. j med ethics hist med. 2022; 15: 12. in confirmatory factor analysis, appropriate values were obtained for the goodness of fit indices, and cronbach’s alpha was 0.68 0.84 for the various factors. based on the results mentioned above, this scale showed an appropriate validity and reliability for measuring the ethical attitude of dentists. keywords: code of ethics; dentistry; attitude; psychometrics. the ethical attitude of dentists scale: development and psychometric properties 1. professor, behavioral sciences research center, life style institute, faculty of nursing, baqiyatallah university of medical sciences, tehran, iran. 2. assistant professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran; department of medical ethics, school of medicine, tehran, university of medical sciences, tehran, iran. 3. professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran; endocrinology and metabolism research center, endocrinology and metabolism clinical sciences institute, tehran, iran. 4. professor, dental research center, dentistry research institute, tehran university of medical sciences, tehran, iran. 5. researcher, dental research center, dentistry research institute, tehran university of medical sciences, tehran, iran;medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. abbas ebadi 1, amirahmad shojaei 2, bagher larijani 3, mohammad sadegh akhoundi 4, azam khorshidian 5* the ethical attitude of dentists scale: development and psychometric properties j. med. ethics. hist. med. 2022 (dec); 15:12. 2 introduction dentistry has been moving forward as a profession for several decades. while the characteristics of the profession demand adherence to the codes of ethics, public concerns regarding ethical issues in the field are increasing (1 2). numerous ethical principles and guidelines for professional conduct have been compiled by dental councils that define the obligations and duties of dentists, and meeting these principles is a requirement for membership in the profession (3 5). during the past decade, special attention has been paid to the field of dental ethics in iran and in 2019 the national dentistry ethical codes were proposed (6), but dentists continue to face dilemmas in their daily practice. they may at times undermine the norms and guidelines, and as a result, the entire profession will be harmed (7). it is important to determine why ethical codes are ignored by dentists. rational and reasoned criticism helps to approach objective realities (8), and therefore, one of the tools that can help to foster values in any profession is selfcriticism. cserzo et al. investigated self-criticism among dentists in the context of professionalism and found four major issues in this regard: “communication, the cost of treatment, the role of the dental team and consequences of professionalism concerns” (9). thus, the dentistpatient interaction plays a critical role in clinical practice, and by combining technical advancements with the humanistic side of the profession, the dentist-patient relationship can be reinforced (8). let us take a look at the root of ignoring ethical codes from a different perspective. psychologists define attitude as an informed tendency to evaluate things, people, issues, objects or events. previous experience, social roles and norms, long-term observation and classical or operant conditioning are effective in the formation of attitudes (10). having an ethical attitude and its reflection in clinical practice reduce the gap between science and practice (11). several questionnaires in the form of self-evaluation scales have been developed to assess the ethical attitude of dentists. janakiram and gardens used an adapted questionnaire of a previous study to assess attitudes related to healthcare ethics among medical and dental postgraduate students in india. some issues that were investigated in the above-mentioned questionnaire were: paternalism, medical error, informed consent for treatment and research, necessity of ethical conduct to avoid legal issues, and respect for ebadi a., et al. 3 j. med. ethics. hist. med. 2022 (dec); 15: 12. patients’ decisions and their right to refuse treatments. responses showed a lower level of adherence to health-care ethics among dental postgraduates than their medical peers (13). a questionnaire survey conducted by chopra to investigate dentists’ attitudes toward health-care ethics showed that the majority of dentists were aware of dental ethics, but needed to rethink about their application of moral values (14). chatti et al also designed a questionnaire based on a previous study to assess the attitudes of 424 students, dentists and teaching staff at visakhapatnam university in india about ethical issues (15). a change in attitude seems to be emerging among upcoming dentists, for example on the issue of marketing. in a questionnaire-based survey conducted by alsadiya et al., 300 dental interns from different colleges in india commented on marketing dentistry. although more than half of the interns agreed that marketing has a negative impact on the profession, the majority of them strongly agreed that it has served the society when combined with better clinical skills (16). these questionnaires were perhaps the closest thing to evaluation tools for assessing the attitudes of individual dentists at the time we developed our scale. the cosmin is a checklist that was created to measure the methodological quality of studies related to the development of tools. (17). according to the cosmin checklist, previous questionnaires are not valid for assessing dentists' ethical attitudes. the rationale is that ethical attitudes depend on the cultural context of the community. in order to design a questionnaire, it is necessary to bring the cultural concepts of the society and the researcher's views together (18). it is very important to try to evaluate the ethical status of dentists as well. moreover, being aware of the circumstances under which unethical behaviors occur helps to enable dentists, and one way to provide this awareness is the use of valid questionnaires. despite the fact that various questionnaires exist for assessing dentists’ ethical attitude, there is no specific tool for evaluating the attitude of iranian dentists toward ethical codes. therefore, in this article a culture-based scale was designed and validated for evaluating dentists' attitudes according to the needs of the iranian dental community. it is hoped that the ethical attitude of dentists scale (eads) will suit the purpose of monitoring and analyzing dentists’ ethical attitudes in their daily practice. methods study design: the ethical attitude of dentists scale: development and psychometric properties j. med. ethics. hist. med. 2022 (dec); 15:12. 4 this cross-sectional, analytical study was conducted between september 2020 and march 2021 in iran. the aim was to develop a comprehensive scale to assess dentists’ stances on all elements of ethical attitude. this study was based on a mixed‐method design. the first part includes findings from a qualitative study conducted in 2019 on codes of ethics for iranian dentists, the results of which have been published in a previous article (6). the items of the scale were produced based on resources developed by researchers on ethical codes, thus creating a pool of items. in this part, the psychometric analysis was also performed. it should be noted that this scale is completely researcher-made and does not include any items from other questionnaires. participants were informed about the aims of the study according to the statement of research objectives at the beginning of the scale. participation in the study was voluntary, and confidentiality and anonymity of all the obtained data were respected. the questionnaire took approximately 15 minutes to complete, and the data were evaluated only for research purposes. participants: face validity was confirmed by ten dentists working in dental clinics. seven faculty members from the tehran university school of dentistry and three biomedical ethicists who were experts in scale development were invited to evaluate the content validity. item analysis was done by 54 dentists and dental students selected from different clinical settings. three hundred and eleven dentists participated in in exploratory factor analysis (efa), and 200 dentists in confirmatory factor analysis (cfa) from different cities of iran. from different cities of iran. scale validation: assessment of the psychometric properties of the scale was conducted through face, content and construct validity as well as reliability. face validity: face validity only refers to the appearance of the scale from the perspective of the respondents. in the present study, qualitative methods were used for face validity assessment. in the previous study (6), the necessity and importance of the items had been evaluated by expert panels, so we skipped the quantitative face validity. ten dentists were selected through convenience sampling, and faceto-face interviews were conducted. the participants were asked to read the items out loud, and the problematic or ambiguous words were edited and reworded based on their comments. thus, item clarity and comprehensibility were ebadi a., et al. 5 j. med. ethics. hist. med. 2022 (dec); 15: 12. improved by rewording and editing for simplification (19). content validity: we used qualitative and quantitative methods to assess the content validity of the questionnaire. ten experts in dentistry, medical ethics and scale development from the tehran university school of dentistry were invited for this stage. in the qualitative part, the appropriate wording, grammar, items allocation and scaling of the items were assessed, and the scale was edited according to the recommendations (19). the quantitative assessment was done by calculating the content validity ratio (cvr) designed by lawshe for each item. for this purpose, we used the opinions of experts in the field of the scale content. we began by explaining the objectives of the scale to the experts and then asked them to rate each question on a three-point likert scale: 1) essential, 2) useful but not essential, and 3) not essential. based on lawshe’s recommendation, for ten evaluators, a content validity ratio (cvr) value higher than 0.62 was considered appropriate (20). item analysis: items were scored on a five-point likert scale, with a score of 1 indicating “strongly disagree” and a score of 5 indicating “strongly agree”. the scale was distributed to 54 participants. in a pilot study, the internal consistency was assessed before measuring the construct validity in order to indentify the problems in the eads. the cronbach’s alpha and correlation coefficient were calculated. if the correlation coefficient between an item and the whole scale was less than 0.3, the item was deleted. also, if the correlation coefficient between two items was more than 0.7, one of those items was deleted or merged (21). construct validity: factor analysis was used to evaluate the construct validity of the scale. exploratory factor analysis: interpretation of the factor analysis was based on some tests, including the kaiser-meyer-olkin (kmo) test, which was used to determine sampling adequacy. kmo values of 0.7 0.8 and 0.8 0.9 are interpreted as acceptable and indicate large sample sizes. the bartlett’s test of sphericity was used to examine the null hypothesis that the variables are not correlated. in bartlett’s test of sphericity, a significance level of p < 0.05 is acceptable. in order to determine the appropriateness of the factor analysis and the number of factors, scree plot and eigenvalues were used. the "elbow" of the graph where the eigenvalues leveled off was found and factors on the left side of the elbow were retained (22). also, the ethical attitude of dentists scale: development and psychometric properties j. med. ethics. hist. med. 2022 (dec); 15:12. 6 the variance report of each factor and the cumulative variance were calculated by all factors. assignment of at least 50% of the variance of the concept by factors was the basis of judgment (23), and latent factors would be extracted through maximum likelihood .the model with promax rotation had a better fit in terms of item arrangement logic. factor load is the correlation between the item and its hidden factors, and a minimum factor loading of 0.30 was used as the criterion to retain each item (24). finally, the factors were named according to the common meaning of the items, and those that provided the best interpretation were included. study subjects were recruited based on a random sample of 311 dentists (equivalent to 6 people per item. at this stage, the scale consisted of 51 items. the participants were dentists working in dental schools or those on telegram groups of the dental association in different provinces. confirmatory factor analysis: confirmatory factor analysis was done on a sample of 200 dentists who were included similarly using exploratory factor analysis. as the next step, the most common goodness of fit indices were evaluated based on the accepted threshold using confirmatory factor analysis (cfa). the indices included: root mean square error of approximation (rmsea), comparative fit index (cfi), adjusted goodness of fit index (agfi), minimum discrepancy function divided by degrees of freedom (cmin/df), and normed fit index (nfi). cut-off criteria of model fit indices for latent variable models are presented in table 4 (24). reliability: the reliability of the scale was evaluated using internal consistency and assessment of stability over time. this study was carried out on 20 dentists with different levels of employment (including faculty members, private practitioners and charity center dentists). the result of internal consistency assessment was reported as cronbach’s alpha, and values higher than 0.7 were considered to have an acceptable level of reliability (21). stability of the scale over time means obtaining the same results for the same participant if the test is repeated. the important point in the test-retest technique is that the time interval between the two tests be long enough for the subjects to forget the items without the phenomenon changing (21). at this stage, 40 dentists completed the scale twice with a two-week interval. the intraclass correlation coefficient (icc) and pearson’s correlation coefficient between the test and the retest scores were calculated, and values between 0.8 and 0.9 were considered as good reliability (25). responsiveness ebadi a., et al. 7 j. med. ethics. hist. med. 2022 (dec); 15: 12. was also determined by the standard error of measurement (sem) and the minimal detectable change (mdc) (26). the sem indicates whether discrepancy in two tests is real or related to measurement errors. the mdc provides a range of values in which the participant's score is expected to remain at a 95% confidence level without really changing over repetitive tests (27). the percentage of mdc can determine the real relative changes between repeated measurements over time and show the relative amount of random measurement error. an mdc lower than 30% is acceptable, and below 10% excellent (28). it should be mentioned that all the statistical analyses were done using spss 26 and lisrel 8.8. the study was approved by the ethical committee of the research council of tehran university of medical sciences (number: ir.tums.medicine.rec.1397.442), tehran, iran. results a pool of items was generated based on the ethical codes prepared in the previous study (6). the primary pool consisted of 119 items. the research team did their best to choose the clearest and most relevant items in relation with the concept of dentists’ ethical attitude. the item pool was assessed by the research team in 6 sessions. some items were combined, and the final pool included 75 items. a total of 511 dentists completed the scale online. table 1 shows the participants' characteristics during the construct validity assessment. the majority of the respondents were general practitioners (48%), females (58%), and in the age group of 25 35 years (46%). in addition, 37% of the dentists had less than 5 years of work experience. in order to assess the psychometric properties of the eads, its face, content, construct validity and reliability were evaluated. table 1. characteristics of participants (n = 511) characteristics n (%) gender female 295(58) male 216(42) age group ( years) 18-24 93(18) 25-34 356(46) 35-44 111(22) >45 72(14) qualification general dentists 244(48) dental specialist 122(24) postgraduate student 104(20) undergraduate student 41(8) years in practice <5 189(37) 5-10 122(24) >10 159(31) undergraduate student 41(8) the ethical attitude of dentists scale: development and psychometric properties j. med. ethics. hist. med. 2022 (dec); 15:12. 8 table 2. item analysis question number cronbach's alpha coefficient in case of omitting items q1 .898 q2 .899 q3 .899 q4 .896 q5 .900 q6 .897 q7 .897 q8 .897 q9 .896 q10 .898 q11 .898 q12 .899 q13 .898 q14 .897 q15 .907 q16 .898 q17 .897 q18 .897 q19 .902 q20 .895 q21 .895 q22 .898 q23 .899 q24 .896 q25 .897 q26 .897 q27 .896 q28 .912 q29 .896 q30 .896 q31 .899 q32 .895 q33 .897 q34 .899 q35 .897 q36 .896 q37 .899 q38 .897 q39 .899 q40 .895 q41 .895 q42 .897 q43 .899 q44 .898 q45 .896 q46 .894 q47 .896 q48 .896 q49 .896 q50 .899 q51 .897 q52 .898 q53 .895 q54 .896 ebadi a., et al. 9 j. med. ethics. hist. med. 2022 (dec); 15: 12. face validity: regarding qualitative face validity, the wording of 13 items was changed based on the opinions of the studied target group of dentists. content validity: in the content validity sessions, the corrections proposed by the participants were applied in the formulation of the 25 items in a way that they would be clear and simple. the content validity ratio was calculated, and according to the lawshe table, for 10 participants, 22 items that had cvrs lower than 0.62 were not considered necessary, and 54 items were retained. item analysis: cronbach’s alpha was calculated to be 0.899. according to table 2, 3 items (5, 15 and 19) were deleted because they had a correlation of less than 0.3 with the whole scale, and based on the loop method, cronbach's alpha was increased by removing them. construct validity: in factor analysis, the kmo test result was 0.934, which indicated sampling adequacy. moreover, the bartlett’s test of sphericity revealed a significant interrelationship between the items (χ2 value = 2255.27, df = 899, p < 0.001), denoting the appropriateness of the factor analysis model. these results confirmed that factor analysis was appropriate. table 3. factors extracted from factor analysis items load factors maintaining the standing of the profession in relationships var: 32.3% providing dental services while maintaining trust in the profession var: 11.3% providing information for the benefit of the patient var: 4.3% 1. dentists should not accept gifts from patients or pharmaceutical companies because this might influence their professional judgment. they should politely apologize to the donor. .867 2. dentists should not accept or offer rewards and incentives for patient referral. .839 3. if the patient has already been treated by other colleagues, the dentist should make a fair and clear comment on the current status and condition of the patient. .782 4. upon encountering an adverse reaction to the materials and instruments used, dentists should report the matter to relevant authorities. .739 5. dentists should practice according to their professional knowledge and expertise and refer the patients to more skilled colleagues if they lack the required skills. .731 6. dentists should refrain from exaggerating the severity and extent of the disease and should not give their patients false hopes and guarantee of treatment. .720 the ethical attitude of dentists scale: development and psychometric properties j. med. ethics. hist. med. 2022 (dec); 15:12. 10 7. dentists can use commercials and advertisements to gain the patients’ trust and attract them. -.704 8. when a patient is referred to a second dentist for certain treatments, the second dentist should inform the first dentist about the excess treatments and obtain permission. .697 9. when dentists’ abilities are weakened by old age, disease, fatigue, drug use or mental health problems, they should not continue to practice. .687 10. dentists should communicate effectively with the patient through appropriate communication skills. .678 11. in case of referrals, dentists should consider patients' interests and the capabilities of the referral centers. .675 12. dentists should not establish any non-professional relationships with patients irrelevant to the treatment process (including romantic, sexual and occupational relationships as well as social friendships). .608 13. dentists’ comments in various situations, including practice, the social media and the community, should be evidence-based. .585 14. dentists should provide real explanations about treatment options and the materials, instruments and equipment being used, and avoid unrealistic advertising. .577 15. at the request of the patient, the dentist can provide futile services (such as unnecessary cosmetic services). -.545 16. when patients’ interests conflict with those of patients’ companions, other colleagues or dentists, dentists should consider the patients’ interests as a priority. .545 17. if the dentists believe that the people visiting their office or other referral health-care centers are at risk of injury for any reason (lack of hygiene of the practice environment, infectious diseases of the colleagues and staff, or their unprofessional conduct), they should resolve the issues or report the matter to relevant authorities. .542 18. dentists should always try to update their knowledge, skills and performance. .539 19. dentists should listen to their patients’ words and concerns carefully and with empathy. .519 20. if the patient is referred for consultation, the dentist can continue treatment without informing the consulting dentist. -.517 21. dentists should not be involved in direct sales and marketing or make recommendations to buy dental products. .449 22. in case of dealing with organizational regulations contradicting patients’ rights and interests, dentists should provide proper feedback to the related authorities (such as the director of the clinic, etc.). .420 23. dentists should not start treatment without obtaining the patients’ or their legal guardians’ informed consent, except in urgent cases. .922 24. dentists should prioritize the proper care of emergency patients over other patients and politely inform other patients. .851 25. disclosure or nontreatment use of patient information should be done with the patient's permission or by judicial order. .848 26. dentists should not discontinue the treatment of a patient unless the patient wishes it and is fully aware of the consequences. .810 27. dentists should not force patients to make decisions and must give them enough time for decision-making. .800 28. disclosure of patient information by law or judicial orders should be limited to the same case in particular and with the least amount of information disclosure. .785 29. if dentists refrain from visiting a patient, they should not be discriminatory or disrespectful. .764 ebadi a., et al. 11 j. med. ethics. hist. med. 2022 (dec); 15: 12. 30. if a patient has already been treated by a colleague, the dentist should not judge the colleague's social, scientific and practical personality. .721 31. dentists should oblige their staff to observe order and ethics and accept responsibility for their actions. .683 32. dentists should not accept contracts that lead to violation of patients’ rights or disrupt the public trust in professional dentistry. .613 33. during medical consultations, dentists should ask for patients’ permission to disclose their information. .603 34. dentists should keep the relevant and unrelated information about patients' treatment confidential and refrain from disclosing it. .539 35. dentists should consider building trust as a top priority in all professional relationships. .521 36. dentists should place the "patients’ rights charter in iran" where patients/clients can see it and adhere to it. .515 37. dentists should consider their scientific competence and the best interest of patients when cooperating with commercial companies and industrial centers related to the field of dentistry. .483 38. if a dentist makes a mistake during teamwork, he / she should accept the responsibility and compensate for the mistake by offering either free of charge treatment or reimbursement. .461 39. dentists should have a good and respectful relationship with the patients’ companions and provide them with a suitable environment. .459 40. dentists should provide patients with the information necessary to make decisions and explain the advantages and disadvantages of the patients’ choices. .374 41. dentists should guide patients with complete and understandable answers. .605 42. dentists should inform patients of treatment costs in detail. .570 43. dentists should avoid misleading phrases and statements, and never offer inappropriate treatments. .548 44. dentists should make every effort to support the children who are at risk of child abuse. .500 exploratory factor analysis: exploratory factor analysis was performed using the maximum likelihood method to determine the factor structure of the scale. interpretation of factor extraction was based on scree plot diagram and the kaiser criterion for eigenvalue. the “elbow” where the plot drops off was considered in figure 1. regarding factor extraction, the results of the initial analysis were obtained based on the promax rotation. the results listed three factors to explain the dimensions of dentists' ethical attitudes. table 3 shows the eigenvalues and percentages of variance for each item. the factor loadings represent how much of an item is described by a factor. items were allocated to the factors with the greatest factor load, and after promax rotation, the eigenvalues of the three factors were greater than one. results had identified three factors that together account for 48% of the total variance. items that did not explain the main factor variance were identified and removed. there were 7 items that had a weak correlation with the factors or were the ethical attitude of dentists scale: development and psychometric properties j. med. ethics. hist. med. 2022 (dec); 15:12. 12 not clearly loaded on a factor, and therefore, the decision was made to remove them. thus, the revised scale included 44 items reflecting 3 factors. after extracting the factor structure of the eads, the conceptual fitness of the factors with the domains and the sub-domains was re-evaluated, and factors were labelled according to their respective items. table 3 shows the factor structures of the eads. • the first factor had an eigenvalue of 32, included 22 items and was entitled "maintaining the standing of the profession in relationships”. • the second factor had an eigenvalue of 11, included 18 items and was entitled “providing dental services while maintaining trust in the profession”. • the third factor had an eigenvalue of 4, included 4 items and was entitled “providing information for the benefit of the patient”. figure 1. scree plot diagram explaining factors of the eads ebadi a., et al. 13 j. med. ethics. hist. med. 2022 (dec); 15: 12. table 4. accepted threshold of common goodness of fit indices of the model based on cfa. fit index (full name) accepted range results х2 2255.27 df 899 root mean square error of approximation (rmsea) good < 0.08 moderate = 0.08 0.1 weak > 0.1 0.087 standardized root mean square residual (srmr) < 0.1 0.09 parsimonious normed fit index (pnfi) > 0.5 0.85 normed fit index (nfi) > 0.9 0.89 adjusted goodness of fit index (agfi) > 0.8 0.83 goodness of fit index (gfi) > 0.9 0.66 relative fit index (rfi) > 0.9 0.89 incremental fit index (ifi) > 0.9 0.93 comparative fit index (cfi) > 0.9 0.93 minimum discrepancy function divided by degrees of freedom (х2 / df) good < 3 acceptable < 5 2.5 non-normed fit index (nnfi) > 0.9 < 0.93 confirmatory factor analysis: the factor structure extracted by efa was confirmed through cfa. cfa can evaluate the goodness of fit results of factor structure, which can lead to a more accurate and definitive assessment of latent factors. the characteristics of goodness of fit indices of the model are presented in table 4. it should be added that the model indicated a good fit as can be seen in figure 2. reliability: table 5 shows the results of internal consistency (cronbach’s α) and test-retest reliability (intraclass correlation coefficient/icc) of 3 factors and the total scale. cronbach’s alpha was found to be 0.86, and the internal consistency was very good. the results indicated acceptable levels of reliability and repeatability for the scale. the icc between these two tests was 0.897 (0.804 0.945) at the significance level of 0.0001, which confirmed the stability of the scale over time. the ethical attitude of dentists scale: development and psychometric properties j. med. ethics. hist. med. 2022 (dec); 15:12. 14 figure 2. confirmatory factor analysis of the eads (n = 200) ebadi a., et al. 15 j. med. ethics. hist. med. 2022 (dec); 15: 12. table 5. cronbach’s alpha coefficient, intraclass correlation coefficient and standard error of measurement discussion the eads was found to be a reliable and valid scale for assessment of dentists’ ethical attitude. to design this scale, psychometric assessments, including face, content and construct validity, item analysis and reliability were carried out extensively. the final scale consists of three domains. according to the results, the scale has good face and construct validity and very good internal consistency. moreover, the acceptable level of reliability confirmed the stability of the questionnaire over time. in 1976 martin fishbein and icek ajzen developed a theory that predicted how a person would act based on their attitudes and behavioral intentions (29). some studies have reported that the ethical attitudes of health-care professionals are not influenced by ethical codes or oaths, and that the importance of developing a positive attitude in dealing with moral dilemmas is less than claimed (30). continuing education in ethical practice programs can assist dentists in promoting ethics in their profession. even as regulators tighten their oversight procedures, until dentists have a more ethical outlook, strict measures on unethical practices are certainly ineffective. the study findings showed that most of the dentists were acquainted with codes of ethics and patients’ rights (31), but in clinical settings, adherence to ethical codes is repeatedly ignored (7). therefore, there is a gap between knowledge and practice, and attitude can be the missing link in this problem. “the institutional environment, the health-care setting, professional experience, ethical education and accepted social values” have all been shown to influence professional attitude (32). considering the importance of ethical attitude and the need for standardized tools for evaluating it, this study was conducted to provide a standardized, valid and reliable scale for measuring the ethical attitude of dentists. in this study, a standard, valid and reliable selfadministered scale with 44 items was developed. factors cronbach’s alpha icc (intra class correlation) ci=95% sem mdc maintain the standing of profession in relationships .688 .824 .667-.907 2.19 6.06 providing dental services while maintaining trust in the profession .846 .878 .769-.936 1.92 5.31 providing information for the benefit of the patient .689 .786 .599-.886 .55 1.52 total .86 .897 .804-.945 3.42 9.47 the ethical attitude of dentists scale: development and psychometric properties j. med. ethics. hist. med. 2022 (dec); 15:12. 16 the findings indicated that this new scale meets the criteria of an acceptable scale for evaluating ethical attitudes as all items fully cover the concept of ethical codes. in fact, all the necessary items are included in the scale and therefore respondents can accurately reflect their attitudes on the codes. by using this scale, dentists’ attitudes can be studied objectively and fairly, and they can even be improved through interventions. the strength of this study lies in the fact that it is more comprehensive than other scales related to ethical issues, addresses numerous aspects of clinical ethics, and the qualitative part of the study suitably meets the ethical needs of dentists (6). the final version of the eads consists of 44 items on 3 subscales, all of which demonstrated good reliability and validity in the development of a new scale. these three domains comprehensively and completely cover all the ethical duties of dentists. the important question is, what strategies can ensure the fulfillment of those duties, including the observance of ethical codes. the first domain of the eads has 22 items and is related to maintaining the standing of the profession in relationships. it states that dentists should uphold their status and the social standing of the dental profession, and try to preserve the sanctity of the profession through honest practice by observing professional ethics. dental practitioners have professional and ethical responsibilities toward their patients, the public and the profession that enable them to care for patients and serve the community. professional dentists should adhere to ethical values, practice in a scientific manner and consider their own competencies at all times. such conduct will enable dentists to serve the profession over time and maintain their professional authority. the second domain of the eads has 18 items on maintaining trust in the profession, and could help dentists detect and eliminate issues that undermine trust. trust is a shared understanding between people. patients are more likely to confide in dentists who have the capacity to communicate effectively (33). this type of confidence helps to alleviate patients’ anxiety and fear (34), and lack thereof can destroy their faith in the profession (35). although few studies have dealt directly with the issue, the noonan and evans study has shown some factors that comprise trust, including “the ethical standards of dentists, the communication between dentists and patients, and their shared responsibilities of decision-making” (36). the third domain of the eads has 4 items on providing information for the benefit of the patient. in the literature, there is emphasis on providing ebadi a., et al. 17 j. med. ethics. hist. med. 2022 (dec); 15: 12. patients with information. making patients aware of their condition not only improves their psychological and clinical outcome, but also makes the whole process cost-effective. patients are particularly preoccupied with quality assurance and costs. evidence suggests that patients want more detailed information about dental procedures, which can reduce their anxiety levels and inform them to opt for potentially more cost-effective treatments (37). this domain could help dentists develop an effective strategy for expanding such arrangements in the future. most previous ethical assessment questionnaires addressed only a specific topic. for example, gupta et al. measured the ethical attitude of dentists using a researcher-made questionnaire, but only dealt with the subject of informed consent. the sources used to design the questions were not mentioned and the stability of the scale over time and the validity of the structure were not examined (38). reid et al. designed a tool to measure dentists' attitudes regarding the acceptance of gifts, but the process of validation was not mentioned (39). some studies evaluated dentists' ethical attitudes toward international ethical codes and guidelines (13 14) using previous questionnaires without any changes. also, there is one questionnaire that was designed for physicians rather than dentists (12). the strong points of this study are its sequential exploratory mixed-method design, sampling from various cities and a relatively large sample size, and development of a context-bound scale to assess iranian dentists. in the present scale, a significant number of dentists with different specialties or from diverse fields of practice were employed. the eads is not long, and is a user-friendly scale, designed to be clear, practical and comprehensive. due to its simplicity and acceptable validity and reliability, the eads can be used to evaluate the ethical attitude of dentists in different environments, for instance private and academic settings. however, it is not necessarily without flaws. the questionnaires were administered on all social media of dentistry and online platforms to make it more convenient for respondents. the authors explicitly acknowledge that developing, validating and evolving a new scale are lengthy and ongoing processes. furthermore, the eads is a self-declaration scale and therefore also suffers from limitations of such scales. for instance, we did not know to what extent the respondents were honest in answering the questions, and there was no confirmation of the level of subjectivity. moreover, lack of availability of similar studies at the national level and restrictions in its generalizability were other limitations of the study. the ethical attitude of dentists scale: development and psychometric properties j. med. ethics. hist. med. 2022 (dec); 15:12. 18 conclusion in the present study, we tried to provide sufficient information about the process of evaluating the validity and reliability of the ethical attitude of dentists scale. the results showed that the persian version of eads has an acceptable validity and reliability. we hope our scale not only assesses the ethical attitude of dentists, but also raises their ethical sensitivity. this scale can be used to identify areas in need of feedback as well. therefore, due to a lack of valid and reliable scales and in accordance with the cultural conditions of iran, the authors suggest that the psychometric properties of the scale be evaluated in different regions of the country and in diverse statistical communities. the results of the present study can be useful in planning and conducting future research related to ethics in dentistry. this may be a potentially useful scale for research and educational programs to identify ways and policies in order to motivate, develop and maintain ethics in dentists. we hope our scale will not only enhance the attitude assessment process, but also help dentists improve their ethical attitudes. the scale of dentists' ethical attitude has been designed by using qualitative methods, and by performing accreditation processes, has appropriate validity and reliability and can be used in various situations by researchers and dental policy makers. funding this study was part of a phd thesis that was financially supported by the school of medicine, tehran university of medical sciences, tehran, iran. acknowledgements the authors would like to gratefully acknowledge all academic staff and dentists who participated in this study and provided valuable comments. conflict of interests the authors declare no conflict of interests. ebadi a., et al. 19 j. med. ethics. hist. med. 2022 (dec); 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the ethical attitude of dentists scale: development and psychometric properties j. med. ethics. hist. med. 2022 (dec); 15:12. 22 33. epstein rm. virtual physicians, health systems, and the healing relationship. j gen intern med. 2003 may; 18:404-6. 34. yuan s, freeman r, hill k, newton t, humphris g. communication, trust and dental anxiety: a person-centred approach for dental attendance behaviours. dent j (basel). 2020 oct; 8(4): 118. 35. price j, leaver l. abc of psychological medicine: beginning treatment. bmj. 2002 jul; 6;325(7354):33-5 36. noonan as, evans ca. the need for diversity in the health professions. journal of dental education. 2003 sep;67(9):1030-3. 37. ozar d, sokol d, patthoff d. dental ethics at chairside: professional principles and practical applications, .3ed edittionedition, georgetown university press, washington, dc, 2018 :63-65 38. gupta vv, bhat n, asawa k, tak m, bapat s, chaturvedi p. knowledge and attitude toward informed consent among private dental practitioners in bathinda city, punjab, india. osong public health res perspect. 2015 apr;6(2): 73-8. 39. reid k, mueller p, barnes s. attitudes of general dentists regarding the acceptance of gifts and unconventional payments from patients. j am dent assoc .2007 aug;138(8): 1127-33. microsoft word 5 journal of medical ethics and history of medicine the meeting of psychiatry and humanities: an overview shahin akhondzadeh1*, seyed hesameddin abbasi 2 1.psychiatry research center, roozbeh hospital, tehran university of medical sciences, tehran, iran. 2.central hospital, national oil company, tehran, iran. *corresponding author: shahin akhondzadeh address: south kargar street, tehran 13337, iran. tel: (+98) 21 88 28 18 66 fax: (+98) 21 55 41 91 13 e-mail: s.akhond@neda.net received: 20 may 2009 accepted: 29 may 2009 published: 30 may 2009 j med ethics hist med. 2009; 2:5. © 2009 shahin akhondzadeh and seyed hesameddin abbasi; licensee tehran univ. med. sci. abstract keywords: psychiatry, ethics in psychiatric research, humanity. respect for persons medical sciences is for the benefit of human, and one of the first strictures of medicine in general and psychiatry in particular is to do no harm. the psychiatrist-researcher has difficult task of fulfilling both the role of psychiatrist and of researcher, in that order. generally, the first two consideration in studies involving human subjects are “do the ultimate benefits of the research outweigh the risk for those taking the risks?” and “is the potential benefit to mankind sufficient to ask someone to take risks for the benefit of others?” answering either requires some assessment of risks and gains, the risk/benefit ratio. obviously, the goal is to minimize risk and maximize gain (1, 2). a potentially dangerous therapy, for example may be justified to save a life but not to ameliorate a simple anxiety (3). the three basic principles set forth in the belmont report are as follows: 1. respect for persons: a person is entitled to choice, dignity, privacy, and confidentially. respects for persons incorporate at least two basic ethical convictions: first, that individual should be treated as autonomous agents and second, that persons with diminished autonomy and thus need of protection are entitled to such protection (3). 2. beneficence: maximize good/minimize harm. on a practical basis this means that the research effort is to be constructed so as to maximize the anticipated benefit to the subject while minimizing any foreseeable risk. two general concerns regarding ethics of psychiatric research were a critical point in research when lots of news was announced about human rights abuses in the nazi germany. however, even nowadays, psychiatric research involving people suffering from different types of psychiatric disorders can still be distorted and, rather than fulfilling its promise of improved understanding of psychiatric disorder and its treatment, can result in serious harm to patients who participated in these investigations. this review focuses on some important ethical aspects in psychiatric research. j med ethics hist med 2009, 2:5 shahin akhondzadeh and seyed hesameddin abbasi page 2 of 4 (page number not for citation purposes) rules have been formulated as complementary expression of beneficent in this sense: a) do no harm, b) maximize possible benefits and minimize possible harms (4-6). 3. justice: justice requires that we treat persons fairly and give each person what she or he is due or owed. the philosophical underpinnings of the concept of justice are complicated and beyond the scope of this text, but in a practical matter come down to the following: a) there will be no exploitative or coercive recruitment of subjects, and b) those bearing risk of a condition will have a right to participate in and reap benefits of research (1-3, 7). informed consent generating a good consent form is probably one of the most important aspects of one interaction with institutional review board (irb); not providing one is likely to result in delays in the approval process in the form of stipulations. two issues need special consideration in relation to psychiatric research involving people suffering from mental illness (8). firstly, possible inability of the potential research participant to make rational and considered decisions and, secondly, the protection of people subject to legislated involuntary treatment (9, 10). a standard consent form requires the investigator to: a. identify the study as a research study and describe the object and procedures of the study in non technical, easily understood language. b. state that participation is voluntary and can be terminated by the subject at any time without prejudice to subsequent care. c. explain how subjects are selected. d. list of the foreseeable benefit and risks of the study to the subjects. e. ensure confidentiality. f. list alternative therapies g. explain treatment plans for any untoward effects (11-15). the use of a guardian or proxy is controversial because of significant pitfalls. whereas, a proxy’s consent might be necessary if a patient is to receive a medical treatment, whether there is an expected benefit with a medically acknowledgement risk, different factors are opening in entering a research study, where one must assume a certain risk for altruistic reasons; this must be a personal choice (12, 13, 16, 17). subject selection and recruitment subject selection can be even trickier than assessing the risk/benefit ratio. everyone agrees that subjects in human research should be free, uncovered volunteers, fully aware of the study and its risk. sometimes this is much easier to say than to do (14, 15). informing mentally intact medical subjects is largely a matter of defining unfamiliar terms. the task is much more difficult when dealing with individuals with mental illness, and is especially difficult when dealing with children who are mentally ill or retarded. on the other hand, without study, no treatment can ever be devised. clearly, that is evil. imposing a treatment on one individual based upon the consent of another, be illegal guardian or parent, may also be evil. indeed, there really is no general solution to the dilemma. each case is unique and must be assessed separately (15). accordingly, institutional review boards were separated from the investigator. it is difficult task to review assessments of risk/benefit ratios, assure subject anonymity, and assess inclusion and exclusion criteria, recruiting procedures, and adequacy of informed consent. they must also ensure that coercion of any kind, economic, or social, is absent, that provisions are made for subjects to withdraw from the study at will and without prejudice, and that subjects receive medical treatment for any untoward effects (13, 14). drugfree studies, washout studies, and placebo research beyond institutionally mandated ethical principles are ethical problems within experimental protocols. a typical example is whether drug tests should compare a new drug against placebo; against another, therapeutically accepted drug; or against nothing. the first alternative controls for the psychological (and thereby physiological) effects of the new drugs, are using placebo. the second (and most favored by review board) treats both groups but assumes that the comparison drug, at the given dose, is active against the population tested. the third determines if the drug alters the natural course of the disease (17). each of these approaches poses a moral dilemma. in drug placebo studies, the advantage of determining if the drug is better than nothing is offset by leaving one group essentially untreated ( but also spared side effects). the drug-drug comparison has the advantage that both groups are treated but the disadvantage is that neither treatment, for that group, may be better than no treatment. the last has advantage of assessing the drug against the natural course of the disease but again at cost of leaving one group untreated (18, 19). in may 1994 the office for the prevention of research risks (oprr) of the nih reported two complaints against schizophrenia researchers at the university of california-los angeles (ucla). this important study involved a group of patients with schizophrenia who were followed on a fixed dose of prolixin decanoate (a typical j med ethics hist med 2009, 2:5 shahin akhondzadeh and seyed hesameddin abbasi page 3 of 4 (page number not for citation purposes) antipsychotic) for 1 year and then, after a withdrawal protocol, randomized to prolixin versus placebo for up to 1 year, or until psychotic relapse occurred. the study was looking into predictors of successful functioning exclusive of neuroleptic medication. the oprp found that the monitoring of patients was acceptable. however, faults were found with the informed-consent process and with the clinicians’ not being clear that they were also acting as investigators. indeed, one of the research subjects was quoted as saying he was delighted to get into the research program” because i thought i was going to get the premier treatment, while they did a little research on the side”. during this period, one subject experienced a severe relapse and threatened to kill his parents, at one point approaching his mother with a carving knife. one year after leaving the study, a former subject who was drug free but was still being studied by the researchers committed suicide (17-19). there are significant potential ethical pitfalls to be considered in the use of placebo controlled groups, particularly in psychiatric populations. indeed, the declaration of helsinki indicate that every patient including those of a control group, if any, should be assured of the best proven diagnostic and therapeutic method. of particular importance to be considered in the placebo controlled study, and in the use of investigational drugs in general, is the role of the third-party payer. a growing number of insurance companies, particularly in managed care, will not pay for drug therapy intended for investigational use (18). one way to answer whether or not placebo group is ok is to insist that placebo studies be done only when there is no other way to acquire information of vital importance for subjects with particular ailments and conditions. the ethical problems are further compounded by the dilemma of whether to switch all participants to what appears, at the time, to be the most effective treatment. the benefit of not doing so is to obtain further evidence that what seems to be more effective, really is. the drawback is that some patients, for that study, may not receive the better treatment. of course, reality tempers all these considerations. patients often drop out if treatment does not work or, paradoxically, if it works so well they no longer feel the need for treatment. there are no simple solutions to these problems. what is important, however, is awareness that the problems exist and require consideration. fortunately, most studies in psychiatric research involve minimal physical risk or discomfort, and most psychiatrist researcher have sufficient insight into their own motives and feeling to discharge both duties appropriately (18, 20). conclusion mental disorders are highly common conditions with significant morbidity yet only modestly effective treatments. for finding new treatments for major depression, obsessive compulsive disorder, or schizophrenia, for example, the suffering and loss caused by these diseases call for the development of truly novel interventions. investigating new medications can carry risks of significant harm even while raising hopes for future profit (20). in addition, the very nature of many psychiatric disorders creates ethical complexity because many persons with such disorders have deficit memory. if a patient’s cognition impairment is severe enough, she or he will be incompetent to give informed consent for research. publication of patient records; risky experimental use of placebo; scientifically is necessary but dangerous “wash-out” periods in clinical trials; and contribution of potentially defenseless, decisionally “incapable” patients have stimulated argument, threatening the continuation of some psychiatric research activities (10). j med ethics hist med 2009, 2:5 shahin akhondzadeh and seyed hesameddin abbasi page 4 of 4 (page number not for citation purposes) references 1. wettstein rm. research ethics and human subjects. psychiatr res rep 1995; 10: 1–14. 2. eichelman b, wikler d, hartwig a. ethics and psychiatric research: problems and justification. am j psychiatry 1984; 141: 400–5. 3. fulford kw, howse k. ethics of research with psychiatric patients: principles, problems, and the primary responsibilities of researchers. j med ethics 1993; 19: 85–91. 4. oldham jm, haimowitz s, delano sj. protection of persons with mental disorders from research risk: a response to the report of the national bioethics advisory commission. arch gen psychiatry 1999; 56: 688–93. 5. kantor je. ethical issues in psychiatric research and training. in: annual review of psychiatry; vol 13, edited by oldham jm, riba mb. washington, dc: american psychiatric press inc; 1994, pp. 343–64. 6. sider rc. ethics, in core readings in psychiatry: an annotated guide to the literature. 2nd edition, edited by sacks mh, sledge wh, warren c. washington, dc: american psychiatric press inc; 1995. 7. hirschfeld rm, winslade w, krause tl. protecting subjects and fostering research. striking the proper balance. arch gen psychiatry 1997; 54: 121–3. 8.anonymous. principles of informed consent in psychiatry. http://www.psych.org/search.aspx?searchphrase=%22principles+of+informed+consent+in+psychiatry%22 (accessed on 2008) 9. carpenter wt jr, gold jm, lahti ac, et al. decisional capacity for informed consent in schizophrenia research. arch gen psychiatry 2000; 57: 533–8. 10. eichelman b, wikler d, hartwig a. ethics and psychiatric research: problems and justification. am j psychiatry 1984; 141: 400–5. 11. schwartz v, appelbaum ps. improving the quality of informed consent to research. irb 2008; 30: 19-20. 12. appelbaum ps. consent and coercion: research with involuntarily treated persons with mental illness or substance abuse. account res 1995; 4: 69-79. 13. kim sy, appelbaum ps, jeste dv, olin jt. proxy and surrogate consent in geriatric neuropsychiatric research: update and recommendations. am j psychiatry 2004; 161: 797-806. 14. kim sy, appelbaum ps, swan j, et al. determining when impairment constitutes incapacity for informed consent in schizophrenia research. br j psychiatry 2007; 191: 38-43. 15. appelbaum ps, lidz cw, klitzman r. voluntariness of consent to research: a conceptual model. hastings cent rep 2009; 39: 30-9. 16. anonymous. national commission for the protection of human subjects of biomedical and behavioral research: the belmont report: ethical principles and guidelines for the protection of human subjects of research. washington, dc: us government printing office; 1979. 17. anonymous. ethical principles and practices for research involving human participants with mental illness. psychiatr serv 2006; 57: 552-7. 18. miller fg. placebo-controlled trials in psychiatric research: an ethical perspective. biol psychiatry 2000; 47: 707–16. 19. d’souza dc, krystal jh. psychopharmaceutical challenge studies in psychiatric research. int rev psychiatry 2001; 13: 40–6. 20. weijer c. research involving the vulnerable sick. account res 1999; 7: 21–36. microsoft word 12 journal of medical ethics and history of medicine ethical considerations in animal studies mehdi ghasemi1, ahmad reza dehpour2* 1.department of pharmacology, school of medicine, tehran university of medical sciences, tehran, iran. 2.professor of pharmacology, department of pharmacology, school of medicine, tehran university of medical sciences, tehran, iran. *corresponding author: ahmad reza dehpour address: department of pharmacology, school of medicine, tehran university of medical sciences, enghelab sq.,tehran, iran. postal box: 13145-784 tel.: (+98) 21 66 11 28 02 fax: (+98) 21 66 40 25 69 e-mail: dehpour@yahoo.com received: 29 may 2009 accepted: 13 jul 2009 published: 30 jul 2009 j med ethics hist med. 2009; 2: 12. © 2009 mehdi ghasemi and ahmad reza dehpour; licensee tehran univ. med. sci. abstract key words: ethics, code of ethics, ethics in research. introduction ‘‘frankenstein science’’ is a phrase never far from the lips of those who object strongly to some aspects of science or indeed some supposed abuse by scientists (1, 2). we should not, however, forget the powerful obligation there is to undertake, support, and participate in scientific research, particularly biomedical research, and the powerful moral imperative that underpins these obligations. now, it is more imperative than ever to articulate these obligations and to do so is the subject and the object of this paper (1). one of the pivotal issues in scientific research is to consider ethics in animal experimentation. animal research has had a pivotal contribution to a large number of scientific advances of the past century and continues to aid our understanding of various diseases (3-5). additionally, the use of animals in experimental research parallels the development of medicine, which had its roots in ancient greece (aristotle, hippocrate). experiments on animals initially could be performed without great moral problems which were in accordance with the cartesian philosophy in the 17th century. the discovery of anaesthetics and darwin's publication on the “origin of species”, defending the biological similarities between man and animal, contributed to the increase of animal experimentation (68) and this issue besides the increased interest and concern in animal welfare issues led to legislative regula tions in many countries and the establishment of animal ethics committees (6). for instance, it has been reported that approximately 2.7 million scientists undoubtedly owe their great advance and knowledge in biomedical research to millions of animals which they use every year in often‐times extremely painful and distressing scientific procedures. one of the important issues in scientific research is to consider ethics in animal experimentation. since this is a crucial issue in the modern era of medical research, in this paper, we have provided some guidelines (most of which have been adopted from guidelines for ethical conduct in the care and use of animals provided by american association of psychologists) which could be useful for researchers to design studies on a variety of animals. j med ethics hist med 2009, 2:12 mehdi ghasemi and ahmad reza dehpour page 2 of 3 (page number not for citation purposes) regulated animal procedures were conducted in 2003 in the uk half the number performed 30 years ago (4). legislation of animal experimenta tion in modern societies is based on the supposition that this is ethically acceptable when certain more or-less defined formal (e.g. logistical, technical) demands and ethical principles are met (9). the main parameters in this context correspond to the "3rs" concept as defined by russel and burch in 1959, i.e., that all efforts to replace, reduce, and refine experiments must be undertaken (4, 5, 9, 10, 11). the licensing of animal experiments normally requires an ethical evaluation process, often-times undertaken by ethics committees (12, 13). since considering ethics in animal experiments is a crucial issue in the modern era of medical research, in this paper, we have provided some guidelines (most of which have been adopted from guidelines for ethical conduct in the care and use of animals provided by american association of psycholo gists) which could be useful for researchers to design studies on a variety of animals. justification of the research before using animals, it is mandatory for re searchers to clearly clarify their scientific purpose. there should be a reasonable expectation that the research will result in increasing scientific know ledge in different aspects of biomedicine and also will increase understanding of the species under study or provide results that could improve the quality of health or welfare of humans or other animals. the scientific purpose of the research should be of sufficient potential significance to justify the use of animals. the species chosen for study should be the best suited to answer the question(s) posed. moreover, it is noteworthy that good experimental design helps reducing the number of animals used in research since they allow scientists to collect data using the minimum number of animals required. however, a sufficient number must be used to enable precise statistical analysis and results, preventing the repetition of experiments and the consequent need to use more animals (4). personnels and researchers scientists should ensure that all individuals who use animals under their supervision receive explicit instruction in experimental methods and in the care, maintenance, and handling of the species being studied. refining the experimental proce dures themselves and refining the management of pain are the most important issues that researcher should be aware of. they should carefully assess the method of administration, the effects of the substance on the animal, and the amount of handling and restraint required. the researchers should handle the animals carefully and administer appropriate anaesthetics and analgesics during the experiments. these works can help to reduce any pain experienced by the animals during procedures. this culture of care is achieved not only through strict regulations but also by ensuring that animal technicians and other workers understand and adopt such regulations 4, 9, 14, 15). therefore, adequate training is an important aspect of the refinement of animal research, and should conti nually be reviewed and improved (4). care and housing animals all procedures on animals are to be reviewed by a local animal care committee to ensure that the procedures are appropriate and humane. in the event that it is not possible to constitute an appro priate local animal care committee, scientists are encouraged to seek advice from a corresponding committee of a cooperative institution. responsi bilities for the conditions under which animals are kept, both within and outside of the context of active experimentation or teaching, rests with the researcher under the supervision of the animal care committee and with individuals appointed by the institution to oversee animal care. therefore, researchers are encouraged to consider enriching the environments of their laboratory animals. in this regard, legislation in britain, scandinavia and in many european countries has been seemingly efficient and effective because of the relatively small number of research institutions and scientists in those countries (4, 9, 10). however, american scientists are facing three possibilities: mandatory regulation (legislation), self-regulation, or some combination of both. self-regulation of animal experimentation appears to be the optimal choice. it would reflect the success of animal protection groups in raising the consciousness and concerns of scientists about the humane treatment of experi mental animals: (1) reducing the numbers of animals used for experimentation, (2) unnecessary duplication of experiments, and (3) minimizing pain and distress. although scientists are proceed ing toward a program(s) of self-regulation, this approach will be based on the scientific method and will not satisfy completely the differences between scientific and animal protection groups (4, 5, 10, 14). experimental procedures humane consideration for the well-being of the animal should be incorporated into the design and conduct of all procedures involving animals. surgical procedures require close supervision and attention to humane considerations by the scientist. aseptic techniques must be used on laboratory animals whenever possible. all surgical procedures j med ethics hist med 2009, 2:12 mehdi ghasemi and ahmad reza dehpour page 3 of 3 (page number not for citation purposes) and anesthetization should be conducted under the direct supervision of a person who is competent in the use of the procedures. if the surgical procedure is likely to cause greater discomfort than that attending anesthetization, and, unless there is specific justification for acting otherwise, animals should be maintained under anesthesia until the procedure is ended. animals cannot be subjected to successive surgical procedures unless these are required by the nature of the research, the nature of the surgery, or for the well-being of the animal. multiple surgeries on the same animal must receive special approval from the animal care committee. conclusion millions of animals are used every year in many extremely painful and distressing scientific procedures. legislation of animal experimentation in modern societies is based on the supposition that this is ethically acceptable when certain more-or less defined formal (e.g. logistical, technical) demands and ethical principles are met. in this paper, we gathered some guidelines for using animals in medical research which could be useful for researchers to design their studies on a variety of animals. references 1. harris j. scientific research is a moral duty. j med ethics 2005; 31(4): 242-8. 2. williams c, kitzinger j, henderson l. envisaging the embryo in stem cell research: rhetorical strategies and media reporting of the ethical debates. sociol health illn 2003; 5: 783-814. 3. degrazia d. regarding animals: mental life, moral status, and use in biomedical research: an introduction to the special issue. theor med bioeth 2006; 27: 277-84. 4. festing s, wilkinson r. the ethics of animal research: talking point on the use of animals in scientific research. embo rep 2007; 8(6): 526-30. 5. foex ba. the ethics of animal experimentation. emerg med j 2007; 24: 750-1. 6. baumans v. use of animals in experimental research: an ethical dilemma? gene ther 2004; 11 suppl 1: s64-6. 7. baumans v. science-based assessment of animal welfare: laboratory animals. rev sci tech 2005; 24: 503-13. 8. bernstein m. marginal cases and moral relevance. j soc philos 2002; 33(4): 523-39. 9. kolar r. animal experimentation. sci eng ethics 2006; 12(1): 111-22. 10. sechzer ja. historical issues concerning animal experimentation in the united states. soc sci med f 1981; 15(1): 13-7. 11. thompson pb. animal biotechnology: how not to presume. am j bioeth 2008; 8(6): 49-50. 12. weatherall d. animal research: the debate continues. lancet 2007; 369(9568): 1147-8. 13. weatherall d, munn h. animal research: the debate continues. j intern med 2007; 262(6): 591-2. 14. kaminsky c, peppin rj. ethical treatment of animals in research. j acoust soc am 2003; 113(1): 32-3. 15. phaosavasdi s, thaneepanichskul s, tannirandorn y, et al. animals and ethics. j med assoc thai 2005; 88(2): 287-93. microsoft word 10 journal of medical ethics and history of medicine a brief history of enviroethics and its challenges marjan laal specialist of general surgery, sina trauma and surgery research center, tehran university of medical sciences, tehran, iran. *corresponding author: marjan laal address: sina trauma and surgery research center, sina hospital, hassan abad sq., hafez st., tehran, iran. postal box: 11365/3876 tel:(+98) 21 66 71 74 22 received: 16 may 2009 accepted: 23 may 2009 published: 09 jun 2009 j med ethics hist med. 2009; 2:10. © 2009 marjan laal; licensee tehran univ. med. sci. abstract keywords: ethics, environment, health, crises. introduction enviroethics or environmental ethics (ee) is a part of environmental philosophy that extends the traditional boundaries of ethics from only including humans to including the non-human world. it has come to exert significant influence over a number of human science disciplines including theology, law, economics, sociology, ecology, and geography in relation to sustainability and human well-being (1). ee studies the moral relationship of human beings to the environment and its contents (2). traditional western ethical views are human centered or anthropocentric (3). anthropocentrism simply places humans at the centre of the universe; therefore, everything else in existence should be evaluated in terms of its utility for us. all environmental studies should include an assessment of the intrinsic value of non-human beings (4). environmental ethics has emerged during the early 1970s, when environmentalists started urging philosophers to consider the philosophical aspects of environmental problems. environmental ethics considers the ethical relationships between humanity and non‐human world. the union of concerned scientists, a group of over two thousands scientists, has concluded that climatic change is beyond dispute, and already changing our environment. environmental instability portend ill for public health and well‐being. this paper attempts to apply ethical theories to support environmental concerns and provides moral grounds to preserve the earth's environment. this article documents consensus among environmental philosophers as given by synthesis data provided via survey among articles, websites, and books by the keywords: environment, ethics, health and crises. the field has come to exert significant influence over a large number of human science disciplines in relation to environmental sustainability and human wellbeing. environmental ethics focuses on the possibility of the identification of human ego with nature, means the larger ecological self deserves respect, too. environmental ethics expands the boundaries of ethics to include the nature and considers its sustainability to ensure human wellbeing. this study emphasizes mainly on a brief history of environmental ethics and its protection against damage. environmental changes and extreme weather events in plus to species distinction and a growth of diseases are impossible to hide and ought to be impossible to ignore. the health decline associated with various forms of these changes is continuing. it raises crucial issues about environmental justice. j med ethics hist med 2009, 2:10 marjan laal page 2 of 5 (page number not for citation purposes) therefore, ee as a branch of environmental philosophy considers the actual and possible ethical relationships between humanity and non-human nature. considering questions such as our obligation to future generations, to other species and even non-living aspects of the natural world are among questions investigated by the field (5). purpose this paper attempts to apply traditional ethical theories to support environmental concerns. it provides moral grounds to preserve the earth's environment and describes the field landscape of ee. material and methods data for this article is based on scientific consensus among various theories and theses for the field and surveys opinion of environmentalists via search by the keywords as: environment, ethics and crises. this article contributes the appearance of ee and challenge of the field. inclusion and exclusion criteria: data entry contained the common agreement between environmentalists. describing various positions individually not included. results although nature was the focus of much nineteenth and twentieth century philosophy, contemporary ee only emerged as an academic discipline in the 1970s (4). the academic field of ee grew up in response to the work of scientists such as rachel carson (6) and events such as the first earth day in 1970, when environmentalists started urging philosophers to consider the philosophical aspects of environmental problems. the earth day celebrated april 22, is a day designed to inspire awareness and appreciation for the earth's environment (7). among the accessible work that drew attention to a sense of crisis was rachel carson's silent spring (8), which consisted of a number of essays earlier published in the new yorker magazine. more recently, silent spring was named one of the 25 greatest science books of all time by the editors of discover magazine (9). the main challenge of ee is anthropocentrism (i.e., human-centeredness). for example, aristotle maintains that “nature has made all things specifically for the sake of man” and that the value of nonhuman things in nature is merely instrumental (3). in the literature on ee the distinction between instrumental value and intrinsic value has been of considerable importance. instrumental value is the value of things as means to further some other ends, whereas intrinsic value is the value of things as ends in them regardless of whether they are also useful as means to other ends, a kind of value independent of its usefulness for others. for example, we can consider a person who teaches others. it is normally said that a person, as a person, has intrinsic values, i.e., values in his or her own right independently of his or her prospects for serving the ends of others. in addition to such values, the teacher has instrumental value for those who want to acquire knowledge. alternatively, we can suppose the nature as the creature of god, which is itself intrinsically valuable (or sacred) despite the state of being beneficial for us and ought to be respected. it is commonly agreed that something's asset of intrinsic value generates a direct moral duty on the part of moral agents to protect it or at least avoid to damage it (10-13). all environmental studies should include an assessment of the intrinsic value of non-human beings. despite the variety of positions in ee, they have focused mainly on issues concerned with wilderness and the reasons for its preservation (14 16). the importance of wilderness experience to the human psyche has been emphasized by many environmental philosophers. some encourage us to spend time dwelling in situations of intrinsic value (17). likewise, the critical theorists believe that aesthetic appreciation of nature has the power to re enchant human life (18). rolston seeks re-creation of the human soul by meditating in the wilderness (19, 20). the focus on the value of wilderness and the importance of its preservation has overlooked another important problem – namely that lifestyles in which enthusiasms for nature rambles, woodland meditations or mountaineering can be indulged demand a standard of living that is far beyond the dreams of most of the world’s population. discussion the questioning and rethinking of the relationship of human beings with the natural environment over the last thirty years reflected an already widespread perception in the 1960s that the late twentieth century faced a serious environmental crisis. national and international science academies and professional societies have assessed the current scientific opinion on climate change (cc). these assessments have largely followed or endorsed the intergovernmental panel on climate change (ipcc) position that "an increasing body of observations gives a collective picture of a warming world and other changes in the climate system”. there is new and stronger evidence that most of the changes observed over the last 50 years are attributable to human activities (21). scientific consensus is that the increase in environmental crises observed since the start of the industrial era (22, 23). j med ethics hist med 2009, 2:10 marjan laal page 3 of 5 (page number not for citation purposes) cc is the most serious problem we face in 21st century. air pollutants, which had stood at the safe baseline for 10,000 years, were today having caused global temperatures to increase, sea levels to rise several centimeters, dry areas to become even drier and wet areas to get still wetter (24). the predicted effects of cc on the environment and for human life are numerous and varied. drought, changing weather patterns, the expected burden of caring for environmental refugees, the effects of consumerism, and the health decline associated with various forms of pollution are continuing and major problems for human beings themselves (2527), and raise crucial issues about environmental justice (28). at the same time, the continuing destruction of natural environments and the widespread loss of both plant and animal species pose increasing problems for other forms of life on the planet. climate instability portend ill for public health and well-being. cc encompasses temperature changes on global, regional and local scales, and changes in the rainfall, winds, and possibly ocean currents (29). any deliberate attempt to reach a rational and enduring state of equilibrium by planned measures, rather than by chance or catastrophe, must ultimately be founded on a basic change of values and goals at individual, national and world levels (30). the call for a basic change of values in connection to the environment (a call that could be interpreted in terms of either instrumental or intrinsic values) reflected a need for the development of ee as a new sub-discipline of philosophy, therefore, the field emerged in the early 1970s, when environmentalists and philosophers began to consider the philosophical aspects of environmental problems and ee became a subject of sustained academic philosophic reflection. from the ee viewpoint, individual interests and well-being should be subordinated to the holistic good of the earth's biotic community. a thing is right when it tends to preserve the integrity, stability, and beauty of the biotic community. it is wrong when it tends otherwise. the land as a community is the basic concept of ecology, but that land is to be loved and respected as an extension of ethics (31-34). new evidence of environment change suggests it could be serious, and the greatest danger that civilization has faced so far. it is a warning of worse to come (35). resistance and resilience strategies to unavoidable impacts can be built into development planning and policies (36, 37). unicef notes that environmental changes will reduce access to clean water and food supplies, particularly in africa and asia. disasters, violence and disease are expected to be more frequent and intense, making the future of the world's poorest children bleaker (38). increases in catastrophes resulting from extreme weather are mainly caused by increasing population densities, and anticipated future increases are similarly dominated by societal change rather than cc (39). in this way, to protect our environment and consequently our well-being, ee came to focus on the possibility of the identification of the human ego with nature. the idea is, briefly, that by identifying with nature i can enlarge the boundaries of the self beyond my skin. my larger ecological self (the capital “s” emphasizes that i am something larger than my body and consciousness), deserves respect as well. to respect and to care for my self is also to respect and to care for the natural environment, which is actually part of me and with which i should identify. “self-realization”, in other words, is the reconnection of the shriveled human individual with the wider natural environment (40). interdisciplinary approaches link ee with biology, policy studies, public administration, political theory, cultural history, post-colonial theory, literature, geography, and human ecology (41-45). conclusion the academic field of ee developed when philosophers started considering the philosophical aspects of environmental problems. ee became a subject of sustained academic philosophic reflection in the 1970s. from anthropocentric view we tend to evaluate things wrongly in terms of their usefulness to further us, that humans are at the center of reality, and it is right for them to be so. ee discovers that everything has a unique value and that the nonhuman environment as well as human has intrinsic value. no single discipline could claim sole ownership of those quandaries we now face about the origins of modern environmental crisis and the relation between environmental problems and social injustice, and that how human beings should relate to the natural environment regarding to happiness and well-being. in facing these problems, there will likely be great opportunities for co-operation and synergy between philosophers and both natural and social scientists. finally, a person with day-to-day non anthropocentric thinking acts more benignly towards the nonhuman environment on which his or h e r we l l -being d ep e nd s . this wo u l d provide reason for encouraging non anthropocentric thinking. j med ethics hist med 2009, 2:10 marjan laal page 4 of 5 (page number not for citation purposes) references 1. anonymous. environmental ethics. a. http://en.wikipedia.org/wiki/environmental_ethics-97k (accessed on 2008) 2. brennan a. stanford encyclopedia of philosophy. a. http://plato.stanford.edu/entries/ethics-environmental (accessed on 2008) 3. aristotle. politics. translated by barker e. oxford: oxford university press; 1948. 4. singer p. environmental values. oxford: oxford university press 1991; 12-16. 5. anonymous. environmental ethics and sustainability. www.oneplanetinstitute.com/maenvethics.html (accessed on 2009) 6. anonymous. rachel carson. http://en.wikipedia.org/wiki/rachel_carson -138k (accessed on 2009) 7. anonymous. earth day. http://en.wikipedia.org/wiki/earth_day (accessed on 2009) 8. carson r. silent spring. london: hamish hamilton; 1963. 9. anonymous. discover magazine. http://en.wikipedia.org/wiki/discover_ (magazine) 32k (accessed on 2009) 10. callicott jb. intrinsic value in nature: a meta ethical analysis. the electronic journal of analytic philosophy 1995; (3). 11. o'neill j. the varieties of intrinsic value. monist 1992; 75: 119-37. 12. jamieson d. morality's progress: essays on humans, other animals, and the rest of nature. oxford: clarendon press; 2002. 13. schönfeld m. introduction to justifying value in nature. the electronic journal of analytic philosophy 1995; (3). 14. callicott jb. beyond the land ethic: more essays in environmental philosophy. albany: suny press; 1999. 15. callicot jb, ames rt. nature in asian traditions of thought. albany: state university of new york press; 1989. 16. callicott jb. in defense of the land ethic: essays in environmental philosophy. albany: suny press; 1989. 17. næss a. ecology community, lifestyle. translated and editted by rothenberg d. cambridge: cambridge university press; 1989. 18. sapontzis sf. the nature of the value of nature. the electronic journal of analytic philosophy 1995; (3). 19. rolston h. philosophy gone wild. new york: prometheus books; 1989. 20. rolston h. feeding people versus saving nature? in aiken w, lafollette h, eds. world hunger and morality. englewood cliffs: prentice hall; 1996, pp. 248-67. 21.anonymous. ipcc, intergovernmental panel on climate change. http://en.wikipedia.org/wiki/scientific_opinion_on_climate_change (accessed on 2007) 22. anonymous. the science of climate change. http://royalsociety.org/displaypagedoc.asp?id=13619 (accessed on 2009) 23. anonymous. rising to the climate challenge. nature 2007; 449 (7164): 755. 24.anonymous. global warming: background. www.eartheasy.com/article_global_warming_background.htm (accessed on 2009) 25. henry s. climate. editted by jamieson d. malden ma: blackwell press; 2001, pp. 11–20. 26. thompson pb, hannah w. advances in biochemical engineering/biotechnology, heidelberg :springer berlin press; 2008; pp. 229-64. 27. thompson pb. land and water. sci eng ethics 2000; 6 (2): 275-8. 28. shrader-frechette k. environmental justice: creating equality, reclaiming democracy. oxford: oxford university press; 2002. 29. chan ny, ebi kl. smith f, wilson tf, smith ae. an integrated assessment framework for climate change and infectious diseases. environ health perspect 1999; 107 (5): 329-37. 30. eckersley r. environmentalism and political theory. london: ucl press; 1992. 31. norton b. toward unity among environmentalists. new york: oxford university press; 1991. 32. leopold a. a sand county almanac. oxford: oxford university press; 1949, pp. 224-5. 33. nash r. the rights of nature: a history of environmental ethics. madison, wi: university of wisconsin press; 1989. j med ethics hist med 2009, 2:10 marjan laal page 5 of 5 (page number not for citation purposes) 34. norton b. ethics on the ark: zoos, animal welfare, and wildlife conservation. washington: smithsonian institution press; 1995. 35.anonymous. global warming 'biggest threat'. http:// news.bbc.co.uk/1/hi/sci/tech/3381425.stm (accessed on 2009) 36. anonymous. climate and adaptation. www.worldwildlife.org/climate/whyitmatters.html(accessed on 2009) 37. pielke jr ra, gratz j, landsea cw, collins d, saunders m, musulin r. normalized hurricane damage in the united states: 1900–2005. natural hazards rev 2008; 9 (1): 29–42. 38.anonymous. the tragic consequences of climate change for the world's children. www.unicef.org.uk/press/news_detail_full_story.asp?news_id=1120 (accessed on 2009) 39. rousseau jj, butterworth ce. the reveries of the solitary walker. translated by france p. usa: penguin classics press; 1979. 40.boseley s. health hazards. www.guardian.co.uk/environment/2005/jun/30/climatechange.climatechangeenvironment4 (accessed on 2009). j med ethics hist med 2009, 2:10 marjan laal page 6 of 5 (page number not for citation purposes) 1. shrader-frechette k. science policy, ethics and economic methodology. dordrecht: d reidel; 1984. 2. gruen l, jamieson d. reflecting on nature. new york: oxford university press; 1994. 3. karliner j. the corporate planet. san francisco: sierra club books; 1997. 4. diesendorf m, hamilton c. human ecology, human economy. st leonards, nsw: allen and unwin; 1997. 5. schmidtz d, willott e. environmental ethics: what really matters, what really works. new york: oxford university press; 2002. jmehm-7-1 journal of medical ethics and history of medicine applying professional values: the perspective of nurses of isfahan hospitals mohsen shahriari1, elahe baloochestani2* 1 assistant professor, nursing and midwifery research center, faculty of nursing and midwifery, isfahan university of medical sciences, isfahan, iran; 2 msc, department of operating room nursing, faculty of nursing and midwifery, isfahan university of medical sciences, isfahan, iran. corresponding author: elahe baloochestani address: isfahan university of medical sciences, faculty of nursing and midwifery, department of surgery email: e_baloochestani@nm.mui.ac.ir tel: 98 0311 7922950 fax: 98 03116699968 received: 30 jun 2013 accepted: 17 dec 2013 published: 6 jan 2014 j med ethics hist med, 2014, 7:1 © 2014 mohsen shahriari et al.; license tehran univ. med. sci. abstract applying professional values is an important issue in nursing practice. it is also crucial to find out nurses’ perspectives toward ethical and professional values in the clinical environment. for this purpose, we aimed to utilize a standard tool to survey perspectives on applying these values in nursing care in hospitals of isfahan, iran. this is a descriptive-analytical study in which 150 nurses working in hospitals of isfahan, iran in 2010 were recruited by quota convenience sampling, and their perspectives on professional values were assessed. data were collected by the nurses professional values scale (npvs) and analyzed using spss software version 16 applying descriptive and interpretive statistics. in the present study, 84% of the participants were female and 88% had bachelor's degree in nursing. the average age was 34.2 (sd=7.3), and the average years of working in a hospital were 11 (sd=7.3). no significant association was present between demographic characteristics such as age, sex, educational level or work records and applying professional and ethical values. results also demonstrated that respect for professional values is similar among nurses of different employment types. in this study, we addressed the most and the less important professional values specified by nurses with different types of employment and also different experiences. iranian nurses believe in respecting the legal and ethical rights of patients as the most prominent value in the nursing profession. we suggest that these professional values be specified and assessed based on iranian culture. keywords: professional values, ethics, nurses mailto:e_baloochestani@nm.mui.ac.ir j med ethics hist med 7:1 jan, 2014 jmehm.tums.ac.ir mohsen shahriari et al. page 2 of 7 (page number not for citation purposes) introduction nursing science is engaged in practice-based roles and highlights the importance of professional values which have been founded on specific human values (1). nursing is a combination of knowledge and skills for an effective professional care (2). by regarding ethics as a form of knowledge, nurses can develop their professional values. these values are the standards for action and also provide a framework for evaluation (3). nurses are expected to be aware of the ethical dimensions of nursing practice and apply them in their work (4). ethical principles are among the fundamentals of nursing, so any form of care should meet patients’ rights based on these standards (4). nurses are expected to provide physical, social, and psychological care (5) that should be moral and ethical as well. the new rapid changes caused by technology can influence these values (6), and therefore professional and ethical standards must be set to fulfil professional obligations (3) new evidence has shown that these standards and values are not fully respected by most of the nurses (7). on the other hand, it should be considered that nurses face complex professional and ethical issues in their workplace, such as different levels of personnel, developments in technology, and budget constraints (8, 9). they face many professional challenges while interacting with clients and organizations so they need to deal with them professionally to provide care with confidence and peace of mind (10) because of the moral and ethical sensitivity of their job (2, 11). if nurses do not engage actively with these daily ethical issues, they will fail to deliver the optimum standard of care (12). many situations in nursing practice have a potential for ethical dilemmas. to respond effectively to these dilemmas, nurses should have knowledge of their professional values (13). nursing values influence nurses’ goals, strategies and actions. they can be considered as resources to guide nurses when involved with ethical challenges (14, 15). among some studies on nurses’ professional values, mcneese-smith and crook stated that knowledge about these values can improve nurses’ practice, assist in team performance and cohesion, and aid in performance of counselling. these are all traits of the nursing profession that require attention (16). chitty and black introduced some of the professional and ethical values from the nurses’ perspective such as: accountability and responsibility for own actions, balancing cure and care, benevolence, caring as a foundation for relationships, collaborative multidisciplinary practice, compassion, and competence (17). in nursing education, studies have shown that professional values and moral ideals of nurses in the clinical environment are often considered as dilemmas (18). however, in some cases nurses have shown a poor ethical performance. tefagh et al. assessed observation of professional ethics regarding medication and found out that most of the participants had a poor performance in medication process and respecting values (19). arzani et al. aimed to evaluate nurses’ respect for professional and ethical values from their own perspective. they found that only 40% of nurses fully consider these values in their practice (20). applying professional and ethical values in nursing is an important subject which has been neglected for many reasons. nurses will face dilemmas, not only in nursing care, but also in relation to other health professions, their work place, and their own profession. among the barriers in applying professional ethics, however, most of the challenges are mainly about the nursepatient interaction (21). in addition to finding and implementing strategies to enhance nurses’ ability in ethical care, it is recommended to survey their perspective about applying ethical values in their profession. therefore, this study was designed with the aim of evaluating nurses’ perspective on applying professional values in isfahan hospitals in 2010. method this is a descriptive-analytical study that was conducted in selected hospitals in isfahan to survey application of professional values from nurses’ perspective. the hospitals in this study consisted of four educational hospitals, two hospitals affiliated to the social security organization, and two private hospitals. study samples were nurses in all roles who met the cited inclusion criteria of having a nursing bachelor’s degree or higher, were listed in the category of formal nurse, contract nurse, corporate nurse, and planed nurses, were of iranian descent, and had graduated from official universities of iran. according to the number of nurses in each hospital that was assigned as a research area, and also based on the intended sample size of 250 nurses, a quota was determined for each study area in sampling method. all the questionnaires were given to the nurses in different shifts with prior coordination with the director of nursing. at first, permission from the research committee of the iranian nursing organization was obtained and offered to the hospital authorities. then, the aim of the study was explained to the subjects and their informed consent was obtained. since an interval was needed to take back the questionnaire, it was adjusted with the subjects at first. data were collected using a two-part questionnaire, including demographic characteristics and j med ethics hist med 7:1 jan, 2014 jmehm.tums.ac.ir mohsen shahriari et al. page 3 of 7 (page number not for citation purposes) professional values data. the first part was a researcher made tool for gathering the demographic data of participants, and the second part was a standard tool titled “nursing professional values scale (npvs)”. weis and schank have designed and used this instrument in a study with the aim of describing nurses’ professional values (13). this scale includes 26 items; each item in this scale is a short descriptive phrase reflecting a specific code of ethics from the american nursing association in 1985. this is a norm referenced with likert type format ranging from 1 (not important) to 5 (most important), and ranges above 3 indicate strong professional orientation. the possible range of score is 26 to 150, and therefore scores above 78 were considered as respecting professional and ethical values. the reliability and validity of this questionnaire was approved by weis and schank measuring the cronbach's alpha coefficient of 0.94 by using pre-test post-test method (22). in another study by martin et al. performed on 1366 participants, cronbach's alpha was 0.95. the content validity was established by experts in the field of ethics (23). in a study by parvan et al. in iran, the reliability of this tool was approved with a cronbach's alpha that was 91% (24). in the present study, due to cultural differences, the questionnaire was translated into persian and sent to six ethics experts for content validity. with a few changes, it was translated back into english. of the 250 distributed questionnaires, 162 were returned, whereas 12 were not fully completed. therefore, 150 questionnaires were analyzed by means of the statistical software spss version 16. to determine the relationship between gender, level of education, work experience, different categories of employment, and place of employment and professional values, pearson correlation, independent t-test and anova test were applied. to show the relation between age and score of professional values, spearman correlation test was used. results in this study, of the 150 participants, 84% were females and 88% had bachelor degree in nursing. the mean age was 34.2 (sd=7.3), and the average years of employment as a nurse was 11 (sd=7.9) years. no significant association was found between demographic characteristics such as nurses’ age (p = 0.975), gender (p= 0.169), education (p= 0.150), and work records (p= 0.148) and their perspective on applying professional ethical values (table 1). table 1 correlation of demographic characteristics and scores of professional values demographic characteristics number frequency (%) score for profession-al ethics (mean) p value age(year) >30 59 39.3 4.02 0.878 30 to 40 60 40 3.97 <40 31 20.7 3.03 sex male 24 16 4 0.169 female 126 84 4.06 education bs 144 96 4.02 0.558 ms 2 1.3 4.48 phd 1 0.7 4.46 work records (year) >5 52 34.7 3.9 0.384 5 to15 60 40 3.98 15 to 25 27 18 4.16 <25 11 7.3 4.05 type of employment formal 47 31.3 4.12 0.103 contract 23 15.3 3.98 corporate 53 35.3 3.99 planned nurse 17 11.3 3.84 bs= bachelor degree; ms= master of science; phd= doctor of philosophy. the mean of professional values score among participants was 101.53 (sd=18.12), and considering the standard average of values score that is 78 for this questionnaire, it can be concluded that all the participants had a positive perspective toward applying professional values in nursing practice. no significant association was found between variables such as the type of hospital nurses’ position (p= 0.258) and the type of their employment (p= 0.196) and applying nursing professional values. there was no significant association between samples’ employment types and applying professional values. the most prominent criteria of professional values that were noted by nurses were: protecting the health and safety of the public (mean j med ethics hist med 7:1 jan, 2014 jmehm.tums.ac.ir mohsen shahriari et al. page 4 of 7 (page number not for citation purposes) = 4.35), protecting the moral and legal rights of patients (mean = 4.21), practice guided by principles of fidelity and respecting individuals (mean = 4.13), and respecting patients' right to privacy (mean = 4.33) (table 2). table 2 professional values according to the assessment scale sd mean most important very important important somewhat important not important nurses professional values 1.12 3.65 30.6 25 28.5 13.2 2.8 engage in on-going self-evaluation 1.02 3.84 30.7 36.7 21.8 8.8 2 request consultation /collaboration when unable to meet patient needs 0.96 4.35 62.2 18.9 12.8 5.4 0.7 protect health and safety of the public 1.02 3.15 14.4 20.5 37.7 20.5 6.8 participate in public policy affecting distribution of resources 1 4.04 41.8 31.5 17.8 8.2 0.7 participate in peer review 0.96 4.13 44.9 32.7 16.3 4.8 1.4 establish standards as a guide for practice 0.96 3.97 35.9 34.5 22.1 6.9 0.7 promote and maintain standards where planned learning activities for students take place 1 4.02 38.6 39.3 11 9.7 1.49 initiate actions to improve environments of practice 1.06 4.01 42.2 31.3 15 10.2 1.4 seek additional education to update knowledge and skills 1 3.88 32.2 34.9 22.6 8.9 1.4 advance the profession through active involvement in health related activities 1.11 3.56 23.1 32 26.5 14.3 4.1 recognize role of professional nursing associations in shaping health care policy 1.07 3.91 36.3 36.3 15.1 9.6 2.7 promote equitable access to nursing and health care 1.07 3.74 28.8 35.6 21.2 11.6 2.7 assume responsibility for meeting health needs of the culturally diverse population .097 3.91 34.2 34.9 21.2 8.9 0.7 accept responsibility and accountability for own practice 0.93 4.05 37.2 42.8 12.4 6.2 1.4 maintain competency in area of practice 0.94 4.21 53.2 30.2 11.5 4.3 0.7 protect moral and legal rights of patients 1.13 3.77 34.3 31.4 17.5 11.7 5.1 refuse to participate in care if in ethical opposition to own professional values j med ethics hist med 7:1 jan, 2014 jmehm.tums.ac.ir mohsen shahriari et al. page 5 of 7 (page number not for citation purposes) 0.91 4.13 46.4 32.1 15.7 5 0.7 act as a patient advocate 1 3.87 30.5 38.3 19.9 8.5 2.8 participate in nursing research and/or implement research findings appropriate to practice 1.07 3.85 35.5 33.3 17.7 11.3 2.1 provide care without prejudice to patients of varying lifestyles 0.95 3.87 31.2 36.9 23.4 7.1 1.4 safeguard patient's right to privacy 1.02 3.68 23 41 20.1 13.7 2.2 confront practitioners with questionable or inappropriate practice 0.93 3.91 31.4 41.6 19 6.6 1.5 protect rights of partici-pants in research 0.91 4.13 42.6 39 12.1 5 1.4 practice guided by principles of fidelity and respect for person 0.97 4.33 62.9 25.7 5.7 4.3 1.4 maintain confidentiality of patient 1.15 3.60 27.1 30.7 25 10.7 6.4 participate in activities of professional nursing associations discussion the overall results indicated that no significant association was present between demographic characteristics such as age, gender, education, and nurses’ work records and the nurses’ perspective on applying professional values. some other studies have reached the same result as well. leduc and kotzer aimed to use npvs as an instrument to evaluate nurses’ perspective on applying professional ethical values in nursing students, newly graduated nurses, and seasoned professionals. they came to the conclusion that these three groups of nurses are the same in applying professional values. therefore, the claim that nursing experience can be effective in promoting professional values was not approved (25). in their study, lynn et al. have found no significant difference between the professional and ethical values of senior baccalaureate and associate degree nursing students (26). the similarity between the results of this study and other studies in this area shows that people who choose nursing as their job consider ethical values among the important and essential fundamentals of their profession. the results of this study revealed that the association between age and nurses’ perspective on applying professional values is reversed. it might mean that as the nurses get older, their respect for professional values will be decreased, although some studies have shown that no significant association is present between professional values scores and age of the samples (23). in their study, parvan et.al have shown a significant negative correlation between age and the total score of values in nursing students. this means that as the nurses grow older, their respect for professional and ethical values decreases (24). the most prominent criteria of professional ethics in this study were: protecting the health and safety of people, respecting the moral and legal rights of patients, practice guided by principles of fidelity and respecting individuals, and protecting patients' right to privacy. shih et al. found out, however, that the most important criteria according to the perspective of nurses in taiwan are: caring for clients with a humanistic spirit, providing professionally competent and holistic care, fostering growth and discovering the meaning of life, experiencing the ‘give-and-take’ of caring for others, receiving fair compensation, and raising the public’s awareness of health promotion (27). according to silen et al, nursing professional values as specified by thailand nurses’ association can be viewed as: sublime states of mind, loving kindness, compassion, and sympathetic joy and equanimity (28). in the study conducted by weis and schank the most important professional values of nurses were related to the provision of nursing care and believing in the importance of the process of professionalization (22). shahriari et al. have expressed that ethical values of nurses from the perspective of iranian nurses include maintaining patients’ dignity, commitment and work ethics, human communication, fairness, honesty and j med ethics hist med 7:1 jan, 2014 jmehm.tums.ac.ir mohsen shahriari et al. page 6 of 7 (page number not for citation purposes) integrity, and striving to promote personal and professional competence (29). parvan et al. showed the most important statements from the students’ perspective were "maintaining confidentiality of patients" and "maintaining clinical competency". nursing faculty and students’ awareness of the need for strong professional values is important in preparation of nurses capable of managing patient care in an ethical and professional manner (24). the difference between moral professional values in various studies reflects the differences in societies in terms of dominant values based on cultural, social, economic and religious situations. hence it is essential to identify nurses’ professional values as well as factors influencing disrespect of professional ethics and standards in patient care (7). it is obvious that nurses cannot avoid facing ethical dilemmas, but they should be capable enough to manage these challenges through receiving proper training. as a matter of fact, this is not exclusively related to nurses; rather, all of the treatment team encounter such challenges and manage them based on their knowledge and training. in their study regarding the purpose of determining ethical conflicts in nurse practitioners and physician assistants in managed care, ulrich et al. have found that nurses encounter ethical challenges more than physicians. some of the participants (44%) believed that they had been well prepared for managing these challenges because they had been well trained (15). thus, the role of education in preparing nurses and other health care providers for facing ethical dilemmas is further highlighted. the important point here is that despite the great importance of ethical issues, we still encounter many cases of non-compliance with the ethical values, and challenges in the field of patients’ rights. rezaei et al. have showed that in the emergency departments of a total of ten hospitals in lorestan (province of western iran) which were assessed for their compliance with professional ethics standards and patient’s rights, these items have not been fully met (30). the fact here is that it is not enough to train nurses and other health care providers to achieve desired outcomes; following relevant feedbacks in the system is important as well. conclusion in this study, we addressed the most and the less important professional values specified by our nurses with different types of employment and different experiences. iranian nurses believe in respecting the legal and ethical rights of patients as the most prominent value. it is concluded that nurses’ professional values must be specified and assessed based on each country’s circumstances to sensitize students and nurses about ethical issues and problems. in addition, identifying and removing barriers to professional ethics play an important role in applied professional values in nursing. more studies with greater sample size are needed for generalization of the outcomes. acknowledgement the authors would like to acknowledge the isfahan council directress of the iranian nursing organization. references 1. rassin m. nurses’ professional and personal values. nurs ethics 2008; 15: 614–30. 2. johnson mb, webber pb. an introduction to theory and reasoning in nursing. philadelphia: lippincot publishing; 2005. 3. schank mj, weis d. service and education share responsibility for nurses' value development. j nurses staff dev 2001; 17(5): 226-233. 4. dugas b. principles of patients care: a holistic approach. translated by atashzade f, eds. golban publication; 2003, p. 9. [in persian] 5. johnstone mj. bio ethics: a nursing perspective. churchill livingstone publishing; 2004. 6. horton k, tschodin v, forget a. the value of nursing: a literature review. nurs ethics 2007; 14: 716-740 7. saharkhiz h. effect of group discussions about professional ethics with nursing student on promoting of professional ethics, [dissertation]. tehran: tarbiat modares university, faculty of medical sciences; 2008. [in persian] 8. verpeet e, casterel bdd, lemiengre j, gastmans c. belgian nurses' views on codes of ethics: development, dissemination, implementation. nurs ethics 2006; 13: 531-545. 9. hood jl. conceptual bases of professional nurses. philadelphia: wolter, lippincot publishing; 2010. 10. mahmodi shen gh, ahmadi f, kazemnejad a. nurses' ethical issues in professional life: a qualitative study of the inductive content analysis approach. iran j med ethics hist med 2009; 2(4): 63 – 78. [in persian] 11. butis j, rich kl. philosophies and theories for advanced nursing practice. boston: jones, bartlett publishing; 2011. 12. chaloner c. an introduction to ethics in nursing. nurs stand 2007; 21: 42-6. 13. weis d, schank mj. an instrument to measure professional nursing values. j nurs scholarsh 2000; 32: 201-4. 14. jormsri p, kunaviktikul w, ketefian s, chaowalit a. moral competence in nursing practice. nurs ethics j 2005; 12: 582–94. j med ethics hist med 7:1 jan, 2014 jmehm.tums.ac.ir mohsen shahriari et al. page 7 of 7 (page number not for citation purposes) 15. ulrich cm, danis m, ratcliffe sj, et al. ethical conflict in nurse practitioners and physician assistants in managed care. nurse res 2006; 55(6): 391-401. 16. mcneese-smith dk, crook m. nursing values and a changing nurse workforce. j nurs adm 2003; 33(5): 260-270. 17. chitty kk, black bp. professional nursing concepts & challenges, 5th edition, saunders; 2007. 18. astorino ta. a survey of professional values in graduating student nurses of traditional and accelerated baccalaureate nursing programs, [dissertation]. indiana university of pennsylvania, 2006. 19. tefagh mr, nikbakht nasrabadi a, mehran a, din mohammadi n. the effect of the professional ethics compliance in medical orders applying by nurses] hayat 2004; 10(23): 77 – 85. 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[in persian] 22. weis d, schank mj. development and psychometric evaluation of the nurses professional values scale—revised. j nurs meas 2009; 17(3): 221-31. 23. martin p, yarbrough s, alfred d. professional values held by baccalaureate and associate degree nursing students. j nurs scholarsh 2003; 35(3): 291-6. 24. parvan k, hosseini f, zamanzadeh v. professional values from nursing students’ perspective in tabriz university of medical sciences: a pilot study. iran j nurs 2012; 25(76): 28-41[in persian] 25. leduc k, kotzer am. bridging the gap: a comparison of the professional nursing values of students, new graduates, and seasoned professionals. nurs educ perspect 2009; 30(5): 279-84. 26. lynn hayes t. an exploration of professional values held by baccalaureate and associate degree of nursing students, [dissertation]. the florida state university school of nursing; 2006. 27. shih fj, lin ys, smith mc, et al. perspectives on professional values among nurses in taiwan. j clin nurs 2009; 18(10): 1480-9. 28. silen m, tang pf, ahlstrom g. swedish and chinese nurses’ conceptions of ethical problems: a comparative study. j clin nurse 2008; 18(10): 1470 – 9. 29. shahriari m, mohammadi e, abbaszadeh a, bahrami m, fooladi m. perceived ethical values by iranian nurses. nurs ethics 2013: 19(1): 30-44. 30. rezaeei k. ethical principles of nurse-patient communication. abstract book of the national congress of applied medical ethics, mashhad university of medical science, 2006. [in persian] microsoft word 15 journal of medical ethics and history of medicine biomedical ethics teachings to postgraduate doctors yasmin wajahat sobhraj maternity hospital, pakistan. *corresponding author: yasmin wajahat address: sobhraj maternity hospital, pakistan e-mail: ywajahat@gmail.com received: 30 may 2009 accepted: 01 aug 2009 published: 19 aug 2009 j med ethics hist med. 2009; 2:15. © 2009 yasmin wajahat; licensee tehran univ. med. sci. introduction postgraduates programs in bioethics are avail able globally in canada, usa, australia, uk, europe and now with the efforts of unesco across much of asia including india, china and japan (1). in islamic republic of pakistan, the first formal move in introducing bioethics teachings in the medical students’ curriculum was made at aga khan university, karachi in 1984. it was in 1997 that workshops and courses focused on local ethical dilemmas were made mandatory for the postgra duate clinical training of the residents at aku (2). pakistan medical and dental council (pmdc) in 2001 stipulated that bioethics must be included in the medical curriculum (3). the centre for bio medical ethics and culture was established at the sindh institute of urology and transplantation in 2004 and began the postgraduate diploma course in bioethics in 2006 (4). informal postgraduate teaching of bioethics is conducted in different institutions at karachi and also by karachi bioeth ics group (formed in 2004). this platform allows postgraduates, residents and faculty to educate themselves about emerging bioethical issues through discussions (5). a bioethics curriculum for postgraduates has been implemented at sobhraj maternity hospital (smh) from january 2007. smh is a public sector hospital, located centrally in karachi, pakistan. on average, approximately 200 patients are seen daily in the outpatient department. the various problems faced by the doctors are busy outpatient department leading to overcrowding, shortage of staff with one doctor dealing with forty patients and lack of general resources. due to this scenario, various ethical concerns that arise include issues of patient-physician relationship, truth telling, privacy, confidentiality, disclosure and informed consent. hence there is a great need for training of the postgraduates in biomedical ethics so that they can carry out their clinical practice in an ethical manner. this paper highlights the experience of teach ing biomedical ethics to postgraduate trainees for membership of college of physicians and surge ons (mcps), pakistan examinations, who come for two years training and doctors who come for their six month internship in obstetrics & gynecology specialty to smh. discussion as biomedical ethics education is a mandatory discipline globally, this intervention of teaching postgraduates is required to build capacity in ethical reasoning skills of young doctors. this would assist them to resolve everyday conflicts and enable them to relate global issues in terms of our own traditions, religious, and socio-cultural norms. such concerns include issues of beginning of life, brain death, persistent vegetative state (pvs), organ donation and end of life care / palliative care. teaching program in bioethics was initiated at smh in january 2007. at the outset, the curricu lum was designed for six months but it took more time as it was planned. currently we are in the third j med ethics hist med 2009, 2:15 yasmin wajahat page 2 of 3 (page number not for citation purposes) round of teaching which began in september 2008. the topics discussed include privacy and confiden tiality, maintaining physician patient relationship, euthanasia and aspects related to reproductive health such as miscarriage, prenatal diagnosis, surrogacy and ovum donation. teaching methodology incorporates class room, interactive discussions done in large groups, and bedside small group discussion. the classroom sessions are conducted twice a month, each lasting for an hour. bedside teaching is done during clinical rounds. this makes four to five rounds each month. bedside teaching helps in both, practical oriented learning as well as in overcoming the time constraints faced, as these sessions have to be scheduled along with the postgraduate training. several activities are implemented to sensitize the students and engage them in discussion. presentations are made by students on topics selected from unesco textbook “a cross cultural introduction to bioethics” and from chapters on ethical dilemmas, given in the text book of obstetrics & gynecology. these presenta tions are followed by a question & answer session. reading and discussion of articles from local newspapers constitutes a learning activity. this creates the ability of critical thinking amongst trainees. executing role plays on given scenarios, for example taking informed consent and watching and analyzing movie clips for ethical issues, contributes to learning, complimented with recreation. another classroom activity was the compila tion of a glossary by students. initially, a list of selected words was distributed amongst the students. they add new words, which they come across and find related to the subject of bioethics, to this list. written assignments also constitute an important part of the class activities. they help the students to share their opinions regarding the given topic; for e.g. “is it ethical for doctors to receive gifts from pharmaceutical companies?” in addition to this, in order to analyze the understanding of trainees, a small question related to the subject was added to the monthly obstetrics & gynecology test, which helped them to learn the simple definitions and critical writing. bedside teaching during clinical rounds is also incorporated in the teaching methodology. this gives the trainees on ground opportunity to implement what they learn during class, for example, to maintain privacy during the discourse with the new patients, developing the skills of communication to establish a good patient physician relationship and to develop the skill of taking informed consent from the women patients undergoing surgery. for ensuring respect for patients, all trainees were required to involve the patient in the disclosure and comprehension and make sure that a consent form was duly filled and signed, first by the patient herself and then by her spouse or guardians. this was perhaps the most difficult aspect in a male dominated society where consent from women is not regarded important. most of the women patients were not willing to take the initiative themselves and left the responsi bility of giving consent to their spouse or guar dians. initiation of this teaching program was rela tively easy because of the seniority level of the trainer in the hospital and support of medical superintendent. however, managing the program as decided was slightly tricky and challenging. one of the major issues was the inconsistency of following the planned topics as the trainees were on rotation basis for specific periods; therefore, certain topics had to be repeated with the entry and exit of trainees. also, the planned topics were not followed as sequenced when current issues were added in the discussion. another obstacle was changing mindsets of trainees. it was not easy to stress on the application of concepts that had been excluded from previous education especially at undergraduate level in medical education. however, exposure to biomedi cal ethics education made the trainees think differently and look for solutions to ethical problems in their clinical practice. conclusion the feedback was obtained from the trainees and according to them, “these sessions have opened new concepts and enabled them to think abundant ly”. now, textbooks of obstetrics & gynecology also include chapters on biomedical ethics, which add to the interest of the trainees. a larger number of postgraduate diploma holders in bioethics are also available to train the younger doctors. moreo ver trainees, who continue to work in the hospital, after clearing their mcps exam having a previous exposure to bioethics teachings, serve as an additional hand to guide the junior trainees in dealing with ethical issues. although it is a two years short experience, a more positive outcome can be expected in future. a conscious effort is still required as ethical practice may be neglected during emergency situations. j med ethics hist med 2009, 2:15 yasmin wajahat page 3 of 3 (page number not for citation purposes) references 1. anonymous. abstracts of presented papers at the eighth asian bioethics conference (abc 2007). eubios j asian int bioeth 2007; 17(3): 65-96. http://www.eubios.info/ejaib52007.pdf (accessed on jul 2009) 2.ahmed a. country report: pakistan. indian council of medical research. 2006, http://icmr.nic.in/bioethics/cc_biothics/presentations/int_chennai/cr_pakistan.pdf (accessed on jul 2009) 3. moazam f, jafarey a. pakistan and biomedical ethics: report from a muslim country. cambridge quarterly of health care ethics. cambridge university press; 2005, 14: 249-55. 4. anonymous. centre of biomedical ethics and culture. pakistan. http://siut.org/bioethics (accessed on jul 2009) 5. bashir nw. building networks: the karachi bioethics group. pakistan j med ethics 2008; 9: 7-9. journal of medical ethics and history of medicine original article pediatric residents’ and attending physicians’ perspectives on the ethical challenges of end of life care in children alireza ebrahimi1, sedigheh ebrahimi2* 1 student of medicine, student research committee, shiraz university of medical sciences, shiraz, iran. 2 associate professor, department of medical ethics, shiraz university of medical sciences, shiraz, iran. corresponding author: sedigheh ebrahimi block no.2, department of medical ethics and philosophy of health, school of medicine, zand ave., imam hosein sq., shiraz, fars, iran. email: sedighehebrah@yahoo.com tel: (+98) 713 2349985 fax: (+98) 713 2348980 received: 7 sep 2018 accepted: 29 dec 2018 published: 30 dec 2018 j med ethics hist med, 2018, 11: 16 © 2018 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract one issue that has received less attention in present health care protocols is pediatric palliative care (ppc), which is an approach to care starting with the diagnosis of life-threatening diseases in children. it embraces physical, emotional and spiritual elements. ethical issues are major concerns in today’s pediatric health care guidelines and must be considered by residents and attending physicians in this field. the present study was conducted in namazi teaching hospital, shiraz, iran. forty-eight out of 92 pediatricians were enrolled in this research, including 8 attendings, 6 fellows, and 34 residents. the study questionnaire consisted of 66 items. it was built based on previous reliable and validated questionnaire; also the calculated cranach’s alpha was 0.815. data were analyzed and presented by mean ± sd and percentage. while seventy-five percent of the participants reported involvement in pediatric palliative care, fifty-six percent did not acknowledge any information about the subject. more than half of the participants perceived the pediatric palliative care services in namazi hospital as somewhat or completely satisfactory. furthermore, thirty-five percent of the applicants stated that they encounter an ethical problem with regard to ppc once a week. there are many challenges to providing decent palliative care for children, including symptom controlling, shifting to end of life care, background dissimilarities of patients, financial restrictions, and acceptance of death. our applicants believed that offering psycho-spiritual support was the most important challenge in ppc. however, further investigations are needed to determine other requirements for providing a comprehensive guideline on ppc. keywords: ethics, medical residents, palliative care, pediatrics j med ethics hist med 11: 16, december, 2018 jmehm.tums.ac.ir alireza ebrahimi et al. introduction palliative care (pc) has been internationally acknowledged as a human right and a public health issue, since it involves themes such as dignity of individuals, universality and nondiscrimination (1). as announced in article no. 25.1 of the universal declaration of human rights, “everyone has the right to a standard of living adequate for the health of himself and his family, including food, clothing, housing and medical care and necessary social services….” (2). “attention and care for chronically and terminally ill persons, sparing them avoidable pain and enabling them to die with dignity” has also been mentioned in general comment no. 14 (2). world health organization (who) defines palliative care as active care for patients who have no curative alternative, and the principal points include control of pain and other symptoms such as psychological, social and spiritual breakdowns in order to improve the quality of life (qol) (3, 4). pediatric palliative care (ppc) could be defined as measures taken to manage children who are suffering from terminal diseases, and it should be applied when cure cannot be achieved by other treatments (5, 6). ppc has physical, emotional, social and spiritual aspects and is aimed at helping patients and their families improve their qol throughout death and loss (5, 6). educating the patients and their families, social support, and involving the affected parties in discussions about planning ppc should all be handled in an open and transparent way (5, 7). the emerging paradigm of ppc embraces the concept of applying ppc codes at the primitive stages of life threatening diseases and creating a multidisciplinary system of support around the children and their families, and can be provided in different settings such as the hospital or hospice care unit, school and home (8, 9). usually, children especially young children cannot engage in the decision-making process; however, they often know they are dying and they may have treatment preferences (10 17). an additional aspect of ppc involves families as they are the ones who see the child’s discomfort and distress before death, must make difficult choices near and after the point of death, and lose a child and have to experience the sort of grief that is considered the most intense bereavement (18, 19). reports demonstrate that the incidence of emotional disturbances is high in these families (about 50% in at least one family member). moreover, parental grief has been reported to last deeply for 4 years. thoughts of suicide, self-accusation and social withdrawal have also been observed in parents who have lost a child (20 24). previous investigations have shown that families of dying children need respect and a true relationship provided by the nursing team; in addition, they expect health care providers to treat their children as individual patients with explicit diagnoses, relieve their distress, and give them sufficient care (25). determining the suitable time to open a conversation about a child’s death is challenging, as the beliefs and situations of parents must be well understood. alleviating the families’ feeling of bereavement after the loss could be achieved by multiple means available through palliative care, including psychologists and psychiatrists, clergymen and spiritual aids, and support groups (26 29). former studies also indicate that health-care providers’ writing condolence messages and attending the memorial service could help families cope with the grief (26 29). students and residents normally feel awkward in their confrontations with dying patients. they see death as a medical failure and generally do not perceive palliative care as an obvious component of medicine (30, 31). however, educationalists and legislators are paying more attention to the issue of palliative care in order to develop knowledge and investigation in this field (30, 31). the present study examined pediatricians’ perspectives on ethical subjects related to this field to improve the agenda of palliative care by using a questionnaire covering issues such as pediatricians’ uncluttered explanations, decision-making and psycho/spiritual support. the study targeted residents and attendings to find out if they had established maladaptive attitudes or practices. method population and data collection the present study was performed on 48 of the 92 pediatric residents, fellows and attendings of namazi teaching hospital in shiraz university of medical sciences, shiraz, iran between december 21, 2016 and may 21, 2017. the population consisted of 8 attendings, 6 fellows and 34 residents (54.2% male and 45.8% female), including 12 first-year, 13 second-year, and 9 third-year residents. the questionnaire was designed based on previously published surveys and consultations with experts in the field of medical ethics (32 34). in order to evaluate its validity and reliability, the questionnaire was given to 20 residents who were selected randomly. after a month, the questionnaire was given to the same people, and the outcome was evaluated by using spearman correlation test. using cronbach’s alpha (< 0.7), the questions that were found to create a significant bias were omitted page 2 of 13 j med ethics hist med 11: 16, december, 2018 jmehm.tums.ac.ir alireza ebrahimi et al. (appendix 1); moreover, cronbach’s alpha was calculated for all questions jointly to estimate the consistency of the questionnaire, which was 0.815, and thus the questionnaire was finalized (appendix 2). the questionnaire consisted of 3 sections. the first section contained the basic demographic data. the second section included queries designed in 5-point likert-scale questions to assess the level of satisfaction with palliative care services (5 = completely satisfactory to 1 = completely unsatisfactory). the third section was based on likert-scale responses to assess the participants’ general opinion about the topic and ethical challenges to implementation of pediatric palliative care. the second and third section of the questionnaire consisted of 66 items and were given to participants who were gathered in a conference room on the same day. the data were extracted by a trained person who was unaware of the names and degrees of the people who filled the forms. after analysis of the data, questions that had a significant bias according to the correlation test were omitted. the finalized data were sent for statistical evaluations, and the study protocol was approved by the medical ethics committee of shiraz university of medical sciences, shiraz, iran. participation in this research was voluntary, and participants were assured that their information would be kept confidential. data management and statistical analysis the collected data were reviewed for accuracy and verified by two independent experts. descriptive statistics were analyzed by mean ± sd and percentage calculations. the discrete and ordinal data were compared using student’s t-test, and spearman’s correlation and pearson’s correlation tests were applied. the differences with a p-value ≤ 0.05 were regarded as statistically significant. statistical analyses were performed using spss version 19.0 (spss inc., chicago, il). results the data are presented in tables 1 to 5 below. table 1 shows the demographic data of the participants. the participants’ experiences (both as contributors and as observers) regarding working hours, knowledge and their exposure to palliative care are demonstrated in table 2. table 1demographic data of the study participants gender percent male female 54.2 45.8 marital status single married 70.8 29.2 age 20-29 30-39 40-49 50-60 27.1 50 18.8 4.2 position attending 1st year resident 2nd year resident 3rd year resident fellow 16.7 25 27.1 18.8 12.5 table 2participants’ experiences of palliative care months of working in pediatrics ward 53.88± 70.58 months of working in pediatrics icu 14.31± 20.42 practicing hours per week 64.64± 30.50 practicing palliative care yes no 75 22.9 information about palliative care yes no 56.3 43.8 source of information medical education resources internet and journals methodological education 37.5 12.5 >6 hours <6 hours 10.4 52.1 number of participants patients who needed palliative care 1-5 6-10 11-15 16-20 >20 29.2 14.6 8.3 8.3 37.5 number of the participants patients who died 1-5 6-10 11-15 16-20 >20 35.4 16.7 10.4 2.1 31.3 page 3 of 13 j med ethics hist med 11: 16, december, 2018 jmehm.tums.ac.ir alireza ebrahimi et al. seventy-five percent of the participants reported involvement in pediatric palliative care, and 38% of the residents, fellows and attendings had had over 20 patients in need of palliative care. an additional 31% had observed more than 20 patients expiring, while 56% of the participants did not acknowledge any information about palliative care. table 3 presents participants’ responses to the questions designed to assess the level of satisfaction with palliative care services. more than half of the participants (84.5% of all medical service providers and 68.9% of those in the icu) perceived the pediatric palliative care services in namazi hospital, shiraz, iran as somewhat or completely satisfactory. table 3participant’s satisfaction with palliative care services questionnaire item n minimum maximum mean sd how do you evaluate the facilities prepared by all medical provider sections for dying patients? 45 1.00 4.00 3.0889 .76343 how do you evaluate the appreciation of medical services by families of dying patients? 45 1.00 4.00 2.8222 .77720 how do you evaluate the pediatric palliative care in intensive care units? 45 2.00 5.00 3.4444 .78496 how do you evaluate your own implementation of pediatric palliative care? 44 1.00 4.00 2.9318 1.02066 values based on likert-scale responses (1= completely unsatisfactory, 2= unsatisfactory, 3= somewhat satisfactory, 4= satisfactory, 5= completely satisfactory) table 4general comments on implementation of pediatric palliative care questionnaire item n minimum maximum mean sd the lack of education in physicians about pediatric palliative care limits appropriate services. 48 1.00 5.00 3.6875 1.15143 i have difficulty understanding the principles of palliative care. 43 1.00 5.00 3.5814 1.00552 there is a lack of information and resources in the field of palliative care. 44 1.00 5.00 3.4091 1.08517 more studies and investigations must be conducted in this field in order to enhance the application of suitable palliative care. 44 2.00 5.00 4.2273 .91152 i believe authorized education must be promoted in this field, and i will participate in this education. 43 2.00 5.00 4.2791 .90831 we must actively participate in the field of palliative care during our education. 46 2.00 5.00 3.8043 .93380 i control the expiring patients’ symptoms (such as nausea, vomiting, constipation) sufficiently. 46 1.00 5.00 4.2391 1.03676 i can identify the poor-prognosis symptoms in dying patients. 45 1.00 5.00 3.6000 1.09545 due to lack of time and workforce, it is not possible to provide patients and their families with psychological support. 46 1.00 5.00 2.6522 1.47900 due to cultural differences between families and healthcare providers, psychological support is unachievable. 46 1.00 5.00 3.1957 1.27575 lessening the dying patients’ physical symptoms is the most important challenge in palliative care. 46 1.00 5.00 3.1739 .90196 providing the physiological needs of terminal patients must be the first priority in palliative care. 45 2.00 5.00 3.7111 1.01404 palliative care should be practiced by anesthesiologists. 44 1.00 5.00 2.2955 1.15294 palliative care should be practiced by oncologists. 44 1.00 5.00 2.1364 1.11211 specialists should be trained in the field of palliative care. 44 1.00 5.00 3.5000 1.19105 palliative care should be provided in primary care facilities. 43 1.00 5.00 2.4884 1.26061 there should be units that are specialized in palliative care. 25 2.00 5.00 4.0400 .97809 palliative care must be provided in patients’ homes. 26 2.00 5.00 3.6538 1.01754 page 4 of 13 j med ethics hist med 11: 16, december, 2018 jmehm.tums.ac.ir alireza ebrahimi et al. questionnaire item n minimum maximum mean sd the best way to train in this field is to capture the attendings’ experiences and bedside teachings. 44 1.00 5.00 3.5682 1.08687 the best way to train in this field is to experience the situation individually. 44 1.00 5.00 2.6591 1.19967 the best way to train in this field is to participate in related conferences. 44 1.00 5.00 3.2273 .91152 interdisciplinary groups must be appointed between different factions of the health-care system to improve palliative care. 44 3.00 5.00 4.2045 .76492 educating patients and their families is necessary for the improvement of palliative care. 44 2.00 5.00 4.0682 .89955 values based on likert-scale responses (1= disagree, 2= unsure, 3= somewhat agree, 4= mostly agree, 5= totally agree) table 5-general topics in ppc questionnaire item n minimum maximum mean sd patients’ relatives obtain information from unauthorized individuals instead of their cognizant healthcare providers. 46 1.00 5.00 4.4130 .97925 families have difficulty deciding on continuation of invasive treatments. 47 1.00 5.00 2.9787 1.34309 the lack of suitable facilities and plots limits dying patients and their families’ privacy. 47 1.00 5.00 3.9787 1.29362 the nursing team’s lack of education about pediatric palliative care limits provision of appropriate services. 46 1.00 5.00 3.5652 1.55852 the lack of applicable guidelines about approaching dying children limits proper pediatric palliative care. 44 1.00 5.00 3.6818 1.44307 values based on likert-scale responses (1= disagree, 2= unsure, 3= somewhat agree, 4= mostly agree, 5= totally agree) table 6ethical challenges of pediatric palliative care questionnaire item n minimum maximum mean sd it is very difficult for me to discuss palliative care with patients and their families. 28 1.00 5.00 3.5714 1.31736 i provide the information to dying patients and their families about altering curative treatments to palliative therapy. 47 1.00 5.00 3.5106 1.26615 i announce the diagnosis of the life-threatening disease to patients’ families in a meeting. 47 1.00 5.00 3.9149 1.21279 i ask the dying children to participate in these meetings. 47 1.00 4.00 1.6170 .89814 i explain the dnr1 protocol to patients’ families. 47 1.00 5.00 2.5319 1.48691 families have difficulty deciding on the dnr protocol or termination of mechanical ventilation. 47 1.00 5.00 4.0213 1.15136 patients’ families are not prepared to accept that their child’s disease is incurable. 47 1.00 5.00 3.6596 1.08901 i am afraid of discussing the cessation of curative treatments. 46 1.00 5.00 2.6522 1.32023 it is very challenging for me to discuss altering curative treatments to palliative therapy with patients and their families. 47 1.00 5.00 3.6809 1.14410 i feel awkward facing the families’ reactions, and i do not know what to tell them. 46 1.00 5.00 3.5000 1.11056 patients’ families do not understand the terminal nature of the disease, so i do not explain the situation to them. 47 1.00 5.00 1.8723 1.22682 altering curative treatments to palliative care could hurt the families’ trust in the health-care system that did not cure their child’s disease. 47 1.00 5.00 2.7660 1.25478 page 5 of 13 j med ethics hist med 11: 16, december, 2018 jmehm.tums.ac.ir alireza ebrahimi et al. questionnaire item n minimum maximum mean sd patients’ families must decide whether to start palliative care or not. 47 1.00 5.00 4.0638 1.05097 patients’ families must be informed after the decision has been made to start palliative care. 46 1.00 5.00 3.2609 1.59770 i assist the patients and their families with spiritual and psychological support. 47 1.00 5.00 4.4043 .87625 initiation of palliative care resembles doing nothing for the patients. 46 1.00 4.00 2.0000 1.15470 palliative care has been designed to decrease the economic burden of dying patients. 45 1.00 5.00 1.9778 1.19637 continuation of curative treatment in dying patients sometimes seems illogical. 45 1.00 5.00 3.1111 1.30074 in patients with life-threatening conditions, early initiation of palliative care could be more beneficial. 46 1.00 5.00 3.4565 1.14904 even if there is no hope for treatment of the disease, we must continue the curative and invasive therapies. 45 1.00 5.00 2.0222 1.17722 we must continue invasive treatments for dying patients because we could be sued by their families. 45 1.00 5.00 3.0889 1.44320 doctors do not accept their patients are dying. 46 1.00 5.00 2.0000 1.21106 we must discuss the situation of every expiring patient uniquely, considering their conditions. 42 1.00 5.00 4.3333 1.00406 no matter how long i have practiced in the field of pediatric palliative care, encountering children who are suffering from end of life conditions is difficult for me. 46 1.00 5.00 3.1522 1.42933 doctors have a significant role in supporting the patients and their families through psychological and spiritual help. 46 1.00 5.00 4.4130 .83203 psychological and spiritual support must be provided by other groups such as psychologists and nurses. 46 1.00 5.00 2.9783 1.34146 providing the patients and their families with appropriate information is the greatest challenge. 45 2.00 5.00 3.9111 1.04059 providing psychological and spiritual support is the most important challenge in this field. 46 2.00 5.00 4.0217 .95427 palliative care services are important in dealing with patients. 44 2.00 5.00 4.2273 .96119 how often do you encounter ethical issues with regard to pediatric palliative care? 45 1.00 5.00 3.8444 1.14724 values are based on likert-scale responses (1= disagree, 2= unsure, 3= somewhat agree, 4= mostly agree, 5= totally agree); 1= never, 2= 1 time until now, 3= 2-3 times until now, 4= once a week, 5= always discussion there are many challenges to providing decent palliative care for children such as symptom controlling problems in terms of scheduling, sufficiency, and competency of management. some of these challenges could be due to fear of speeding the child’s death, difficulties associated with management of neonates, the shift from curative care to end of life care, noticing the issue of ppc at a national level, personal differences among different patients, background dissimilarities of patients, lack of time, financial restrictions, dealing with patients’ apprehensions, and acceptance of death by patients, families and health-care providers (5, 6, 35 38). on the other hand, there is inadequate literature on the essentials and effectiveness of many ppc interventions which could be due to absence of study cases, unavailability of a baseline score for assessment of pain and qol in pediatrics, and the fact that ppc is a novel subject (39). moreover, there is no evidence-based tool to determine which patients would benefit from palliative care, and therefore initiation of palliative care should be personalized (38). previous studies have suggested policies with regard to pc for various psychosomatic symptoms such as page 6 of 13 j med ethics hist med 11: 16, december, 2018 jmehm.tums.ac.ir alireza ebrahimi et al. dyspnea, pain, nausea, seizures, agitation, anxiety, depression and grief, which can develop differently from one person to another (40 45). however, palliative care organizations have been mostly focused on physical care and the medical treatment of suffering rather than the psychological, sociological and spiritual aspects of death. studies have shown that health-care professionals could be frustrated due to compassion fatigue and burnout while providing ppc. this might be due to interaction problems, disagreements on decisions, lack of system support such as excessive workload and workforce unavailability, subjugated grief, and legal issues (6). palliative care practitioners have reported a feeling of “powerlessness” over dying patients, and that “there is always something more to be done”; thus the pressure of choosing between acting or not acting arises in daily communications with patients as well as in the philosophy of good death (46). most of our participants (75%) claimed that they practiced ppc but about half of them stated that they did not have adequate information about ppc. most of the applicants who asserted they had received training in ppc said they had obtained information in this field from medical education resources. most of the participants evaluated their satisfaction with palliative care services as somewhat satisfactory; however, they were mostly not pleased with the appreciation of medical services by families of dying patients. our data also revealed that improper palliative care services may be due to a number of reasons such as lack of education in physicians and nurses, insufficiency of educational courses and workshops about ppc, problems in identification of poor-prognosis symptoms, inadequate understanding of the principles of ppc, lack of resources, shortage of research in ppc, lack of time and workforce, cultural differences between health-care providers and patients’ families, absence of a systematic approach and role modeling around ppc, and insufficient family education. our applicants also declared that some problems could be related to the families of dying patients, for instance they might have difficulty deciding on the continuation of treatments, or attempt to obtain information from unauthorized persons. although most of our applicants admitted to some difficulties in starting palliative care discussions, they said that they mostly informed patients’ families about the situation, but they did not involve the children in educational meetings. insufficient education both in families and healthcare providers may also lead to certain misunderstandings about ppc. the consequences may include: failure to recognize the terminal condition of the disease, emotional complications, inconsistencies in terms of rituals and spiritual beliefs, being sued by the dying children’s families, and impairment of the families’ trust in the healthcare system. most of the participants insisted that the families must be the ones to make the decision to start palliative care; however, informing them after deciding to start ppc was also perceived as favorable. our results also depicted that although physicians mostly provided psychological and spiritual support to the families of dying children, they generally preferred the task to be left to other groups such as nurses and psychologists. even though decreasing the economic burden of dying patients is a major concern in ppc, it did not appear to be particularly important for our participants. on the other hand, our physicians mostly insisted on the effectiveness and early initiation of ppc in dying patients in order to reduce suffering and end-of-life complications for these patients. our participants also perceived psychological and spiritual support to be the most important challenges to pediatric palliative care; thus, further investigations are required in order to provide comprehensive guidelines in this field. conclusion of the numerous issues that could be considered as challenges to the implementation of ppc mentioned above, the spiritual and psychological aspects of ppc were found to be the most important ones. the results showed that it is essential to educate patients’ families as well as health-care providers, and that educational courses and obligatory guidelines would be helpful in this case. investigations are still highly required to determine other demands and considerations regarding provision of a comprehensive guideline on ppc. acknowledgments this study was extracted from the doctorate thesis of alireza ebrahimi and was supported by shiraz university of medical sciences, shiraz, iran. the authors would like to thank the personnel of the department of medical ethics and shiraz medical school in shiraz university of medical sciences, shiraz, iran. we would also like to express our gratitude to dr. soheil ashkani-esfahani and the simr co. for editing and improving the text. conflict of interests none declared. page 7 of 13 j med ethics hist med 11: 16, december, 2018 jmehm.tums.ac.ir alireza ebrahimi 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bioethics. pediatrics. 1996; 98(1): 149-52. 41. anonymous. palliative care for children: committee on bioethics and committee on hospital care. pediatrics. 2000; 106(2): 351-7. 42. collins jj. intractable pain in children with terminal cancer. j palliat care.1996; 12(3): 29-34. 43. sirkiä k, hovi l, pouttu j, saarinen-pihkala um. pain medication during terminal care of children with cancer. j pain symptom manage. 1998; 15(4): 220-6. 44. cassel ck. principles for care of patients at the end of life: an emerging consensus among the specialties of medicine. usa; 1999. 45. lorenz ka, lynn j, dy sm, shugarman lr, et al. evidence for improving palliative care at the end of life: a systematic review. ann intern med. 2008; 148(2): 147-59. 46. mcnamara b. good enough death: autonomy and choice in australian palliative care. soc sci med. 2004; 58(5): 929-38. page 9 of 13 j med ethics hist med 11: 16, december, 2018 jmehm.tums.ac.ir alireza ebrahimi et al. appendix appendix 1evaluation of validity and the reliability of the questionnaires by using cronbach’s alpha test question no. cronbach’s alpha 1 0.877 2 1 3 1 4 0.954 5 1 6 0.926 7 0.993 8 0.962 9 0.963 10 1 11 0.953 12 1 13 1 14 1 15 1 16 0.884 17 1 18 0.985 19 1 20 0.640 21 0.802 22 0.964 23 0.883 24 0.768 25 0.808 26 0.889 27 0.982 28 0.958 29 0.985 30 0.986 31 0.864 32 0.960 33 1 34 0.859 35 0.924 question no. cronbach’s alpha 36 0.924 37 0.673 38 0.734 39 0.628 40 0.728 41 0.803 42 0.304 43 0.784 44 0.829 45 0.881 46 0.611 47 0.968 48 0.931 49 1 50 0.951 51 0.961 52 1 53 1 54 0.974 55 1 56 0.909 57 0.980 58 0.970 59 0.975 60 0.689 61 0.988 62 1 63 0.898 64 0.961 65 0.758 66 0.941 page 10 of 13 j med ethics hist med 11: 16, december, 2018 jmehm.tums.ac.ir alireza ebrahimi et al. appendix 2the finalized questionnaire evaluating participants’ satisfaction with palliative care services items completely satisfactory = 5 satisfactory = 4 somewhat satisfactory = 3 unsatisfactory = 2 completely unsatisfactory = 1 how do you evaluate the facilities prepared by all medical provider sections for dying patients? completely satisfactory satisfactory somewhat satisfactory unsatisfactory completely unsatisfactory how do you evaluate the appreciation of medical services by families of dying patients? completely satisfactory satisfactory somewhat satisfactory unsatisfactory completely unsatisfactory how do you evaluate the pediatric palliative care in intensive care units? completely satisfactory satisfactory somewhat satisfactory unsatisfactory completely unsatisfactory how do you evaluate yourself implementing pediatric palliative care? completely satisfactory satisfactory somewhat satisfactory unsatisfactory completely unsatisfactory general topics and ethical challenges to implementation of pediatric palliative care how many times do you encounter ethical issues with regard to pediatric palliative care? always once a week 2 3 times until now 1 time until now never patients’ relatives obtain information from unauthorized individuals instead of their cognizant healthcare providers. always once a week 2 3 times until now 1 time until now never families have difficulty deciding on continuation of invasive treatments. always once a week 2 3 times until now 1 time until now never the lack of suitable facilities and plots limits dying patients and their families’ privacy. always once a week 2 3 times until now 1 time until now never the nursing team’s lack of education about pediatric palliative care limits provision of appropriate services. always once a week 2 3 times until now 1 time until now never the lack of applicable guidelines about approaching dying children limits proper pediatric palliative care. always once a week 2 3 times until now 1 time until now never it seems very difficult to me to start a discussion about palliative care. totally agree mostly agree somewhat agree unsure disagree physicians’ lack of education about pediatric palliative care limits provision of appropriate services. totally agree mostly agree somewhat agree unsure disagree i provide the information to dying patients and their families about altering curative treatments to palliative therapy. totally agree mostly agree somewhat agree unsure disagree i announce the diagnosis of the life-threatening disease in a meeting to patients’ families. totally agree mostly agree somewhat agree unsure disagree i ask the dying children to participate in these meetings. totally agree mostly agree somewhat agree unsure disagree i explain the dnr protocol to the patients’ families. totally agree mostly agree somewhat agree unsure disagree patients’ families are not prepared to accept that their child’s disease is incurable. totally agree mostly agree somewhat agree unsure disagree it is very challenging for me to discuss altering curative treatments to palliative therapy with patients and their families. totally agree mostly agree somewhat agree unsure disagree i feel awkward facing the families’ reactions, and i do not know what to tell them. totally agree mostly agree somewhat agree unsure disagree patients’ families do not understand the terminal nature of the disease, so i do not explain the situation to them. totally agree mostly agree somewhat agree unsure disagree altering curative treatments to palliative care could hurt the families’ trust in the health-care system that did not cure their child’s disease. totally agree mostly agree somewhat agree unsure disagree patients’ families must decide whether to start palliative care or not. totally agree mostly agree somewhat agree unsure disagree page 11 of 13 j med ethics hist med 11: 16, december, 2018 jmehm.tums.ac.ir alireza ebrahimi et al. patients’ families must be informed after the decision has been made to start palliative care. totally agree mostly agree somewhat agree unsure disagree i am afraid of discussing the cessation of curative treatments. totally agree mostly agree somewhat agree unsure disagree families have difficulty deciding on the dnr protocol or termination of mechanical ventilation. totally agree mostly agree somewhat agree unsure disagree i assist the patients and their families with spiritual and psychological support. totally agree mostly agree somewhat agree unsure disagree i control the expiring patient’s symptoms (such as nausea, vomiting, constipation) sufficiently. totally agree mostly agree somewhat agree unsure disagree i can identify the poor-prognosis symptoms in dying patients. totally agree mostly agree somewhat agree unsure disagree initiation of palliative care resembles doing nothing for the patients. totally agree mostly agree somewhat agree unsure disagree palliative care has been designed to decrease the economic burden of dying patients. totally agree mostly agree somewhat agree unsure disagree continuation of curative treatments in dying patients seems illogical sometimes. totally agree mostly agree somewhat agree unsure disagree in patients with life-threatening conditions, early initiation of palliative care could be more beneficial. totally agree mostly agree somewhat agree unsure disagree even if there is no hope for treatment of the disease, we must continue the curative and invasive therapies. totally agree mostly agree somewhat agree unsure disagree we must continue invasive treatments for dying patients because we could be sued by their families. totally agree mostly agree somewhat agree unsure disagree doctors do not accept their patients are dying. totally agree mostly agree somewhat agree unsure disagree we must discuss the situation of every expiring patient uniquely, considering their conditions. totally agree mostly agree somewhat agree unsure disagree no matter how long i have practiced in the field of pediatric palliative care, encountering children who are suffering from end of life conditions is difficult for me. totally agree mostly agree somewhat agree unsure disagree we must actively participate in the field of palliative care during our education. totally agree mostly agree somewhat agree unsure disagree doctors have a significant role in supporting the patients and their families through psychological and spiritual help. totally agree mostly agree somewhat agree unsure disagree psychological and spiritual support must be provided by other groups such as psychologists and nurses. totally agree mostly agree somewhat agree unsure disagree due to lack of time and workforce, it is not possible to provide patients and their families with psychological support. totally agree mostly agree somewhat agree unsure disagree due to cultural differences between families and healthcare providers, psychological support is unachievable. totally agree mostly agree somewhat agree unsure disagree lessening the dying patients’ physical symptoms is the most important challenge in palliative care. totally agree mostly agree somewhat agree unsure disagree providing the physiological needs of terminal patients must be the first priority in palliative care. totally agree mostly agree somewhat agree unsure disagree providing the patients and their families with appropriate information is the greatest challenge. totally agree mostly agree somewhat agree unsure disagree providing psychological and spiritual support is the most important challenge in this field. totally agree mostly agree somewhat agree unsure disagree optional questions: palliative care services are important in dealing with patients. totally agree mostly agree somewhat agree unsure disagree i have difficulty understanding the principles of palliative care. totally agree mostly agree somewhat agree unsure disagree there is a lack of information and resources in palliative care. totally agree mostly agree somewhat agree unsure disagree palliative care should be practiced by anesthesiologists. totally agree mostly agree somewhat agree unsure disagree palliative care should be practiced by oncologists. totally mostly somewhat unsure disagree page 12 of 13 j med ethics hist med 11: 16, december, 2018 jmehm.tums.ac.ir alireza ebrahimi et al. agree agree agree specialists should be trained in palliative care. totally agree mostly agree somewhat agree unsure disagree palliative care should be provided in primary care facilities. totally agree mostly agree somewhat agree unsure disagree there should be units that are specialized in palliative care. totally agree mostly agree somewhat agree unsure disagree palliative care must be provided in patients’ homes. totally agree mostly agree somewhat agree unsure disagree i believe authorized education must be promoted in this field, and i will participate in this education. totally agree mostly agree somewhat agree unsure disagree the best way to train in this field is to capture the attendings’ experiences and bedside teachings. totally agree mostly agree somewhat agree unsure disagree the best way to train in this field is to experience the situation individually. totally agree mostly agree somewhat agree unsure disagree the best way to train in this field is to participate in related conferences. totally agree mostly agree somewhat agree unsure disagree interdisciplinary groups must be appointed between different factions of the health-care system to improve palliative care. totally agree mostly agree somewhat agree unsure disagree educating patients and their families is necessary for the improvement of palliative care. totally agree mostly agree somewhat agree unsure disagree more studies and investigations must be conducted in this field in order to enhance the application of suitable palliative care. totally agree mostly agree somewhat agree unsure disagree page 13 of 13 ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ commentary copyright © 2021 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. journal of m edical ethics and h istory of m edicine ethical concerns in the age of an advanced psychopharmacology gentian vyshka1*, dritan ulqinaku2, tedi mana3 1.biomedical and experimental department, faculty of medicine, university of medicine in tirana, albania. 2.department of chronic diseases, institute of public health, tirana, albania. 3.service of psychiatry, university of medicine in tirana, albania. introduction controlling, modulating or influencing mental activity, thoughts, beliefs and even human behavior has been an everlasting challenge in medicine and psychology. the nature and the environment have granted humanity different options to try to regulate sleep and wake. as demonstrated by history, papaver somniferum and wine have had their say on sleep induction since antiquity (1). overcoming grief, stress and anxiety have also been among the targets, especially for traumatized persons. nepenthe was the homeric anti-sorrow drug, obviously not related to the panoply of antidepressants that are so widely used in the modern times (2). the unending debate on mind-soul duality has had obvious philosophical implications but contributed very little to treatment of psychiatric patients (3, 4). before the advent of antipsychotics, controlling agitated patients without the use of (maybe) inhuman mechanical contention was hardly achievable, although many attempts were made to do so (5, 6). chance discoveries antipsychotics and antidepressants were serendipitous discoveries, as they were both initially the byproducts of active principles that were synthetized and tried for other medical conditions. their discovery was the result of previous, extensive research in chemistry that dated back to the nineteenth century. in an exhaustive review, lópez-muñoz et al. offered plenty of historical details regarding the synthesis of the first antipsychotic: chlorpromazine (7). *corresponding author gentian vyshka address: rr. e dibrës 371, tirana, albania tel: (+355) 69 28 28 140 email: gvyshka@gmail.com received: 20 dec 2021 accepted: 28 dec 2021 published: 30 dec 2021 citation to this article: vyshka g, ulqinaku d, mana t. ethical concerns in the age of an advanced psychopharmacology. j med ethics hist med. 2021; 14: 29. ethical concerns in the age of an advanced psychopharmacology 2 j med ethics hist med. 2021 (december); 14: 29. journal of m edical ethics and h istory of m edicine according to some sources, this medication is the same as the laborit drug, named in honor of the french doctor who led a team of researchers looking for an anti-shock cocktail in the field of anesthesia (8). the discovery of chlorpromazine was in fact everything but mere chance, since related advancements in chemistry and continuous research had been ongoing for decades. working on aniline and coal dyes, as well as their byproducts, scientists were able to synthetize phenothiazines (7). while studying the antimalarial effects of methylene blue and adding amino-alkylate chains to the phenothiazine ring, derivative compounds with antihistaminic properties were discovered that soon found their way into psychiatry. the ‘magic bullet’, a concept developed by paul ehrlich (1907) while working on trypan red as a valid treatment for syphilis, some years later became the ‘effet dedésintéressement’ (effect of disinterest) of henry laborit (1951), the french military physician. together with his collaborators (huguenard and quarti) and other psychiatrists (delay and deniker), laborit witnessed how calm, disinterested, quiet and collaborative psychiatric patients became as a result of taking chlorpromazine (9, 10). many of them were catatonics and had even refused to eat until a few days before taking the medicine for the first time (11). however, chlorpromazine was obviously not the only psychiatric drug discovered by chance: the anti-maniacal effects of lithium and the anti-depressant effects of isoniazid had a similar story. in the early 1950s kline, loomer and saunders highlighted the efficacy of iproniazid (an antitubercular drug) as an antidepressant and ‘energizer’ even among patients not suffering from tuberculosis (12, 13). imipramine, a tricyclic antidepressant, was likewise a serendipitous discovery (13). the effect of lithium as a mood stabilizer has had the same trajectory of discovery. a neurologist from philadelphia (s.w. mitchell) appraised the anticonvulsant and hypnotic properties of lithium as early as 1870 (14). however, john cade rediscovered some psychotropic properties of the element in melbourne (1949) while reporting the sedative but non-hypnotic effects of lithium salts in mania patients (15). since the number of chance discoveries in the field of psychopharmacology is considerable, dedicated authors have concentrated even on specifying what to call as purely “serendipitous” as opposed to what seems to be so. thus, lópez-muñoz et al. classified four patterns of this phenomenon (16):  pure serendipitous discoveries (for example, valproate sodium)  serendipitous observation leading to nonserendipitous discoveries (imipramine)  non-serendipitous discoveries secondarily associated with serendipitous observation (barbiturates)  non-serendipitous discoveries (haloperidol). beyond all doubts, apart from the dedication and passion in the work of renowned chemistry and pharmacology researchers, the discovery and the ensuing wide use of psychoactive drugs have enjoyed the spirit of vyshka g., et al. 3 j med ethics hist med. 2021 (december); 14: 29. journal of m edical ethics and h istory of m edicine change – the so-called zeitgeist – and have been supported by culture and the positive approach of the public at that specific period of time (17). ethical issues: competence and beyond psychotropic drugs are not without side effects. however, this is not and must not be a deterrent against their use, as the risk/benefit ratio is clearly favorable. turning an otherwise aggressive and confused patient into a sociable individual, calming him/her down, encapsulating if not wiping out delusions, liberating people from hallucinations and distorted reality perceptions are some of the good that these drugs can do, and have done. nevertheless, with litigation trends increasing in the field of medical treatment (fortunately much less in psychiatry than other specialties), and with antipsychiatry as a half-philosophical movement always at the corner, there can never be enough prudence and caution (18, 19). the dilemmas and debates are serious enough to lead to the coinage of the term postpsychiatry: apparently, closing an era and heading nowhere (20). one of the major ethical issues related especially to the use of antipsychotics pertains to settings particular to certain individuals, above all prisoners, anti-regime advocates and political adversaries. especially notorious is the abuse of these drugs in eastern european countries, as well as the coining of particular forms of mental disease to stigmatize and discriminate issenters (21). the russian concept of schizophrenia and the sluggish form of it – widely unclear and not accepted – was the tip of an iceberg (22). much more dangerous and crueler were of course the atrocious experiments on humans inside nazi german concentration camps (23). the fact is that for reasons beyond politics and extra-medical abuse, psychoactive drugs need special monitoring and their side effects are serious and have long-term implications. severe adverse effects include: tardive dyskinesia, neutropenia, iatrogenic parkinsonism, cardiac arrhythmias, malignant hyperthermia, impotence, and amenorrhea resulting from the use of antipsychotics, and the very much debated issue of increased suicide rate related to the use of new-generation antidepressants. furthermore, vulnerable groups such as patients of minor age, octogenarians and pregnant women will need extra monitoring (24), which is unfortunately not always feasible. due to the chronic nature of a psychiatric diagnosis, the future does not seem very bright for these patients. there is also the unlucky burden of suffering (both emotional and economic) placed on a family destined to take care of a person that will likely never become independent. these patients are forced to rely on parental and societal help, mercy and charity for decades of their painful life. remember what dante alighieri wrote in paradise (canto xvii, lines 58 60): ethical concerns in the age of an advanced psychopharmacology 4 j med ethics hist med. 2021 (december); 14: 29. journal of m edical ethics and h istory of m edicine tu proverai sì come sa di sale / lo pane altrui, e come è duro calle / lo scendere e ‘l salir per l’altrui scale. you shall feel how salty is the taste / of another man's bread, and how hard is the way / up and down somebody else’s stairs this is true for all psychotics, particularly for people suffering from schizophrenia, since they will be incompetent and unable to perform socially for the biggest part of their life (25). the role of proxies and surrogates in decision-making is, within this frame, highly debatable. psychotics may not be able to give their consent for starting and maintaining a pharmacological therapy even if formally requested. meanwhile, compliance (otherwise called adherence to treatment) is measured and controlled, but some patients will have very little insight into their ailment during considerable periods of time (26). instead of a conclusion modulating an individual’s thoughts is not merely a metaphor. the set of beliefs, ideas and convictions one has grown with are integrated into one’s lifestyle, and are therefore part of a unique identity forming an individual. sub-clinical delusional experiences might be evolutionary adaptive mechanisms, and therefore not blamable (27). navigating between antipsychiatry, denial of mental illness and futurism – while waiting for the precision medicine to integrate into the discipline of psychiatry and its therapeutic armamentarium – will help little to clarify dilemmas (28, 29). there is also a bulk of probably insufficient data that hamper the enthusiastic views on psychopharmacology, in particular on the use of antipsychotics. we are not merely talking about the side effect profiles: every treating clinician will ponder the riskbenefit ratio case after case. progression is obvious and measurable, but ‘miracle drugs’ need to be treated with prudence and cautious skepticism. not casually, maybe, malaria therapy of neurosyphilis for which wagner jauregg was granted a nobel prize in medicine (the only one won from a psychiatrist), did not survive the proof of time, like many other therapies, and is actually only of historical interest (30). changing the mind while trying, for example, to efface delusions can very well be the consequence of a tissue remodeling (31). in this case we are talking about cerebral tissue, whose structure is moldable in a rather dramatic way, that is, through psychosurgery. more subtly, psychopharmacology seems able to do the same. chronic exposure to antipsychotics might cause the brain to shrink or undergo other changes in size (32). nonetheless, there are numerous uncertainties surrounding these concerns as well, including: are these changes due to psychosis itself, and who can dispute the enormous improvements in terms of the quality of life and socialization for all psychotic patients since the discovery of antipsychotics? very few will be able to uphold this suspicion, and not the authors of these lines, at any rate. vyshka g., et al. 5 j med ethics hist med. 2021 (december); 14: 29. journal of m edical ethics and h istory of m edicine references 1. tekiner h, kosar m. the opium poppy as a symbol of 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introduction, 4th ed. usa: wiley; 2003, p. 45-49. 18. frierson rl, joshi kg. malpractice law and psychiatry: an overview. focus (am psychiatr publ). 2019; 17(4): 332-6. 19. whitley r. the antipsychiatry movement: dead, diminishing, or developing? psychiatric services. 2012; 63(10): 1039-41. ethical concerns in the age of an advanced psychopharmacology 6 j med ethics hist med. 2021 (december); 14: 29. journal of m edical ethics and h istory of m edicine 20. kecmanovic d. postpsychiatry: how to throw out the baby with the bathwater. psychiatr danub. 2009; 21(3): 276-82. 21. vyshka g, kazaferi a, kapo i, mana t. forbidden insanity: the systematic denial of mental health issues from a state-run psychiatry. psychiatr danub. 2018; 30(4): 385-9. 22. tobin jp. editorial: political abuse of psychiatry in authoritarian systems. ir j psychol med. 2013; 30(2): 97-102. 23. lopez-munoz f, alamo c, garcia-garcia p, molina jd, rubio g. the role of psychopharmacology in the medical abuses of the third reich: from euthanasia programmes to human experimentation. brain res bull. 2008; 77(6): 388-403. 24. carrier f, banayan d, boley r, karnik n. ethical challenges in developing drugs for psychiatric disorders. prog neurobiol. 2017; 152: 58-69. 25. sluijs wh. descending on steps which are never thy own, dissertation and advice concerning support by cordaid momoe of projects for the reform of psychiatry and care for the disabled, and construction of mental health care in central and eastern european countries 2002. [cited dec 2021]; available from: https://archives.law.virginia.edu/records/mss/81-9s 26. lincoln tm, jung e, wiesjahn m, wendt h, bock t, schlier b. the impact of negative treatment experiences on persistent refusal of antipsychotics. compr psychiatry. 2016; 70: 165-73. 27. devylder je. fixity of thinking and the foundations of identity: an argument for the evolutionary adaptiveness of delusions. early interv psychiatry. 2019; 13(3): 720-1. 28. fountoulakis kn. should denialism of mental illness and its treatment be included among conspiracy theories? eur arch psychiatry clin neurosci. 2021; 271(4): 591-93. 29. serretti a. the present and future of precision medicine in psychiatry: focus on clinical psychopharmacology of antidepressants. clin psychopharmacol neurosci. 2018; 16(1): 1-6. 30. karamanou m, liappas i, antoniou ch, androutsos g, lykouras e. julius wagnerjauregg (1857-1940): introducing fever therapy in the treatment of neurosyphilis. psychiatriki. 2013; 24(3): 208-12. 31. turkheimer fe, selvaggi p, mehta ma, et al. normalizing the abnormal: do antipsychotic drugs push the cortex into an unsustainable metabolic envelope? schizophrenia bulletin. 2020; 46(3): 484-95. 32. dorph petersen ka, pierri jn, perel jm, sun z, sampson ar, lewis da. the influence of chronic exposure to antipsychotic medications on brain size before and after tissue fixation: a comparison of haloperidol and olanzapine in macaque monkeys. neuropsychopharmacology. 2005; 30:1649-61. introduction islam 9 (309)-galley proof journal of medical ethics and history of medicine original article general approaches to ethical reasoning in islamic biomedical ethics discourse hamideh moosapour1, jannat mashayekhi2, farzaneh zahedi3, akbar soltani4, bagher larijani5* 1ph.d candidate in philosophy of medicine and medical ethics, evidence based medicine research center, endocrinology and metabolism clinical sciences institute, tehran university of medical sciences, tehran, iran. 2ph.d candidate in medical ethics, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran; department of medical ethics, school of medicine, tehran university of medical sciences, tehran, iran. 3director of medical ethics research group, endocrinology and metabolism research center, endocrinology and metabolism clinical sciences institute, tehran university of medical sciences, tehran, iran. 4professor, evidence based medicine research center, endocrinology and metabolism clinical sciences institute, tehran university of medical sciences, tehran, iran. 5professor, endocrinology and metabolism research center, endocrinology and metabolism clinical sciences institute, tehran university of medical sciences, tehran, iran. corresponding author: bagher larijani address: no. 10, jalal al-ahmad st., next to shariati hospital, chamran hwy, tehran, iran. email: larijanib@tums.ac.ir tel: (+98) 21 88 63 12 97 received: 01 aug 2017 accepted: 14 july 2018 published: 9 sep 2018 j med ethics hist med, 2018, 11: 11 © 2018 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract islamic and non-religious ethics discourses have similarities and differences at the levels of meta-, normative, and applied ethics (e.g. biomedical ethics). mainstream biomedical ethics (mbme) uses the language of contemporary, non-religious, western ethics. significant effort has been dedicated to comparing islamic biomedical ethics (ibme) and mbme in terms of metaand normative ethical positions, and final decisions on practical ethical issues have been reached. however, less attention has been given to comparing the general approaches of the two aforementioned discourses to ethical reasoning. furthermore, ibme uses different languages to approach ethical reasoning, but identification and conceptualization of these approaches are among the important gaps in the literature. the aim of this study was to conceptualize general approaches to ethical reasoning in ibme. through review and content analysis of the existing literature and the comparison between the languages employed by ibme and mbme, an inductive distinction have been made. the languages used in conceptualized approaches include the followings: (i) a language in common with the one employed by mbme; (ii) mbme language adjusted to the basic, common beliefs of muslims; (iii) a language based on fatwas; and (iv) a language based on ibme principles. in the authors’ opinion, major challenges of the above-mentioned four approaches include, respectively: identifying the lack of religious sensitivity or islamic considerations regarding an issue; acknowledging specific beliefs as the basic, common beliefs of muslims; diverse fatwas and relations between juridical soundness and ethical soundness; and agreement on the same principles and rules as well as who should apply them. keywords: ethical reasoning, islamic biomedical ethics, islamic biomedical ethics principles, ethical decisionmaking mailto:larijanib@tums.ac.ir j med ethics hist med 11: 11, september, 2018 jmehm.tums.ac.ir hamideh moosaopour et al. page 2 of 10 introduction ethical reasoning is a practical reasoning about what moral agents should do. ethical arguments, like all other arguments, have the structure or form apart from the content (i.e., a conclusion and its supporting premises). general structures of ethical reasoning in biomedicine have been mainly adopted from the discipline of philosophy. the three main levels of the philosophical study of ethics include meta-ethics, normative ethics, and applied ethics. in biomedical ethics as a branch of applied ethics, reasoning depends mainly on the metaand normative ethical assumptions of the decision maker. this dependency also exists in the case of reasoning in islamic biomedical ethics (ibme) (1). similarities and differences between islamic and nonreligious ethics in metaand normative ethical assumptions lead to the similarities and differences between the two discourses in ethical reasoning about biomedical issues (2).the discipline of biomedical ethics has taken its form and content from contemporary, non-religious, western ethics to shape the mainstream biomedical ethics (mbme). an extensive body of literature on ibme compares fairly diverse islamic positions and their supporting arguments with non-religious ones. moreover, a vast amount of literature exists on laws and regulations in muslim-majority countries, and exists on slightly different juridical positions on sensitive issues. in addition, subjects such as islamic meta-ethical and normative ethical positions, methods employed in islamic jurisprudence (fiqh), and basic islamic concepts similar to the main concepts of mbme are extensively discussed in the literature. however, an important gap exists in the literature on different approaches to ethical reasoning in ibme, i.e., regarding how ethicists reason (or should reason) about biomedical issues in islamic discourse (2). moreover, it seems that islamic biomedical ethicists use different languages for ethical reasoning, for example a language similar to non-religious biomedical ethics, or to that of islamic jurisprudence. the aim of the this study was to identify and conceptualize general approaches to the ethical reasoning utilized in ibme discourse. method in this study, we reviewed and analyzed relevant literature on ibme, and then made an inductive distinction of the languages used for ethical reasoning in this discourse. this review was not systematic by definition; however, the authors searched pubmed and google scholar databases for combinational keywords from the following categories: 1) islamic, islam, shi’a, shiite, shi'ite or sunni, 2) biomedical ethics, medical ethics, or bioethics, and 3) method, approach, reasoning, thinking, process, debate, epistemology, or philosophy. the distinction was conceptualized by comparison between the languages of ibme and mbme. additionally, the authors provided several main challenges confronting each approach, though a comprehensive discussion of all the challenges was beyond the scope of this work. the results of our work have been organized in the present article as follows: firstly, a short overview of the most important approaches to ethical reasoning in mbme is provided. these approaches have often been the issue of comparison between ibme and mbme in relevant literature. secondly, four approaches of ibme conceptualized in this work are briefly presented. thirdly, each approach is detailed with examples, and subsequently the challenges of each approach are discussed. lastly, a conclusion is provided. approaches to ethical reasoning in mbme the discipline of biomedical ethics has a rich history of approaches to ethical reasoning. while the principlist and utilitarian approaches of english language biomedical ethics are the leading parts of the mainstream, there is considerable interest in different alternatives contributing to enrichment of the area. instances include casuistry, virtue ethics (which is enjoying a strong upsurge and renewal of interest), deontology, empirical ethics as an impressive turn in the field, hermeneutic perspectives, reflective equilibrium, narrative ethics, feminist ethics, pragmatist approaches, communitarianism, deliberative ethics, european philosophy approaches such as phenomenological perspective, existentialism, and ethics of care (3, 4). philosophy provides valuable approaches to ethical reasoning in biomedical ethics. these approaches have been analyzed, classified, and evaluated from different perspectives. according to the position that may be taken on metaand normative ethical problems, a distinction could be made among the most important philosophical approaches to ethical reasoning by answering these questions: (i) where should we seek right-making features (or characteristics that make an action right) to make an ethical decision? (ii) which features of the action make it ethically right? (iii) how many right-making features are necessary to form sound bases for ethical reasoning? answers to the first question have developed three well-known types of ethical theories: virtue, deontological, and consequentialist ethics. virtue theories guide and assess the character traits of a j med ethics hist med 11: 11, september, 2018 jmehm.tums.ac.ir hamideh moosaopour et al. page 3 of 10 moral agent; in contrast, theories of deontology and consequentialism guide and assess the action we ought to take depending on the action adherence to ethical obligations or consequences of that particular action, respectively (1). the next two questions are pertinent to the nature and number of right-making features in ethical reasoning. their answers develop normative ethical theories that seek not only to determine the right acts, but also to identify their properties. to take well-known examples, the right-making feature in utilitarian theories is utility. these theories have an absolute supreme principle saying that the right action is one that maximizes the balance of good consequences over bad ones (1). the ‘four principles approach’, on the other hand, is an example of a theory with multiple principles or right-making features. it is developed by beauchamp and childress. in this theory, each of the four principles (respect for patients’ autonomy, beneficence, non-maleficence, and justice) introduces a right-making feature (5). ross's ethical theory as another example lists seven right-making features for ethical reasoning as prima facie duties including fidelity, reparation, gratitude, beneficence, nonmaleficence, self-improvement, and justice (6). general approaches to ethical reasoning in ibme in this section, four approaches of ibme conceptualized in this work are briefly presented at first, and then each approach is detailed with examples. the approaches are as follows: 1) ethical reasoning using a language in common with mbme language 2) ethical reasoning using mbme language adjusted to the basic, common beliefs of muslims 3) ethical reasoning using a language based on fatwas 4) ethical reasoning using a language based on ibme principles for most biomedical issues, non-religious sensitivity is considered; hence, a language in common with mbme language is generally used in ethical reasoning for those issues in ibme (approach 1). for example, ethical reasoning about professional commitments such as honesty or altruism is independent from religious beliefs (7). however, this approach is not sufficient for religiously sensitive issues such as advance directive, organ transplantation or abortion. in the case of some religiously sensitive issues, there is general recognition that it is not necessary to seek relevant fatwa(s), i.e., juridical opinions issued by chosen qualified scholars in islamic jurisprudence (marja’ taqlid1 or mufti2) for ethical reasoning. in 1 in shiite schools of islamic jurisprudence such cases, islamic considerations in ethical reasoning are based on the basic, common beliefs of muslims, but not necessarily on fatwas (approach 2). for instance, arguments concerning the ethical aspects of advance directive in ibme may be based on a language in common with mbme language, e.g., the four principles approach (5). nevertheless, the principle of 'respect for patients’ autonomy' cannot be applied in ibme as in mbme; this principle is adjusted to a customized version because of the limited definition and scope of autonomy in islamic beliefs (8). by contrast, muslims (including islamic ethicists) believe that it is essential to seek and follow a fatwa to gain an islamic perspective on religiously sensitive issues such as organ transplantation or abortion; consequently, ethical reasoning in this case will be in line with a given fatwa to put forward a convincing argument. for example, fatwas of the supreme leader on therapeutic abortion (ta) and assisted reproductive technologies (arts) have made those practices legitimate in iran (9 11). some authors have proposed using a principle-rule based language in ibme (12 16). the principles and rules of the ethico-legal reasoning employed by islamic jurists have the potential for applying to ethical reasoning in ibme. for example, the rule of necessity allows a muslim to choose a lesser harm over a greater one, and therefore this rule allows the mother to prefer her own safety to that of the fetus in a maternal life-threatening situation. hence, abortion is not unethical from an islamic point of view in this situation (12). moreover, we emphasize that this classification is based on the conceptual distinctions made for a theoretical, heuristic purpose. hence, developing arguments or making decisions on a specific subject in practice or in ibme literature is not restricted to just one approach. however, a combination of approaches is usually applicable to most issues. this is like other formal distinctions where conceptually distinct things always exist alongside one another in reality. approach 1: ethical reasoning using a language in common with mbme language a language in common with mbme language is often used for ethical reasoning in ibme. examples are found in issues such as medical professionalism, healthcare resource allocation, research on animals, and research on human subjects. decisions or ethical considerations about these issues in ibme (as reflected in ethical codes, for instance) are generally the same as those of mbme (7, 17 19). however, the philosophy behind ibme positions in these cases may be different from those of mbme. in addition, 2 in sunni schools of islamic jurisprudence j med ethics hist med 11: 11, september, 2018 jmehm.tums.ac.ir hamideh moosaopour et al. page 4 of 10 the religious orders or recommendations on these issues not only provide guidance on relevant ethical considerations, but also specify divine rewards and punishments guaranteeing that those ethical codes are obeyed faithfully and without external supervision (20, 21). approach 2: ethical reasoning using mbme language adjusted to the basic, common beliefs of muslims for some morally and religiously sensitive issues such as euthanasia, living will, advance directive, informed consent in children and other similar issues, ethical arguments unavoidably involve the basic, common beliefs of muslims such as eternity of life (the immortal soul and life after death), and seeking perfection. hence, ethical reasoning in these cases may employ a language in common with mbme language, but it is necessary to adjust this language to the basic, common beliefs of muslims (22 25). some authors have reflected on ibme to seek the main concepts of mbme in islamic resources, and explore the differences between ibme and mbme from this perspective. good examples can be found in studies explaining ethical reasoning in islam in terms of important concepts in western moral philosophy, e.g., the three theories of virtue, deontological, and consequentialist ethics, or studies making interpretations of mbme theories, for example the four principles approach, based on islamic beliefs. as regards these three well-known ethical theories, ibme seems to be mainly based on duties and obligations at first glance, whereas mbme seems more based on rights, particularly those of the individual (26, 27); however, ibme uses all three approaches mentioned above, i.e., virtue, deontological, and consequentialist ethics. ibme literature contains many arguments based on the concepts of principles, duties, rights, consequences, or virtues (15, 28). regarding deontological ethics, muslims evidently try to find moral obligations in sharia sources because of a religious, moral duty to obey god’s orders. the moral obligation to save patients’ lives to preserve human dignity is such an example. regarding consequentialist ethics, the important principle of the common good or public interest (maslaha) evidently has a consequentialist view. when the authoritative hierarchy of islamic resources does not provide god’s command to his followers about a definite issue, maslaha can be used to approach that issue, and consequently incorporate new issues into the muslim community (12, 13). ethical reasoning about therapeutic cloning and embryonic stem cell research are examples for which consequentialist arguments such as weighing the benefits to society were made by jurists (28). regarding virtue ethics, professional medical ethics in the islamic tradition known as adab or akhlaq represents the tradition of virtue ethics in islam. for instance, firdaus al-hikma fi al-tibb by ali bin sahl rabban at-tabari or adab al-tabib by al-ruhawi emphasize virtue ethics in physicians’ practice, which could resolve or prevent numerous moral dilemmas in medicine. as weber said, the islamic tradition has emphasized moral virtues in the practice of medicine to the extent that the criteria for a virtuous physician in islam are analogous to those for a reliable legal witness in sharia law. these criteria include being a) an adult muslim, b) sane, c) unbiased, d) and ‘adil, i.e., having a good and blameless reputation (28). due to the importance of reliable legal witnesses in sharia law, islamic ethics demands that physicians have high standards of moral virtues. in recent years, the four principles approach has been extremely prominent while general approaches to ethical reasoning in mbme have been the subject of much debate. the principles are ‘respect for patients’ autonomy‘, ‘beneficence’, ‘non-maleficence’ and ‘justice’. this set of moral principles provides a starting point for resolving ethical problems in biomedicine (5). hence, a number of studies have tried to seek the main concepts of the four principles approach in islamic resources and explore the differences between ibme and mbme from this perspective (29). these studies demonstrate that the roots of the four principles are evident in islamic resources; however, there are some differences in the application of these principles in ethical reasoning, especially in the case of autonomy. on the one hand, significant room exists for autonomy in islam. considering human beings as god’s vicegerents on earth, the importance of ‘ilm’ (knowledge) in making reasoned decisions, humans’ direct accountability for their actions before god without the mediation of a clergy, and their free will to either accept or reject the divine command are proofs for the importance of individual autonomy in islam. according to islamic teachings, one must surrender only to god and to no other creature and that is the definition of abd (29). on the other hand, a feeling of responsibility toward god limits the personal choices of a devout muslim as some actions are forbidden by sharia. another limitation of autonomy for muslim patients is the importance of social coherence where the family, relatives and public interest influence the patients’ decisions (26, 30). in muslim societies, the principle of public interest (maslaha) and the principle of justice take priority over autonomy as the collective interest takes priority over the benefits of individuals. it seems that this value may be rooted in the spirit of islam or in the culture of islamic societies mainly in asia, africa, and the middle-east or both of them (31). approach 3: ethical reasoning using a language j med ethics hist med 11: 11, september, 2018 jmehm.tums.ac.ir hamideh moosaopour et al. page 5 of 10 based on fatwas in islamic discourse, rightness or wrongness of an ‘action’ is traditionally discussed in the field of ‘islamic jurisprudence’ (fiqh) rather than in ‘islamic ethics’. the former is more established, rigorous and disciplined than the latter. the field of ‘islamic ethics’ is mostly focused on the ‘moral agent’ to promote his or her ethical virtues. spiritual growth and striving to be a perfect human depend not only on obeying the juridical obligation, but also on promoting ethical virtues. in comparison with islamic discourse, rightness or wrongness of an ‘action’ in modern, nonreligious discourse is generally discussed in the field of ‘ethics’; likewise, rightness or wrongness of biomedical practice is discussed in the field of biomedical ethics. when muslim patients or muslim healthcare providers face a medical issue not fully compatible with the general guidance of sharia (especially about medical issues of higher ethical and religious sensitivity), they seek the relevant fatwas to obtain the islamic perspective on that issue. for instance, when a continued pregnancy endangers the mother's life and therapeutic abortion is an available option, the muslim mother or her doctor seeks relevant fatwas on the case. they need to know whether abortion is ethically and religiously justified under the circumstances, or whether preferring the mother’s life to the fetus’ life is ethically and religiously right. ethical reasoning regarding such issues is mainly based on relevant fatwas. a fatwa is a muslim jurist’s perspective on a definite subject inferred from islamic resources and issued in the form of a legal opinion to respond to and guide his followers. however, medical fatwas are not so numerous that they can cover all questions in ibme, and they may be applied when: 1) it is crucial to seek the islamic judgment on the issue at hand due to its extreme religious and moral sensitivity for muslims, and 2) reaching the islamic judgment is not easy and straightforward due to the complexity of the situation (unlike approach 2). fatwas have two main functions at individual and social levels. at the individual level fatwas define the follower’s (mukalaf’s) religious duty, which he or she has an inner obligation to fulfill. at the social level, they have great potential to make a concern legitimate in muslim societies. fatwas are not legally obligatory, although in muslim-majority countries current fatwas have affected the laws directly and indirectly. fatwas play two roles in the laws of these countries. first, they are followed by physicians and patients when the national laws are silent about a medical procedure or technology. second, they are used to provide an opportunity to make certain sensitive practices socially and then legally legitimate (9, 10, 32-35). legitimacy of assisted reproductive technologies (arts) in iran could be a good example. ayatollah khamenei, the supreme leader of iran and a qualified religious scholar, issued a fatwa in 1999 in response to increasing public demand for infertility treatments. his statement permitted some art methods including the use of donated embryos or donated gametes of third parties in the process of assisted reproduction for infertile families. after arts were justified non-officially through the fatwa of the supreme leader, the ensuing practice initiated a more official pathway in the case of embryo donation to approve a relevant act by the parliament: the iran embryo donation to infertile spouses act (iedisa). subsequently, the iranian legal medicine organization (lmo) and the ministry of health and medical education (mohme) issued relevant guidelines for arts (9, 10, and 32). approach 4: ethical reasoning using a language based on ibme principles some theorists of biomedical ethics, especially sachedina, suggest a principle-rule based approach to ethical reasoning, which is similar to principlism as an important philosophical approach in mbme. this approach suggests that ethical reasoning in ibme should be done through some well-known islamic principles generally used by islamic jurists for juridical reasoning, because ‘islamic jurisprudence’ (fiqh) has been more established and disciplined than ‘islamic ethics’ (discussed in approach 3). these principles include the principle of ‘public interest’ or ‘the common good’ (maslaha), the principle of ‘no harm, no harassment’ (la darar wa la derar), the principle of ‘necessity’ (darura), and the principle of ‘no hardship’ (la haraj) (12 14). the principle of public interest (maslaha) is an important principle that new rulings are generally derived from. maslaha is also used to suspend earlier rulings out of consideration for public interest and welfare. however, some sunni and shiite jurists do not regard maslaha as an independent source for ruling (12, 13). in shiite or the mutazila school of sunni, maslaha means providing benefits or preventing harms for people as much as possible. in the ash'ari school of sunni, maslaha refers to what is assumed to be good according to sharia laws, and protects the religion, lives (nufus), reason (uqul), lineage (nasl), and property (mal) of people (12, 13). some islamic principles are similar to the principles of mbme. for instance, the principle of ‘no harm, no harassment’ is similar to the two distinct principles of beneficence and non-maleficence. however, some significant islamic rules are usually under-valued in mbme. according to sachedina, one example is that the rule of consultation (shura) is substituted by the principle of autonomy in mbme (13). some of these principles have been applied in ethicolegal reasoning to justify abortion under specific j med ethics hist med 11: 11, september, 2018 jmehm.tums.ac.ir hamideh moosaopour et al. page 6 of 10 circumstances. for instance, the principle of ‘protection against distress and constriction’ (‘usr wa al-haraj’) is the main argument to justify abortion in case of a fetus younger than 4 months with severe malformation, retardation or abnormality that could lead to an unbearable suffering or difficulty for its mother. similarly, the principle of ‘choosing the lesser harm’ between two harms is the main argument to prefer the mother’s life to that of the fetus, and can thus justify abortion when the mother is in a lifethreatening condition (12, 36). challenges of general approaches to ethical reasoning in ibme in this section, some main challenges of each approach are discussed, but a comprehensive investigation of all the challenges is beyond the scope of this article. challenges of approach 1 the first approach has the potential for effective communication between ibme and mbme discourses using the same language. one important challenge is how decision makers identify the lack of religious sensitivity or islamic considerations about a specific issue, and consequently acknowledge that approach 1 is sufficient to deal with the problem; another challenge is to determine who should acknowledge this sufficiency. challenges of approach 2 similar to approach 1, approach 2 has the potential for communication between ibme and mbme discourses. comparative analyses focusing on ethical reasoning using approach 2 can explore root causes leading to disagreements on the same issue in the two discourses. for a specific issue, approach 2 can be used appropriately based on the underlying assumptions which may be challenging. they are as follows: (i) the issue is religiously sensitive. (ii) some islamic beliefs are so basic and common that in ibme, ethical reasoning about that issue can be based on those beliefs. (iii) decision makers can take islamic considerations about that issue into account using mbme ethics adjusted to the basic, common beliefs of muslims. (iv) decision makers do not need to seek fatwas to take islamic considerations into account in ethical reasoning about that issue. (v) decision makers can recognize the above conditions for a specific issue. other important challenges are: who should be the decision makers; how they should acknowledge the sufficiency of approach 2 for ethical reasoning about that issue; how they should recognize the basic, common, beliefs of muslims regarding ethical reasoning in that case; and how they should adjust mbme language to these basic, common beliefs of muslims. challenges of approach 3 approach 3 works well for issues that cannot be resolved using the two previous approaches. in this case, decision makers rely on fatwas to take islamic considerations into account in ethical reasoning about a specific issue. in this age of communication and information, fatwas are easily found in the media worldwide. although a general agreement exists among islamic jurists in many cases, sometimes different and even contradictory fatwas have appeared on the same issue during a given period of time, in various geographical locations, or even in the same country (37, 38). diversity in fatwas results from different interpretations of sharia and raises the problem of authority (i.e., which fatwa should be followed). this causes the most important challenge of approach 3: how healthcare professionals can resolve the conflicts among themselves or conflicts with their patients in the presence of diverse fatwas. fatwas on abortion can be considered as an instance of diversity in islamic fatwas. abortion is generally prohibited in various schools of islamic jurisprudence. after the 120th day of gestation (when according to islam the ensoulment occurs), islamic jurists unanimously agree that therapeutic abortion is permissible only if a life-threatening condition places both mother and fetus in serious danger. however, abortion before the 120th day of gestation is an area of disagreement. as a case in point, the majority of shiite jurists do not permit abortion at any time unless an acceptable reason exists (e.g., a life-threatening condition or an unbearable suffering (usr wa haraj); however, a majority of sunni muslims, the hanafies, permit an abortion up to the 120th day of gestation, whereas most malikies categorically prohibit abortion (37). variety also exists in islamic positions on abortion for non-medical reasons, for instance a woman’s physical or mental health, fetal impairment, social or economic reasons, and also in the case of incest or rape (36). along with diversity in fatwas on abortion, there are different positions on the ‘abortion right’ in islamic countries. a study drawing a cross-country comparison of abortion rights in muslim-majority countries demonstrated substantial diversity: while 18 out of 47 countries are so conservative that they do not allow abortion under any circumstances except to save the mothers’ life, 10 countries allow abortion ‘on request’ before a specific period (37). council (shura) in fatwa may be a solution to address the challenge caused by diversity in fatwas. some islamic scholars have proposed to validate a fatwa by appointing groups of scholars qualified in islamic j med ethics hist med 11: 11, september, 2018 jmehm.tums.ac.ir hamideh moosaopour et al. page 7 of 10 jurisprudence. issuing fatwas by such groups of scholars in institutional bodies has been a practical solution to the problem of diversity in fatwas since the1990s. examples of these institutional bodies include: ioms (the islamic organization for medical sciences, established 1994); ifa (the islamic fiqh academy in mecca, established 1977); iifa (the international islamic fiqh academy in jedda, established 1981); and ecfr (the european council for fatwa and research in dublin, established 1997) (15). additionally, we believe that in order to use approach 3 properly, theorists need to take a position on several challenging questions regarding the definition of fatwa in ibme discourse: (i) whether juridical soundness of a biomedical practice makes it ethically sound. (ii) whether juridical soundness is a sufficient condition, necessary condition, both, or neither for ethical soundness in ibme. (iii) whether a fatwa must cover the full range of ethical concerns in biomedicine. (iv) whether the juridical permissibility of a biomedical practice in fatwas specifically reflects the non-negative general view of islam on that issue, i.e., ethical concerns need to be evaluated by muslim biomedical ethicists. challenges of approach 4 in our opinion, the workings of this approach are an excellent starting point to theorize and provide simple, effective models for ethical reasoning in ibme. however, it is necessary to address several important challenges to develop this approach as seen below: (i) the different shiite and sunni juridical schools (hanafi, hanbali, maliki, and shafi’i) do not agree on the principles and how they are deduced from basic, rationalistically established ethical theories in islam, according to sachedina (12, 13). (ii) this approach has adopted islamic ethicolegal reasoning as an integrated reasoning in islamic discourse. such reasoning works under two assumptions: 1) juridical obligations are necessarily consistent with ethical obligations, and 2) the aim of juridical obligations is to guarantee ethical obligations (12, 13). these assumptions are not accepted by all islamic scholars. (iii) it is unclear how these principles and rules have been selected from all islamic juridical laws. in addition, the order of priority and the process of prioritization in the context of a moral dilemma are not determined. (iv) the agent who should use these principles and rules to make ethically sound decisions in ibme is not well-defined, and it is not clear if it is biomedical ethicists, healthcare professionals, or both. whether these principles or rules are user-friendly enough to be applied by the moral agent is unknown as well. (v) sachedina has made serious attempts to explore “distinctly islamic, and yet crossculturally communicable, principle-rule based deontological-teleological ethics that is operative in the muslim legal-moral culture in assessing moral problems in ibme” (13). nevertheless, it is yet unclear how this theory integrates principlism, deontology and teleological ethics, or how these principles can be “distinctly islamic” and at the same time “cross-culturally communicable”(13), and if these two concepts are consistent. likewise, these islamic principles and non-religious ethical principles must be practically weighed and balanced to make decisions in biomedical practice, which is yet another issue that needs to be determined. conclusion in this article, authors identified and conceptualized general approaches to ethical reasoning used in ibme discourse. these approaches include: 1) ethical reasoning using a language in common with mbme language; 2) ethical reasoning using mbme language adjusted to the basic, common beliefs of muslims; 3) ethical reasoning using a language based on fatwas; and 4) ethical reasoning using a language based on islamic biomedical ethics principles. this conceptualization is founded upon the distinctions drawn for a theoretical, heuristic purpose. it should be noted that in practice, developing arguments and decision-making concerning a specific subject should not be restricted to any one of these approaches, and a combination of these approaches is usually used for most issues. this is similar to other formal distinctions where the conceptually distinguished entities always exist in reality together. to conceptualize general approaches to ethical reasoning in ibme, authors made an inductive distinction by review and content analysis of existing literature, as well as comparison between the languages of ibme and mbme. however, this review, content analysis and comparison have not been systematic, which is the biggest limitation of our work, and therefore this conceptualization may be regarded a tentative, starting point. we believe that in order to develop a coherent theory for ethical reasoning in ibme, there is still a lot of work that needs to be done. to describe existing approaches to ethical reasoning in ibme and to prescribe new approaches, theorists must formulate more generic concepts and address the challenges of j med ethics hist med 11: 11, september, 2018 jmehm.tums.ac.ir hamideh moosaopour et al. page 8 of 10 those approaches. this theorization requires further multidisciplinary work by biomedical ethicists, islamic scholars, humanity and biomedical scientists, healthcare professionals, and laypersons from muslim population. conflict of interests authors have no conflict of interest to declare. acknowledgement we should declare that this article is a part of dr. hamideh moosapour’s ph.d. thesis entitled “theoretical challenges in conceptualization of evidence-based islamic biomedical ethics: a comparative study in philosophy of medicine and medical ethics”. the article and related investigations were developed at evidence based medicine research center, endocrinology and metabolism clinical sciences institute, tehran university of medical sciences. j med ethics hist med 11: 11, september, 2018 jmehm.tums.ac.ir hamideh moosaopour et al. page 9 of 10 references 1. zalta en. the stanford encyclopedia of philosophy. 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part ithe theoretical section nazafarin ghasemzadeh1, fariba asghari2, mandana shirazi3, fatemeh faramarzi razini4, bagher larijani5* 1phd candidate in medical ethics, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. 2associate professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. 3associate professor, department of medical education, school of medicine, tehran university of medical sciences, tehran, iran. 4mentor jurisprudence and islamic law department, urmia university, urmia, iran. 5professor, endocrinology and metabolism research center, endocrinology and metabolism clinical sciences institute, tehran, iran; medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. corresponding author: bagher larijani address: no.23, 16 azar ave, keshavarz blvd, tehran, iran. email: larijanib@tums.ac.ir tel: (+98) 21 66 41 96 61 received: 23 jun 2018 accepted: 13 aug 2018 published: 16 dec 2018 j med ethics hist med, 2018, 11: 14 © 2018 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract end-of-life care and protection of the patient in the near-death moments are part of a patient’s rights and the duties of the medical staff. as the beginning and end of human life are most sensitive moments, there are various religious rules associated with them. the ethical issues regarding practicing medical procedures on nearly dead patients are of particular complexity and are consistent with invaluable and profoundly religious recommendations. in addition, the purpose of medical training is to provide physicians with the knowledge and skills necessary to practice appropriately and within legal and ethical frameworks. therefore, respecting patients’ cultural and religious beliefs is an ethically accepted principle in the health systems of different countries and is the basis of respect for human dignity. the present study used a qualitative content analysis to explain how to practice medical procedures on a dying or nearly dead patient in accordance with islamic jurisprudential rules. it was finally concluded that according to the islamic jurisprudential rules of “authority”, “no harm”, “necessity”, and “public interest”, procedures performed on a dying patient could be used for training purposes under certain circumstances. nevertheless, such activities should only be done with the patient’s permission and provided they cause no unnecessary harassment, and they may take place in the absence of alternative methods. keywords: medical training, dying patient, death agony, islamic jurisprudential rules mailto:larijanib@tums.ac.ir j med ethics hist med 11: 14, december, 2018 jmehm.tums.ac.ir nazafarin ghasemzadeh et al. introduction in addition to providing health services to people, medical science universities have an important role in training skilled human resources and specialists required in different sectors of the society. therefore, medical training must be continuously reviewed and upgraded by eliminating the deficiencies (1). the process of medical training is influenced by several factors and variables including students, professors, educational arenas, training procedures and training resources (1). performing clinical procedures on a patient who is clinically dead (newly dead, while the corpse is still warm) for training purposes has a long history and is common practice in many medical education centers. these procedures can be invasive or non-invasive. endotracheal intubation or central venous catheter insertion (cv line) are among procedures that are not entirely learnable by other devices. nowadays, alternative methods such as simulators and computer simulations are used in skill labs to train students in the abovementioned procedures, but the issues are still of great importance in discussions (2). traditional training activities commonly performed on dead or nearly dead patients include endotracheal intubation and central venous catheter insertion, thoracocentesis, pericardiosis, placement of pulmonary artery catheter, insertion of transient intravenous pacemaker, and peripheral vascular catheter. it is clear that some physicians assume to have prerogative to use these patients’ bodies for training purposes (3). the most serious moral challenges in this type of training are manifested in dying patients. people experience mysterious moments throughout their lives, and the beginning and end of life are among the most sensitive and important times. these two points, the latter in particular, enjoy various rules in the form of customs and religious ceremonies (4). since islamic teachings have emphasized respect for the dignity of the dying person (5), moral considerations are very important at the time of patients’ death, because their dignity must absolutely be respected. at the same time, respect for patients’ cultural and religious beliefs is an ethical principle accepted in the health systems of different countries. to carefully investigate this important issue, the present study provides a comprehensive perspective on death agony in islamic teachings and the use of nearly dead patients for medical training, and explores the islamic jurisprudential rules in this respect. 1al-baqarah, verses 133 and 180; al-nisaa, verse 18; & ma'ida, verse 106. method this research study consists of both theoretical (part 1) and field (part 2) sections. in the theoretical part, extracts were obtained from related contents in the search engines of noormags, magiran, google scholar, and sid by reviewing articles and using keywords such as “dying patient”, “death”, “islamic teachings”, “juridical rules”, “medical training”, and “ethical considerations”. the data were supplemented through an investigation of islamic articles and texts, jurisprudential books, and ahl al-bayt (pbuh) and ganjineh-ye ravayat-e noor comprehensive jurisprudence softwares. the contents of the aforementioned data were also analyzed using a descriptive approach. the content analysis used in this method was conceptual analysis, that is, the components of the scriptures were dissociated and the relationship between the quranic texts was explored. in fact, through analyzing the content of the concepts, the semantic relations between words were investigated in terms of meaning, synonymy, and semantic comparison using the principles of linguistic semantics. as a result, synonymous, opposite, general, particular, primary and secondary, convergent and divergent, single focal and multi-focal concepts and terms were distinguished (6). results the concept of death agony ehtizar (death agony, dying stage, or dying) comes from the root of hazar, which means “to be present”. the term along with the word “death” (mawt) appears in four verses of the holy quran1. according to the encyclopedia of islamic teachings, a person who is dying and is overwhelmed with death is referred to as mohtazar (moribund) (7). in other words, the term refers to a person who is on the verge of dying (8). bahrani states, “this moment is called "ehtizar (dying) because of the presence of angels or family members around a dying person, or believers who are arranging a ceremony and turning the person toward the qiblah (the point to which all the muslims face at prayer, that is, mecca)” (9). in this regard, saheb javaher also states, “because the dying patient is close to death or because of the presence of the angels and the imams (pbut), or the presence of believers at the patient's bedside for the purpose of planning a funeral, or a wise authority, or for all of these reasons, these moments are called ehtizar (dying)” (10). also, it is said that consciousness and the presence of the mind is very intense in the dying moments (11). page 2 of 12 j med ethics hist med 11: 14, december, 2018 jmehm.tums.ac.ir nazafarin ghasemzadeh et al. dying in islamic texts the quran has addressed the issue of dying but has not used the term “ehtizar”. instead, it has used the following terms and expressions: “sakr al-mawt”1 (agony of death); ghamaratu al-mawt2 (the pangs of death); the presence of death3; the coming of death4; the soul of a dying person cometh up to his throat5; and tawwaffa, which means the taking and keeping of the soul6. therefore, expiring or dying in quran and the traditions of ahl al-bayt (pbut) are also called moments of sakrat (agony) and ghamarat7 (pangs). given the lack of a clear definition for death in the holy quran, and despite the assumptions made about the indicators of death in the traditions and practices of prophet muhammad, the task of defining death cannot be assigned to the existing literature, because they describe death using incorrect terms (13). for this purpose, we examined islamic sources to find the signs of death. the quran has indicated some signs for the dying person. in verses related to the battle of the parties (ahzab), when the fear of failure appears in a group of saboteurs, they are described as being surrounded by death; they are distressed and their minds start to decay. “as the fear comes, you will see them in the throes of death, their eyes revolving in their sockets” 8 (14). there are also signs of being on the brink of death in hadiths (a collection of traditions containing the sayings of the prophets). imam baqer (pbuh) said, “when dying, the believer’s face goes pale, it turns whiter than any other part of his body, his brow is covered with sweat, and tears fall from his eyes; these are the signs that show the soul is leaving the body” (11). by these descriptions, it is not difficult to identify the dying person (mohtazar) and recognize the signs, although it is not impossible to be mistaken either. in juridical texts, there are recommendations regarding dying persons in the form of religious duties that are obligatory (wajebat); recommended acts, which are desirable and rewarding but not mandatory (mustahabat); and detestable acts, which should best be avoided though not absolutely unlawful (makruhat). one of the most common recommendations is to help the dying person face the qiblah (15-17), which is obligatory for every muslim and for which the guardian’s permission is not necessary (18, 19). it is also advisable to read the surahs yasin and saffat at the dying person’s bedside (20). in addition, placing heavy objects on their abdomen or talking endlessly in their presence is to be 1ghaf , verse 19. 2an’am, verse 93. 3nisaa, verse 18. 4an’am, verse 61. 5waqi`ah, verse 83. 6nahl, verse 32. avoided (makruh) (18, 21, 22). importance of medical training and the challenges of the use of nearly dead patients in the field of medical education, professional and clinical skills cannot be learned solely through reading books and attending lectures, but need to be acquired in real-life situations and environments (23, 24). therefore, it is essential to use patients for the purpose of medical training, as they have always been involved in medical education (25-27). in terms of clinical training, dying patients have long been the focus of educational programs, and have therefore received careful considerations. patients who are in their death throes have two educational advantages over newly dead patients. firstly, they create a real environment for practicing procedures such as cardiopulmonary resuscitation (cpr) as, for instance, endotracheal intubation and central venous catheter insertion are more difficult to perform on these patients during chest compressions. the second advantage is related to procedures in which physiological responses are a sign of technical success, as these signs are absent in the dead person. examples include fluid return during lumbar puncture and blood return during insertion of the central venous catheter (3). although respect for the dying person has been emphasized in islamic culture (5) and certain rules exist in this regard, serious ethical challenges arise occasionally due to the delicacy and inseparability of medical treatment and educational activities. as an example, resuscitation is a procedure that is not discernible for the families, and may therefore be unethically extend by physicians in order to create further training opportunities for trainees. nevertheless, resuscitative procedures are recommended merely for medical purposes so as not to cause further pain and suffering for the patient. when performed for educational purposes, resuscitative activities may prevent immediate death and thus prolong the dying process, or aggravate the patient’s condition and lead to disabilities resulting from the inefficiency of the trainee as well as unfavorable conditions (3). physicians assume that the significance and benefits of such educational procedures are far greater than, their potential physical harms. it should be noted, however, that there are other considerations in this regard, including the social expectations for proper behavior and treatment of dying patients and newly dead corpses, 7-‘ghamarat’ is the plural form of ‘ghamre’ meaning cyclones and hardships. in fact, at the time of near death, man undergoes a sort of senselessness in which the whole world is seen as darkness and there is no sensation except excruciating pain (12). 8ahzab, verse 19. page 3 of 12 j med ethics hist med 11: 14, december, 2018 jmehm.tums.ac.ir nazafarin ghasemzadeh et al. the demand for these patients to benefit from appropriate care, and the health and welfare of future patients (3). on the other hand, dying patients should be regarded as living persons and it is necessary that the procedures on these patients be based on medical necessity and compassionate care. essential medical procedures should be performed on everyone without discrimination, and should therefore be practiced for dying patients and logged in their medical records on a regular basis. moreover, all procedures performed by trainees should be carefully monitored by qualified physicians. medical staff and health-care providers should respect the dignity of each patient until death, and should continue to respect the corpse afterwards. it should also be noted that training activities should not interfere with the patient’s family visits and must have no effects on the results of an autopsy or evidence of forensic medicine (28, 29). on the one hand, in order to promote the educational system and improve learners’ skills especially in life support procedures, using dying patients for training purposes seems inevitable, since artificial substitutes will not be as effective. on the other hand, patients have the right to receive the best physical care and emotional support possible, and their dignity should be protected in all situations. respect for human dignity philologically, respect (ehtiram) means having reverence, or being honored (30), and dignity (karamat) means greatness or being venerable (31). dignity can be examined at least in three areas: human dignity, divine dignity, and conventional/social dignity (32). therefore, human dignity is considered to be one of the fundamental rights and the basis for other rights (33) because dignity means to value humanity and requires that individuals enjoy their innate, natural and social rights including the right to live, the right to freedom of thought, and so on (33). however, dignity is not considered a right in the strict sense of the word, although it is the intrinsic identity and innate nature of humans. therefore, dignity is not separable from humanity, and for this reason, all individuals, regardless of their opinions, beliefs and religions, are entitled to dignity (34). according to the universal declaration of human rights, dignity is based on human rights as a principle, that is, mankind is human and merely because of that, he/she has certain rights. accordingly, no external issue can take away a person’s rights and his/her honor or humanity, and dignity should be protected in any event (35). therefore, since humans are endowed with human nature and intrinsic faith as one of its components, they have dignity and they are bound to protect it. moral and legal rules also help individuals honor that most valuable essence of self-worth (36). it is noteworthy that in religious texts and sources, there are two kinds of dignity: intrinsic dignity and acquired dignity. this categorization in its essence represents the comprehensiveness of the religious perspective on this human attribute, which has not been extensively taken into account in non-religious legal sources. a. intrinsic dignity dignity is inherent in all human beings from the first days of their lives as well as the onset of their individual development, and will remain an intrinsic part of everyone’s existence until they deprive themselves of its merits (37). in other words, humans enjoy such an attribute as long as they do not reject it through committing a crime or betraying themselves and others by their own will (38). according to various legal schools of thought, both divine and nondivine, the inherent dignity of humans is the basis for the emergence of different rights for human beings, although each school regards human beings according to its particular worldview and analyzes them comprehensively or partially (33). in other words, this kind of dignity is innate, intrinsic, and unbound by religion (39). the verses and authentic narrations refer to this type of dignity. the root of the word karam and its derivatives have been cited 47 times in different verses of the quran (in 29 surahs and 46 verses). meanwhile, verse 70 of surah al-asra, which describes how god has honored man, is the most important evidence of human dignity: “and indeed we have honored the sons of adam, and we mounted them [on horses] in the midst of the land and the sea, provided them with clean things (lawful edibles) and given them obvious superiority over many of our creatures” (14). b. acquired dignity acquired dignity, which is also called value dignity, is non-intrinsic and dependent on individuals’ opinions, and is defined in terms of man’s relation to god (39). this is the kind of dignity and honor which humans acquire voluntarily and through the use of their talents and inherent abilities in the process of growth, perfection, and acquisition of moral virtues (40). the criterion of acquired dignity is virtue. verse 13 of surah hujurat points to this criterion: “o mankind, we have created you from a male and female, and made you into nations and tribes that you may know one another. verily, the most honorable of you in the eyes of god is the believer who is the most righteous” (14). it is worth mentioning that in terms of human rights, there are different principles for human dignity in the west, so that it is based on thoughts such as humanism, natural (innate) rights, positivism, and pragmatism (41). nevertheless, the mentioned categories are not consistent with religious thought. consequently, from the contemporary western perspective, universal human rights have page 4 of 12 j med ethics hist med 11: 14, december, 2018 jmehm.tums.ac.ir nazafarin ghasemzadeh et al. made human dignity visible only in inherent dignity, and do not take into account the higher dignity that we call “value dignity” and thus stop the perfection of humanity in the course of reasonable life (38). however, all human beings are presumed to have inherent dignity, and exercising this right leads to certain rights and duties. in medical education, this important issue is also true of a dying patient. therefore, medical service providers should also respect the dignity of all patients until their death, and should even respect the corpse after death (28, 29). a detailed investigation of different schools suggests that dignity is the most important human attribute and must be preserved unconditionally. therefore, it is essential to respect the dignity of dying patients in the course of medical training. from the point of view of islam, dignity pertains to the human soul, and the body also follows dignity (42). thus, even though medical education is necessary, training activities should not threaten human dignity or prolong the process of dying. in this regard, islamic jurisprudential rules (qawaid feghhi) and the views of jurists can be used to find answers, since jurisprudential rules play a significant role in the comparison of particular cases, and examples of each of the general rulings are of particular importance. islamic jurisprudential rules invoking jurisprudential rules is merely possible in the proposed discussion. the following sections will examine the most important juridical rules, namely, “the rule of saltanat (monarchy/authority)”, “the rule of la-zarar (no harm)”, “the rule of zarurat (necessity)”, and “the rule of maslahat (expediency/public interest)”. the rule of authority (saltant or taslit) one of the most established rules of jurisprudence has been referred to by different names: the rule of “authority”, “dominance”, “monarchy”, “control”, and “the absolute dominion rule”, but is commonly known as “the rule of monarchy” (taslit) in jurisprudence. the word “taslit” philologically denotes that someone is dominated by another with paramount authority (43), and the concept is rooted in the prophetic hadith “al-naso mosallatoun ala amvalehem” (people have domination over their properties) (44). the word “al-nas” refers to all people, men and women alike, because the relative pronoun “al” is inclusive of both male and female genders. there are both positive and negative components in the rule, which means every owner has domination over every one of his/her properties, and this domination can be limited neither by a person nor an institution (45). the rule is based on the holy book (quran), tradition (sunnah), consensus (ijma), and reason (aql). there are several verses in the quran that indicate people have full control over their possessions and are entitled to any kind of seizure, including surah alnisaa verses 2 and 29. in this regard, surah albaqarah, verse 188 states: “and do not seize one another’s properties unjustly, and do not offer a part of it [as bribe] to the judges to help you take possession of other people’s properties sinfully while you are [well] aware of it” (14). careful consideration of the above verses indicates that every human being has dominance over his/her property and has the right to any seizure in concordance with religious principles, and the seizure of others’ properties is subject to the consent of the owner (46). “people dominate their property” (44) is the most famous narrative cited by jurisprudents. in terms of documentation, the narration is weak, but its weakness is compensated by the actions of the companions of the imamiyah (pbuh) who are all trustable witnesses and tradition narrator jurisprudents. thus the hadith of taslit has such great credibility that, despite the weakness of the narrative, it is considered as a jurisprudential rule (47). in particular cases, narrations have also been cited that imply the owner’s control over his/her property, including the following: mohammed the prophet (blessings of god be upon him and his descendants) said, “a muslim’s property is respected just like his blood” (48). moreover, the prophet (pbuh) says in another narrative, “it is not permissible to use a muslim’s property except with his consent” (49). referring to jurisprudential books, it becomes clear that all jurisprudents have reached a consensus on this rule and have referred to it in various cases (50-52). also, examining this rule reveals its rationality, and rational scholars have acted upon it since the past until the present day. some even believe that rather than being a rational rule, this rule is a natural one that is rooted deeply in the human soul, and because of the conformity of sharia law with the laws of nature, sharia has also confirmed this innate law; therefore, the content of this rule is not an islamic order, but a natural and rational statement that islam has also confirmed (46). although documented evidence suggests that the rule of taslit pertains to property, some jurists have applied it to rights as well (53). rights have not been mentioned in hadiths, but the rational idea is that every person has control over his/her property as long as the holy sharea (legislator) has not issued a command otherwise. on the other hand, based on the implication of priority, people’s domination over their property should be generalized to their rights as well (46). in other words, control over one’s property can be exercised over one’s soul and rights. this is the rational rule of “people having domination over their property and souls” (54). the point is that if possession of property is contingent on consent of owners, possession of their rights and souls page 5 of 12 j med ethics hist med 11: 14, december, 2018 jmehm.tums.ac.ir nazafarin ghasemzadeh et al. must also be based on their consent. therefore, when practicing medical procedures on dying patients, their consent should be obtained in order to respect their rights (28, 55). in this case, performing certain procedures for training purposes would raise no objection on the side of the patients or their families, since they have given their consent with respect to this rule. in recent years, the use of the four ethical principles of autonomy, beneficence, non-maleficence and justice has become widespread in the field of biological and medical ethics in relation to human beings. these principles have their origin in the west and at times share similarities with some other concepts, creating challenges in certain areas. autonomy is a case in point that is sometimes confused with free will, and therefore a discussion of these two categories is presented below. autonomy considering the large number of references to autonomy in the field of biological and medical ethics, nowadays there is a need to answer the question of what autonomy is, and to explore the basis, of autonomy as well as its similarities and differences with free will. autonomy, which is synonymous with free will and self-government, means that individual independence is one of the external factors and rights of a person in terms of his/her personal affairs (56, 57). the concept has been influenced by imanuel kant, who believed that in order to clarify free will, we must understand that it has the power to create works and deeds, but is not the effect of something else (58). he considers freedom as the autonomy of will, so this will must lay down laws that individuals must obey. he defined will in the sense of free causality, according to which the effect is prompted by the cause. but the law of autonomy is fundamentally different from the natural law of cause and effect, because the will that is induced by natural necessity is not free, since the causal action is the subject of something other than the subject itself and cannot be considered freedom. in nature, the causal action of an efficient cause is brought about by something else and not spontaneity. in other words, the law governing causal action is not self-imposed, but is laid down by another, and it is called “heteronomy”. consequently, if the law of will is to be imposed by something else, that is, it is not autonomous; then it is not compatible with the will of man (58). according to kant, religious morality is a type of ethics in which the acts of humans are regulated by divine commandments centered on the hope for paradise or fear of hell, and is therefore part 1al-kahf, verse 29. 2ar-ra'd, verse 11; al-anfal, verse 53. of a heteronomous ethics that kant does not consider ethical (58). in view of his reliance on autonomy, there is no place for heteronomous ethics in kantian philosophy. free will all divine laws are based on the principle of free will. divine prophets themselves were the harbingers of free will and invited people to seek and establish freedom (59). as god says in quran, “then, whoever wants may believe and whoever wants may disbelieve, as we have prepared a fire for the oppressors”1. furthermore, in two verses of quran, god has stated, “he would not change people’s destiny until they themselves change their destiny” 2, and “we showed him the way, whether he be thankful or ungrateful” 3 (14). thus, free will is the integral cause of human actions. in fact, god bestowed wisdom, free will and power upon man, giving him a position superior to other living things to be autonomous in his own acts (59). human autonomy is the cornerstone of islamic juridical and ethical system in defining law, duty, and responsibility. the coming of prophets and the revelation of heavenly books would clearly be in vain without the autonomy of humans. this shows that god and prophets recognize the power of free will (60). on the other hand, according to kant, the will is to be regarded as the originator of works and actions, which should not have sources other than the individuals’ willpower. on the basis of unity of divine acts, all actions throughout the world are god’s and all acts and influences are issued through the essence of god and no subject has independence in effect (61). however, the will of god and man are dependent on one another, that is, what is done by the will of man is a result of god’s will (60). nevertheless, since the action arises directly from man’s free will, attachment to the divine will does not lead to obligation as the arbitrary criterion of action is that it derives from free will (62). in addition, reference to the principle of “authority” in islamic jurisprudence and islamic law involves the ability of people and their domination over their properties and their lives, so that they are free to use them and others do not have any rights to dominate and seize them. on the other hand, kant also believes that morality becomes meaningless if humans are not free. respect for the principle of human being’ freedom and their inherent right requires that no actions occur against their will and desire. however, the four logical principles indicate that there is a logical relationship between autonomy and free will, that is, they do not completely conform to each other, but there are common similarities and 3al-insan, verse 3. page 6 of 12 j med ethics hist med 11: 14, december, 2018 jmehm.tums.ac.ir nazafarin ghasemzadeh et al. differences between them. freedom should be considered as a common aspect between autonomy and free will. a dying person who has allowed the medical staff to practice clinical training activities on his/her bedside (through consent or will) has decided based on his/her own free will without any obligation. the rule of no harm (la-zarar) one of the most famous juridical rules that has been considered a significant resource in many jurisprudential issues is the “no harm” rule. this rule is so significant that for centuries, numerous jurisprudents have devoted a complete treatise to it (63), and have exponentially elaborated it. the rule of “no harm” has a strong quranic and narrative validity as there are verses in the quran that have made rulings by specifying the term zarar (harm or loss) and its derivatives in certain cases. instances include verses 282, 231, and 233 of baqarah, as well as verse 12 of nisa. as an example, verse 233 of surah baqarah states, “no mother shall be harmed by her child, and no father shall be harmed on account of his child” (14). according to this verse, it is prohibited and illegal for anyone to harm another. this denial of what many consider to be the reality is due to reverence for human life, and does not pertain to one particular case. in other words although the verse speaks about parents, it is not limited to paternal and maternal characteristics (64), and can be extended to similar cases. there are also so many hadiths related to this principle that mention the same point exactly and deal with the same subject (63), and in all of them incurring loss has been forbidden. the most prominent narrative based on this rule is one that has been continuously mentioned in credible sources. according to this narrative, prophet muhammad (pbuh) once said, “you are a harmful man and harmfulness is not acceptable in a believer” (65, 66). the words used in the cited narratives of the abovementioned rule do not have a particularly religious meaning, but should be interpreted in their conventional sense. thus, the term “zarar” refers to any defect that is inflicted on the property, body, honor and rights of individuals (67). in addition, rational thinkers’ criteria should serve as a firm foundation for this rule. undoubtedly, wise people agree that causing somebody harm is considered an unpleasant act in social and civic life and whoever causes damages is responsible for payment and compensation, and therefore this principle has been accepted in all legal systems. since the holy sharea has imposed no prohibitions on such a rational criterion, confirmation of the holy sharea (legislator) is taken in this respect (63) and as a result, it can be used to counteract permission that may lead to another harm (68). in the light of this rule, any training activity on a nearly dead patient is permissible only in the absence of harm to the patient, as prevention of harm is the most important issue according to the documents on the rule. the word ‘harm’ specifically includes any loss that may be inflicted on the rights of individuals. moreover, the dying patient is not excluded from this rule, and any harm by the trainee is an encroachment on the patient’s rights, which contradicts the ‘no harm’ rule. therefore, it is acceptable to provide compensation for the harm and trainers are liable for injuries caused by their trainees during training period. the rule of necessity (zarurat) in arabic terminology, “zarurat” (necessity) is the noun for “ezterar” (urgency) (43). in common sense, necessity and urgency (zarurat and ezterar) are used together in the sense of necessity and urgency (69). necessity may be the ground for committing certain prohibited acts (70). in islamic law, a crime may be justifiable through concepts such as “prohibitions become permissible under necessity”, or “necessity knows no law” or “necessity precedes the law”. as a result, necessity has always been a reason for renunciation of liability throughout history (71). in addition, it is reasonable to ignore the lesser benefit in order to maintain the greater one in a state of emergency (72). the justification is that harm is permissible whenever there is a significant necessity or expediency that can be achieved through causing the harm (73). it is worth noting, however, that alongside the above rule, there is also the principle of “what is required is measured by what is required” or “there are always specified extents for necessities that should be observed accordingly”. the abovementioned principles form a valid juridical rule, that is, the secondary ruling that is due to necessity or urgency and is only limited to what is necessary. this rule prevails in legal affairs including civil responsibility (74). in other words, the scope of the necessity rule is not broad and the smallest degree of necessity should suffice. various verses and narratives have confirmed the importance of necessity directly or by provision, which can be referred to as evidence for the rule. there are verses in the holy quran that could be mentioned as grounds for the rule of emergency. verse 173 of surah al-baqarah, for instance, states, “[allah] has forbidden you only carrion, blood, and the flesh of swine, and that which is [slaughtered as a sacrifice] for others than allah (or has been slaughtered for idols, etc., on which allah’s name has not been mentioned while slaughtering); [but] if one is forced by necessity, [one can eat these meats to save one’s life and] there will be no willful disobedience nor transgression of the due limits, and it is no sin. truly, allah is the oft-forgiving, and the most merciful” (14). the ordinance of the verse does not page 7 of 12 j med ethics hist med 11: 14, december, 2018 jmehm.tums.ac.ir nazafarin ghasemzadeh et al. pertain to the afore-mentioned circumstances, and the case is not exclusive. if the case and the cause of revelation for this verse was limited to a particular reason, we could assume that most of the verses had been provided for a particular case or a specific cause of revelation and could not be generalized to other occasions (46). another verse states, “why should you not eat that upon which the name of allah has been mentioned [at the time of slaughtering the animal], while he has explained to you in detail what has been forbidden to you, except what you have forcibly required?”1 (14). in the above verse, what is known in islam as haram (forbidden, prohibited, not legal or allowed by law), or is ordinarily regarded as filthy, is considered permissible in the light of a general and universal rule (urgency), and the scope extends to all harams, since the exception in this verse refers to any of the harams mentioned by the holy legislator. the exception, that is, the permission to commit a haram in an emergency, will belong in the territory of all haram deeds (46), as there is no intention to commit a haram in the field of medical education in the case of a nearly dead patient. at the same time, the training may also help solve some of the problems of the medical community in the future. the most important reason for the narration referring to urgency is the hadith known as the hadith of the raf'. in this hadith the prophet (pbuh) said, “my ommat (community) will not be condemned for 9 errs: mistake, forgetfulness, what they do out of necessity, what they do not know, what they are unable to do, what they are forced to do, jealousy, evil omen (auspices), and the temptation to think of creating life, as long as they are not spoken or performed” (48, 75). in addition, this hadith is ordained by the holy legislator for the benefit of the community and cannot be confined to a particular person or individual (71). medical training activities that are performed on dying patients seem to be a case in point and can be the subject of the above rule. 1an’am, verse 119. the rule of expediency (maslahat) the principle of maslahat (public interest) should be considered as one of the rules applicable to various affairs of the society, as well as an effective rule of jurisprudential dynamics. maslahat is based on maf’alat (an arabic rhythm) and is derived from the word solh (peace), meaning “interest”, the opposite of which is corruption. about this word, ibn-e-manzour writes, “eslah (improvement, reform) is the opposite of fasad (corruption), and maslahat means eslah” (43), and in majma albahreyn, he also states, “…and in the affair there is interest or good” (76). in this regard, saheb jawaher writes, “it is inferred from the narrations and sayings of the jurisprudents as well as the quran that all transactions and non-transactions are proclaimed for the expediency and worldly or other-worldly benefits of the people, all of which are conventionally called expediency and interest” (51). according to allamah heli, expedient is something that is compatible with human intentions, either worldly or other-worldly, or even both (77). all muslims believe that god has a reason for his ways, and all the sharia rulings have specific purposes and intentions, because otherwise, everything would be in vain (78). people’s actions are no exception to this, and there should be an underlying purpose for every action. there are some issues that the holy legislator has not addressed, delegating them to people to resolve according to the benefit of the community (79). clinical medical training performed on a dying patient is one such case. the term maslahat does not appear in the quran, but many derivatives of this term, such as eslah (their affairs, improvement), aslah (reform) and saleh (righteous), have been used dozens of times. the holy legislator urges human beings to be peacemakers and serve the benefit of the community, and observe what is considered to be public interest, in verses such as surah a’raf, verses 85 and 170; surah al-baqarah, verse 220; and surah al-hud, verses 116 and 117(80). nowadays the principle of utilitarianism has overshadowed everything, and medical education, especially when involving a dying person, is no exception, since lack of training in certain conditions may harm the success of medical education. therefore, it is essential to allow this type of training to be provided for the benefit of the community, on the religious condition that no distress and constriction is imposed on the dying patient. page 8 of 12 j med ethics hist med 11: 14, december, 2018 jmehm.tums.ac.ir nazafarin ghasemzadeh et al. conclusion by considering the islamic jurisprudential rules mentioned earlier, it can be concluded that they can be applied when practicing medical procedures on a dying patient. in this regard, see table 1 below. table 1application of islamic jurisprudential rules in practicing medical procedures on a dying patient islamic jurisprudential rules their application in practicing medical procedures on a dying patient saltant (authority) patient-centeredness, informed consent zarurat (necessity) necessity of medical education on dying patients in lack of alternative methods la-zarar ( no harm) avoidance of any harm, distress or prolongation of the dying process maslahat (public interest) community-centeredness, benefit to community as previously pointed out, the foundations of human dignity differ in islam and the west. in the islamic view, the integration of soul and body has dignity and therefore the body deserves respect due to the presence of the soul. in the west, due to the intellectual foundations that are mostly rooted in the human nature, dignity is regarded rather similarly. however, the intrinsic human dignity should be considered as a common prospect in all schools of thought. moreover, free will adds to this dignity, and at the same time entails various issues such as obtaining the consent of a dying patient for medical training as well as using his/her body for medical practices according to his/her will. nevertheless, it has been extensively explained in this article that free will should not be considered equal to autonomy since the human will is dependent on the will of god. the conflict here is that on the one hand, medical training, particularly on a dying patient, is essential for the education of trainees, and on the other hand, the patient is not completely dead, and training procedures need to be practiced objectively and experimentally. even though some forms of training could not be practiced in any other environment, muslims’ right and dignity must be observed and respected. in such cases, one should refer to the narrative that “necessity removes the ban”, or consider the justification that the health of the community depends on these training procedures. under the circumstances, performing training activities on dying patients is permissible, provided that the patient’s consent is obtained. however, these activities should not result in any harm or distress, and in the presence of a will (a patient’s will or advanced directive), the procedures should be performed according to it. acknowledgements the paper is extracted from nazafarin ghasemzadeh’s ph.d. dissertation entitled “compiling national ethical guidelines for medical teaching based on religious and cultural beliefs in iran”, supported by tehran university of 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[in persian] 80. salarzaei ah, janjan f. criminal policy originated from the holly quran. crime prevention studies quarterly. 2012; 6(21): 99-118.[in persian] page 12 of 12 microsoft word 13 journal of medical ethics and history of medicine brief history of pharmacy ethics in iran hassan farsam professor, faculty of pharmacy and pharmaceutical sciences research center, tehran university of medical sciences, tehran, iran. *corresponding author: hassan farsam address: faculty of pharmacy and pharmaceutical sciences research center, tehran university of medical sciences, tehran, iran. tel: (+98) 21 66 95 90 62 e-mail: farsam@tums.ac.ir received: 02 jun 2009 accepted: 13 jul 2009 published: 30 jul 2009 j med ethics hist med. 2009; 2:13. © 2009 hassan farsam; licensee tehran univ. med. sci. abstract keywords: pharmacy, ethics, persian history, pharmacy history. introduction iran (formerly persia) is located in southwest asia with a territory of 1,648,195 square kilometers and a population of more than 70 million people (1). iran with its five major climates has been pre sented a unique diversity of medicinal plants (2). this country, also, played an important role in the history of medicine and pharmacy in the world, but, unfortunately a very small part of this history has been taken into consideration (3). history of ethics is closely related to the pres ence of human being in the world. in other words, ethics are born during the social activity of the people and everybody has its own role. the aim of this study is a brief excursion on the history of pharmacy ethics in iran. our biblio graphy showed a few investigations on this topic (4, 5). on the contrary, we found many papers regarding medical ethics in iran. it is partly due to this fact that pharmacy during centuries was associated with medicine in their responsibility with regard to preserving health of the people. brief history of pharmacy in iran history of pharmacy in iran goes back to sev eral centuries ago. the ancient history of pharmacy in iran is an amalgamation of medico-pharmaceutical beliefs of babylonians, assyrians, inhabitants of mesopota mian plains as well as greeks, indians, egyptians, and ancient iranians (3, 6-9). babylonians and assyrians believed that health and diseases were gift of gods and treatment was based on prays and incantations. but their beliefs were not confined to magic and spiritual activities. r campbell thomson examined hun dreds of clay tablets obtained from library of king assurbanipal and found a valuable materia medica. he identified 250 vegetable drugs, 120 mineral drugs, alcoholic beverages, and parts of animals being used as drugs (9). in one of the clays, prepared by the kremers and other scientists which considered as one of the oldest medical documents in the world, the laws and ethical rules are de scribed. in these rules, rewards and punishments of the physicians are clearly described (10). of the pharmacy is an ethical profession. the aim of this study was to investigate the history of pharmacy ethics in iran. in the ancient persia, medical and pharmaceutical ethics were related to religious rules, and everybody had to respect it. the ethical rules were similar to some current pharmacy ethics. during islamic era, the pharmacy ethics were edited according to the islamic rules. after introduction of european pharmacy into iran, the pharmacy ethics did not change and was regarded as before. by presentation of bioethics and medical ethics in recent years, new activities are carried out for better manipulation of their rules in health professions including pharmacy. j med ethics hist med 2009, 2:13 hassan farsam page 2 of 4 (page number not for citation purposes) oldest documents of medicine and pharmacy of ancient persia, one can mention the holy book of avesta (11), as well as the dinkard, the zadspe ram, and the memories of some greek historians (3, 7, 8, 12). it is interesting to mention that the term ”drug” is probably derived from the avestan ancient term “darav” meaning the stem of a plant as the origin of medicinal herbs, (dar in current farsi language stands for tree). this word later changed into “darug” in the median farsi language, and then changed to “droga” in latin, “drogue” in french” drug” in english and “daru” in farsi language (13, 14 ). the jundishapur academic center was estab lished during sassanid dynasty. this scientific center, due to its cosmopolitan centrality, can be considered as one of the earliest universities (15). one of the famous pharmacists in this school was shapur sahl. he composed his aqrabadin kabir (great formulary) in 869 ce, which became the first formulary to receive widespread acceptance and use in hospitals and pharmacies of the time (3, 16). according to edward brown: “the most cogent evidence for ancient iranian interest in pharmacy is the iranian origin of many drug names in medieval medicine” (17). with the establishment of islamic government in iran (638 ce), the medico-pharmaceutical knowledge of many countries came under the rule of islam. a new era of medical, pharmaceutical and other sciences commenced and became a brilliant period of scientific knowledge, which later disseminated into europe; thence greatly influ enced the european renaissance (6, 8, 18) the role of iranian scholars was very important in the advancement of sciences and art (15). the arabic language became the dominant scientific language (3, 8, 19). but, unfortunately, later, this word was used to denote a race or a nation. an in-depth discussion on this era ( 1000 yrs) is not possible in this short space. it is necessary to mention that, according to martin levy, “during this era, over 600,000 manuscripts were dispersed in depositories throughout the world.” these manuscripts were mostly in arabic language and some in persian (20). therefore, it is reasonable to abridge review ing the history of pharmacy in iran to a few well known iranian scholars. mostly, those whom we consider as physician-pharmacists are so called because they have writings on pharmacy and pharmacology. ali ibn sahl rabban tabari (circa 818-870 ce) this iranian scholar was born in marv, taba ristan, from a respectable jewish family. his father was a well known physician and a reputable philosopher. he received his education in the discipline of medicine, calligraphy, astronomy, mathematics and literature. he had also studied syriac and greek languages. later he left marv to ray (near tehran). then he moved to baghdad where he converted into islam. some historians have introduced him as a tutor of rhazes which was rejected rationally by other historians due to the differences on their birth and death dates. however, rhazes, as a disciple mentioned him in his well-known book al-hawi fi tibb. it is quite possible that rhazes borrowed many aspects of medicine and pharmacy from his book entitled “ferdous-al hikmat” (the paradise of wisdom). three out of seven sections of his book are dedicated to drugs, poisons, flavors and diet. tabari clearly demonstrated his reliance on the greek medicine and indian herbal drugs (19, 2124). mohammad ibn zakariya razi (rhazes in latin) 865-825 ce rhazes was master of alchemy, chemist, phar macist, philosopher, theologian and a great clinical physician in medieval medicine, and, also, well known as ‘the galen of east’ (23, 25, 26). his famous book al hawi fi tibb (the continens of rhazes) is an enormous encyclopedia in 26 volumes. the first edition of this book was printed in brescia, italy in 1486. three volumes of this book were dedicated to pharmacy containing many extracts from greek and hindu authors (27). these books were used as a source of pharmacology for many years in european universities (26). rhazes wrote more than 180 books and treatises in medicine, pharmacy and other sciences (23). two of his books concerned with ethics are: 1) alsirat al-falsafiya (the nature of philosophies) and 2) tibb-e rohani (spiritual medicine) (27, 28). rhazes in his book shukuk ala jalinus (doubts about galen) denoted his critics on the works of galen. abu mansur muwaffaq heravi he was a physician–pharmacist who lived after rhazes and we have not enough information about his living time period. he is famous for his book written in farsi on pharmacy and pharmacology under the title “ketab ul-abniya an haqa' iq'il adviya” (the book of the foundations of real properties of the remedies). this book can be considered as the first pharmaceutical writinng after domination of arabic language as a scientific language which was not understood by ordinary people. with this book a new era of pharmacology began to work (3). abu ali al-husain bn abdullah ibn sina (avicenna in latin) (980-1037 ce) he is considered the greatest scientist of islam ic period. he was also a poet, writer, theologian, philosopher, mathematician, and psychologist. he was called "the prince of physicians" by the europeans (29). j med ethics hist med 2009, 2:13 hassan farsam page 3 of 4 (page number not for citation purposes) his masterpiece ‘the canon of medicine’ was translated into latin and other languages and taught in many european universities for years. he dedicated two volumes of the 5 volumes of this book to pharmacy and pharmacology. his writings had significant effect on western medical curriculum and was helpful to the euro pean renaissance (29, 30) western medicine and pharmacy in iran european pharmacy and medicine was intro duced to iran with the establishment of dar-ul fonun (polytechnic school) in tehran in 1850 ce. western medicine was taught by european physicians. humoral theory was the bases of pharmacy before the advent of western medicine into iran. traditional knowledge of pharmacy and medicine was pushed away from the mainstream of the medicine. historical remarks as mentioned before, pharmacy in ancient persia was integrated into medicine, and physicians were engaged in pharmaceutical affairs; for example, ibn masawayh was the head of jundisha pur hospital but, he was also a famous pharmacolo gist. therefore, the ethical principles of pharmacy and medicine were associated with each other. in that period, ethics was mostly based on reli gious orders. plato remembered of iranian ethical art such as knowledge, justice, selfishness, free dom, mercifulness and kindness as persian training rules (31). ethical rules in medicine including the character of a good physician, medical behavior including deontology, kindness, humility, avoiding giving abortifacient and denying poor patients are mentioned in avesta and pahlavi sources. ignoring these rules was associated with hard punishments (6, 28, 32). furthermore, as mentioned in other sources, the physicians and the pharmacists had to attain qualifications, listen to patients with calm ness and gentleness, take honor in their profession, and be god fearing, etc (3). many of these parame ters are very similar to those are recommended today. during islamic era in iran, ethical issues of pharmacy and medicine were taken into more consideration. the well-known iranian physicians such as tabari, rhazes, avicenna, and others allocated parts of their writings to ethics (23, 33). haly abbas (ali abbas majors ahwazi) translated and modified the hippocratic oath and brought it into his book under the title of "ahwazi letter of advice". this statement contains many ethical parameters nowadays presented as pharmacy code of ethics (34). during safavid state, an iranian government came into being. pharmacy in this period had more advancement than before. elgood called this period "the golden age" of pharmacy of iran; however pharmacy ethics were not considered by unofficial drug sellers (3). during education of medicine and pharmacy in dar-ul-fonun, the ethical issues were dependent on the behavior of the educators. tehran university was opened in 1934 ce. in the faculty of medicine, pharmacy and dentistry, no place was allocated to pharmacy ethics. dr. etemadian wrote a book on medical ethics in 1963 ce (35). the content of this book was not taught in the faculty of pharmacy and no syllabus was introduced for pharmacy ethics. just the dean of the faculty was reminding the responsibilities of the pharmacists in the society and was mentioning some advices in respecting social behaviors and keeping the prestige of the pharmacy profession to the students, for one or two hours. in current academic year (2008-2009), a course of pharmacy ethics (one credit) is being launched for the undergraduate pharmacy students of faculty of pharmacy of tehran university of medical sciences. bioethics was presented as a new concept. this term was not so new in medicine and pharma cy in iran because physicians and pharmacists have preceptions and regulations concerned with those presented in bioethics (6, 28, 32-34). by the explosive advancement of sciences like biotechnology, nanotechnology and biomedical sciences, the issues of bioethics and medical ethics are put into consideration in iran. the obligations of bioethics and medical ethics are also put into action; further activities in these fields are under investigations (36). conclusion pharmacy (and medicine) has been a profes sion engaged with ethical measures in the ancient period of iran. during early islamic periods, many medico-pharmaceutical scholars wrote treatises regarding ethics. introduction of european pharma cy (and medicine) led to the establishment of tehran university in 1934 ce. pharmacy ethics in that period was dependent on the behaviors of the instructors and cultural religious beliefs of that time. thirty years after the opening of tehran university, the first book in medical ethics was published. this book was not taught in the faculty of pharmacy. by the introduction of bioethics and advancement of biosciences, bioethics was taken into consideration in iran and their obligations were put into action; so today ethics is 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(in persian) 35. etemadi mn. medical ethics and customs. tehran: tehran university press; 1963. 36. larijani b, zahedi f. medical ethics activities and plans in iran at a glance. iran j allergy asthma immunol 2007; 6 (suppl. 5): 14. journal of medical ethics and history of medicine case report ethical and legal aspects of patient’s safety: a clinical case report maliheh kadivar1, arpi manookian2*, fariba asghari3, nikoo niknafs4, arash okazi5, asal zarvani6 1professor, division of neonatology, department of pediatrics, children’s medical center, tehran university of medical sciences, tehran, iran. 2assistant professor, school of nursing & midwifery, tehran university of medical sciences, tehran, iran. 3associate professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. 4assistant professor, division of neonatology, department of pediatrics, vali-e-asr hospital, tehran university of medical sciences, tehran, iran. 5assistant professor, department of forensic medicine, tehran university of medical sciences, tehran, iran. 6nursing student, school of nursing & midwifery, tehran university of medical sciences, tehran, iran. corresponding author: arpi manookian address: school of nursing & midwifery, tehran university of medical sciences, tehran, iran. postal code: 1419733171. email: ar-manookian@sina.tums.ac.ir tel: (+98) 21 61054322 received: 2 jul 2017 accepted: 25 dec 2017 published: 30 dec 2017 j med ethics hist med, 2017, 10:15 © 2017 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract since patient safety is multidimensional and grounded in ethical and legal imperatives, both ethical and legal challenges should be taken into account. in this regard, a falling incident case of a 12-day-old newborn was raised in the monthly ethics round in the children's medical center of tehran university of medical sciences, iran, and the ethical and legal dimensions of patient safety were discussed by experts in various fields. this report presents different aspects of patient safety in terms of root cause analysis (rca) and risk management, the role of human resources, the role of professionalism, the necessity of informing the parents (disclosure of medical errors), and forensic medicine with focus on ethical aspects. keywords: patient safety, risk management, ethics, legislation, case study mailto:ar-manookian@sina.tums.ac.ir j med ethics hist med 10: 15, december, 2017 jmehm.tums.ac.ir maliheh kadivar et al. page 2 of 5 introduction according to the non-maleficence principle of medical ethics, ensuring patients’ safety and preventing any injury or damage to them is a major priority for healthcare providers (1). thus, it has been the most emphasized component of the quality of health care services all around the world. the institute of medicine (iom) released a report in 1999 entitled "man is fallible: create a safe health system" in relation to the incidence of medical errors in united states, and consequently, initiated widespread international change in the field of patient safety (2). correspondingly, the iranian health care system implemented special plans purposed to deliver standard health care services and prevent any mistakes and an organized approach to risk management, systematic deficiency, and patient safety improvement (3). one of these programs is clinical governance which was introduced by the ministry of health and medical education (mohme) and initiated since november 2009. although great emphasis has been placed on the importance of clinical governance by the mohme, there are some challenges in achieving the desired outcomes (4). this could be the result of healthcare providers’ inadequate understanding about the importance of clinical governance and lack of organizational safety culture (5, 6). studies showed that a non-negligible percentage of patients are exposed to health care-related injuries. based on world health organization (who) report, the possibility of harming patients in the process of providing health care services is 1 out of 300, whereas the possibility of aviation accidents is 1 out of 100,000. since 2004, with the beginning of the patient safety project, so far 140 countries have attempted to improve their patients' safety plans in their own health system (7). the most common cause of injury is medication errors and falling. although falling includes 21% of total incidents, only 4% of them are serious. meanwhile the neonatal falling statistics in the usa is 1.6-4.4 in 10,000 live births, an estimated 600-1600 falling incidents in a year. these cases are often the result of shortcomings in systems and processes, organizational complexity and ambiguity, and poor communication (8, 9). despite various patient safety guidelines and standards, less attention is paid to the ethical and legal aspects of this issue. from a moral perspective, the main goal of patient safety in the health system can be studied from two aspects. it can be studied as a practical value, in the sense that the main focus is its positive outcomes and benefits. it can also be studied as a moral value by focusing on the protection and promotion of humanity and human dignity. it should be emphasized that both aspects are important in the health system. from a professional point of view, moral values in patient safety are not separated from basic medical obligations, but are so central that they may be the source of other moral values emphasized in medicine. this means that patient safety is closely related to the concept of human dignity and all patient safety measures taken must insure the protection of human’s dignity (10). in other words, the responsibility of the health care staff and professional commitment, in general, are closely related to human dignity (11). this case was raised in the monthly ethics round in the children's medical center of tehran university of medical sciences, iran, and ethical dimensions of patient safety were discussed by experts in various fields. the opinions expressed in this article are a summary of the views of experts in various fields including neonatology, medical law, ethics, and nursing. it is worth mentioning that the ethics round has been held every month for more than 5 years in the children's medical center. a complicated case is discussed in each session with the presence of different relevant experts. the clinical case a 12-day old newborn infant was hospitalized in the neonatal intensive care unit (nicu) because of multiple seizures. he was the first child of the family. the mother’s and family history was negative for seizures or any other disease. seizures were controlled by medications, and diagnostic assessments including electroencephalography (eeg) were ordered. as the infant was stable and had tolerated breast feeding, it was planned to transfer him to the level ii nicu, but it was postponed due to lack of available beds. on the evening shift of the third day of admission, his nurse heard a sudden noise and noticed that the incubator door was open and the baby was on the floor. the in-charge nurse immediately announced the incident to the on-call physician. the newborn was examined thoroughly and no physical injuries were found. moreover, the incident was reported to the chief physician of the department and the record of this incident was immediately sent to the hospital officials. later, all other incubators were inspected to make sure they were secure enough. when the staff informed the newborn’s father of the falling, he accused the mother of neglecting the child, although she had said that she was resting at the time of the incident. the questions raised in the meeting were as follows: what are the factors leading to this incident? how could this incident been prevented? what is the responsibility of the staff in dealing with this incident? based on professional commitments, what is the duty of medical and nursing staff in such events? what are the ethical issues of patient safety in this case? what are the legal obligations and consequences of this case? j med ethics hist med 10: 15, december, 2017 jmehm.tums.ac.ir maliheh kadivar et al. page 3 of 5 discussion root cause analysis and risk management searching for the causes and finding the right solution, in other words, the basic analysis of the incident is one of the initial and essential measures taken to decrease the incidence of patient injuries. it should be noted that the mentioned process must be free of any bias and should focus on finding the main cause and resolving it instead of identifying the responsible person. one way of preventing such events is to have a special guideline for reporting the event in a suitable organized ethical atmosphere without accusing anyone. indeed, fear of blame, penalties, limited organizational support, inadequate feedback, and lack of knowledge about the associated factors are some of the barriers to reporting medical errors in hospitals (12). assessment and reduction of patients’ risk of injury, or risk management in the clinical setting is influenced by several factors. one way is the establishment of an organizational culture based on mutual trust and effective communication in all hospital levels (13, 14). from an ethical perspective, the value of trustworthiness is a prerequisite of successful risk management. this value is connected to safety culture since it refers to physical safety, psychological safety, and cultural safety. thus, the managers’ responsibility is to create mental and physical safety settings based on openness in order to promote patient safety and care quality. furthermore, it is important for the managers to encourage multidisciplinary collaboration to facilitate transparent reporting (10). in this case, the apparent reason was that the incubator door was left open by someone or was not correctly closed. questions raised in this context include the following: was the nurse occupied with other emergency and essential actions? was the incubator door latch broken? why would the nurse forget to accurately examine the door? is it possible that lack of guidelines for patient safety led to this incident? the most important step to reduce the possibility of such events in clinical settings is to establish policies and procedures that work best for each ward. furthermore, the continuous training of the personnel in patient safety, steady supervision, and controlling the efficacy level of the performed actions are some other steps that can be taken in this regard. for instance, in this case, frequent checking of the incubator door, the use of two locks, and explanation of safety tips regarding the incubator to the staff are also important. furthermore, evaluation and constant controlling of compliance with patient safety rules, and feedback are also necessary. the role of human resources the quantity of human resources is also noteworthy in the field of patient safety. in other words, quality assurance depends on the quantity of manpower. therefore, in order to prevent similar incidents, providing an adequate number of staff at the bedside is essential (12). the role of professionalism professional ethics and patient safety are intertwined fundamental concepts in medicine. patient safety is grounded in ethical principles which are considered as care quality indicators (15). the realization of patient safety requires the provision and implementation of a professional code of ethics. based on the iranian healthcare professional code of conduct, it is expected that all patients be treated with dignity and be protected from any possible harm (16). accordingly, adherence to ethical principles requires healthcare providers to identify potential safety failures to prevent falling incidents (15). the establishment of patient safety has different individual, professional, and organizational aspects with a special focus on ethics. professional and organizational commitment leads to detecting and reporting of both one’s own and others’ errors (10). from an ethical view, the following actions are recommended: following professional and institutional guidelines (if any exist) related to falling incidents; taking basic actions to assess the patient’s physical health and rescue his/her life; informing the in-charge staff; punctual assessment of the situation, and complete documentation and reporting of the event (important data such as the time of the incident, the infant’s position, level of consciousness, vital signs, those present at the scene, actions taken in the process, and etc.) should be documented; informing the parents and providing them with emotional support. informing parents (disclosure of medical errors) it seems in case of any error made by the care team, the event must be announced to the parents honestly without blaming the care providers. moreover, irritating phrases such as “it happens” and “nothing has happened though” should not be used. under circumstances in which errors were caused by inappropriate pattern of providing hospital services, parents should be reassured that all services will be paid for by the hospital. it would be better if the parents were informed by the chief physician or the head nurse and given enough time to express their concern or anger. although anger under such circumstances is a natural reaction, we cannot hide medical errors because of fear of parents’ reaction. moreover, parents’ anger would be more severe if they found out that the hospital personnel have concealed the truth. it should be considered that knowing the truth is one of the basic rights of patients and their family members. according to similar studies, explaining the error to the patients could be a stressful situation combined with intense emotional reactions from patient/family members or the care team. generally, the person who committed the error has a sense of guilt or fear of punishment, and patient/family members experience feelings such as anger and anxiety. furthermore, it should be noticed that j med ethics hist med 10: 15, december, 2017 jmehm.tums.ac.ir maliheh kadivar et al. page 4 of 5 primary conversations usually take place when there is not accurate and comprehensive information about the event, so recognizing, understanding, and explaining all the details in complicated clinical situations is not possible. thus, it is suggested that in such situations, information be given in several stages and by providing psychological support for the patient. furthermore, while they may need supportive interventions, the patient's family can be considered as an important source of information in the process of root cause analysis (rca) of similar incidents (1720). since creating ethical patient safety is a multidimensional accomplishment, it should be considered that actively partnering with the patient’s family may be a high-yield approach to detecting and preventing medical errors (10). in addition, regarding the presented case, the father should be ensured that hospitalizing the newborn was necessary and the mother should not be blamed. in fact, he should be ensured that the incident was entirely due to system error and not by the mother. basically, maintaining the integrity of the family is essential and medical staff must consider family support at all stages, especially in such circumstances. indeed, an important ethical point in this case is the necessity of offering an honest apology. it is not always as simple as saying: “we are sorry”. the way of informing the parents is a sensitive issue and there is an urgent need for training healthcare providers in sensitive interpersonal relationships and related skills to facilitate honest and proper communication with the patient’s family (20). forensic medicine aspect laws and regulations related to patient safety, which may vary based on the legislation system of each country, should encourage the disclosure of medical errors while supporting the implementation of the ethical imperatives of patient safety. in general, based on the medical law, the patient who is a victim of negligence is supposed to be fairly compensated. in addition, these rules provide possibilities for promotion of transparency and open communications in all levels. reaching this goal requires regarding all stakeholders in the healthcare system (21). in the mentioned case, some questions could be raised. either the falling was in the presence of the mother or not. if it was in her presence, the hypothesis is that she dropped the baby intentionally. however, if there is no sign of any apparent trauma, it seems there was no specific hurtful force or he fell from his mother’s arms, and it shows the mother’s lack of experience. accordingly, it should be considered that maternal postpartum sleepiness is one of the major risk factors for falling of newborns. half of all newborn falling incidents in hospitals have occurred while the mother was holding the infant in a hospital bed. therefore, recognizing the risks of neonatal falling during mother–baby care situations and teaching the mothers is a major nursing responsibility (22). if the mother is incapable of taking care of the hospitalized baby, she should be under supervision of the care team and should be educated. furthermore, notifying the father is an appropriate act if the complaint was raised by the father. the main task of the physician or nurse after a detailed examination and treatment is the detailed registration and description of all events without any assumptions. if the examinations found evidence of neglect, it would be a completely different discussion and calling the social services would be absolutely necessary. the question might also be raised that “if nothing happened to the child and we did all the assessments to insure his health, are we obligated to inform the parents?” there is an obligation to inform the patient or the family about every unwanted event in healthcare settings. the idea that there is no need to disclose errors which did not affect the patient is based on the traditional stance of the law. furthermore, today, it is well known that such disclosures will enhance patients’ trust to healthcare professionals while making them aware of that which is going on around them. in addition, through this approach, healthcare professionals can respect the patients’ autonomy and dignity (21, 23). conclusion despite increased attention toward the quality of health care services, there are still numerous threats to patient safety in healthcare settings. since patient safety is multidimensional and grounded in ethical and legal imperatives, both ethical and legal challenges should be taken into account. reaching the ultimate goal of the healthcare system, which is to ensure quality and safety of the services, requires structured policies and processes to foster the safety settings based on mutual trust. this can be facilitated by encouraging multidisciplinary collaboration for the transparent reporting of medical errors and also active participation of the patients and their families in detecting medical errors. furthermore, the provision of emotional support and legal protection of the staffs by the organization is essential to encourage voluntary reporting of incidents. moreover, training and emphasizing on the professional code of ethics can be effective on deepening the understanding of and belief in the moral foundations of patient safety. conflict of interest the authors declare that there is no conflict of interest. j med ethics hist med 10: 15, december, 2017 jmehm.tums.ac.ir maliheh kadivar et al. page 5 of 5 references 1. durgun h, kaya h. the attitudes of emergency department nurses towards patient safety. int emerg nurs. 2017; pii: s1755-599x (16)30113-6 2. ulrich b, 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university of medical sciences, shiraz, iran. 2associate professor, department of medical ethics, shiraz university of medical sciences, shiraz, iran. 3professor, department of sociology, shiraz university, shiraz, iran. 4assistant professor, department of medical ethics, shiraz university of medical sciences, shiraz, iran. corresponding author: sedigheh ebrahimi address: block no.2, department of medical ethics and philosophy of health, school of medicine, zand ave., imam hosein sq., shiraz, fars, iran. email: sedighehebrah@yahoo.com tel: (+98) 917 1129908 fax: (+98) 713 2348980 received: 04 march 2018 accepted: 12 jun 2018 published: 9 sep 2018 j med ethics hist med, 2018, 11: 10 © 2018 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract learning professionalism is a central topic in medical education. while many factors could affect the educational process of professionalism, hidden curriculum is considered one of the most important ones. as the working components of a hidden curriculum might be specific to the settings, this study explored its components in terms of professionalism and ethical conduct from the viewpoint of iranian undergraduate medical trainees. semi-structured and in-depth interviews were used to collect medical students' experiences and viewpoints, which were then analyzed through simple content analysis and the codes and categories were extracted. finally, themes were derived as the central organizing concepts. saturation occurred after 17 interviews. seven main themes were extracted as the working components of hidden curriculum regarding professionalism in the setting: ‘convenient patients’, ‘evaluate me’, ‘trust as the base of team interactions’, ‘perceiving encouragement’, ‘relationship satisfaction and authenticity’, ‘workload and students’ well-being’ and ‘role modeling at the heart of professionalism’. students' perception and experiences are a rich source of gaining a deeper understanding of the working hidden curriculum. in this study, two groups of human-related and environment-related elements were extracted. they were effective in the formation of the current 'ethical climate', which shaped the professional and ethical identity of medical trainees. moreover, specific plans regarding the condition of the settings may provide opportunities for medical educators to enhance professionalism in their institutions. keywords: hidden curriculum, professionalism, undergraduate medical student, content analysis, in-depth interview mailto:sedighehebrah@yahoo.com j med ethics hist med 11: 10, september, 2018 jmehm.tums.ac.ir sajjad azmand et al. page 2 of 12 introduction there is still a noticeable gap between what medical educators intend to teach medical trainees through formal curriculums and what they learn through nonformal or hidden curriculums (1). the existing literature shows that teaching, learning and evaluating professionalism have been a matter of serious concern for medical educators (2 4). however, they worry about how medical students’ professional identity, attitudes and behaviors are formed and developed according to formal plans (5). educators know that designing professional guidelines and instructions, developing assessment tools, making curriculum reforms, etc. are helpful but not enough, and the working hidden curriculum should also be taken into account (6, 7). therefore, enhancing professionalism through formal reforms without considering specific hidden curriculums and their components in educational contexts is doomed to fail (8). haffetry and frank introduced the concept of hidden curriculum in medical education in their article “the hidden curriculum, ethics teaching, and the structure of medical education” (9). this concept opens different arenas to medical educators and makes them think how hidden curriculum might operate in the shadow of formal curriculum (10). however, there is no consensus about its definition, nature and working process in medical contexts (11, 12). researchers might usually approach this concept within various fields of study, including interpersonal relationships and organizational, cultural and motivational topics (13). professionally, as different studies have shown, the hidden curriculum could be particularly effective (as an output) in medical trainees' emotional neutralization (14), changes in their ethical integrity (8), formation of their professional identity (5, 9), the professionalization process (15), students’ career choices (16), physician-patient relationship (9), students’ attitudes towards patients (17) and faculty development (18). since each context is unique, in many cases investigators have tried to explore and understand a hidden curriculum specific to their own academic grounds through qualitative (19 21) or quantitative (22) research. despite this specificity, many extracted components of hidden curriculum are common in different studies; instances of such commonality are hierarchy (23, 24), role modeling (25, 26), haphazard interactions (8, 20), disease-centered medicine (27), etc. considering the wide (and to some extent profound) effects of hidden curriculum, educators actively plan to approach hidden components aiming at reversing or diminishing the negative elements and bolstering or increasing the positive ones. in order to do so, they might adopt different strategies and techniques, including reflection, support systems, creative outlets, etc. to empower trainees to confront the phenomenon ‘hidden curriculum’ more effectively (28). there has not been enough research on an accurate perception of hidden curriculum in the specific culture of iranian health settings. therefore, this exploratory qualitative study was conducted to determine what elements might affect iranian medical students’ professionalism and ethical conduct at bedside through hidden curriculum. method the present study was performed to discover the specific working components of hidden curriculum regarding trainees’ medical professionalism. medical professionalism is mostly learnt by or transferred to medical trainees under real bedside circumstances. moreover, what is learnt by trainees in medical school could be practiced throughout their life. the emphasis and focal point of medical education at shiraz university of medical sciences (sums) is on learning medicine through practice at bedside. for this reason, we received approval from sums review board, and consequently began an exploratory qualitative research on medical trainees between october 2014 and august 2015. in iran, general medical education is a seven-year period ending in three years of clinical stages (studentship, externship and internship). based on the study objective, the clinical phases of medical education (years 5 through 7) were important for selection of the study informants, so participants were chosen from medical students in these clinical training stages. they were recruited using the maximum variation purposive sampling technique based on sex, educational year, total average score and extracurricular activities such as active participation in social or cultural studentship affairs. all informants were confirmed to be suitable for the study based on the personal recognition of the researchers. eventually, seventeen medical trainees including 8 females and 9 males were interviewed. the data were collected through semi-structured and in-depth interviews. participants were generally briefed on the research topic and the study aims before the interview session. interviews started with general and warm-up questions (e.g. “what do you think about the ethical climate of the educational environment at bedside?”) and continued with more specific questions (e.g. “as a student, what elements do you think are affecting your ethical/professional behavior at bedside?”). for in-depth following of the opinions and clarification of different aspects of the statements, probing questions such as the following were used: "can you think of any examples?” "what j med ethics hist med 11: 10, september, 2018 jmehm.tums.ac.ir sajjad azmand et al. page 3 of 12 does this mean?" and "could you explain more?". the questions were designed based on the related literature, researchers’ personal experiences and insights achieved during interviews. the interviews generally lasted from 30 to 60 minutes. all interviews were conducted by the same person (the first author), and were audio taped and then transcribed verbatim. data collection continued until saturation, when no new and significant data were obtained and extracted in the last two interviews. the data were analyzed applying simple content analysis (29). the meaningful phrases (codes) were extracted from the scripts and then conceptually rearranged into the categories and themes. disagreements in the coding process were resolved through rechecking the primary codes with the interviewees. discussion and consensus between researchers followed in cases of disagreement over categories and themes. according to guba’s criteria, there are four attributes that indicate the trustworthiness of qualitative studies: credibility, transferability, dependability and confirmability (30). in this research the following steps were taken to ensure trustworthiness: examining previous studies to design the research and plan the interviews and the primary interview questions; applying semi-structured questioning to gather data; including various informants with divergent ideas, views and experiences; endeavoring not to interfere the researchers’ beliefs and ideas in the coding and analyzing process; requesting participants to confirm the primary extracted codes of the interviews; and having the authenticity of the coding scheme reviewed and approved by two other investigators. ethical considerations this study was approved by shiraz university of medical sciences’ review board under license number 93-7264. we obtained informed consent from all participants and assured them of the confidentiality of their data at the beginning. results seven main themes emerged from the data, revealing the factors that might affect participants in terms of professionalism and their ethical behavior. each theme is explained through a number of sub-themes presented below: a) convenient patients some patients’ behavioral features and characteristics can regulate medical students' relationship with them ethically and professionally. the category consists of two sub-categories: “patients' relationship with students” and “patients' characteristics”. i. patients’ relationship with students: our findings showed that patients’ positive or negative behaviors emotionally guide medical trainees to react based on what they believe the patient deserves. according to the interviews, three main parameters that are encouraging for medical students are: "showing respect for and appreciation of trainees’ professional attempts", "patients’ trust in and compliance with students’ medical orders" and "expressing satisfaction with the trainees, especially in words". in this regard, some participants' statements are presented below: “… it is a kind of self-teaching; the student himself could judge the correctness of his behavior by analyzing patients' reaction to the act. i myself can decide whether the way i behaved was appropriate or not." [participant no. 3] “there are patients that can communicate well with trainees; [as a result, medical] students try to spend more time with them since they feel they are respected by those patients." [participant no.12] ii. patients’ characteristics: trainees' professional thinking and conduct could be affected by a variety of other elements, such as "patients’ personal characteristics", their "socioeconomic background", "type and severity of their disease" and "the state of their mental health". in this regard, some trainees stated: “generally, younger patients, those with non-chronic and slight illnesses, and patients with higher levels of education and a better socio-economic position are much more respected by the medical staff. ethical principles are also observed more closely in the case of these patients." [participant no.10] “… [once] i was in the hematology department. there were patients with specific [types of] diseases such as aids, hepatitis and so on. yes, i felt the students’ behavior could be affected by these [diseases] to some extent" [participant no.12] our findings implied that elements related to patients are influential in earning trainees' trust in their work. consequently, these elements could encourage them to work with higher self-confidence and help them shift their focus from mere technical affairs to a more professional practice. b) evaluate me according to participants, the more seriously and precisely professionalism is evaluated as an educational competency, the more effectively trainees will try to perform in their professional function. in this regard, two sub-categories emerged according to our findings: i. attention to ethics in evaluation: participants believed that if responsibility, commitment, good professional relationship and similar factors were considered in evaluating the students’ competencies, they would attribute more importance to these characteristics. as a result, trainees would make an attempt to develop those competencies. in this regard, participants said: “very soon [the students] might analyze the j med ethics hist med 11: 10, september, 2018 jmehm.tums.ac.ir sajjad azmand et al. page 4 of 12 conditions surrounding the evaluation process. they might reason, “we’re not evaluated for feeling concern for the well-being of patients, so why should we care?” [participant no.3] “i never thought that our way of behaving toward patients could be important in the evaluations!” [participant no.10] ii. interfering factors: our findings show that there are negative interfering factors that jeopardize the effectiveness of professional evaluations. for instance, the process of evaluation might easily be diverted by the interference of friendship and sexually-biased relations. this phenomenon could occur especially when the process is trusted to a senior resident without adequate higher supervisions, and will send wrong messages to medical students. “there isn’t a logical and legitimate [professional] evaluation. a student who is really good in terms of knowledge and professional manner may easily get lower scores than other students in view of a third person! why? because interpersonal relationships are at work here." [participant no.13] c) trust as the base of team interactions findings reveal that reciprocal relationships between medical students and the nursing team affect the quality of medical trainees' professional practice. in this regard, three sub-categories were extracted, explaining that such elements are working within medical education environments: i. nurses as specific role models: at the bedside, medical trainees might model nurses' attitude toward patients and even try to imitate their professional practice and relationship. “it is working there; when [trainees] see a nurse who is really committed to observing ethical duties towards patients, they will be motivated [to be so].” [participant no. 3] ii. mutual understanding and positive attitude and/or behavior: according to participants, the more positive and reliable the nurses were in their professional interactions with medical students, the more professionally medical trainees would interact with the staff and also with the patients. some students confirmed this fact in their statements: “i was in a ward with good-natured nurses, so i felt cheerful and could communicate easily. i was inspired by their good morale. i modeled their professional conduct and was able to learn what a professional relationship between a doctor and a nurse really means." [participant no.14] “if we treat the nurses right and they behave properly toward us, tasks will be fulfilled much more effectively. challenges among the staff could affect the morale of students negatively so they might not perform their duties as well." [participant no.17] iii. nursing ethical climate: data demonstrated that cooperative interaction with the nursing team could help and encourage trainees professionally and ethically. some instances of negative influence on students’ professional attitude towards practice include: an atmosphere of dishonesty and mistrust, a feeling of being monitored, and a feeling of duty imposed by nurses on students. in this regard, a participant explained a negative situation that is presented below: “[in general,] staff [nurses] influence students to a lesser degree, or their influence is temporary and transient; unprofessional or annoying behavior toward patients by a nurse or other staff might make me nervous all day, render me less effective in performing my duties, and cause me to ignore things that could increase the quality of the work.” [participant no.4] “non-circular staff greatly affect the ethical climate. they’re there, it’s their ward; [therefore,] seeing the quality of their behavior toward patients and all those conventional interpersonal interactions are influential." [participant no.12] d) perceiving encouragement any perception of encouragement could help trainees be enthusiastically more active in their ethical and professional behaviors. the participants categorized the most prominent encouraging factors into the following four sub-themes: i. encouragements related to patients: “noticing patients regain good health” and “patients’ satisfaction with trainees' professional performance” were extracted from the data as two main subcategories. “one of the encouraging factors is the patients themselves. when you solve their problem and they thank you in return…. with their eyes, by their words. this is a positive factor." [participant no.13] “for instance, you may do something good for a patient, and then he or she is cooperative, makes you feel assured, or establishes a good relationship; this surely could motivate you to perform your duties better." [participant no.17] ii. constructive feedback from seniors or nurses: according to our findings, trainees found the effect of positive encouragement rather prominent and constructive. thus, students could be motivated when nurses or senior peers reacted to their good acts or ethical behavior with positive behavior or verbal encouragement. “the nursing staff could have an impression, and there may be a few [nurses] who are more extroverted. they may talk with us, tell us about their past experiences, or encourage students.” [participant no.14] “[another factor with] a great influence is peers or other trainees who are in the rotation with you. my j med ethics hist med 11: 10, september, 2018 jmehm.tums.ac.ir sajjad azmand et al. page 5 of 12 senior trainee (a 6th year medical student) was [fortunately] supportive and encouraged me a lot." [participant no.14] iii. faculty recognition: participants mentioned repeatedly that small, positive feedback on students’ behavior could be an important incentive. “another positive factor is when the others understand you [and your situation]. an understanding resident or faculty member might guide you, encourage you and behave respectfully toward you, give you a kind look and criticize [something you did], and at the same time praise you." [participant no.13] “when you explain something to a patient thoroughly even though it isn’t your duty, there are professors who acknowledge [the effort] and thank you [for it]." [participant no.7] iv. internal incentives: in addition to external incentives, there are internal ones that foster ethical and professional practice in medical students. “having religious beliefs” and “a feeling of moral development” followed by a previous successful and prepossessing experience were among the important elements that helped trainees act as ethical agents. “we can see that some internal incentives are at work here: some [students] have beliefs; religious beliefs may help, [so can] familial convictions. and personal experiences such as saving the life of a loved one could be helpful.” [participant no.13] therefore, according to our findings, absence of supportive and encouraging elements within the educational environment, whether internal or external, is considered a serious barrier to stability of students’ ethical behavior. in fact, receiving positive signals might guarantee students’ perseverance with good practice and ethical behavior. e) relationship satisfaction and authenticity the positive attitude and professional behavior of medical students could be influenced by the timely and effective feedback that they receive from senior trainees. the participants mentioned positive reinforcement of professional behavior as an indicator/predictor of how professionally they would act and interact in their practice at the ward. cooperative, compassionate and respectful relationships between trainees can normally enhance the quality of their professional conduct and promote ethical decision-making. on the contrary, relationship challenges such as ridicule and blame could result in a decline in the quality of trainees' professional and ethical behavior. in this regard the participants said: “it is very important that all the students in the ward be cooperative. otherwise, challenges arise and cause a waste of energy. surely, in a cooperative atmosphere tasks will be performed better and we will have a better attitude toward patients." [participant no.17] “when together in a group, one student may be disciplined but others may not. the undisciplined ones could impose their duties on others and consequently others will take a stance against them." [participant no.2] f) workload and students’ well-being workload and academic demands emerged in two sub-categories. generally, students who found it difficult to see a clear rationale in the course content were also more likely to perceive their workload as being too heavy. i. undesirable outcomes of substandard workload: in respondents’ view there was a deep relationship between workload and a number of issues related to professionalism at the bedside. the main points that participants believed were negatively affected by substandard workload included: quality of studentpatient relationship, students’ ethical sensitivity, quality of undertaking professional responsibilities, students’ ability to exercise self-control in challenging situations, efficacy of medical decisionmaking, and having a positive attitude toward oneself. in this respect students stated: “in wards with higher workload, we actually see that students assume less responsibility [to perform their duties].” [participant no.4] “[i] really think that workload is the most important thing that makes us tired, lowers our threshold and tolerance, and subsequently causes ethics not to be practiced." [participant no.16] ii. undesirable outcomes of standard situations: participants believed that even when there is no real pressure resulting from substandard conditions, there might be defects related to workload such as negligence, irregularity and irresponsibility on the part of students: this might occur consciously or unconsciously. “when the workload is heavy, we are too pressed for time to perform all the tasks flawlessly. however, in subsequent low workload rotations when we attend new educational wards with fewer patients and have more time, we have learned that some tasks could be done imperfectly. we might even know that we cannot do certain things without being sorry, or without being held responsible." [participant no.11] g) role modeling at the heart for professionalism role modeling was determined as the most important component of hidden curriculum according to our findings. moreover, it was revealed to deeply influence the professional attitude and behavior of trainees in the settings of the research. medical residents and particularly faculties were considered to be in the position to provide role models for participants. the importance of the issue was explained by two of the participants as follows: “generally, everything in the ward depends on the faculty professor who is in charge of the monthly shifts. everything forms based on what she or he likes or doesn’t like, and the overall atmosphere of the j med ethics hist med 11: 10, september, 2018 jmehm.tums.ac.ir sajjad azmand et al. page 6 of 12 ward changes with that monthly change. i can say that this is true in almost all the wards that i have attended as a medical student." [participant no.12] “really, when a faculty member shows more responsibility and spends more time [with patients and on education], the effect on medical trainees will be more than hours of lecturing in the classroom.” [participant no.10] as shown in table 1, three categories were extracted to explain the theme through indicators and some participants’ statements. i. role modeling with regard to patients: students can be professionally inspired with what they observe in role models when they treat patients or talk with them. mostly, students would easily accept the way role models act, react or think as a mark of standard to imitate when they practice. ii. regulating professionalism at the bedside: the data showed that role models could regulate professionalism through the positive or negative signals they send by their way of thinking and behavior towards trainees and their practice. iii. non-holistic or specific role modeling: this refers to the specific professional attributes of each role model and emulating the ones that acted more perfectly. according to the participants, these particularities could facilitate and increase the effectiveness of the role modeling process among medical trainees with the message to "take specific attributes from specific role models and not search for a perfect one". the categories, subcategories and the specific instances of each category relating to role modeling are presented in table 1. table 1categories, sub-categories and participants' statements regarding the theme "role modeling: the heart of professionalism" theme categories sub-categories participants statements r ol e m od el in g at th e h ea rt o f p ro fe ss io na lis m i. role modeling with regard to patients ∑ being respectful toward patients ∑ paying attention to patients' nonmedical needs ∑ dedicating time to patients ∑ quality of addressing patients’ questions and concerns ∑ general sense of responsibility toward patients “trainees are highly influenced by faculties who practice responsibly, have good morale, interact with patients respectfully, etc.” [participant no.17] ii. regulating professionalism at the bedside ∑ contempt for trainees' acts or attempts for any reason ∑ discriminating against trainees on the grounds of race, gender, etc. ∑ the quality and fairness of encouragements ∑ the quality of the feedback given on trainees' practice and professional behavior ∑ respecting students’ human dignity ∑ emotional support in distressing situations ∑ efficacy and accuracy of evaluation of trainees’ professional activity “… and when the faculty does not disrespect and humiliate you on the [educational] round [of the patients], even if you didn’t know the answer to a [scientific] question, and instead, concentrates on the teaching part, surely that affects you much more deeply and creates a mentor-mentee relationship.” [participant no.14] iii. non-holistic or specific role modeling ∑ possessing discipline, skill & professional accuracy ∑ responsibility toward trainees ∑ eagerness to educate ∑ level of scientific knowledge ∑ consistency in behaving ethically under stressful circumstances “i really felt like my father was talking to me [with all the compassion and responsibility]. i had this feeling about a few of the faculty professors who came to the ward on educational rounds ... they were very eager to teach students.” [participant no.17] “dr. s. gave me a deep sense of responsibility. that month, i learnt that as a physician, i should be very responsible toward my patients and their health.” [participant no.12] moreover, participants believed that picking up ethics from those with superior scientific or professional characteristics was more interesting and noteworthy than faculties with no particular attribution of morale and professionalism. in this regard one of the trainees stated: j med ethics hist med 11: 10, september, 2018 jmehm.tums.ac.ir sajjad azmand et al. page 7 of 12 “… the influence of the words of that faculty professor about ethics on students was certainly considerable as he was a high professional expert in his special field." [participant no.5] discussion using an exploratory content analysis, we investigated the elements of hidden curriculum that were influential on medical students’ professional and ethical behavior during the clinical years of medical education. consequently, seven main themes emerged as the working components of hidden curriculum specific to our context as seen in the results section, items a to g. previous studies in the field of education show that hidden curriculum consists of a spectrum of diverse components and elements (6, 31, 32). furthermore, some authors have investigated the educational results and outcomes of hidden curriculum (15, 16, 20, 33) and the processes in which the components might work (26). the extracted components of this study can be categorized as either “human-related” or “environment-related”. role models, patients, health staff and other trainees were the main actors of the first category while the workload, evaluation process, encouragement and supporting elements were the major components of the second one. findings revealed that almost all participants had experienced and were aware of the hidden components at work, but surprisingly were affected by them within the educational context. furthermore, they believed that the impact of hidden curriculum was more than the formal trainings in several instances. nevertheless, participants believed that either no specific plan existed, or they could not perceive that any plan was being followed for approaching influential factors. they did not have any idea for a schedule aimed at providing a guidance or management guideline for ethical and professional behaviors within educational settings. due to this lack of general and specific plans, role models, especially faculties, undertake the above-mentioned responsibility. however, a wild fluctuation is to be expected based on faculties’ different performance or decision-making strategies. although a great deal of positive messages could be transferred to trainees through the correct conduct of the role models, lack of practical standards might render ethical standards person-dependent and (in some instances) cause them to be neglected even though they are professionally necessary and obligatory. the results showed a significant part of the positive and negative effects of role models in this study were similar to other studies, whilst there were some findings dissimilar to the literature reports. table 2 shows many characteristics of role modeling in the context of hidden curriculum, as well as characteristics mentioned both in this research and the related literature. table 2-functioning and characteristics of role modeling based on the research data and related literature as mentioned by the majority of participants and also in related literature, standard workload provides the condition for improving students’ ethical and professional functionality. according to the participants, standard workload could enhance the positive influences of other components of ethical common characteristics between this study and the literature extracted characteristics specific to this study spending adequate time on diagnosis, treatment and educating patients (34) treating medical students unfairly or discriminatorily paying attention to the concerns of patients in addition to their medical needs (35) lack of discipline and precision when practicing feeling responsibility toward others and the medical environment (36) not being stable and consistent in ethical and professional behaviors showing humility in relationships with others (37) encouragement, support and/or punishment of trainees (38, 39) being interested in education (34) possessing an acceptable level of theoretical knowledge and practical skills (40) j med ethics hist med 11: 10, september, 2018 jmehm.tums.ac.ir sajjad azmand et al. page 8 of 12 hidden curriculum, and help manage and reduce the negative influences of disturbing elements. on the contrary, excessive workload is generally reported to be one of the serious impediments to the ethical and professional performance of the health staff (41, 42). based on the findings of this study, consequences of excessive workload as one of the major problems of our educational contexts were very similar to the literature reports; nevertheless, there were a few instances that could not be found in other reports. table 3 shows similarities and differences of the negative consequences of the workload based on the literature and our findings. table 3negative consequences of excessive workload based on the research data and related literature common consequences between this study and the literature consequences in the related literature consequences extracted in this study stress (43 45) patient and student safety (46, 47) students’ moral sensitivity fatigue or well-being of students (42, 48, 49) burnout (50) the quality of interaction with other health staff job satisfaction (51) team work (42) responsibility of students (52) reduced inclination for working (53) communication with patients and taking care of them (42) not spending time on personal development (53) according to our findings, playing an active role in the hidden curriculum, patients’ characteristics and their behaviors could affect trainees’ professional functionality either positively or negatively. this has also been shown by higashi et al. (17) who demonstrated that medical trainees accredited the patients with labels based on their age, compliance with diagnostic and treatment plans, (not) being addicts or drug abusers, etc. thus, medical students adjusted their professional and ethical behaviors based on these criteria. participants stated that their ethical and professional behavior did not have a firm place in the process of their professional evaluation. gaufberg et al., on the other hand, has explained in her study that students feel that they are under a sort of hidden assessment – not necessarily an official one – which actually consumes a lot of their energy (20). in addition to internal incentives, there are external factors that could help trainees maintain their positive performance based on the study results and also supportive literature. rewards and punishments for specific ethical behaviors (54) and presence of supportive mechanisms for patient-centered behaviors (22) are such instances. contrary to our findings and to the best of our knowledge, the literature did not contain supportive data regarding the positive effects of professional interactions between nurses and medical students. as some authors have mentioned, students could help each other interpret the unwritten codes and values pertaining to clinical services (55). we also found that medical students’ professional interactions with each other, the norms associated with them and what they learned from one another were important elements of professional hidden curriculum. considering the seven extracted themes brings us to the conclusion that they explain the ‘ethical climate’ of our educational environment. nevertheless, contribution of each component to the formation of such an ethical climate was different in various departments. therefore, many students believed that ethical climates were specific to clinical departments and students usually adapt their professional and ethical behaviors to that specificity. in this way, repeating behaviors (either professional or nonprofessional) and adaptation to such conditions could internalize behaviors as part of trainees’ professional identity. interestingly, as perceived during the study and also confirmed by a few participants, the effect of each component and the whole ethical climate on the students' professional and ethical functionality differed based on the personal characteristics of each student. in other words, trainees might be influenced based on their specific attitudes and beliefs, and the basic features of their personality. for example, a particular student might be more influenced by a professor whom she/he perceives to be more likeminded to himself/herself than other professors. in fact, we need to know that students are not passive recipients of the existing hidden curriculum, but they mostly interact actively within the context, even though they are not conscious players. j med ethics hist med 11: 10, september, 2018 jmehm.tums.ac.ir sajjad azmand et al. page 9 of 12 conclusion establishment of a proper professional and ethical identity in medical trainees calls for careful consideration of the influencing hidden curriculum and its working components. in this respect, medical trainees' related attitudes, beliefs and experiences were investigated as a valuable source for recognizing and exploring the native condition of iranian educational health settings. in this regard, seven main themes including humanrelated and environment-related elements were extracted as components of the ethical hidden curriculum. role modeling, health staff, peer students, patients, workload, systematic evaluation of ethics and professionalism, and encouraging incentives were the main players of the ethical hidden curriculum. all components were important in the formation of the current 'ethical climate' while, according to the participants, the weight of each component differed according to the department. moreover, the effect of the ethical climate on each trainee was largely dependent on his/her personal characteristics, attitudes and beliefs. exploring the working hidden curriculum components in particular settings helps devise better plans to direct ethical and professional behaviors. here are some suggestions for improving professionalism and the ethical conduct of medical students through hidden curriculum based on the findings of the study: ∑ raising consciousness among faculties and educators about the importance and impression of hidden curriculum beside formal education as well as their active role in improving medical students’ professionalism through it ∑ improving evaluation processes regarding professionalism and students’ ethical manner ∑ improvement of workload through implementation of standards and improving duty hours while maintaining the quality of education ∑ empowering students to deal with hidden curriculum actively, to select positive messages and to manage and control negative ones ∑ encouragement 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metabolism clinical sciences institute, tehran university of medical sciences, tehran, iran. 2assistant professor, endocrinology and metabolism research center, endocrinology and metabolism clinical sciences institute, tehran university of medical sciences, tehran, iran. corresponding author: ata pourabbasi address: no. 10, jalal al-ahmad st., next to shariati hospital, chamran hwy, tehran, iran. email: atapoura@gmail.com tel: (+98) 21 88 63 12 97 received: 05 may 2018 accepted: 02 sep 2018 published: 24 sep 2018 j med ethics hist med, 2018, 11: 12 © 2018 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract professional commitment plays a significant role in all professions. moreover, schools are valuable fields for teaching the principles of these concepts especially through novel methods such as gamification. "earthquake in the city" was implemented in a school in tehran, iran, and its effectiveness on learning the concepts of professional commitment was evaluated. "earthquake in the city" was built based upon a fantasy scenario occurring in an imaginary city. each student took on a role in the city (citizen or healthcare provider). after finishing the game, participants were asked about the concept of professional commitment. their definition was scored by a group of medical ethics experts separately in terms of compliance with the actual definitions and compared with their peers in the control group who did not participate in the game. a group of 16-year-old teenagers studying in the 11th grade participated in this intervention. the average score of conformity with the actual concept of professional commitment among the case group participants was significantly higher than the average value for the control group (p < 0.05). the results of this study could provide insights to planners and educators engaged in the education system so that gamification can be incorporated as an influential tool to teach the concepts of professional commitment. this experience can also be generalized to other concepts, but designing the appropriate scenario will be the most important component of the intervention in these cases. keywords: professional commitment, gamification, adolescents, education mailto:atapoura@gmail.com j med ethics hist med 11: 12, september, 2018 jmehm.tums.ac.ir solmaz sadat naghavi alhosseini et al. page 2 of 8 introduction in different communities, various occupations are formed in response to the society’s needs and necessitate different skill levels (1). the term professionalism refers to the skills, attitudes, and behaviors that individuals are expected to exhibit in their occupation, including concepts such as maintaining competence, ethical behavior, integrity, honesty, altruism, serving others, following professional codes, justice, and respect for others (2). each profession has different moral standards in proportion to the type and sensitivity of the services it provides and its responsibilities toward the society. the understanding of these ethical standards and adherence to them is effective on the moral and professional excellence of individuals (3). one of the most important professions in terms of professional commitment and ethics is the medical profession (4). healthcare workers must adhere to continuing education throughout their professional life and obtain necessary and cutting edge knowledge and skills; otherwise, the rate of medical errors in the community will be increased (5). there are some controversies regarding the relation between medical errors and professionalism in related studies (6, 7). however, the statistics available in the field of medical errors across countries have resulted in more close consideration of this issue by researchers (5). in addition, studies have revealed that increased level of professional commitment among nurses is associated with improved patient-caregiver communication, and better and safer care of the patients. furthermore, increased professional commitment entails an increase in the quality of patient services (8). therefore, professional commitment plays a significant role in the correct implementation of professional and occupational tasks; therefore, teaching of such concepts in different levels of education has been taken into account. schools do not specifically provide vocational training; however, they are fundamentally inspired by scientific research and most curricula are clearly related to professional occupations. therefore, it is necessary to use the school platform to teach the principles of professional commitment. moreover, the use of school environment for teaching bioethical concepts has been previously reported (9). one of the new methods that have been taken into consideration in schools is the addition of game elements to instruction (10). gamification refers to the application of elements of game playing in learning environments, including online collaborative learning environment, and is becoming a common theme among researchers (11). playing games provides the opportunity to improve students' motivation, to support team work, and to assess them in safe environments (12). games, in addition to knowledge acquisition, also promote creativity, and logical, mathematical, critical thinking, language, communication and collaboration, and problemsolving skills, and the development of individual and social skills (13). professional commitment has an important role in appropriate occupational functioning and its instruction plays an influential role in the professional development of adolescents in the context of schools. thus, the researchers in this study have investigated the impact of gamification on teaching professional commitment with emphasis on ethical behavior, integrity, honesty, serving others, and respect for others among adolescents using the elements of game to encourage and motivate students to learn effectively. to this end, a game called "earthquake in the city" was implemented in one of the schools in tehran, iran, and its effectiveness on learning the concepts of professional commitment was evaluated. method this intervention was carried out in the following stages. participants of the study were chosen from a group of 16-year-old boys studying in the 11th grade in tehran. another group of teenagers at the same educational level of that high school was also participated as the control group. the participants were similar in terms of socio-economic status as well as socio-cultural backgrounds. the approval for this game had already been obtained from the school board. game flow: scenario the game "earthquake in the city" was built upon a fantasy scenario occurring in an imaginary city. this game and scenario were validated by an expert panel including some experienced teachers and researchers to ensure that the targeted concepts are considered in the scenario. this scenario was as follows: two days ago, an earthquake with a magnitude of 6.2 occurred in the town. residential areas have suffered greatly. since the earthquake occurred at night, the number of victims is high. we are still working to find dead bodies and missing persons. the sources of drinking water have been disturbed; so that the sewage system has encountered a problem and the sewage disposal system has been mixed with groundwater supplies. most of the people who survived the earthquake are now living in tents. today, a number of people were infected with various illnesses among which diarrhea, respiratory diseases, and skin disorders are the most prevalent. a 4-year-old child died of gastrointestinal disease yesterday. rescue operations are not being performed as quickly as they should be and do not have much order. the town has no medical facility to treat the injured. the main hospital of the city has been relatively damaged by the earthquake. two days after the earthquake, numerous dead j med ethics hist med 11: 12, september, 2018 jmehm.tums.ac.ir solmaz sadat naghavi alhosseini et al. page 3 of 8 bodies are scattered outside the houses, some of them hard to identify with usual methods. since there is no place to hold dead bodies, they should be inspected and buried quickly because there is a fear that the corpses could transmit other diseases. children and women who have lost their parents, spouses, and loved ones in this incident are in bad mental conditions and are very inactive; therefore, the town is in danger of an emotional catastrophe. due to its geological and geographic location and its proximity to a fault, this area of the country is prone to earthquakes; therefore, foreseeing possible aftershocks and earthquakes in other cities is inevitable. assigned roles the roles were extracted according to the game scenario, some of which were related to the in-need inhabitants of the city who were affected by the earthquake while, different roles were designed for service providers. some service providers were individuals with high professional commitment, and others with low professional commitment. the roles were designed in such a way that for each service provider role there was a corresponding role of an individual needing help. these roles are provided in table 1. each of the roles was written on a piece of paper and placed in a packet on which a number was written. table 1defined roles according to the game scenario roles of individuals needing help corresponding role of service providers i am the father of three children and we live together with the family in a tent. the kids are getting sick. i am a physician working in the internal ward of this hospital. fortunately, during the earthquake, i was on leave. my leave of absence is approved by the hospital head until the weekend. i am father of the child who died of diarrhea. i am a laboratory scientist in charge of the technical diagnostic in the cities’ reference laboratory. it seems that cholera is the common disease associated with diarrhea in this city, and its definitive diagnosis depends upon a laboratory test. but, before setting up my lab, i talked to the head of the city's health network and explained that i would not lift a finger for emergency work. my kids are thirsty and have no water to drink. mineral water packages are not distributed among us, so we have to give the kids water from the pits. i am an environmental health expert working in the health center of this city. due to the disruption of the sewage treatment, we have been working with a team of volunteers for the last two days to repair the facilities. i hope this can somewhat improve the situation of my fellow citizens. i live in a tent with my three children. due to rain, our tent were soaked and last night we had to leave the tent and sleep in the car. i am a disaster management specialist. the main area of my study is crisis management and the design of health facilities in a state of crisis. however, my area of residency is at a distance of about 700 kilometers from this city. my mom has been missing since this earthquake. her body may be among the bodies that cannot be identified. i am a geneticist and have my phd in genealogical identification from johns hopkins university. next week, i must speak at a world congress in turin, italy. but, now my compatriots are more important. i have got 2 kids who have lost their mother in this earthquake. they are very restless. i really do not know what to do with them. i am a psychologist of disaster health. but now i prefer to visit patients in my private counseling clinic that i recently opened in another city and i have to handle paying the rent. i am the mayor of the neighboring town. i really need to know how likely it is for an earthquake to occur in our city, what facilities we need, and how we should build a field hospital. i am a geologist with an earthquake orientation. this morning, two of my students and i will departure with a personal car to the city for geological studies and to foresee aftershocks. i hope my science can be of some help to the people of this city. my brother is trapped under a collapsed wall with a lot of rubble on him. if they do not get him out of the rubble correctly, he may end up with a spinal cord injury forever. i am a rescue specialist and i am a member of the rescuers without borders organization. i just returned from a mission in ethiopia and quickly made my way to this town. i did not even find the chance to get home and visit my family. i am the governor of the city. we are in a crisis situation. the city hospital is almost destroyed. i do not know if i should use the resources to rebuild the icu ward quickly, or to provide antibiotics and distribute them among field hospitals. i am an epidemiologist. my job is to determine the trend of disease outbreaks and identify priority areas. also, evaluating the effectiveness of interventions is among my specialties. but, now i'm studying to take an overseas scholarship test and do not have time. j med ethics hist med 11: 12, september, 2018 jmehm.tums.ac.ir solmaz sadat naghavi alhosseini et al. page 4 of 8 game process initially, the teacher explained the scenario and the game flow to the students. after that, the envelopes were distributed randomly among the students. among the participants, only the teacher was aware of the corresponding association between roles according to the numbers written on the envelopes. after reading the scenario, the teacher announced a random number attributable to a specific role. the student who had that envelope opened it and read his role aloud. then, the teacher, announced the corresponding number from the lists of roles attributable to service providers, and the student who had that envelope opened the envelope and started reading his role aloud. at this stage, the in-need student, with the help of other children, his corresponding was evaluated and the decision was made whether he should be encouraged or punished. if he needed to be encouraged, all pupils would cheer for him, and if punishment was deserved, the in-need role would designed a funny class punishment based on the advice received from other students. the features of this punishment were already announced to students; it was agreed to use a punishment which was not seriously harmful, dangerous, or painful and not to use sharp objects. accordingly, the permissible punishment included sweeping the class, clearing the blackboard without using hands, and standing with both hands and one leg up. assessment after finishing the game, the students were asked to take out a piece of paper and write about the concept of professional commitment, and then, hand their notes in. moreover, they were asked to rate their satisfaction with this class from 0-10 in comparison with the best class they have ever experienced. the control group was also asked to write statements on the definition of professional commitment. scoring definitions a collection of definitions of professional commitment, provided by adolescents in both case and control groups, was compiled as a file. then, after eliminating the students' names, 2-digit codes were created to help label the pupils. records were sent to 4 experts of professional ethics, and they were asked to rate the degree of adaptation of the definitions with the actual concept of professional commitment based on a 0-10 scale. the rater was unaware of the order of definitions and their belonging to either the case or control groups. furthermore, each expert was blinded to the scores from other experts. finally, the average scores of experts to each definition were considered as the degree of conformity with the actual concept of professional commitment. results the participants in this game were a group of 16year-old boys studying in the 11th grade of high school in tehran. the game, with the teachers’ explanation at the beginning, lasted 50 minutes. in addition, 15 pupils from the same educational stage were entered into the study as the control group. the participants demographic data are presented in table 2. table 2socioeconomic data of the students number of students 26 mean age of students 16.3 ± 0.2 (mean ± sd) time spent in school (hours per day) 8.5 time spent in school (hours per week) 51 sd= standard deviation a total of 26 definitions of professional commitment were collected from the participants. these statements and the degree of conformity between the definitions and the actual concept of professional commitment are presented in table 3. table 3statements of pupils on professional commitment and the degree of conformity with the actual concept study group definition of professional commitment by participants degree of conformity with the actual concept of professional commitment professional commitment means someone, for example a physician, has knowledge and should be faithful to it. 5.50 that is, everyone in every occupation and profession has obligations that they must adhere to and be responsible for. 6.00 imam ali says: you should desire for others what you desire for yourself. in my opinion, if those professionals put themselves in other people’s shoes (those in need of urgent services), the situation would be completely clear and 90% of them would help. 4.25 j med ethics hist med 11: 12, september, 2018 jmehm.tums.ac.ir solmaz sadat naghavi alhosseini et al. page 5 of 8 case (game participants) professional commitment means that i should attend if my presence could be of any help even though it may entail harms for me. 4.75 the suitable performance of a job that one is responsible for or has the knowledge of, and adherence to the moral and social principles of society 5.75 professional commitment is being conscientious and performing one’s duties in any situation (in some cases with self-sacrifice). 5.75 complete loyalty to one's occupation at professional levels, such as medicine which the physician is responsible for and should not leave. such a commitment is clearly more pronounced in clinical disciplines. 6.00 completing the assigned tasks as well as doing humanitarian tasks even though they are beyond the scope of duty. 4.25 professional commitment means helping the affected people in critical situations. 4.00 to be called a doctor is a title that cannot be easily achieved. but, when someone reaches this level, he must devote himself entirely to this profession. we swear to serve people as much as we can and do not hesitate in performing our duties. otherwise, it does not make sense. 6.00 that is, i do anything i can, even if i have something else to do, otherwise i feel dissatisfied with myself until the end of my life and never forgive myself. a scholar without action is like a bee without honey! 3.25 study group definition of professional commitment by participants degree of conformity with the actual concept of professional commitment control group in my opinion, professional commitment means to fulfill all our obligations in line with our profession. 4.25 adherence to the professional promise 4.25 commitment to the principles and rules that are given to us at the beginning of starting a profession and to complete assignments successfully 6.75 professional commitment means when we accept something, we should accept it fully and should be responsible for its losses and profits. 5.25 accepting a responsibility, and then, fulfillment of the tasks or duties that we have to do 5.50 i have no idea .50 no definition .50 it means taking responsibility. 3.50 it is a promise according to your profession. 3.25 an important commitment that is fulfilled professionally. 3.00 not to sell unreal. as long as my work and duty are not over, i will not leave my job. 3.50 a professional commitment is an oath and a promise made by individuals, such as doctors, parliamentarians, and presidents, to do their jobs properly. 4.25 it is adhering to what we are responsible for in a profession, such as a lawyer's commitment to honesty and justice. 4.75 when we accept a responsibility, we must take it and not to decline our oath. 4.25 it is the commitment to do right in response to others' trust to our commitment. 4.75 j med ethics hist med 11: 12, september, 2018 jmehm.tums.ac.ir solmaz sadat naghavi alhosseini et al. page 6 of 8 among the definitions, 4 occupations, including physicians, lawyers, parliamentarians, and the president were mentioned; of which the occupation of a physician was the most frequently referred to (in 4 definitions). of these definitions, 3 were mentioned by the participating teenagers in the game. the average score of conformity with the actual concept of professional commitment was 5.04 among the case group participants, which was significantly higher than the average value (3.88) for the control group (p < 0.05). the results of this assessment are summarized in table 4. table 4comparison of mean scores of case and control groups in defining the concept of professional commitment group n mean standard deviation standard error mean case 11 5.0455 0.97991 0.29545 control 15 3.8833 1.67136 0.43154 in addition, the average satisfaction rate of the participants regarding playing the game in the class was estimated as 8.9 out of 10. discussion the results of this study showed that gamification could be an effective way to create the concept of professional commitment in adolescents. these results are largely consistent with those reported by other studies targeted at raising the knowledge of adolescents in various fields (14, 15). however, no study has yet incorporated gamification as a way to raise professional commitment. professional commitment is an essential component of adolescent education and schools could provide a suitable and necessary environment for training and institutionalization of the concepts of professional commitment for future professionals. in order to motivate adolescents to adopt professional behaviors, the educational environment must support and reward professional behaviors and introduce non-professional behaviors using negative roles (16). however, since educational environments may not provide sufficient facilities for instructing professional or non-professional behaviors for various professions, creation of dummy environments through gamification could be a solution to this problem. a body of research on the elements of educational games has revealed that gamification increases participation of students in traditional and online learning settings (11); hence, it has many merits. first, it has an intrinsic value because students love games and they are willing to participate in. second, most games represent a complex situation in which the elements of real life are illustrated in a simple and understandable way which results in sustainable learning and greater participation. games also provide artificial environments for teenagers in which they can imagine themselves and experience differently (17). one of the main advantages of gamification is its low cost and the possibility of learning more. in traditional education methods, lecture-based classes are tedious for students. therefore, the great advantage of gamification technology is its ability to solve this problem (18). kapp et al. have widely investigated the impact of gamification on learning, and have shown that the correct implementation of gamification could have an influential impact on student learning outcomes (19). gamification can greatly promote the learning experience and create a familiar environment for students to develop their abilities (20). a further point of interest is that in the present study gamification was proved to be able to realize educational objectives (i.e., familiarity with the concept of professional commitment). it could be claimed that the most important part of the gamification process is designing of a game scenario well-matched with the learning objectives and target audiences. more precisely, the game scenario should be developed and implemented in accordance with the facilities and access level of target audiences which calls for providing facilities and infrastructures. for example, many of the game scenarios that can be implemented in cyberspace may not be applicable to a large number of audiences due to limited access. however, more studies are needed to determine the role of a game's scenario in its success in achieving educational objectives. one of the most important components of using gamification as an educational intervention is how to create motivation in participants for engagement. in the present study we created motivation by defining a system of reward and punishment, which was partly an entertaining activity. burguillo showed that implementation of the gamification system can increase the amount of task fulfillment in student probably because the competitive environment of games acts as a motivator (21). according to the authors' experiences, it seems that gamification incorporates thinking and dynamism of the game to increase motivation of users and stimulate their active participation, so improves learning. games also provide self-assessment tools, such as a scoring mechanism and moving to higher stages (12), which creates incentives for audiences and eliminates application of the other motivation tools (e.g., rewarding). considering the importance of raising students' j med ethics hist med 11: 12, september, 2018 jmehm.tums.ac.ir solmaz sadat naghavi alhosseini et al. page 7 of 8 knowledge about the concepts of professional commitment and the need to use modern educational methods for this purpose, the results of this study could provide insights to planners and educators engaged in the education system; so that gamification can be incorporated as an influential tool to teach the concepts of professional commitment. this experience can also be generalized to other concepts, but the design of the appropriate scenario will be the most important component of the intervention in these cases. despite the significant results obtained from this intervention, this study had some limitations including the time limit which led to omitting the educator-student discussion that could assist in establishing the concept of professional commitment during the game. furthermore, implementation of this game with a larger number of teenagers can provide a better assessment of effectiveness of the intervention. acknowledgment the authors would like to thank dr. parsapour, dr. shamsi, and dr. shojaee for their kind cooperation. conflict of interest the authors have declared no conflict of interest. j med ethics hist med 11: 12, september, 2018 jmehm.tums.ac.ir solmaz sadat naghavi alhosseini et al. page 8 of 8 references 1. anonymous. skills to pay the bills: mastering soft skills for workplace success. 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55(2): 566-75. https://www.dol.gov/odep/topics/youth/softskills/softskills.pdf microsoft word 8 journal of medical ethics and history of medicine teaching bioethics to medical technology students in pakistan rubina naqvi associate professor, department of nephrology, sindh institute of urology and transplantation, karachi, pakistan. *corresponding author: rubina naqvi address: b-62, rizvia society, phase ii, scheme 33, karachi.75280, pakistan. tel: (+92) 30 12 48 91 72 e-mail: naqvirubina@yahoo.com received: 18 may 2009 accepted: 30 may 2009 published: 31 may 2009 j med ethics hist med. 2009; 2:8. © 2009 rubina naqvi; licensee tehran univ. med. sci. abstract keywords: bioethics, curriculum, medical technology, pakistan. introduction bioethics includes ethical issues related to all branches of knowledge. it has been defined as love of life by some (1). it has evolved over last four decades, predominantly in western world and then spreading its web worldwide. in pakistan, it took off from agha khan medical university in 1997 but remained confined to a group of people. later in 2004, a center was established with name of center of biomedical ethics and culture (cbec) (2). this center is based in sindh institute of urology and transplantation (siut), which is a large institution providing wide variety of urology, nephrology and renal transplant services. siut is largest public hospital doing live related donor incorporating ethics education in curriculum of medical technology students and highlighting the importance of teaching the subject to this particular population in this part of world are our aims. at siut we have a school with name of “zain ul abidin” school of biomedical technology, which is supposed to award b.s. degree in 5 subspecialties that is hemodialysis, radiology, laboratory sciences, operation theater technology and intensive care technology. this school is affiliated by karachi university. the students entering in school have done fellow in science (f.sc.) with premedical group, thus have background knowledge of biology, physics, chemistry, languages, religion and pakistan studies. here for b.s. included in their curriculum are the subjects of anatomy, physiology, biochemistry, microbiology, pharmacology, pathology, islamiat and english for all and then related sub-specialty topics to each group for example student in hemodialysis group more exposed to nephrology topics etc. i planned to add ethics with subjects, which are common to all specialties and designed curriculum. curriculum was approved (after minor changes), from karachi university and i started teaching ethics to these students. this paper highlights methods and tools of teaching and evaluation and results observed. this will be the first examination in bioethics from medical technologists, at university level in the history of country. this is a great achievement in country to start teaching bioethics to medical technologists. karachi university has implemented the same curriculum to other medical technology schools affiliated with university. j med ethics hist med 2009, 2:8 rubina naqvi page 2 of 3 (page number not for citation purposes) renal transplants, this institution runs largest hemodialysis center of asia. besides clinical services, this institution has a school of nursing, a school of medical technology and postgraduate programs for doctors. all facilities at this institution provided free of cost. the medical technology school, zain ul abiden (za) school of medical technology, is named after a senior (late) operation theater technologist and is registered with largest university in town, the karachi university. this school awards degree of bs in five specialties that include hemodialysis, operation theater, clinical laboratory, clinical radiology and intensive care technology. cbec after its emergence started a post graduate diploma (pgd) program in biomedical ethics and registered the first group in january 2006, with the diplomas awarded by karachi university. pgd is of one-year duration and to get the diploma as part of the final examination, every student must develop and present an “ethics project” to class and examiners, which he/she must initiate in the parent institution. as a pgd holder of the first batch, i chose to design and implement a bioethics curriculum for medical technology students of the za school. this paper is an account of my experience of designing and then teaching this curriculum to this particular group of students. so far, i have finished with one batch; these students will be appearing in university exam for bioethics next month (june 2009). bioethics and the need for teaching it to medical technology students as these students deal with human subjects and body fluids on day-to-day basis, it is of immense importance to educate them on ethical issues within our own cultural and religious environment. there are many tools for decision-making, but few guides to indicate when situations might have an ethical implication. yet this awareness is a crucial first step before decisions are made. recognizing the moral context of a situation must precede any attempt to resolve it. ethical dilemmas rarely present themselves as such. they usually pass us by before we know it. there are no absolute rules or values for teaching bioethics; these are more like a rough measurement where an exact one is not possible. they often conflict with each other in practice, and some will rank above others under certain circumstances. however, there are certain principles that need to be considered which appear constant. these principles are compatible with the argument that we should simply follow our intuition and rely on the ‘inner voice’. however, that voice is not always audible, and today’s society presents a wide range of complex circumstances that require more guidance than simply ‘concern for others’ or ‘does it feel right?’ personal ethics might also be called morality, since it reflects general expectations of any person in any society, acting in any capacity. it includes the principles we try to instill in our younger generation, and expect of one another without needing to articulate the expectation or formalize it in any way. principles like concern for well-being of others, respect for the autonomy of others, trustworthiness and honesty, basic justice, being fair, refusing to take unfair advantage, doing good and preventing harm to others. individuals acting in a professional capacity take on an additional burden of ethical responsibility. for example, professional associations have codes of ethics that prescribe required behavior within the context of a professional practice. these written codes provide rules of conduct and standards of behavior based on the principles of professional ethics, which include impartiality, confidentiality and disclosure issues, duty of care and avoiding potential conflict of interest. even when not written into a code (which is true so far for medical technologists), principles of professional ethics are usually expected of people in health care profession, of which medical technologist is a part. each of us influences the world by simply existing; and it is always wise to ‘think globally’. can a person, nation or institution truly be ‘successful’ while causing human suffering? a more modern and complete model of success should also consider impact on humanity. contents of curriculum and teaching tools the karachi university allocates one semester time, at level of 3rd year, to teach bioethics to technologists. one semester has a spread of 4 months, which was divided in 16 sessions of one hour each. i conducted an extensive search on internet before designing curriculum and a few useful sites were found (3-7). the curriculum then designed was divided in 4 disciplines, which included: introduction to philosophy, introduction to great religions of world, introduction to literature (english and urdu), and introduction to contemporary bioethics. during the session on introduction to philosophy, i introduced the students to ancient philosophers like socrates, aristotle and plato, and emphasized the theory of “golden means” from aristotle. from modern philosophers i selected to introduce them to karl marx, bertrand russell and rabindranath tagore (selected poem-“where the j med ethics hist med 2009, 2:8 rubina naqvi page 3 of 3 (page number not for citation purposes) mind is without fear…”). among muslim philosophers, i selected to introduce them to al ghazali, allama iqbal, moulana jalal uddin rumi and dr. ali shariati. in the session on introduction to religion, i introduced the students to judaism, christianity, islam, hinduism, sikhism and buddhism. i discussed different scenarios where health care providers can be held back from taking right decisions (in benefit of patient) due to patient’s religious beliefs. for the session in literature, students were given the task to select poetry, short stories, news items and articles addressing ethical issues. these selected pieces of literature were then discussed among large group of class. the contents of contemporary bioethics taught to these students covered issues in the emergency room, operation theater, radiology department, intensive care department and hemodialysis. these included:  introduction to the importance, contents and process of taking informed consent  physician and pharmaceutical interactions – where to draw a line  ethical issues in clinical trials  patient’s rights and health care workers rights/ obligations  issues of privacy and confidentiality  issues related to transplantation  issues related to contraception and abortion  ethics of dealing with psychiatric patients  end of life issues most of topics were covered during lectures, while for some role-plays were designed and some were addressed through movie clips. other pgd alumni colleagues helped me in teaching this extensive curriculum over a semester. evaluation the students were evaluated at midterm with examination held at institutional level, whereas their final exam will be taken at karachi university. the format of paper includes multiple choice questions, scenario based problem solving and open ended questions. this will be the first time in the history of country that bioethics will be included in exam for medical technology students at university level. students have performed exceptionally well during the midterm exam considering that this was the first opportunity they have ever had of exposure to bioethics. they come up with ideas and arguments with open-ended questions and majority of them recognized major issues in scenario based. for example they were given a scenario “you are responsible for purchasing syringes for a hospital. three companies manufacture equally good quality syringes. the owner of one of these companies offers to pay you rs.10 per packet if this company gets the contract. what is the ethical issue involved in this case? explain why would you accept or decline the offer?” one student writes “ethical issue involved here is conflict of interest, as primary interest here is purchasing good quality syringes for the hospital, which can be unduly influenced by secondary interest of getting benefit of ten rupee. in favor of accepting this offer student writes that as all three companies are making equally good quality syringes, thus without harming the patient, benefit for individual or for institution can be achieved. whereas, as argument for declining the offer this student writes there is kind of bribery involved here, the company which is providing a monetary favor may ask or expect some other favor, and then institution has trusted this person for purchase which will be shaken.” conclusion it is important to understand that the framework of this curriculum was intended to be acceptable to school administration and university and with minor modification; the framework has so far stood the test. as this was not only taught at this school but also provided by karachi university to be included in curriculum for another medical technology school which is associated with another medical college and hospital in city. at this stage i can say “i can see the light at the end of the road”. j med ethics hist med 2009, 2:8 rubina naqvi page 4 of 3 (page number not for citation purposes) references 1. macer dr. moral games for teaching bioethics. haifa: unesco chair in bioethics; 2008. 2. moazam f, jafarey am. pakistan and biomedical ethics: report from a muslim country. camb q health ethics 2005; 14(3): 249-55. 3. anonymous. curriculum initiatives: bentley. www.bentley.edu/teaching-learning/curriculum (accessed on 29sept 2006) 4. anonymous. carlson school of management, university of minnesota, medical industry curriculum. www.csom.umn.edu (accessed on 29sept 2006) 5. anonymous. curriculum integration lessons. www.cnets.iste.org/student/sintegration.html (accessed on 29 sept 2006) 6. anonymous. jacksonville, university of florida, school of medical technology, clinical curriculum. http://jax.shands.org/education/medtech/ (accessed on 29 sept 2006) 7. anonymous. austin’s atheism blog, why beliefs matter. http://atheism.about.com/library(accessed on 5may 2009) ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ original article copyright © 2021 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e exploring the challenges and ethical requirements of medical sciences education during covid-19: a qualitative study *corresponding author maryam aalaa address: endocrinology and metabolism research institute, no. 10, jalal al-e-ahmad ave., north kargar ave., tehran, iran. postal code: 1411713119 tel: (+98) 88 22 00 37 email: ala.m@tums.ac.ir received: 4 dec 2021 accepted: 20 dec 2021 published: 31 dec 2021 citation to this article: ramezani g, aalaa m, zahedi f, soltani arabshahi sk, rasouli d, keshavarzi mh. exploring the challenges and ethical requirements of medical sciences education during covid-19: a qualitative study. j med ethics hist med. 2021; 14: 30. ghobad ramezani 1 , maryam aalaa 2* , farzaneh zahedi 3 , seyed kamran soltani arabshahi 4 , davood rasouli 5 , mohammad hasan keshavarzi 6 1.researcher, center for educational research in medical sciences (cerms), department of medical education, school of medicine, iran university of medical sciences (iums), tehran, iran. 2.researcher, evidence based medicine research center, endocrinology and metabolism clinical sciences institute, tehran university of medical sciences, tehran, iran. 3.researcher, endocrinology and metabolism research center, endocrinology and metabolism clinical sciences institute, tehran university of medical sciences, tehran, iran. 4.professor, center for educational research in medical sciences (cerms), department of medical education, school of medicine, iran university of medical sciences (iums), tehran, iran. 5.assistant professor, center for educational research in medical sciences (cerms), department of medical education, school of medicine, iran university of medical sciences (iums), tehran, iran. 6.researcher, clinical education research center, shiraz university of medical sciences, shiraz, iran. abstract the controversial role of ethics in clinical education and its ability to draw the attention of a large audience is inevitable. the issues and challenges of the covid-19 pandemic have transformed the clinical education environment. this study was conducted to explore the challenges and ethical requirements of medical sciences education during the covid-19 pandemic in 2020. the study was qualitative research and the instrument was a semi-structured interview. the participants included faculty members of the basic and clinical sciences at iran university of medical sciences. after 16 rounds of interviews, theoretical saturation was achieved. qualitative data were analysed using conventional content analysis, which resulted in 81 preliminary codes and 28 sub-categories. finally, two themes of "ethical challenges" and "ethical requirements", and 10 categories were achieved. the categories were consisted of "being patient-centred", "social accountability of curriculums", "ethical challenges of the clinical environment", "the poor performance of the clinical faculty members and students", "being justice-centred", "raising awareness", "observing clinical research ethics", "preservation and promotion of mental health", "patient confidentiality", and "respect for individuals". we hope the ethical challenges in medical education that were created due to the emergence of covid-19 can be reduced and eliminated by defining a framework for ethical requirements. keywords: medical ethics; medical education; covid-19; ethics in education; clinical performance. exploring the challenges and ethical requirements of medical sciences education … 2 j med ethics hist med. 2021(december); 14:30. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e introduction the increasing advances in medical sciences, diagnosis of various diseases, the discovery of effective drugs in the treatment of fatal diseases, and the emergence of new diseases have led to an inevitable necessity for an ethical approach to the medical professions (1). the term “emerging diseases” refers to diseases that evolve from unknown novel infectious agents, or are created by known ones, which expand geographically, or are subject to drug resistance, and are on the rise in terms of prevalence (2). indeed, the causal factors of such emerging infectious diseases have been identified in the past two to three decades. according to this description, we are currently faced with over 30 emerging infectious diseases (3), among which are common diseases between humans and animals. some of the infectious agents responsible for such diseases might undergo more changes and be transferred from human to human in a more exclusive manner (4). basic vulnerabilities of the individuals to emerging diseases have increased so far. reducing the vulnerability necessitates measures that empower individuals and societies to make effective choices, and hence, control health-related risks that they might be exposed to. lack of ethical measures will result in challenges and consequences that will reduce patients’ satisfaction and the quality of care services. therefore, concerning the importance of ethics in providing care to patients diagnosed with newly emerging diseases, with a special emphasis on the novel coronavirus, it is necessary for students involved in an internship, apprenticeship, and the healthcare workforce to be observant about the ethical issues. with regard to the increasing number of covid-19 patients across the world and the surge of covod19 in iran, we are witnessing a distressing mortality rate in hospitals across the nation. meanwhile, the hospital healthcare personnel, especially physicians and nurses, have the highest contact with these patients. thus, it is essential that alongside healthcare issues, the significant ethical challenges and issues created in this regard should be considered (5-7). the emergence of infectious diseases has caused medical sciences universities to respond differently to these emergency conditions (such as full closure or online and virtual teaching), causing several challenges for the students. existing experiences, such as encountering sars in china and canada in the years 2000 and 2003, retrospectively, indicate that replacing the typical curriculum with a distance-learning one has not been very successful (8). the emergence of the covid-19 pandemic has resulted in a great disturbance in medical education and professional training (9. for example, these changes include reduced hours of instruction, students’ exposure to the patients, and lack of skills acquisition in providing clinical care and medical competencies capabilities (10). providing clinical training and assessment, holding reflection workshops and international conferences to participate in educational programs, and using educational scholarships are among the major challenges, as discussed by the american ramezani g., et al. 3 j med ethics hist med. 2021(december); 14: 30. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e medical association (8). considering the global prevalence of covid-19, there is an absolute necessity for adequate measures to be taken to provide better education in all basic and clinical sciences departments for proper healthcare delivery. considering the sensitive role of ethics in clinical training and the high attention on this issue, certain challenges have transformed clinical training environments after the coronavirus pandemic. since qualitative studies provide researchers with more in-depth information, this research was conducted to explore the challenges and ethical requirements for medical sciences education during the covid-19 crisis at iran university of medical sciences. it is anticipated that the results of this study will familiarize professors and students with ethical issues and challenges during the pandemic to help them evaluate these issues and resolve them if deemed necessary. methods study design this qualitative study was conducted with a content analysis approach and purposeful sampling among the specialists and professors of basic and clinical sciences in iran university of medical sciences using semi-structured interviews. study participants the participants were specialists and professors of basic and clinical medical sciences at iran university of medical sciences. the participants’ inclusion criteria were considered as having sufficient expertise in the field of medical science education, being a faculty member of the iran university of medical sciences, and having experience in dealing with issues and challenges caused by covid -19 pandemic in the clinics and university environment. main research questions consisted of “what are the ethical challenges of medical education during the covid-19 crisis?” and “what are the ethical requirements for medical education during the covid-19 crisis?” setting the participants made decision about the time and place of each interview. the interviews were conducted in a preferentially quiet atmosphere in places such as conference rooms, patients' rooms, or hospital courtyards (in coordination with the ward), considering the interviewees’ wishes. due to the covid-19-related conditions and special travel restrictions, nine interviews were conducted by telephone. the researchers were committed to follow the principles of confidentiality and privacy of interviewees. the voices were recorded with permission. the transcripts were anonymous, and the recorded voices were destructed after the completion of the research. the study was conducted between september and october 2020. data collection the interviews were recorded and verbatim transcription was performed by the first author and the concepts were extracted simultaneously. the selection process exploring the challenges and ethical requirements of medical sciences education … 4 j med ethics hist med. 2021(december); 14:30. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e continued until no new data emerged and the theoretical saturation of the data was achieved. finally, the number of participants reached 16 people. participants' views on the ethical challenges and requirements of medical education during the covid 19 crisis were obtained through semi-structured interviews and qualitative content analysis. the duration of the interviews was between 20 and 30 minutes. the interview started with the main question of "what do you think are the challenges and ethical requirements of medical science education during the covid 19 crisis?", and continued with enlightening questions; like: "can you elaborate? give an example!”. data were collected, recorded, coded, and categorized into major concepts over three months. data analysis based on the purposeful sampling method, among the experts and professors of basic and clinical medical sciences, the interview participants were selected and the interviews continued until theoretical saturation was achieved. qualitative data were analysed using conventional qualitative content analysis. in this method, the analysis was performed simultaneously with data collection; codes and categories were extracted directly and inductively from raw data. each interview was reviewed several times to identify the semantic units. then, they were reviewed several times to classify according to the conceptual and semantic similarities. the categories and subcategories were compared to extract more abstract themes. the interviews were analysed using the seven-level colaizzi method. as mentioned earlier, data were collected and analysed simultaneously. in this regard, the interviews were first written orally (word for word), and then the interview reports were prepared. in the next steps, semantic units were extracted as sentences from the text of the interview reports and identified as codes. findings from the interview texts were then analysed and explained in a 7-step method. these steps include: 1. study: study all the descriptions provided by the respondents; first, the researcher reads the whole interview text several times; 2. extraction of important content: at this stage, the text is divided into meaningful units. meaningful units are parts of the text that automatically conveys meanings. these units can be a word, a phrase, or a sentence. 3. compilation of meanings: this step is descriptive coding of the meaningful descriptive units. at this stage, the coding process is started after each interview and revised several times in the course of the study. 4. organizing meanings into categories and themes: in this stage, descriptive codes with common themes are placed in the same category and each category is given a title. these are the interpretive codes, or the meanings that the researcher gives to descriptive codes. 5. detailed description of each theme: in this step, the interpretive codes are collected and merged. 6. development of the main structure: explanatory codes are created in this step. ramezani g., et al. 5 j med ethics hist med. 2021(december); 14: 30. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e 7. final validation of data: this is done by getting feedback from the members of the research team, and also the participants. trustworthiness the trustworthiness of this study was based on two criteria, consistency and confirmability. accordingly, the researcher sent the findings and the extracted codes to the participants; then, the findings were validated with their approval. also, the researcher sent the extracted codes to three experts in qualitative research who provided their opinions about the themes and codes analysis and the execution process. in this method, the codes and categories were extracted directly and inductively. finally, the findings were sent to the participants to confirm the credibility of the results. to verify the credibility of the findings using the member review method, we returned the interviewees' answers that were transcribed exactly on paper to the interviewees. the purpose of this work was to conclude the accuracy of the person's perceptions of the interview. the results indicated the acceptability of the data. the opinion of the qualitative research experts was also used during the data analysis process. at the end of the analysis, the texts of the interviews and the findings were sent to three qualitative research experts to review the analysis process and validate the findings. simultaneous reliability method was used to ensure the reliability of the research method. during the research and collection of interview data, the researchers simultaneously coded and analyzed the data while comparing the results with each other. ethical considerations for the implementation of the study after obtaining the scientific approval, an ethical approval was sought from the research ethics committee of iran university of medical sciences (code: ir.iums.rec.1400.152). in this study, the participants were informed about the purpose of the research, and they were assured that they could leave the study whenever they want. the interviews were recorded only with the consent of the interviewees. result sixteen participants with an age ranging between 38 and 58 years were recruited. nine of these individuals were clinical faculty members who worked both at the university and in the hospitals affiliated with iran university of medical sciences. the other seven participants were faculty members of basic medical sciences. characteristics of the participants are presented in table 1. exploring the challenges and ethical requirements of medical sciences education … 6 j med ethics hist med. 2021(december); 14:30. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e table 1demographic and background characteristics of participants. characteristics number gender male 10 female 6 marital status married 13 single 3 academic degree assistant professor 7 associate professor 6 full professor 3 field of experience basic sciences 7 clinical sciences 9 work experience ≤ 10 years 5 >10 years 11 data obtained from the analysis of the interview contents led to the identification of 81 initial codes, 28 sub-categories and ten categories. four categories, out of 10, were related to ethical challenges and six ones to ethical requirements. therefore, the main themes are categorized into two main themes, as mentioned in table 2. ethical challenges include "to be patientcentred", "social accountability of curriculums", "ethical challenges of the clinical setting", and "the poor performance of clinical members of the faculty and the students". ethical requirements, as the second main theme, consist of "being justice-centred", "raising awareness", "observation of clinical research ethics", "preservation and promotion of mental health", "patient confidentiality", and "respect for individuals". citing some examples of interview contents confirms the findings (table 2). table 2 categories, themes and some quotes. main themes categories quotes ethical challenges being patientcentered "in these acute situations, all the efforts of the medical staff should be focused on the patients’ management and trying to prevent the progression of the disease. in this regard, patients’ isolation, while has social advantages, it is firstly beneficial for the patients themselves." (participant no.9) social accountability of curriculum "when unintended and unforeseen circumstances arise for an unusual period of time, we become more aware of the gap between the theory curriculum and its weak connection to society. here, we can easily say that we have many weaknesses in the resources, outdated teaching methods, use of old curriculums; selection without consideration of competency, and, most importantly, irresponsibility in the educational schedule." (participant no.5) ethical challenges of the clinical environment regarding the ethical challenges of the clinical environment, interviewee no. 10 stated that: "you see, a lot of ethical issues have arisen; for example, the issue of not harming a patients with covid 19 disease is a very important moral and behavioral challenges today. in this disease, you want to treat a patient, so you use different treatments and protocols, but you do not really know how the patient may suffer, because there is not much knowledge about this disease and any treatment protocol may have side effects,. as a case in point, artificial respiration through ventilators, which were used in the early stages of the disease in many countries of the world, have recently been shown to carry a considerable risk and are now trying to use other methods for oxygenation." ramezani g., et al. 7 j med ethics hist med. 2021(december); 14: 30. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e main themes categories quotes the poor performance of the clinical faculty members and students "the current situation has caused that we cannot meet the desired educational standards. on the other hand, because we are at the beginning of the virtual education, this type of educational methods do not solve the problem at the moment, they are only more suitable for raising awareness." (participant no. 8) ethical requirements being justicecentred "the issue of patients' management process and accelerating their treatment and triage is a basic condition and on the other hand is a serious challenge for the health care providers to do the best according to the condition of each patient ". (participant no. 1) raising awareness "the issue of raising awareness and informing about prevention of covid-19 may be primarily a public duty, which national media and other institutions have responsibility in this area, but universities and hospitals are required to be involved in prevention and education, addition to the treatment, which makes their tasks somewhat heavy." (participant no. 7) observation of clinical research ethics "problems that can be raised in the clinical trial studies are the issue of unlicensed medicinal products to patients with covid-19. obviously, it is unethical to prescribe such medication or analgesics by the health care providers, and it cannot be prescribed to the patient until the medication is fully licensed." (participant no. 13) preservation and promotion of mental health "many patients, health-care providers and individuals have developed obsessive behaviours, such as using a disinfectant spray regularly and every few minutes, or having abnormal postures while eating or washing their hands excessively. these actions cause anxiety and endanger their mental health." (participant no. 3) patient confidentiality "expressing the patient's history aloud and disclosure of his personal information for the purpose of education, only because of we are facing a new disease, is something that i have encountered many times on the patient's bedside and in the corridor of the ward." (participant no. 12) respect for persons "in many cases in covid-19 condition, no specific questions were asked of the patient in the first visit, and initial examinations were performed without taking a history. additionally, i saw that in the ward, medical intervention have done without permission of the patients (or those who apparently diagnosed with covide-19); while this is against the standards of patients' ethics." (participant no. 6) discussion in this qualitative research, there were two main themes, that is, ethical challenges and ethical requirements, and 10 categories as mentioned before. these results can encourage us to aim at reducing the ethical challenges of medical sciences education and overcoming the existing ethical obstacles. moreover, ethical requirements in various dimensions (professors, students, curriculum, clinical environment, and defining the necessary ethical requirements) can help with the effective implementation of educational programs when an unprecedented phenomenon such as the covid-19 pandemic emerges. some approaches should be taken into account, as constructive measures, to enhance social responsiveness and the commitment of the healthcare system. as discussed by larijani and zahedi (2013), the issue is particularly important in iran, since the cultural and religious contexts influence medical practice (11). the covid-19 pandemic has created deep gaps in society. this highlights the need for an in-depth review of ethical considerations exploring the challenges and ethical requirements of medical sciences education … 8 j med ethics hist med. 2021(december); 14:30. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e to justify difficult decisions and protect us against those lacking ethical backgrounds (12 13). ethical problems arise in various areas of a pandemic such as restrictions on moving around freely, individuals’ refusal to adhere to preventive intervention, rights and duties of the healthcare workers, allocating limited resources, and off-label use of diagnostic and therapeutic measures (14 15). during the critical time of the covid19 pandemic, it has been crucial for the academic community to learn from this experience and prioritize a prospective and scholarly approach by implementing practical strategies (15 17). accordingly, dehghan nayyeri et al. (16) have reviewed the most important ethical challenges in relation to emerging diseases, including observing patients’ rights and autonomy, maintaining patients’ privacy, the principle of reciprocity, the accountability and responsibility of the government to care for patients, and preventing stigma and discrimination. concerning the newly emerging diseases, the findings indicate the necessity for taking into account ethical considerations in caring for patients. moreover, to optimize the management of these diseases, it is recommended to incorporate professional ethics education and ethical decision-making during pandemics into caregivers’ curriculum (16). one qualitative study (11) conducted to explore faculty-related challenges in medical ethics education found three themes in terms of the types of challenges, including: “specialized abilities of medical ethics professors, “medical ethics education through active teaching methods, and “the gap between teaching theory and practice". each of these themes includes several categories and sub-categories that depict a specific aspect of the existing challenges in medical ethics education related to professors. in general, it was concluded that medical professors and medical ethicists specifically have not been able to play a pivotal role in enhancing students’ moral development (11). in addition, another study (12) was carried out to discover the ethical challenges in the clinical and educational environment of the university based on the experiences of nursing and midwifery students. their findings were categorized into three main themes including “ethical challenges in the educational environment”, “the educational gap between clinical theory and practice”, and “ethical challenges in the clinical environment”. the students’ perspectives on ethical issues was extensive and not limited to professional ethics; rather, they believed social-behavioral dimensions to be of greater significance. the study participants considered abnormal behaviors as immoral acts that could cause tension in the educational environment. however, these challenges can be minimized or overcome with better management of education and issues related to culture (12). examination of the ethical challenges in conventional and modern teaching has demonstrated that modern ethical attitudes are stagnated or neglected, especially due to the recent social developments and changes in value criteria. every dimension in the realm of medicine such as education, research, and practice, from the beginning of the general courses to the highest level of ramezani g., et al. 9 j med ethics hist med. 2021(december); 14: 30. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e specialization and sub-specialization, is reviewed and modified (13). a great leap in iran’s higher education, the increase in the number and variety of universities and higher education institutions, and the everincreasing establishment of disciplines from associate degrees to doctorates, specialties, sub-specialties, and fellowships have enhanced the general scientific level and awareness in the society. however, the inadequate number of professors with appropriate theoretical and practical qualifications as ethical role models for the student community has resulted in changing the selection criteria for professors in higher education institutions from a system based on perfectionistic, traditional ethical rules to one focused on rankings and gpas. sadly, the number of ethical role models and competent professors is declining. one of the results of such an educational system is the transformation in the admission and evaluation methods. there is an educational weakness in medical specialization courses, in which ethical orientation has not been the priority. this is a serious problem that needs to be considered as such, and approaches to resolve it should be thoroughly contemplated. one of the best solutions is to conduct a review using ethical criteria. if authentic ethical criteria are observed by ethics specialists during the selection, training, and assessment process in an accurate and biased manner, many of the current problems and difficulties will be resolved (17). in a review study by farajpour and afshar, the ethical issues of medical clinical education were discussed and an attempt was made to provide appropriate ethical codes of medical education for the cultural and social circumstances in iran. considering the significance of medicine both in islam and from a social perspective, training specialized and committed physicians is an essential undertaking. accordingly, students are expected to be devoutly committed to enhancing their professional views, communication skills, professional encounters, and general behavioral standards during the medical training period (14). specific associations, communities, and professional committees can strengthen ethics in practice and emphasize ethical behavior through spreading the necessary knowledge and facilitating the process of sharing experiences. in recent decades, we have been witnessing significant progress in iran, and certain organizations including the medical council of the ir of iran and the iranian nursing organization have paid more attention to ethics education and strengthening ethical performance by providing codes and guidelines. professional ethics is taught in different courses across various disciplines in malaysia and japan (19). the results of research on the covid-19 pandemic and the ethical challenges in patient care suggest that training healthcare providers in professional ethics and ethical decisionmaking is essential. in addition, preventing ethical challenges, supporting patients’ rights, and providing high-quality healthcare should be considered seriously (25). during pandemics, higher education may exploring the challenges and ethical requirements of medical sciences education … 10 j med ethics hist med. 2021(december); 14:30. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e play a significant role, in empowering human resources to fight the disease. although it is still important to consider the role of higher education in various political, economic, and social contexts during the covid-19 pandemic, educational systems and universities in particular face more complications and difficulties (24 26). when societies pay serious attention to higher education during such a crisis, they make it possible for individuals to adapt more easily to life in the new world, acquire the required knowledge, values, perspectives, and abilities, and take effective steps toward social justice and maintaining their social status. therefore, university systems should be aware of their role and responsibility in different societal crises such as pandemics to resolve problems, consider the consequences, and change their outlook and activities following these conditions. hence, adequate measures and approaches need to be taken to ensure the positive and meaningful performance of university systems. moreover, organizations should regularly opt for self-organizing processes to respond to environmental demands. the main limitation of this study was the inadequate experience of the faculty members in such emergency conditions. as another limitation, students (interns and residents in hospitals) were not a part of our study, while their views could have been of additional value. the strength of this study was the fact that the professors were actively present in educational medical centers and closely witnessed or were involved in the existing challenges. conclusion the emergence and spread of covid-19 have created several problems and challenges for health systems, among the most important ones being the ethical challenges in medical education. the results of this qualitative study emphasize moral and ethical pitfalls that our health system is trying to avoid. the findings also indicated that by defining a framework and ethical requirements, the existing ethical challenges can be reduced or eliminated. it is noteworthy that medical curricula should be reinforced to enhance capabilities, competence, and skills. to meet the above-mentioned requirements, it is essential to consider social needs, especially in critical situations like the covid-19 pandemic, to improve social accountability in the medical education system. declarations ethics approval and consent to participate the present study was approved by the ethical approval of the ethics committee of iran university of medical sciences (ir.iums.rec.1400.152). competing interests the authors declare that they have no competing interests. acknowledgements the authors are grateful to all the participants of the study as without collaboration and support, conduction of the study was not possible. ramezani g., et al. 11 j med ethics hist med. 2021(december); 14: 30. jo u rn a l o f m e d ica l e th ics a n d h isto ry o f m e d icin e references 1. mokhtari lakeh m, nafar m, ghanbari khanghah a, kazemnezhad leili e. nursing students’ views on code of ethics, commitment to the ethic of academic dishonesty and neutralization behaviors. journal of holistic nursing and midwifery. 2014; 24(3): 64-71. 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12(1): 18. 21. rezaei h, mosavi a, yousefi a, et al. strengths of iran for internationalization of medical sciences education. j educ health promot. 2020; 9: 92. 22. zahedi f, emami razavi sh, larijani b. a two-decade review of medical ethics in iran. iranian journal of public health. 2009; 38(suppl. 1): 40-6. 23. larijani b, motevaseli e. needs and necessities of medical ethics education. daru: journal of pharmaceutical sciences. 2006; supplement 1: 21-7. 24. larijani amb, ghaforifard s, zahedi f. ethical considerations in clinical education of medical students. journal of diabetes and metabolic disorders. 2004; 4, supplement of ethics in clinical research: 105-7. 25. sahebi a, moayedi s, golitaleb m. covid-19 pandemic and the ethical challenges in patient care. j med ethics hist med. 2020; 13: 24. 26. papapanou m, routsi e, tsamakis k, et al. medical education challenges and innovations during covid-19 pandemic. postgrad med j. 2021; postgradmedj-2021-140032. microsoft word 6 journal of medical ethics and history of medicine common principles and multiculturalism farzaneh zahedi1, bagher larijani2* 1.endocrinology and metabolism research centre, tehran university of medical sciences, tehran, iran. 2.medical ethics and history of medicine research centre, endocrinology and metabolism research centre, tehran university of medical sciences, tehran, iran. *corresponding author: bagher larijani address: no. 21, 16 azar ave., keshavarz blvd., medical ethics and history of medicine research centre, tehran, iran. tel: (+98) 21 66 41 96 61 e-mail: emrc@tums.ac.ir received: 21 may 2009 accepted: 28 may 2009 published: 31 may 2009 j med ethics hist med. 2009; 2:6. © 2009 farzaneh zahedi and bagher larijani; licensee tehran univ. med. sci. abstract keywords: principlism, ethical relativism, informed consent, truth disclosure. introduction contemporary bioethics has its theories, principles and methods of practice which their application may be different in various cultures. moral conflicts and bioethical dilemmas in different countries are so dissimilar. in the same way, the solutions and practical approaches would be different considering the social and cultural context. the diversity is not limited to the national borders of countries, owing to this fact that many societies are cosmopolitan and multi-ethnic now. cultural barriers may be present within people of a country. so, general knowledge about other cultures and skills of an effective communication should be currently parts of medical and healthcare professionalism. one verse of qu'ran, the holy book of muslims, counts multiculturalism as an advantage of the creation. it states: "o, mankind! verily, we created you all from a male and female [`adam and eve] and appointed for you tribes and nations to be known to each other [by specified characteristics] verily, in allah's sight the most honorable of you is the most pious of you; and allah is the informed owner of knowledge." judgment on rightness and wrongness of beliefs and behaviors is a main issue in bioethics. over centuries, big philosophers and ethicists have been discussing the suitable tools to determine which act is morally sound and which one is not. emerging the contemporary bioethics in the west has resulted in a misconception that absolute westernized principles would be appropriate tools for ethical decision making in different cultures. we will discuss this issue by introducing a clinical case. considering various cultural beliefs around the world, though it is not logical to consider all of them ethically acceptable, we can gather on some general fundamental principles instead of going to the extremes of relativism and absolutism. islamic teachings, according to the presented evidence in this paper, fall in with this idea. j med ethics hist med 2009, 2:6 farzaneh zahedi and bagher larijani page 2 of 6 (page number not for citation purposes) (49:13). though the different cultural contexts may produce difficulties for patients, physicians and other care providers, it would be a tool for empowerment of human being. however, this is a reality that there are different cultures with different traditions around the world. no doubt, many people think that their own culture is superior to others', so they try to criticize other cultures for what they think is morally wrong and indefensible and in need of reform. this is a main challenge in anthropology and intercultural bioethics that whether we should have a neutral position against all cultural contexts or not. there are some customs which obviously violate the human dignity and human rights. so, how we judge them? in response to the mentioned issue, some intellectuals have suggested three different ideas of: "relativism", "absolutism" and "common general principles". bringing the issue in one case can shed more lights on the matter and pave the way for a comprehensive discussion. case 1 : mr. a, born in a eastern culture, recently moved to the west to join family members. when his neck became seriously swollen and spotted with inflamed lymph nodes, he was rushed to the emergency room of a nearby hospital. with symptoms of hodgkin’s disease, he was admitted for further treatment and required assessment for chemotherapy. neither he nor his family was conversant in english. the staff questioned him about his health history and that of his family. from the start, he and his family were deeply offended by the staff’s efforts to inform him of his condition by inquiring into his personal health. he did not respond to many of the nurses’ questions, which he regarded as rude and intrusive. he and his family also believed the staff lacked professional competence. when the staff insisted on his signature for written consent, they were met with resistance and distrust. ahmed and his family could not understand why anything in writing was necessary. ahmed then needed to have a tracheostomy tube inserted after he choked while sipping soup. inserting the tube was difficult, and the long time it took to do so resulted in anoxic encephalopathy. ahmed suffered a severe loss of oxygen to his brain, and from that time on remained in coma. not yet brain dead, his situation deteriorated. his family was extremely offended when the medical staff approached them to discuss treatment options including forgoing treatment. the family 1 . this case was stated in reference 1 for the first time, but we deleted the name of the patient and the countries to use it for a general discussion. this case has been discussed by some authors, including references 2 and 3. remained deeply suspicious of the staff’s motives (1-3). main issues effective communication establishing a good relationship between physician and patients in a multicultural society seems to be a complex matter. the issue would be more complicated when the languages are not the same. namely, there are many situations when the plurality of cultures in the clinical setting can lead to conflict, of which are the issues of "informed consent" and "truth-telling". the differences may influence on effective communication. so, sensitizing physicians and other staff to the differences is necessary. an effective communication is a main factor for a good relationship between patient and care providers. for achieving this, understanding patient's feelings, expectations and values would be very helpful. for instance; for such a patient who has recently moved to a different country, admission to the hospital can put him under an undue stress. this may interfere in his relationship with the staff. navigating stressful circumstances is one of the healthcare team responsibilities. the hospital environment, staff's behavior, and the family sympathy would relief his stress considerably. on the contrary, an unfriendly and inflexible conduct of the physician or staff would ruin the patient-caregivers relationship. medical staff should fulfill their duty to provide a good communication. the goals of communication, according to the 3rd annual disease management outcomes summit in johns hopkins university are to (4): • exchange information; • reach mutually satisfying decisions; • develop a common understanding; and • build trust. linguistic and cultural barriers in the current case, if we want to determine main barriers, we should point out linguistic barrier at first. language discrepancy may result is a kind of miscommunication. the patient and his family were not conversant in english, and the staff was not also familiar with the patient's language. it seems that there was not any other person to translate the words and facilitate the communication. this matter might be impressive on misunderstanding between the patient and the staff. an interesting poem in the book ii of "masnavi" of rumi is noteworthy, in which he tells a story as follows: "four persons, a persian, an arab, a turk, and a greek, were traveling together, and received a present of a dirhem (money). the persian said he would buy "angur" with it, the arab said he would buy "inab," while the turk and the j med ethics hist med 2009, 2:6 farzaneh zahedi and bagher larijani page 3 of 6 (page number not for citation purposes) greek were for buying "uzum" and "astaphil" (staphyle), respectively. now all these words mean one and the same thing, viz. "grapes;" but, owing to their ignorance of each other's languages, they fancied, each one wanted to buy something different, and accordingly a violent quarrel arose between them. at last a wise man who knew all their languages came up and explained to them that they were all wishing for one and the same thing" (5). it is undeniable that in the case of "ahmed", their ignorance of each other's languages has augmented the obstacles in the relationship between caregivers and patients. not satisfied with the linguistic communication, both parties were in distress and ready to complain about not enough assistance. in this difficult situation, differences in values, perceptions, style of expression and cultural mores may produce a strong barrier if the staff is not familiar with these differences. sometimes even phrasing a sentence or question in an appropriate way would result in patient's misunderstanding. some sentences or inquiries may seem insulting. for instance, arabs or muslims are not comfortable with questions about drinking wine or sexual habits, particularly when their privacy is not protected. it is noteworthy that even though some family members have been living in this new country for some years their beliefs and behavior may not be similar to the western people. many immigrants change their style of living in a new country but it is not easy to change a belief or behavior formed after a long rearing. considering the secular nature of bioethics in the west, it is obvious that religion may make a conflict between patient and health caregivers. sometimes the ideas about one subject (like abortion) are completely opposing, but in some cases there is a conceptual variation in which the concepts of ethics and their interpretation about one subject (like autonomy) may be divergent. as macklin stated, cross-cultural misunderstanding can affect the way people in one country perceive a situation in another (6). informed consent one important issue is taking an "informed consent". this notion is related to the concept of autonomy which is the main principle of the western bioethics. some people believe that autonomy is over respected in western culture while in some cultural contexts there is no room for individualism. western culture is low-context and non-western culture is high context, according to edward hall (7). low-context cultures emphasize independence, the individual, and a future time orientation. but high-context cultures emphasize interdependence, interconnections with others and a present time orientation. in a high-context communication, less information is conveyed by verbal expression and most of the message is embedded in the social context or internalized in the communication process itself (7). this theme, while interesting, may cause a big gap between patient and care providers. in this case, the patient (mr. a) and his family do not feel any necessity for a signature, since they think the consent is a kind of approval for being honest. so, request to sign a written form may have a particular meaning of blurred mutual trust for patient, especially when there is not an effective linguistic communication. likewise, the notion of autonomy (vs. paternalism) is acceptable in many cultures but sometimes the people's perceptions and the limits are dissimilar. for instance, privacy of some individual or familiar information in some ethnics, particularly in women, is more sensitive than that in the west. in western culture, query about contraception even in a single young girl is not offensive but it is intolerable in some cultures or religions in which sexual contact before marriage is unlawful. truth telling disclosure of diagnosis and telling the truth about the patient's outcome in a serious illness is a sensitive responsibility of health caregivers, on which cultural and religious background of the patient would influence. in western bioethics, every patient has "the right to know", so the physician or other health caregivers are obliged to tell him the realities of his diseases. but in some cultures, truth telling, and above all telling bad news, should be consulted with family members. some elements would be important in dealing with this issue:  the person who disclose the realities  the manner of telling news  available supports (such as family, spiritual and social support)  the methods of coping with difficulties and stress in different cultures all of above-mentioned elements would influence on the care provider's decision about truth telling. as ornek büken declares, the subject of truth telling may vary from country to country and culture to culture (8). in a high-context culture, family members may play a more prominent role in decision-making in comparison to the patient. emotional support is a real need in many non western cultures, and close family members are the first people who ask to know about realities of disease but patient sometimes do not know the nature of his disease until death. no universal ethical mandate exists to tell patients the truth about their terminal illness, as macklin confirms (6). the patient's close family may keep information about disease from the patient because they think that disclosure of a j med ethics hist med 2009, 2:6 farzaneh zahedi and bagher larijani page 4 of 6 (page number not for citation purposes) cancer diagnosis would have adverse psychological effects. however, it is the duty of physician to know whether the patient is willing to put the responsibility of decision making on shoulder of her family or not, and whether she is in agree with withholding information. this duty should be done in an appropriate way in which the family is also respected. the healthcare professionals should talk to the patient about her ideas about the extent of information which she would like to receive personally from her physician or nurses. the healthcare professionals should evaluate if patient is psychologically ready to hear a bad news about her health and her future. in a dying patient, his values and expectations should be taken into account by health caregivers in order to make the last days of life more pleasant. patient's attitude about "death" is very impressive on his psychological state; being hopeless or depressed. discussion about termination of treatments needs a special attention to the cultural background in order to the trust between patient and health staff remains intact. ethical approaches the main key words in this case study are: mutual respect, effective communication, kind and truthful relationship. according to the 3rd annual disease management outcomes summit in johns hopkins university (4), the intimacy of emotions and the private, often uncomfortable sharing of information between patient and physician require a foundation of mutual responsibilities that include: respect, open and honest communication, trust, and compassion. in the current case, the caregivers should try to overcome the language misunderstanding by using a translator. it is pleasing that the use of experienced translators or interpreters has begun in the current decade in some countries (9, 10). for instance; in the united states, several state medicaid programs now reimburse for translation services (10). the need assessment in different countries, as a primary step, is necessary. it's a common fallacy that in countries with cultural homogeneity, there is no need for interpreters. more profound study may not confirm this. for instance, in iran, most people may have similar culture (let alone immigrants from iraq and afghanistan, etc), but there are many groups of people with different religions, different languages and various accents. turkish, kurdish, lorish, and arabic are some known languages in iran besides farsi. despite this fact, there is any plan for training of cultural competency because there have not carried out studies that show the importance of this issue. in fact, health policy makers should feel the need to provide special, applicable and effective plans for training translators and interpreters. however, this conclusion is obviously true for the descriptive thesis of ethical relativism: truth telling, informed consent, and decision-making about medical treatment vary in different cultures (6). it is not expected that physicians or other caregivers be anthropologists but they should be able to understand patient, his values, feelings, expectations, and the way he views the ethical problem. they should also be respectful to patients' values and beliefs, and not to be seeking a kind of "ethical imperialism" by following their ideas even if they think it would be better for the patient. but whether respect to patient's belief is always ethically sound. consider these two cases: first, scarifying newborn infants as a traditional ritual to prevent drought in an indigenous group in chile; and second, the freedom of sexual relationship in different ages and eradication of fetuses on request in the west. this is a challenging concern that to what extend we should respect cultural beliefs. in this regard, relativists claim that ethical rightness and wrongness are completely related to the cultural context and there is not any universal moral principle by which we can judge. according to the extreme relativists' position, there are no available transcultural standards by which different cultures might be judged on a scale of merit or worth (6). in other words, cultural relativity around the world necessitates a kind of relativism in ethics and ethical conducts. on the contrary, absolutists support fixed universal principles by which we can decide about morality of cultural rite and beliefs. the absolutists believe in a single universal moral standard which all people are obliged to obey. there are some people who believe in the supremacy of the western culture and they judge about other cultures by their westernized principles. unfortunately, this kind of "ethical imperialism" is an ordinary approach in some international organizations. besides these two opposite concepts, some speak about a third notion of "fundamental ethical principles" (6). these anthropologists agree that "despite the superficial diversity of cultures, similar underlying structures and frameworks can be found" (6). for instance; liberty may be considered as a fundamental principle, but privacy is a culturally relative value. so, the attitude and practice of privacy and confidentiality could be different in societies without violating fundamental principles (6). each of these principles can be used for decision making about morality of an action. the islamic faith may confirm this idea, considering the common origin and destination which all humans have. these general principles have been inspired on human by god, since holy qu'ran says: "i swear by the soul and him who j med ethics hist med 2009, 2:6 farzaneh zahedi and bagher larijani page 5 of 6 (page number not for citation purposes) made it perfect, then he inspired it to understand what is right and wrong for it (its sin and its piety), (91:8)". no doubt, simply because a custom or ritual is a "tradition" in a culture cannot serve to justify its perpetuation when it quite clearly violates general ethical principles (6). allameh mohammad taqi jafari indicates some worthy points in the definition of culture (11). he says that every culture element must first originate from sound logic and supreme human emotions, and secondly provide man with the means for his development and perfection. he emphasizes "the more the culture of a society relies on basic, intelligible principles and supreme human perceptions, the more lasting the culture will be". according to him, culture has two aspects: relative and absolute. by absolute aspect we mean the comprehensive, general aspect of culture, such as the culture of appreciating beauty, respect for others, and gaining knowledge, which is applicable to all human societies. the relative aspect of culture arises from the particular ways of thinking, emotions and behaviors of a certain society, like mutual respect (11). giving emphasis to the ideas about fundamental ethical principles, three sources for moral disagreements can be numbered: divergence in facts and probabilities (such as consequences of euthanasia), moral status of the central entity (such as embryo in abortion), and difference in priority setting of values (such as child and parent rights when parents refuse to consent to a treatment) (6). in the cases of disagreements, there would be ethical resolutions by using fundamental ethical principles. macklin's view is that "without ethical principles as part of a framework, there can be no systematic way to justify ethical judgments" (6). there are some things which are relative and some things which are not. many bioethicists go on with four principles of respect for persons, beneficence, non-maleficence and justice, which are abstract but can take different forms in different cultural contexts. these principles are different from absolutistic principle, and could be very useful to judge morality of many cultural customs. the four principles are also acceptable, according to the islamic teachings, but if we want to arrange these principles concerning their importance, we may order them as follows: non maleficence, beneficence, justice, and respect to autonomy. in some cases, we may change the order of principles or may use only one principle. we may have different interpretation and various reading of these principles in different societies. on the other hand, we cannot limit the principles to these broad principles. some islamic principles may also be suggested as main principles including “the public interest” (maslaha), the principle of “do no harm” (la darar wa la derar), the principle of “necessity” (darura) and the principle of “no hardship” (la haradj) (12). owing to this fact that in many eastern cultures the community rights has a special importance in ethical decision making, we may also propose "public interest" to add as the 5th general principle. conclusion putting the mentioned points in a nutshell, physicians and other healthcare professionals are obliged to fulfill their duties by respecting their patients' attitudes and behaviors but they should also observe common ethical standards with its special interpretation in different backgrounds and various cultures. effective culturally sensitive communication is a necessary part of providing high quality care (13). though we cannot determine absolute principles for all societies, there are general fundamental principles which should be respected and by which we can judge rightness and wrongness of beliefs and behaviors. ethical imperialism and belief in the supremacy of the western culture could not be defensible in the contemporary bioethics. taken into account the variety of cultures and languages in iran and presence of a lot of immigrants from other countries such as afghanistan and iraq, and considering the growing attention to bioethics in iran (14,15), as an islamic asian country with a profound culture, iranian physicians should get familiar with intercultural bioethics and the approaches for a better communication in clinical practice. j med ethics hist med 2009, 2:6 farzaneh zahedi and bagher larijani page 6 of 6 (page number not for citation purposes) references 1. meleis ai, jonsen a. ethical crises and cultural differences. west j med 1983; 138 (6): 889-93. 2. hathout mm. comment on "ethical crises and cultural differences. west j med 1983; 139(3): 380–1. 3. brannigan m, boss j. healthcare ethics in a diverse society. new york: mcgraw-hill; 2001, pp. 486-87. 4. anonymous. johns hopkins; american healthways. defining the patient-physician relationship for the 21st century. dis manag 2004; 7(3): 161-179. 5. rumi mjm. the masnavi i ma'navi. abridged and translated by whinfield eh. http://www.sacredtexts.com/isl/masnavi/ (accessed on may 2009) 6. macklin r. against relativism: cultural diversity and the search for ethical universals in medicine. new york: oxford university press; 1999. 7. bowman k. what are the limits of bioethics in a culturally pluralistic society? j law med ethics 2004; 664 -9. 8. buken no. truth-telling information and communication with cancer patients in turkey. jishim 2003; 3: 316. 9. brannigan m. connecting the dots in cultural competency: institutional strategies and conceptual. camb q healthc ethics 2008; 17: 173-84. 10. taylor sl, lurie n. the role of culturally competent communication in reducing ethnic and racial healthcare disparities. am j manag care 2004; 10 spec no: sp1-4. 11. jafari mt. the mystery of life: a secret inside secrets. tehran: allameh jafari institute; 2005, pp. 141-2. 12. larijani b, zahedi-anaraki f. islamic principles and decision making in bioethics. nat genet 2008; 40(2): 123. 13. powell t. culture and communication: medical disclosure in japan and the u.s. am j bioeth 2006; 6 (1): 1820. 14. larijani b, zahedi f. medical ethics activities and plans in iran at a glance. iran j allergy asthma immunol 2007; 6 (suppl. 5): 1-4. 15. larijani b, malek–afzali h, zahedi f, motevaseli e. strengthening medical ethics by strategic plan in islamic republic of iran. dev world bioeth 2006; 6(2): 106–110. hhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh copyright © 2022 tehran university of medical sciences. this work is licensed under a creative commons attribution-non commercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. original article abstract in order to lessen health inequalities, the obstacles to health equity will need to be identified. this study aimed at investigating the barriers to access to health-care services from the medical ethics point of view. data were collected through a qualitative study by performing semistructured interviews. purposive sampling was used to recruit participants involved in health provision and/or management. content analysis was done using maxqda software. overall, 30 interviews were conducted. the content analysis of the interviews identified two themes including “micro factors” and “macro factors”, five sub-themes including “cultural, financial, geographical, social and religious barriers”, and 44 codes. based on our findings, differences in individuals’ perceptions, cultural control, religious beliefs and social stigmas create cultural barriers. financial barriers consist of the financial connection between service recipients and service providers, insurance premiums, and inadequate coverage of health-care services. *corresponding author alireza olyaee manesh address: no. 70, national institute of health research, bozorgmehr st., vesal shirazi st., keshavarz blvd., tehran, iran. tel: (+98) 21 62 92 10 00 email: arolyaee@gmail.com received: 8 may 2022 accepted: 1 dec 2022 published: 28 dec 2022 citation to this article: nezamoleslami d, mohamadi e, larijani b, olyaeemanesh a, ebrahimi tavani m, rashidpouraie r, bathaei f. barriers to health equity in the iranian health system from the medical ethics viewpoint. j med ethics hist med. 2022; 15: 14. the most important geographical barriers identified in our study were differences in urbanization, inequality in various geographical areas, marginalization, and inequality in resource distribution. finally, differences in the level of income, education and occupational diversity were among the social barriers. given the wide range of barriers to access to health-care services, a comprehensive plan covering various dimensions of health equity should be implemented. to this end, innovative and progressive strategies emphasizing the principles of equity and social equality should be developed. keywords: health equity; health services accessibility; medical ethics; health disparities. barriers of health equity in the iranian health system from the medical ethics viewpoint 1. phd candidate in medical ethics, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. 2. assistant professor, health equity research center (herc), tehran university of medical sciences, tehran, iran. 3. professor, institute of endocrinology and metabolism, tehran university of medical sciences, tehran, iran. 4. professor, health equity research center (herc), tehran university of medical sciences, tehran, iran; national institute of health research, tehran university of medical sciences, tehran, iran. 5. assistant professor, group of quality improvement, monitoring and evaluation, center for health network management, deputy for public health, ministry of health & medical education, tehran, iran. 6. researcher, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. 7. researcher, department of medical ethics, school of medicine, tehran university of medical sciences, tehran, iran. davoud nezamoleslami1, efat mohamadi2, bagher larijani3, alireza olyaeemanesh4*, masoumeh ebrahimi tavani5, roya rashidpouraie 6, fataneh sadat bathaei7 barriers to health equity in the iranian health system from the medical ethics viewpoint j. med. ethics. hist. med. 2022 (dec); 15: 14. 2 introduction health is considered as a foundation for achieving social equity, a precondition, indicator and output of sustainable development of societies. hence, as a basic right of all individuals, health-care services of desired quality and without financial difficulties should be provided by governments. among the various complexities of health-care provision, health equity as one of the ultimate goals of the care system has a significant impact on health outcomes, and therefore health managers and decision makers should carefully and persistently consider it in planning and implementations (1, 2) it is also important to consider equity as an extension of the four principles of medical ethics. ethical theories have different perspectives on justice and equity in terms of access to health services. according to the utilitarian theory, health equity and allocation of health resources should be done in a way that maximizes profit (3). according to the theory of egalitarianism, the government has a responsibility to actively remove potential barriers to equal opportunities for all individuals, and because illness and disability create such a constraint, it is the duty of the government to promote health conditions for everyone (3, 4). equity in access to health services is one of the most important dimensions and manifestations of justice in an islamic society that should be considered by the islamic system. moreover, health as a human right has received special attention in islam (5). although fulfilling equity in health-care service provision is a significant objective, health systems, especially in the context of averageand lowincome countries, have been facing fundamental challenges in this regard. according to the most successful health-care systems worldwide, attending to the important concept of equity and ensuring underprivileged patients' access to quality health-care at a reasonable cost is essential in achieving sustainable health development (6). the issue of health inequalities can be inspected from three aspects: equitable financing contribution, inequalities in health-care access and utilization, and inequalities in health outcomes (7). equitable access to health-care services for all community members includes providing the right services at the right time and in the right situation. this promotes the health level and thereby prepares the ground for social activities as well as growth and development in the community. thus, access to health-care services is a prerequisite for nezamoleslami d., et al. 3 j. med. ethics. hist. med. 2022 (dec); 15: 14. achieving equity in the society, and the right to health services creates equal opportunities for community members (8). access to health-care services has three main dimensions including geographical access, financial access, and cultural accessibility (or acceptance) (9). access to healthcare involves various factors including service affordability, availability, acceptability, and adaptability to needs. these factors are interconnected with the provision of access to health-care services; likewise, enhancement of one factor alone cannot improve the access level, promote equitable access, or facilitate use of the services (10). substantial research has been conducted in several countries on the various aspects of health equity (equitable financial involvement, access to healthcare, and health outcomes, to name a few). studies show that treatment expenses vary according to the type of disease, and the costs are significantly higher in households with patients suffering from chronic conditions, particularly cancer. in iran, the percentage of households exposed to catastrophic expenses has changed in the last two decades (6 9), which was somehow reduced after the implementation of the health transformation plan (htp) in 2014. the minimum rate of catastrophic costs in these studies was 1.3% (10), and the highest recorded rate was 42.6% (11). some of the factors that significantly affect catastrophic costs are: the socio-economic status and the education level of the head of the household, presence of a person over 65 years of age in the household, health services, health insurance status, and using inpatient services, rehabilitation and dentistry (11 18). given the scope of the problem, one of the conditions that must be met throughout the nation is establishing a thorough system to monitor health equity. due to the ongoing limitations in availability of resources and the increasing demand for health-care services, health managers at various levels aspire to the highest performance using minimum facilities, so that all individuals have equitable access to health-care services. to minimize health-care inequalities, the system’s maximum capacity must be identified to make the necessary plans for promoting health equity in the short, medium and long term. the present study aimed at assessing access to health services from the medical ethics perspective and examining the barriers from geographical, financial and cultural aspects as well as providing solutions to overcome such barriers. barriers to health equity in the iranian health system from the medical ethics viewpoint j. med. ethics. hist. med. 2022 (dec); 15: 14. 4 methods qualitative approach this qualitative study was conducted using semistructured interviews. the multi-triangulation approach was adopted for data collection to ensure completeness of the findings and confirm them. from june 22, 2018 to march 6, 2019, data were collected through semi-structured, open-ended interviews with experts in the fields of health management and economics, medical ethics and specialized medical fields by purposive sampling until data saturation (table 1). table 1. descriptive analysis of interviewees variables statistics value gender number of females (%) 5 (16.6) number of males (%) 25 (83.3) age (years) mean (sd) 47.8 (7.3) (min./max.) (32/60) work experience (years) mean (sd) 24.4 (5.9) (min./max.) (10/35) length of interview (minutes) mean (sd) 45 (12) (min./max.) (25/84) researcher characteristics and reflexivity four out of eight members of the research team were female. the study was conducted by dn who was an md and phd candidate in medical ethics. ao, met and em, were the academic members of a national research institute, while bl, rr, and fb were the academic members of a research center affiliated to tehran university of medical sciences, tehran, iran. all the team members contributed to the study, but the interviews were performed by dn. the researchers intended to find out the barriers to equity in access to health-care services by obtaining the viewpoints of health managers, economics experts and ethicists. context and sampling strategy the purposive sampling method was used in this study. to achieve maximum variation views, participants were chosen from among general practitioners, specialists in medical sciences and public health who were experts in the fields of health management, economics and medical ethics, and specialized medical experts. at first, 15 participants were selected, and at the end of the interview, they were asked if they could introduce other experts in the field. in this way, 15 more people were identified and added to the study. ethical issues pertaining to human subjects nezamoleslami d., et al. 5 j. med. ethics. hist. med. 2022 (dec); 15: 14. the study participants were contacted so that they could be prepared for the interview sessions and answer the questions at their preferred time and location. in the introductory sessions, informed consent was obtained for participation and interview recordings, and the necessary explanations were given regarding the principles of confidentiality, non-disclosure of information, and preservation of audio records. the study protocol was approved by the research ethics committee of the school of medicine, tehran university of medical sciences, tehran, iran (ir.tums.medicine.rec.1401.110). data collection instrument the interview framework was designed based on the objectives of the study. at first, the initial interview questions were formulated. next, to ensure the validity of the content and structure of the framework, the questions were shared with the members of the research team (including the supervisors and consultants) and their opinions on the questions were obtained. finally, the framework was reviewed and agreed upon by the team members. the framework was designed so as to request the study participants’ point of view about barriers to access to health-care services by considering difficult situations, as well as cultural, financial, geographical, social and religious differences, and ask them to suggest solutions. data collection methods to collect data, in-depth, face-to-face and individual conversations were conducted. each interview lasted between 25 to 80 minutes. notes were taken during the interviews, which were audio recorded and transcribed verbatim. data collection continued until data saturation, which was reached at 30 interviews. units of the study a total of 30 interviewees participated in this study. overall, 7 general practitioners, 14 specialists in medical sciences and 9 phds in public health who were involved in health management were enrolled in the study. data processing, analysis, and confirmation the primary data analysis was done simultaneously with the interviews. after data saturation, the researchers started the second and main stage of data analysis through content analysis. these two steps are typically performed at the same time in qualitative studies. data analysis was performed through multiple readings of interview transcripts. first, important sentences and concepts were identified, and to facilitate subsequent sorting, they were written on index cards or information control barriers to health equity in the iranian health system from the medical ethics viewpoint j. med. ethics. hist. med. 2022 (dec); 15: 14. 6 files to determine main concepts and topics. after the interviews and reaching data saturation, the main topics were extracted, and then the relationships among these concepts and a comprehensive description of the study subject, main themes and codes were inserted into tables. using the common technique of inductivedeductive coding of qualitative content analysis, the analysis units were summarized. at this stage, the explicit or implicit messages of the semantic units were categorized to form the primary codes, followed by removing duplicates, summarizing, merging and aggregating. next, the team members started the review and qualitative evaluation of the codes and classes extracted from the text. the results were then analyzed using qualitative study analysis methods and related software such as maxqda 10. techniques to enhance trustworthiness all interviews were recorded and transcribed verbatim. to ensure transparency of the statements, we sent the transcripts to interviewees and asked them for clarification whenever necessary. we also verified the accuracy of all interviews by cheking them with interviewees. reporting this study is presented according to the “standards for reporting qualitative research” (srqr) guideline (12). results in this study the barriers to access to health-care services in iran were identified and categorized based on lichter's model (13) in two themes including “micro factors” and “macro factors”, five sub-themes including cultural, financial, geographical, social and religious barriers, and 44 codes (table 2). theme 1: micro factors 1.1. cultural barriers analysis of cultural barriers to health-care services yielded 11 sub-themes (table 2). as a primary concern in achieving equity in healthcare, the initial barrier in effectiveness of health interventions involves the provision and accessibility of primary, secondary and tertiary health-care services. other barriers are related to the method of providing health-care services and accessing them, as well as health literacy and its impact on service recipients’ perceptions of the nature of health effects, risk factors and management of such factors. one participant stated: nezamoleslami d., et al. 7 j. med. ethics. hist. med. 2022 (dec); 15: 14. “the differences in individuals’ understanding and acceptance indicate the importance of preventive measures, which are called screening or rehabilitation services.” [interviewee no. 1] cultural barriers to equitable access can be related to service providers’ induction of demand or false demand for commercial brands and cultural control targeting the community’s perception and acceptance through advertising, especially in the private sector. such cultural barriers affect the service recipients’ culture and lead to confusion, magnification and ultimately biases in choosing services, thereby causing inequity in access to healthcare. depending on their religious and social beliefs, service recipients may have conflicting reactions to certain types of health-care services and providers. social stigmas can act as a cultural barrier to access to health-care services; however, in public services where stigmas and margins do not exist, access to healthcare does not involve a particular challenge, and the main bottleneck can be related to individuals’ health literacy. accordingly, one participant mentioned: “having cultural outlook means that the cultural differences of service recipients should be taken into account. requesters of health-care services may or may not receive customized access in line with their culture. generally, there are no stigmas, margins and barriers [in public sector], and the level of health literacy is such that when you set up a service center, requesters come to use health services. if there are no other barriers, the cultural barrier will have less effect on access.” [interviewee no. 13] from another cultural aspect, health-care providers may be influenced by their religious, psychological and philosophical beliefs and backgrounds in providing services to a specific group of service recipients (e.g., the elderly, the physicallydisabled, the mentally-disabled, or patients with certain mental health conditions). one of the study participants stated: “except in special cases, the impact of cultural issues is often not considered. some subgroups, such as the elderly or those kept in distinct prisons and camps, may be affected by cultural issues that are typically not taken seriously.” [interviewee no. 13] senior and intermediate system managers are often physicians, and consciously or unconsciously have conflict of interests in policymaking and defining, implementing, communicating, monitoring and reviewing equity in healthcare. as a result, they are driven to assign and distribute the services based on their personal interests or perceptions. barriers to health equity in the iranian health system from the medical ethics viewpoint j. med. ethics. hist. med. 2022 (dec); 15: 14. 8 despite the availability of access to typical healthcare services, the tendency to make unusual choices about service delivery to recipients is another cultural barrier that was presented by one participant: “religious and ethnic beliefs have a profound effect on health culture and acceptance of the services provided.” [interviewee no. 25] table 2. themes, sub-themes and codes of barriers to access to health-care services in the iranian health-care system themes sub-themes codes m ic ro f ac to rs cultural barriers 1. the difference between individuals’ perception of the type, method and level of access 2. the effect of religious, psychological and philosophical perceptions, beliefs and backgrounds on health-care service providers 3. patients’ admission and treatment in the private sector 4. induction of demand or false demand 5. utilizing advertisements and commercial brands 6. health-care recipients’ religious beliefs 7. factors affecting cultural acceptance in the context of health 8. social stigma 9. contradictory reactions to healthcare 10. individuals’ religious and ethnic beliefs 11. perspectives based on lack of early benefits financial barriers 1. designating equitable insurance premiums 2. receiving larger fees from individuals with higher incomes 3. direct payments 4. lack of adequate financial support for service recipients 5. financial connection between physicians and patients 6. challenges in the coverage of health-care services 7. not allocating sufficient resources to the insurance industry 8. segmentation of insurance systems 9. discrimination on the grounds of income level 10. induced demands 11. barriers to access to outpatient services 12. incompatibility of legal and sometimes primary and supplementary insurance obligations religious barriers 1. preference of certain religions 2. the religious attitude of service providers 3. typical therapeutic interventions and modern technologies 4. not observing some religious issues m ac ro f ac to rs geographical barriers 1. geographical access under four categories 2. natural hazards, natural disasters and accidents 3. lack of access to resources 4. the effect of managerial biases 5. concentration of health-care services in provincial capitals 6. considering the needs of specific geographical areas 7. establishment of high-tech services in a geographical area 8. availability of services as a main infrastructure 9. lack of service leveling and referral system 10. physical distances and geographical dispersion 11. not differentiating among different geographical areas social barriers 1. a direct relationship between income level and social access 2. the effect of the type of occupation on social access 3. literacy level and social access to health-care services 4. tendency of low-income individuals to avoid health services 5. social level or class as a significant barrier 6. the impact of social factors such as income and literacy levels nezamoleslami d., et al. 9 j. med. ethics. hist. med. 2022 (dec); 15: 14. 1.2. financial barriers analysis of financial barriers to health-care services yielded 12 sub-themes (table 1). the financial connection between physicians and patients is an important barrier that must be eliminated through different methods. high service costs and cash payments are other financial barriers. lack of adequate insurance coverage affects health promotion and is an obstacle to accessibility of service delivery, prevention, treatment, rehabilitation and palliative care. this issue was explained by one of the study participants: “one measure is to provide public insurance with adequate coverage. to achieve proper public health coverage, we must provide all five levels of services including health promotion, prevention, treatment, rehabilitation, end-of-life care or palliative care in a fair and non-discriminatory manner without any financial pressure on individuals.” [interviewee no. 17] moreover, the difference in coverage offered by various insurance companies creates financial inequalities. one participant stated: “presently, 7 to 9 percent of individuals do not have insurance coverage. apparently, primary insurances are all similar. insurance plans offered by some companies, for instance the ministry of oil, the municipality, the ministry of energy and banks always have supplementary health insurance. but the supplementary health insurance in our workplace is not really considered an additional service....” [interviewee no. 17] “supplementary health insurance for government employees or other insurance holders may induce demands and waste the resources in many countries, and primary and essential services may be overshadowed by the supplementary health insurances.” [interviewee no. 26] depreciation due to rampant inflation and sanctions against iran has affected individuals’ financial ability to receive health-care services, which has resulted in under-utilization and less access to health-care services. the public sector tries to offset the financial burden on the lower income groups within the community by accepting a deductible. one interviewee mentioned: “in the public sector, the franchise is a justifiable amount for at least 30% of the population and can be a hindrance for a percentage of people, even in the public sector.” [interviewee no. 17] 1.3. religious barriers analysis of religious barriers to access to healthcare services yielded four sub-themes (table 1). the main concern of religion-oriented clients is related to the observance of religious issues. non barriers to health equity in the iranian health system from the medical ethics viewpoint j. med. ethics. hist. med. 2022 (dec); 15: 14. 10 acceptance of typical therapeutic interventions and modern technologies (e.g., fertility treatments) should be examined from religious perspectives. moreover, the religious attitude of health-care service providers can be an obstacle in diagnosing and treating diseases and conditions such as aids and alcohol abuse. in this regard the participants said: “religious views undermine policymaking in terms of diagnosis and treatment of diseases and conditions such as hiv and alcohol consumption.” [interviewee no. 10] “rejection of some typical treatments and use of modern technologies, especially in matters related to infertility, is a religious barrier.” [interviewee no. 25] theme 2: macro factors 2.1. geographical barriers analysis of barriers to geographical access to health-care services yielded 11 sub-themes (table 1). inequality in regional development is among the topics that have recently been raised in the regional planning culture. in iran, the rapid pace of urbanization in the past several years has created marginalization, and consequently, geographical deprivation. the latter can be examined from different perspectives: geographical differences among different provinces and the impact of these differences on their inhabitants’ health and life expectancy, differences between urban and rural areas, marginalization and distinct geographical areas. inequality in regional development was examined under the four categories of urbanization, inequality in geographical areas and provinces, border settlement, and marginalization. these issues were mentioned by one of our participants: “unfairness in geographical access is based on the following factors: first, inequity in the physical distance; second, inequity in accessing provincial centers and medical universities for marginal cities; third, the urban-rural inequality; and fourth, inequity in the areas surrounding cities.” [interviewee no. 1] in the specialized and sub-specialized leveling systems, the distribution of equipment and facilities can always be improved. one obstacle in the geographical distribution of health resources and facilities is managerial bias. natural disasters can also be examples of geographical barriers to human health. these barriers were further explained by the interviewees: “one problem is that we do not distribute our resources based on the needs and conditions of the geographical areas.” [interviewee no. 2] nezamoleslami d., et al. 11 j. med. ethics. hist. med. 2022 (dec); 15: 14. ” management biases play a major role in the geographical distribution of resources and facilities.” [interviewee no. 2] “natural barriers can be geographical or caused by epidemics. this classification that you suggested lies in the category of geography.” [interviewee no. 1] the functionality of health-care services in many situations violates equity. the best services are mainly provided by provincial centers, which may be equitable from the health-care standpoint, but unfair from the service recipients’ perspective. on this point, one participant said: “geographically, the best service is provided in the provincial capitals, and not all facilities are available for everyone, which is inequitable from the service recipient’s point of view. however, such provision may implement equity from the healthcare perspective.” [interviewee no. 6] participants also mentioned social inequity and the benefits enjoyed by individuals living in more affluent provinces: “psychological vulnerability varies in rural and urban areas, and even in diverse parts of a city, from the suburbs to affluent neighborhoods. therefore, an approach commensurate with the needs of a particular geographical area is required.” [interviewee no. 10] “coverage is very important in geographical access, and service leveling is crucial to achieving such coverage.” [interviewee no. 10] lack of essential infrastructure was another barrier to access to health-care services in deprived areas that was presented in this study. “you can provide high-tech services, such as mri. for example, you can install mri equipment in a place where the related services can be delivered.” [interviewee no. 12] despite its facilitative nature, the leveling of the referral system can limit access to health-care services from a geographical perspective. the health-care system inevitably uses the service leveling model to ensure equity in access to healthcare services. the leveling model expedites provision of maximum access, but imposes several restrictions as well, which was stated by one participant: “the leveling of the referral system, despite its advantages, forcibly imposes restrictions on access to health-care services in the geographical dimension.” [interviewee no. 24] 2.2. social barriers analysis of social barriers to access to health services yielded six sub-themes (table 1). social class, income level, occupation type, literacy and education level all affect equity. lower income barriers to health equity in the iranian health system from the medical ethics viewpoint j. med. ethics. hist. med. 2022 (dec); 15: 14. 12 levels, stressful jobs and social class pertinent to literacy level affect access to health-care services. the participants stated: “low-income populations lose access to certain health-care services due to their income level." [interviewee no. 8] “many social classes have disappeared, and incorrect information is distributed through social networks in villages and in the southern and northern parts of the city.” [interviewee no. 11] achieving equity in access to health-care services requires that the service coverage be equitable. government employees receive insurance coverage; however, the unemployed and the rural residents are usually either completely or partially deprived, which is a form of discrimination, whereas all social classes are community members and should have equal human rights. this issue was mentioned by one interviewee: “without providing fair coverage, high-income individuals receive better services. why? because low-income individuals do not have access to proper healthcare due to catastrophic costs.” [interviewee no. 12] discussion observing justice by achieving equity is the most important ethical principle in providing health-care services. understanding inequity and observing equity in providing access to health-care services are significant in policymaking and development, implementation and monitoring of health-care systems, but are subject to criticism and the opinions of health-care system experts and seniors, as well as top-, middleand field-level managers and supervisors in the ministry of health and medical education (14). in this study the barriers and challenges associated with access to equitable health-care services were found to fall under five categories: cultural or perceptual (acceptability), financial (affordability), geographical (availability), social and religious factors. among the important criteria in access to healthcare services, cultural or perceptual aspects affect the service recipients’ assumptions and context, and consequently how health-care services are provided (15). acceptability should be considered when designing, evaluating and implementing health-care interventions, and mutual understanding between service providers and recipients can help optimize the content and quality of health-care services. one of the cultural barriers identified in this study was understanding the importance of access to a particular service, which was influenced by factors such as induced demand. various studies have also shown the effect of nezamoleslami d., et al. 13 j. med. ethics. hist. med. 2022 (dec); 15: 14. induced demand and advertising in this regard (16). according to these studies, induced demand can change the way patients think about health-care services, which in many cases results in reduced access to care (17). social stigma is another cultural barrier to accessing services. a review of other studies also confirms this, and the fact that it is especially true for the disabled (18). one study showed that the conflict of interests of managers in the health system can affect the volume, dimension and provision of health services. it seems that this problem can be solved by controlling conflicts of interests by choosing the right managers and policymakers within the health system (19). understanding and accepting service recipients is an important factor affecting the type and manner of service delivery; however, this perception can be influenced by advertisement of brands that induce demand and affect the health system. for example, increasing the demand for medications can affect the functionality of the health-care system (20, 21). in line with our findings, other studies have shown that individuals’ assumptions and beliefs have a significant effect on service recipients’ cultural component, and mutual understanding between service providers and recipients can improve the quality of the services (21, 22). in agreement with this study, many studies have highlighted the significant effect of individuals’ financial capacity on access to health-care services, and hence on health level (23-25). insurance premiums can play a major role in facilitating access to health services, and evidence shows that health insurance improves the health status of insured individuals. by adjusting out-of-pocket payments and thus managing catastrophic back-up costs, insurance premiums provide service recipients with access to health-care services and reduce the burden of disease (26, 27). challenges related to insurance mechanisms such as inefficiency of insurance funds in pooling resources, setting equitable premiums, determining health-care service packages and purchasing services, in addition to affecting equitable financing, can lead to inequality in access to healthcare (25-27). geographical differences are among the major barriers to equitable access to health-care services due to the disproportionate distribution of services and disparities in the infrastructures of diverse provinces and regions (28, 29). one of the most important geographical barriers identified in this study was the different condition of informal settlements and marginal areas. studies in other countries also confirm this finding, stating that barriers to health equity in the iranian health system from the medical ethics viewpoint j. med. ethics. hist. med. 2022 (dec); 15: 14. 14 border regions and provinces often face special issues and problems that non-border provinces do not (30-34). these deprivations and challenges affect the health of residents in various ways, because in addition to the lack of access to health facilities, the human resources of the health sector, including physicians, nurses, midwives, etc. are less willing to serve in these areas and as a result, their benefit from health services is reduced (35). also, a study of access to slum health services showed that on average, more than 10% of the population lived in informal settlements, 21% of the households did not have physical access to health centers, and 34% of the pregnant women did not receive prenatal care (35). limited access to health services combined with slum dwellers' insufficient knowledge of healthcare is the most important barrier to accessing health services in urban slums (35). from a geographical perspective, having a biosocial view can help achieve a realistic outlook on the circumstances (36). the leveling of services and referral systems are significant measures through which natural hazards and distances between urban and rural areas can be managed. if it is not possible to provide services in some areas, the travel costs should be compensated; however, the localization of services can also help achieve equity in access to healthcare (37). social status is considered as a classifier, and the levels of income and health literacy affect access to health-care services. high-income groups benefit more from the available facilities as they have better access to health-care services (38). one of the most important factors that determine the social status of individuals is their level of education; numerous studies confirm the positive impact of literacy on access to health services and health outcomes (39-41). for example, pregnant mothers with higher education are more aware of the significance of healthy nutrition and child care as well as the prerequisites for being healthy (42). in this study, factors such as occupational class, income and education level have been identified as the most important social determinants of access to health services. low-income groups are often deprived of the available minimums and refer to medical centers less often; such lack of referral is not due to their high health levels, but rather because they cannot afford health-care costs and expensive services (37). religion has also been identified as an effective barrier to accessing health services. one study examined religious barriers at three levels: first, the patient level, which is related to the patient’s nezamoleslami d., et al. 15 j. med. ethics. hist. med. 2022 (dec); 15: 14. culture, including religious beliefs and practices; second, the physician level, suggesting that clinicians’ views on religion can affect how they interact with patients; third, the system level, which means it is important to understand the designation of religious institutions in health service delivery (43). despite the fact that using the clergy for some health services produces acceptable outcomes, our understanding of the structure of faith-based health service delivery is limited (44). in addition, the optimum balance between faith-based services and formal health services has often been lacking (44). provision of adequate access to health-care services for different groups of individuals is not enough as it alone cannot guarantee access for all individuals, regardless of their religious and ethnic backgrounds (45). the general approach of the health-care system in iran is to provide maximum access for all religious and ethnic groups, regardless of their tendencies and inclinations, in order to observe equity, beneficence and nonmaleficence. moreover, offering special or customized types of health-care services for various religions, beliefs, and indigenous or ethnic groups provides freedom and satisfies the principle of autonomy. from the perspective of the social determinants of health (sdh), most studies on inequality in access to health-care services have focused on the healthcare system (33, 11). however, the other factors affecting healthcare and health inequalities have not been examined, including genetics and biology, food and nutrition, environmental and social factors, and governments’ macro-social and economic policies. therefore, as future work, comprehensive studies emphasizing various factors affecting healthcare from the health equity perspective should be conducted. it seems that most of the shortcomings in this field are due to lack of valid, reliable and comprehensive databases to be used in equity-oriented health advocacy. therefore, a comprehensive, complete and longitudinal data system should be designed and implemented to conduct equity-oriented studies on healthcare in iran. to the best of our knowledge, this is the first deep and extensive study of the barriers to achieving equity in access to health-care services in the iranian health system from the medical ethics viewpoint. the findings of this study can answer some long-waiting questions of health policymakers in this regard, and the proposed solutions are based on scientific and objective evidence that have been approved by experts. however, our study had some limitations; for instance, to examine the barriers to accessing barriers to health equity in the iranian health system from the medical ethics viewpoint j. med. ethics. hist. med. 2022 (dec); 15: 14. 16 health services from an ethical standpoint, it would be better to add people's perspectives to the study, but this was not done due to time and cost constraints. conclusion according to the present study findings, the realization of the principle of equity in access to health-care services requires attention to the existing barriers, including cultural, financial, geographical, social and religious obstacles. to achieve such equity, iranian policymakers and planners should keep in mind the three main stages of access to health-care services (acceptability, affordability and availability) in line with the four principles of bioethics (justice, autonomy, beneficence and non-maleficence). therefore, in addition to adapting the health-care system structure to methods of achieving equity in access to health-care services, the challenges in policies and plans, and their implementation and monitoring need to be addressed and resolved. the desired equity in the health-care system, a mission considered by policymakers and planners, needs to be put to practice with minimum discrepancy and opposition with other aspects of healthcare. promoting equity in access to health-care services requires attention to several structural factors. moreover, policymaking and legislative aspects of this structure must be reformed and reinforced. initially, assessment and evaluation of previous actions and the current situation in the health-care system can change and correct attitudes. subsequently, the development of innovative and progressive strategies with emphasis on the principles of equity and social equality and protection of the deprived and the outcast in particular will be a primary requirement in improving morality in the health-care system. funding the study was not funded. acknowledgements we would like to thank the study participants for their frank and honest contribution. conflict of interests the authors report there are no competing interests to declare. nezamoleslami d., et al. 17 j. med. ethics. hist. med. 2022 (dec); 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5:6. http://journals.tums.ac.ir/abs/22177 © 2012 fariba borhani et al.; licensee tehran univ. med. sci. abstract keywords: ethical climate, job satisfaction, nurses. introduction iran, similar to most other countries, is faced with the issue of nursing shortage. an iranian government report indicates that although health care facilities need 220,000 nurses in order to deliver optimal nursing care, the stock of nursing workforce is only 90,026 in iran. additionally, according to the iranian nursing council data, approximately 10,000 nurses are employed in non health related sectors, and 200 nurses immigrate to other countries annually due to poor work condi tions, low salary, low benefits and unsuitable working conditions. the increasing turnover of nurses has made job satisfaction an important issue in nursing studies. job satisfaction is explained as the high turnover of nurses has become a universal issue. the manner in which nurses view their organization’s ethical climate has direct bearing on their job satisfaction. there is little empirical evidence confirming a relation ship between different sorts of ethical climate within organizations and job satisfaction in iran. the aim of this study was to determine the correlation between nurses’ perception of ethical climate and job satisfaction in the teaching hospital of kerman university of medical sciences. a descriptive analytical design was used in this study. the sample consisted of 275 nurses working in 4 hospitals affiliated with the kerman university of medical sciences. the instruments used in this study included a demo graphic questionnaire, ethical climate questionnaire (ecq), and job satisfaction scale (js). data analysis was carried out using pearson’s correlation, one-way anova, t-test and descriptive statistic through statistical package for social science (spss), version 16. across the five dimensions of ecq the highest mean score pertained to professionalism (mean = 13.45±3.68), followed by rules climate (mean = 13.41±4.01), caring climate (mean = 12.92±3.95), independence climate (mean = 11.35±3.88), and instrumental climate (mean = 8.93±2.95). the results showed a positive correlation among ethical climate type of: professionalism (p=0.001), rules (p=0.045), caring (p=0.000), independence (p=0.000) with job satisfaction, and no correlation was found between instrumental climate and job satisfaction. the result of this research indicated a positive correlation among professionalism, caring, rules, independence climate and job satisfaction. therefore managers of hospitals can promote nurses’ job satisfaction by providing ethics training programs that establish a working team and a culture that strengthens team spirit among nurses. j med ethics hist med 2012, 5:6 fariba borhani et al. page 2 of 6 (page number not for citation purposes) “the feelings a worker has about his or her job experiences related to previous experiences, current expectations, or available alternatives” (1). in other words, general job satisfaction is the amount of pleasure an employee has with the job (2), and can differ from employee to employee and is a subject widely researched in organizations (3). current researches indicate that employee job satisfaction is associated with perceptions of types of the organizational climate (4). according to littell, organizational climate is the most important factor contributing to job satisfaction in service occupations. among the existing organizational climates, ethical climate plays an important role in employees’ performance (5). one study in nigeria showed that an organization could increase its employees’ job satisfaction by developing the proper ethical climate (6). other studies demon strated that organizational ethical climate is related to higher job satisfaction and lower intention to leave the job, less burnout, suitable workloads and increased adherence to organization (7-9). since ethical climate can be influenced by culture, work environment, and religion, it can vary from one country to another. therefore, this study is trying to investigate the moral atmosphere in one specific culture. although numerous studies have examined nurses’ job satisfaction in iran, it seems there has not been adequate research on the relationship between ethical climate and job satisfaction. this investigation was conducted in order to examine the types of ethical climate existing in hospitals and their relationship to job satisfaction among nurses in teaching hospitals of kerman university of medical sciences; subsequently this study prompt ed a question: what is the relationship between nurses’ percep tion of ethical climate and job satisfaction? theory of ethical climate the concept of ethical work climate was first introduced by victor and cullen (10). one dimension of work climate is defined as “the shared perceptions of what is ethically correct and how ethical issues should be handled within an organization” (11). victor and cullen reported that organizational ethical climates grow along dimensions like ethical theories (10). major classes of ethical theory consist of egoism, benevolence, and principle. a tendency to maximize self-interest is characteristic of the egoism category of ethical theory, actual concern for the well-being of others is determined by benevolence, and allegiance to duties, rules, and laws is characteristic of the principle category of ethical theory. (11). these categories can be seen in the theory of ethical work climates proposed by victor and cullen. they suggested five distinct types of organizational ethical climate including caring, professionalism, rules, independence, and instrumental (12). caring caring climate is based on the benevolence ethical criterion (7). in this climate the most important concern is what is best for others and people look out for each other’s good and the primary goal is to offer the greatest good for the greatest number of people (12). professionalism this dimension is related to the principle ethical criterion. in this climate, the first consideration is whether a decision violates law and codes. people are expected to strictly follow legal or professional standards and the law or ethical code of profession is the major consideration here. people are ex pected to comply with legal and professional standards over and above all other considerations (7, 10). rules the rules climate is related to the principle ethical criterion (7). based on this climate, it is very important to strictly follow the organizations’ rules and procedures and therefore everyone is expected to do so. people in facilities with this climate strictly follow the organization policies (11). independence the independence dimension is associated with the principle ethical criterion. in this climate, people are expected to follow their own personal and moral believes. each person decides for himself or herself what is right or wrong; in other words, people are guided by their own personal ethics (7). instrumental this dimension is associated with egoistic crite rion and its primary goal is to provide personal benefits. in this climate people protect their own interest above anything else and are mostly out for themselves (12). method a descriptive analytical design was applied in this study. in order to estimate the minimum correlation coefficient of 0.15 with %95 confidence interval, and design effect 2, the required sample size was 300 and had to be selected by non probability quota sampling from the roster of 500 active nurses of hospitals affiliated to the kerman university of medical sciences in southeast iran. the samples of the study consisted of 275 licensed nurses who worked in medical (n=108), surgical (n= 59), critical care (n=54), and emergency (n=54) units of hospitals affiliated with kerman university j med ethics hist med 2012, 5:6 fariba borhani et al. page 3 of 6 (page number not for citation purposes) of medical sciences (the names of the hospitals were: shahid bahonar (n=75), afzalipour (n=98), shafa (n=79) and shahid beheshti (n=23). three hundred questionnaires were distributed to the 4 hospitals agreeing to participate, and 280 completed questionnaires were received. after deleting missing cases, 275 questionnaires re mained and constituted the sample for this study. inclusion criteria were: having a bachelor or master of science degree in nursing; having been working as a nurse for more than 6 months on their present ward, and being employed as a full-time nurse (40 hours or more per week). we applied three questionnaires for data collec tion including: demographic questionnaire, ethical climate questionnaire (ecq), and job satisfaction scale (js). participants’ personal characteristics were ob tained by the demographic questionnaire that contained variables such as age, gender, level of education, work unit, years of work experience, nursing role and average wage. these variables had been chosen by previous studies as well (7). the ethical climate was measured using the 26 item ethical climate questionnaire (ecq) devel oped by victor and cullen (13). this questionnaire outlined five different ethical climate dimensions: caring (items 1, 5, 7, 9, 15, 19), professionalism (items 4, 12, 17, 24), rules (items 2, 8, 10, 22), independence (items 3, 11, 13, 21) and instrumen tal (items 6, 14, 16, 18, 20, 23, 25). the items were measured on a five point likert-type scale (0 = completely false; 5 = completely true). some of the items were: “the most important concern is the good of all the people,” “people in this hospital strictly obey the hospital policies,” “in this hospital, people protect their own interests above all else,” “in this hospital, the law or ethical code of profession is the major consideration.” higher scores on an ecq dimension meant a higher level of that particular measure and vice versa. content validity of the ecq was verified by an expert panel including ten nursing faculties. although the internal consistency of the ecq had been investi gated in previous studies (α=0.86 to 0.92) (12), we examined the reliability of the translated scale by alpha coefficients for each of the domain scores. cronbach’s alpha more than 0.70 indicated internal consistency. caring (cronbach’s coefficient was 0.777); instrumental (coefficient a 0.735); inde pendence (coefficient a 0.711); professionalism and rules (coefficient a 0.798). job satisfaction was measured using a job satis faction scale (js) developed by brayfield and rothe (14). the instrument consisted of 15 items related to nurses’ job satisfaction asking partici pants to show their satisfaction levels with their job on a scale ranging from1 (strongly disagree) to 5 (strongly agree). several factors were considered to determine the nurses’ level of job satisfaction, for example satisfaction with supervisors, satisfaction with co-workers, satisfaction with pay, and satisfaction with the work itself. there was no further classification for these factors; therefore a high score indicates high job satisfaction. this was based on mean scores. both the reliability and validity of the measures were assessed. first, validity assessments were conducted using content validity index. the validity of this questionnaire was 0.80. content validity of ecq was verified by an expert panel, including ten nursing faculties .the cronbach’s alpha measured for this question naire was 0.75, which indicates the reliability of the instrument. data were analyzed using the statistical package for social science (spss), version 16. pearson’s correlation coefficient was the statistical tool selected to assess the questions of the research. the questions were examined using an independent t test and one-way anova. all analyses were conducted at the 0.05 significance level. ethical approval for the study was obtained from the ethical committee of kerman university of medical sciences. before the subjects signed a written consent, they were provided with verbal explanation of the purpose of the study. assurance of maintenance of confidentiality and anonymity was given. results the respondents’ age range was between 24-50 with mean age of 32.7 years and the most of them were female (82.2%). approximately 53% of nurses were married. most of them had a bachelor of science degree in nursing (73.2), with 1-10 years working experience (59%) and the majority of the respondents were in formal employment, and working in the medical-surgical unit. table 1 indicates means and standard deviations for dimensions of ethical climates. most of the respondents identified presence of a professional ism climate. this was followed by rules climate, caring climate, independence climate, and instru mental climate. also the mean for job satisfaction was 10.28 and standard deviation was 2.35. in addition, the study found that most of the variables were significantly correlated (table 2). the strongest correlation existed between car ing climate and job satisfaction. the second strongest correlation was between independence climate and job satisfaction. the third strongest correlation existed between rules climate and job satisfaction. in addition, the study found that the correlation between professionalism climate and job satisfac tion was moderate (means ranged between 0 and 20) finally, there was no correlation between in strumental climate and job satisfaction (table 2). j med ethics hist med 2012, 5:6 fariba borhani et al. page 4 of 6 (page number not for citation purposes) also, the results of this study demonstrated that demographic characteristics such as gender, work experience and educational experience influence nurses’ perceived ideal ethical climate (table 3). discussion the aim of this study was to determine the cor relation between ethical climate type and job satisfaction among nurses in kerman. the results revealed that a caring climate significantly and positively influences nurses’ job satisfaction. this is consistent with ulrich et al. finding that the nurses who believed their hospital had a caring climate were more satisfied with their job (15). wang and hsieh’s study concluded that there is a positive correlation between interpersonal relation ships and nurses’ job satisfaction (16). in order to increase nurses’ job satisfaction, organizations have to support establishment of an ethical climate that encourages collaboration between employees with attention to their wellbeing (17). a caring climate probably makes for greater uniformity among individuals (12). also other studies propose that employees who think the organization cares about their interests show higher levels of support, which in turn results in increased job satisfaction. (7) the results illustrate a positive correlation be tween professionalism climate and job satisfaction. this finding is in line with koh and boo’s study and also with tsai and huang and koh and boo studies that found a relationship between profes sionalism climate and job satisfaction (7, 8). in professionalism climate, there is strict adherence to the codes and regulations of the profession or management. when organizations develop such a climate, they are more likely to be congruent with internalized professional norms and values, which may lead to greater job satisfaction. in addition, other findings show that the rules climate is positively associated with employees’ job satisfaction. this type of ethical climate may be a more pleasant environment to work in, because it may promote ethical values, genuineness and trust, and therefore lead to more job satisfaction (16). tsai and huang stated that the rules climate significantly and positively influences nurses’ job satisfaction (7). application of rules and proce dures may promote ethical values such as justice, clarity, honesty and trust, and therefore influence employees’ perceptions of the support received from the organization (8). similar to previous researches, we found a significant positive correlation between independ ence climate and job satisfaction. if individuals perceive an independence climate in their organiza tion, they feel more professional autonomy. autonomy is an important factor associated with nurses’ job satisfaction (11). tsai and huang proposed that if nurses act according to their own personal and moral beliefs, their satisfaction of the job will be increased (7). finally, among the dimensions of the ethical climate, only instrumental climate had no impact on job satisfaction. this finding is consistent with joseph and deshpande’s study that found no correlation between instrumental climate and job satisfaction (18). in instrumental ethical climate, actors in the organization may interpret organizational behavior to be guided by self-interest or by the interest of the organization. several studies have found that this dimension of ethical climate was least favored by organizational members and had negative impact on job satisfaction (13). also based on this study, there was no signifi cant difference between men’s and women’s definition of a moral atmosphere. the result of another study in iran indicated that there is no relationship between gender and individual perception of ethical climate (18). according to goldman and tabak study there is no meaningful relationship between demographic characteristics such as gender, work experience, education and moral climate (10). another study conducted in british colombia showed likewise that demograph ic variables are not associated with nurses’ views about ethical climate (12). in the current study, individuals with more work experience had more tendencies to favor independ ence and instrumental climate. this can be ex plained by the fact that independence climate reflects authority and power of the individual. nurses with more work experience face more ethical problems while enjoying access to new technology, so in order to solve ethical issues and provide high quality care to patients they need to feel professional authority (12). conclusion nurses who participated in this study reported presence of various ethical climate types in their hospitals. professionalism was the most reported climate by them. the rules climate was reported in second level. a rules climate ensures that all employees strictly obey company regulations, procedures, and policies. the result of this study implies that hospital administrators can positively influence job satisfaction among nurses by nurtur ing such a climate. this study also demonstrated that nurses who believe their hospital has a caring climate are more satisfied with their job. hospitals can foster a caring environment by ensuring that the major consideration is what is best for everyone in the hospital. a caring environment also exists in organizations where people look out for each other. j med ethics hist med 2012, 5:6 fariba borhani et al. page 5 of 6 (page number not for citation purposes) training programs that emphasize utilitarian reasoning can ensure a caring environment. in this study independence climate was pre ferred by nurses. an independence climate is present in organizations where employees decide for themselves what is right or wrong. finally, the study also indicated that climates based on self-centeredness (instrumental) have no impact on job satisfaction. therefore, in order to increase job satisfaction, leaders should primarily generate and promote organizational goals and rules that are in line with law and professional codes (professionalism). developing a principle of group interest (caring climate) and social responsi bility among the nurses, and at the same time weakening self-interest (instrumental) type of ethical climates also seem to be effective strategies for higher levels of job satisfaction. in a nutshell, senior leaders of hospitals should raise understand ing of the standards of professionalism, team work, team morale, and encourage their staff to avoid instrumentalism. limitation descriptive correlation studies cannot find the effect of one variable on another. thus, in this study the relationship between types of ethical climate and job satisfaction cannot be considered as cause and effect. due to the low number of samples, the results of this study cannot be general ized. acknowledgements acknowledgement is made to nurses who partic ipated in the study. the contribution of research deputy of kerman university of medical sciences for funding this research is gratefully acknowl edged. we also wish to acknowledge the assistance of all who contributed to the completion of this study. j med ethics hist med 2012, 5:6 fariba borhani et al. page 6 of 6 (page number not for citation purposes) table 1. mean and standard deviations (sd) for ethical climate dimensions ethical climate mean sd rank professionalism 13.45 3.68 1 rules 13.41 4.01 2 caring 12.92 3.95 3 independence 11.35 3.88 4 instrumental 8.93 2.95 5 table 2. correlation between ethical climate type and job satisfaction ethical climate type job satisfaction pearson correlation p value caring 0.255 0.000** independence 0.234 0.000** rules 0.214 0.001** professionalism 0.125 0.045* instrumental 0.088 0.160 **correlation is significant at the 0.01level, *correlation is significant at the 0.05level table 3. correlation between ethical climate type and sample characteristics demographic data caring instrumental professionalism rules independence mean p mean p mean p mean p mean p gender female 13.06 0.15 11.34 0.78 13.06 0.23 13.43 0.56 8.83 0.15 male 11.85 11.17 12.70 12.95 9.98 work experience <1yr 13.82 0.34 12.08 0.054 13.97 0.63 13.17 0.19 8.45 0.00 1-3yr 12.23 12.26 13.31 13.71 8.97 6-9yr 12.70 10.57 13.59 13.79 9.21 >10yr 12.32 11.11 12.33 13.74 9.25 educational experience yes 13.59 0.09 11.56 0.3 13.93 0.32 13.17 0.002 8.71 0.77 no 12.56 11.19 14.06 14.27 8.78 one-way anova and t-test j med ethics hist med 2012, 5:6 fariba borhani et al. page 6 of 6 (page number not for citation purposes) references 1. zarea k, negarandeh r, dehghan-nayerii n, rezaei-adaryani m. nursing staff shortages and job satisfaction in iran: issues and challenges. nurs health sci 2009; 11(3): 326–31. 2. dendaas n. the scholarship related to nursing work environments: where do we go from here. ans adv nurs sc 2004; 27(1): 12-20. 3. farsi z, dehghan-nayerii n, negarandeh r, broomand s. nursing profession in iran: an overview of opportunities and challenges. jon j nurs sci 2010; 7(1): 9-18. 4. urden ld. the impact organizational climate on nurse job satisfaction management implication. nurs leadersh forum 1999; 4: 44-8. 5. jordan n, leon sc, epsten ra, durkin e, helgerson j, lakin-starr bl. effect of 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impact of ethical climate on job satisfaction and commitment in nigeria: implications for management development. j manag dev 2008; 27: 935-50. 12. filipova a. perceived organizational support and ethical work climates as predictors of turnover intention of licensed nurses in skilled nursing facilities [dissertation]. michigan. western michigan university; united states; 2007. 13. victor b, cullen jb. the organizational bases of ethical work climates. adm sci q 1988; 33(1): 101–25. 14brayfield ah, rothe hf. an index of job satisfaction. j appl psychol 1952; 35(5): 307-11. 15. ulrich c, o´donnell p, taylor c, farrar a, danis m, grady c. ethical climate, ethics stress, and the job satisfaction of nurses and social workers in the united states. soc sci med 2007; 65: 1708-19. 16. wang yd, hsieh hh. toward a better understanding of the link between ethical climate and job satisfaction: a multilevel analysis. j bus ethics 2012; 105: 535–45. 17. dickson mw, smith db, grojean mw, ehrhart m. an organizational climate with regard to ethics: the outcome of leader values and the practices reflecting them. leadership q 2001; 12: 197–218. 18. nakhaee n, mobasher m, garoosi s. assessment of ethical climate of kerman teaching hospitals. j med ethics hist med 2008; 1:6. journal of medical ethics and history of medicine observance of patient’s rights: a survey on the views of patients, nurses, and physicians alireza parsapoor¹, kazem mohammad², hussein malek afzali², farshid ala’eddini³, bagher larijani4* 1.phd student, medical ethics and history of medicine research center, and department of medical ethics, faculty of medicine, tehran university of medical sciences, tehran, iran. 2.professor, faculty of public health, tehran university of medical sciences, tehran, iran. 3.epidemiologist, tehran university of medical sciences tehran, iran. 4.professor, endocrinology and metabolism research center, tehran university of medical sciences and medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. *corresponding author: bagher larijani address: no.21, 16 azar ave., keshavarz blvd., tehran, iran. tel: (+98) 21 66 41 96 61 email: mehr@tums.ac.ir received: 20 may 2011 accepted: 31 jul 2012 published: 02 aug 2012 j med ethics hist med. 2012; 5:5. http://journals.tums.ac.ir/abs/21490 © 2012 alireza parsapoor et al.; licensee tehran univ. med. sci. abstract assessment of patients’ views about the observance of patients’ rights in the health system is of great importance for evaluation of such systems. comparing views of patients (recipients of health services) and physicians and nurses (health care providers) regarding the observance of various aspects of patients’ rights at three hospitals representing three models of medical service provision (teaching, private, and public) is the main objective of this study. this was a cross-sectional descriptive and analytical study, and the information needed was gathered through questionnaires. they were filled out by an interviewer for patients, but self-administered by physicians and nurses. the field of study consisted of three hospitals including a general teaching hospital, a private hospital, and a public hospital, all located in tehran. the questionnaires contained some general questions regarding demographic information and 21 questions concerning the necessity of observing patient's rights. the questionnaires were initially filled out by a total of 143 patients, and then consigned to 143 nurses (response rate = 61.3%) and 82 physicians (response rate = 27.5%) to be completed. the rate of observance of each right was measured on a likert scale ranging from zero (non-observance) to 10 (full observance). considering abnormal distribution of the information, it was analyzed with non-parametrical tests using spss 11.5 software package. the results of this study showed that the study groups had different views about how well different aspects of patients’ rights were observed. the highest level of disagreement was related to the right of choosing and deciding by the patients, which was not satisfactory in the teaching hospital. according to the results, it seems that healthcare providers, especially physicians, should be better informed of patients’ right of access to information and right of choosing and deciding. based on the observed disagreement between the views of the patients and those of the physicians in the present study, it can be asserted that the patients thought that the level of observance of these rights was lower in comparison with what the physicians thought. keywords: patient’s rights, medical ethics, views, iran. j med ethics hist med 2012, 5:5 alireza parsapoor et al. page 2 of 8 (page number not for citation purposes) introduction surveying the rate of observance of patients’ rights in medical services provides a suitable guide for health system management to ensure an appropriate relationship between service providers and service recipients. literature contains numerous studies concerning the degree of observance of various aspects of patients’ rights from the viewpoint of different stakeholders and effects of demographic, environ mental and cultural factors on their awareness (1 6). considering various determinants of stakehold ers' views in regard to observing different aspects of patients’ rights, the main objective of the present study was to compare views of major stakeholders including patients, physicians and nurses at hospitals representing three models of medical service provision, including teaching, private, and public hospitals. the aspects presented in this study regarding the opinions of various groups had not been observed in previous studies. methods this was a cross-sectional descriptive and ana lytical study, and the information was gathered through questionnaires which were filled out by an interviewer for patients, and self administered by physicians and nurses. the questionnaire content was modified after expert consultation was performed to ensure validity. to increase reliabil ity, interviews were performed by the same interviewer at all three hospitals. using the test retest, the mean differences in responses were studied at two stages, which confirmed the reliabil ity of the questionnaire. the research venue was three hospitals includ ing a general teaching hospital, a private hospital, and a public hospital, all located in tehran. the questionnaire comprised of a series of general questions with regard to demographic information and 21 questions concerning the observance of patients’ rights. patients were selected from those hospitalized in the surgery and internal medicine wards of the mentioned hospitals. the exclusion criteria for patients in the study were: 1) patients who had been hospitalized for less than 24 hours; 2) patients suffering from moderate and severe cognitive problems; and 3) patients with moderate to severe pain. interviews were conducted with patients after being informed of the objective of the study. the only inclusion criterion for physicians and nurses was clinical activity in any of the above-mentioned hospitals. before the interview, it was emphasized that interviewees should restrict their judgment to the respective hospital only. questionnaires were distributed, completed, and collected over a three month period. the information related to 143 patients was gathered through interview, and was then sent to the other two groups. respondents were 143 nurses (response rate = 61.3%) and 82 physicians (response rate = 27.5%). the rate of observance of each right was meas ured on a likert scale ranging from zero (non observance) to 10 (full observance). to describe results, the mean, median, and standard deviation (sd) were used for quantitative variables, while the number and percentages were determined to describe qualitative variables. non-parametrical tests were used for comparing the three groups in terms of their views about the rate of observance of each right and other inde pendent variables. as the variable of observing rights had been measured on a scale from zero (non-observance) to 10 (full observance) and had no normal distribution, non-parametrical tests were applied. in cases where independent variables consisted of two groups (such as gender), the mann-whitney test was used, while the kruskal-wallis test was used in cases where independent variables had more than two groups (such as hospital). in assessing responses of the three groups at the three selected hospitals, cases with statistical signifi cance were considered clinically significant provided that the difference between mean scores was more than 2. ethical considerations this study was approved by the research ethics committee of tehran university of medical sciences. information was gathered after obtaining informed consents from the participants. to respect privacy and confidentiality, personal information shall not be disclosed to others without written authorization from participant(s) in the study. also, considering the request of the officials in charge of the hospitals cooperating in this study, no mention will be made of the names of the hospitals. results this study, as a field one, provides information concerning different views of three groups includ ing patients, physicians and nurses concerning how patients' rights are observed, and views of each group at three types of healthcare centers. in the patients’ group, in terms of gender, men outnumbered women at the private hospital (35 out of 50 persons), while there were more participating women at the teaching hospital (23 out of 41) and the public hospital (28 out of 50). the age range of j med ethics hist med 2012, 5:5 alireza parsapoor et al. page 3 of 8 (page number not for citation purposes) patients was between 14 and 80 years (46.57±17.36 years and a median of 46.00 for the whole pa tients). the mean age was 51.36 and 41.29 years for men and women, respectively; the difference was statistically significant (p < 0.001). one hundred and twenty patients were married and 21 were single. marital status in two groups of men and women had similar distributions, and there were no statistically significant differences among hospitals in this regard. the number of illiterate patients was significantly higher in the teaching government-run hospital, and patients holding a high school diploma or bachelor's degrees consti tuted a greater proportion in the private hospital (p < 0.001). the minimum age of physicians was 28 years and the maximum stood at 68 years (45.33±10.017). distribution of work experience showed no statistically significant difference between physicians working at the three hospitals. no statistically significant inter-gender difference was noted in this regard. in the nurses group, the minimum and maximum age was 23 and 58 years, respectively (33.22±7.4). the duration of work experience ranged from 4 months to 384 months (115.26). there were no significant differences among the nurses of the three hospitals in terms of the distribution of gender, age, and work experience. the results of this study demonstrated that the study groups had different views about how well various aspects of patients’ rights were observed. the highest level of disagreement between recipients and providers concerned patients’ right to choosing and deciding, and the situation was not satisfactory in the teaching hospital. results suggest that healthcare providers, especially physicians, should be better informed of patients’ right to access information and right to participate in decision making. to present results, questions can be grouped into four categories: first category: the results shown in table 1 mainly concern respecting the patient and his/her privacy and non-discriminatory treatment. patients have agreed unanimously, at each of the three hospitals, on full observance of this right (mean score > 9) while physicians and nurses’ views regarding non-discriminatory treatment shows a significantly lower level of observance compared with the views of patients. in regards to refraining from disrespectful behavior, although statistically significant differences were observed, they were not of any clinical importance. on the other hand, according to the physicians and nurses’ responses, adherence to non-discrimination was significantly lower at the teaching hospital in comparison with the other two hospitals. the second category: in table 2, the results on observing patients' right to access information regarding their disease are shown. in this study, all three groups, regardless of study venue, agreed that the level of observing patients rights was low to average. in most cases, the level was least at the teaching hospital. in all three hospitals, physicians reported more observance of this right compared to what the patients did; the difference was significant. as far as nurses were concerned, in most cases scores were in-between those of the other two groups. all three groups at each of the three hospitals admitted to an intermediate level of observance of patients’ right to access their medical records; nurses, especially in the teaching and public hospitals, gave lower scores than the other two groups. the third category: table 3 shows the results of the study on observing patients right to choose and decide freely. regarding the observance of the patients’ right to choose their healthcare provider (the main physician), the private hospital showed considera bly higher scores. observance of this right, in the view of all three groups, showed lower rates at the teaching hospital, but a high rate was seen in the private hospital. with regard to seeking the participation of the competent patients for diagnosis and treatment, scores given by patients were lower than that of the other two groups, especially at the teaching hospital. in the patients' group, the observance rate was significantly lower at the teaching hospital com pared to the other two hospitals. it should be noted that the disparity between the other two hospitals was not considerably high. it seems that the possibility of consulting with other physicians was better observed in the private hospital. the fourth category: the results shown in table 4 concern the existence of a complaint system and the necessity of revealing medical errors. the activity of the complaint-examining system at the private hospital was more tangible in the view of physicians and nurses. however, patients’ views did not demonstrate any difference. discussion a review of the opinions of the three groups (patients, physicians, and nurses) in the three types of healthcare service providing centers revealed different views about the observance of patients’ rights from different standpoints. the analysis of the results of the study is presented in four catego ries: the first category (receiving respectful and non-discriminatory services): j med ethics hist med 2012, 5:5 alireza parsapoor et al. page 4 of 8 (page number not for citation purposes) the results of our study demonstrated that there was general consensus among patients in the three hospitals regarding complete observance of these rights (mean score >9). however, literature review showed different results. in the study by kuzu et al. on 166 patients in internal medicine and surgery wards of three general hospitals in denizly, turkey, it was shown that 91% believed that there were no fair accesses to healthcare services; and, 86.1% said that their privacy was respected (4). it needs to be mentioned that the difference in terms of fair access to healthcare services may be due to different perceptions of the interviewees regarding the concept of fairness and justice the results shown in table 1, which indicate differences in the reported rate of observance by the recipients and providers of healthcare, may be due to higher sensitivity of providers to this subject. of course, there may be differences in the healthcare providers and recipients' perceptions of these rights and their applicability. on the other hand, non-observance of these rights, despite its relatively low rate, may leave a persisting effect on the minds of the healthcare providers. another reason for this difference may be higher sensitivity and sufficient attention of the healthcare providers to this subject. further research in this regard is recommended. the considerable difference in the rate of ob servance of these rights in the three hospitals concerned necessitates surveying the factors by the managerial authorities of teaching hospitals. the second category (the right of patient to access information): the low rate of observance of this right indi cates the necessity of paying more attention to management of information transfer between physicians and patients. other studies, similarly, revealed a low rate of observance of this right. in a report by the british patients association in 2005 which was published after a survey on1000 persons over 18 and 333 patients with chronic diseases in order to assess the situation of patients’ rights in the british health system, it was shown that nearly 90% of the participants believed that enough information about their treatment, risks, and benefits was given to them as they expected; however, the observance of the right to see their medical record was mentioned only by 75% of the participants. regarding the possibility of receiving information about prescription and other therapeu tic options, 90% had a positive view. about the possibility of receiving a copy of their medical records from their physician, 60% had a positive view, 10% saw it as limited by conditions and 7% had a negative view (7). in a questionnaire survey, by chan and goh in 2000 in singapore, on the views and performances of 475 physicians concerning physician-patient relations, 85% of the physicians paid attention to patients’ questions about their illness, and in 24% of cases, they did not explain the disease to the patient, while 32% of the physicians never con cealed the patients’ conditions from them. in explaining the probable risks and adverse effects of the prescribed medication, 92% mentioned only common adverse effects, while 29% mentioned all of them, and 10% mentioned only those important to the patient. (3) in the study by basagaoglu and sari on the views of patients regarding ethical considerations, with emphasis on informed consent during clinical training, it was revealed that 29% of patients stated they had signed an informed consent form after being admitted to the surgical ward, while 56% said that they had not received such a form to sign, and 15% could not recall whether they had signed one or not. the truth, however, was that most of the forms were signed by the patients’ relatives, and they were not aware of it. interestingly, only one of the patients was not conscious when admitted. on the other hand, only 19% of the patients had read the form before signing it. in reply to the question about who had given them the form, only 23% identified the person concerned (surgeon, nurse, receptionist) (8). in the study by kuzu et al., 40% of the patients said that they did not ask the personnel for service. the reasons given for this included: fear of the personnel getting angry because of asking, worry ing about the negative effects of such a protest on the quality of care, poverty, shyness, being an immigrant, psychological problems, illiteracy, not being aware of relevant laws and regulations, the personnel being too busy, and poor relationships between patients and care-providers. (4) in another study in turkey, it was demonstrated that only 36% of patients knew about the rules of the hospital (9). in our study, the higher rate of observance stated by physicians doubles the concern because it is indicative of less importance given by physicians to patients’ need for information. preparing patient information packages about the hospital regulations and the process of service provision, as well as giving necessary training to healthcare providers about communicating skills, and finally, practical measures such as specific informed consent forms may help in solving some of these problems. this necessity is more visible at teaching hospitals. the third category (patients’ right to choose and decide): given the nature of the teaching hospital, it seems that the low rate of observance of the patients’ right to choose their healthcare providers is not surprising. this situation is negligible only in cases where the patient has been informed of the situation on admission. one could argue that even at a teaching hospital, patients should have the right j med ethics hist med 2012, 5:5 alireza parsapoor et al. page 5 of 8 (page number not for citation purposes) to choose their healthcare providers from each level of hierarchy. this aspect was not included in this survey. in a report by the british patients associa tion, nearly 80% of patients had the right to choose their general practitioner (gp), but only 45% of them had the same right regarding their specialist physician. in cases where the patient was in doubt about the diagnosis made by the gp, only 40% of them believed that seeking another opinion in this regard was easy, while 27% saw it difficult and nearly 30% did not know (7). concerning the patients’ right to participate in decision making for diagnostic and therapeutic procedures, as in the second category, the rate of observance of this right was low, particularly in the teaching hospital. this calls for the same measures in this case, too. in other studies, although the nurses often hold a positive views in this regard (10), observational studies have shown that, in practice, this right is not observed. on the other hand, although the patients are interested in receiving more information about alternative treatments, they are reluctant to participate in subsequent decision-makings. evidence indicates that more interventions by healthcare professionals are needed to encourage patients to participate in decision making (11). the fourth category (patients’ right with respect to investigation of their complaints and revealing medical errors): the functionality of the complaint system in the private hospital was rated higher, according to the physicians and nurses. this indicates the necessity of informing patients more appropriately regarding this system. in light of the importance of such issues, public hospitals need to implement effective measures so that they can achieve patient cen teredness by improving patient satisfaction. limitations of the study: the relatively low response rate of the physi cians was one of the limitations of this study. however, we tried to minimize this limitation by making arrangements with hospitals directors to endorse the study and follow up the correspond ence with the physicians concerning filling out the questionnaires. to mention the study’s methodological and practical limitations, it was not possible to carry out examine some aspects of patient’s rights. for example, since no research activity was carried out in the private hospital, it was not practical to ask about adhering to research ethics. inquiring about medical error was also not possible either, because of the possibility of worrying patients. that is why some articles of the charter were not included in the questionnaire. generalization of these results to various models of service provision (private, teaching, and public) requires studying on larger samples from several hospitals in each group. conclusion based on the results, it seems necessary for healthcare providers to be better informed of patients’ rights to access information and to choose and decide. this can be asserted as our results demonstrated that the extent of observance of patients’ rights was evaluated lower by the patients compared with the views of health care profession als. this indicates that further investigation is needed to establish and develop proper guidelines regarding this issue. acknowledgement while appreciating the honest cooperation of directors, managers and nursing staff of the three mentioned hospitals and also all of the participants in the present research, we also seize the opportuni ty to express our sincere thanks to dr. fariba asghari and dr. pooneh salari for their critical review, ms. heidarian for conducting the inter views, ms. karimi for carrying out typing affairs and pagination, and ms. aqaii for following up the executive affairs of the study. j med ethics hist med 2012, 5:5 alireza parsapoor et al. page 6 of 8 (page number not for citation purposes) table 1: results on the observance of the right of patients to receive respectful and non-discriminatory service inquired aspect stakeholder type of hospital p value total teaching private public non-discriminatory health service patients 9.95±1.64 9.94±0.41 10±00 0.03* 9.86±0.93 physicians 6.86±2.55 8.42±1.66 8.89±1.61 0.01* 8.03±2.07 nurses 6.42±2.67 8.74±1.80 8.26±2.22 0.00* 8.14±2.28 p value 0.00* 0.00* 0.00* 0.00* respect for religious, national, ethnic, & cultural believes patients 10±00 9.81±1.38 9.96±0.28 0.67 9.92±85.0 physicians 7.62±2.50 9.03±1.15 9.38±0.91 0.08 8.95±183 nurses 7.72±1.83 9.45±1.11 9.61±0.71 0.00* 9.16±1.36 p value 0.00* 0.02* 0.00* --0.00* observing patients’ privacy patients 9.20±2.42 9.71±1.46 9.59±1.23 0.44 9.351±1.72 physicians 6.23±3.30 8.82±1.50 7.75±2.76 0.02* 7.78±2.68 nurses 7.15±2.69 8.75±1.66 8.92±1.77 0.00* 8.84±2.03 p value 0.00* 0.00* 0.00* -0.00* * shows a significant p value. all data are demonstrated as mean (± sd). j med ethics hist med 2012, 5:5 alireza parsapoor et al. page 7 of 8 (page number not for citation purposes) table 2. results on the observance of the right of patients to access their own information inquired aspect stakeholder type of hospital p value total teaching private public informing patients of the regulations on access to clinical and general services patients 2.69±3.67 5.00±4.51 3.10±3.97 0.01* 3.69±4.14 physicians 4.85±2.81 8.30±1.66 6.67±2.69 0.00* 7.15±2.61 nurses 5.16±2.92 7.11±2.11 4.71±2.94 0.00* 5.98±2.78 p value 0.00* 0.00* 0.00* -0.00* providing sufficient information about the disease and its prognosis patients 5.15±4.77 7.77±3.88 7.34±3.66 0.01* 6.87±4.21 physicians 5.95±2.66 8.29±1.59 8.89±1.26 0.00* 7.93±2.21 nurses 5.92±2.69 7.86±1.99 7.74±2.37 0.00* 7.45±2.36 p value 0.62 0.56 0.36 0.14 responding to patients questions about their disease patients 8.05±3.46 8.98±2.42 9.34±1.69 0.20 8.85±2.95 physicians 6.41±2.72 8.60±1.61 8.68±1.22 0.00* 7.93±2.21 nurses 6.08±2.49 8.31±1.64 7.97±1.78 0.00* 7.76±2.04 p value 0.02* 0.17 0.00* -0.00* informing patients of the professional duties of the health care provision team patients 2.37±4.10 6.21±4.74 2.82±4.07 0.00* 3.92±4.64 physicians 5.55±3.00 8.21±1.74 6.10±2.51 0.00* 7.15±2.57 nurses 6.30±2.77 8.76±1.57 7.72±2.44 0.00* 7.95±2.32 p value 0.00* 0.00* 0.00* 0.00* introducing health care provision team patients 1.71±3.05 4.04±4.46 2.06±3.34 0.01* 2.72±3.95 physicians 5.68±2.73 7.98±2.08 6.22±3.45 0.00* 7.04±2.68 nurses 6.00±2.91 8.23±2.30 6.05±3.08 0.00* 7.17±2.78 p value 0.00* 0.00* 0.04* -0.00* providing sufficient patients 4.15±4.53 7.2±4.24 5.61±4.48 0.00* 5.70±4.53 information about treatment options physicians 6.36±2.23 8.53±1.42 7.89±2.93 0.00* 7.81±2.11 nurses 5.96±2.66 9.44±10.28 8.13±2.05 0.00* 8.32±7.46 p value 0.03* 0.18 0.00* -0.00* explaining common risks and side effects patients 2.02±3.92 5.23±4.70 2.50±3.98 0.00* 3.36±4.45 physicians 6.36±2.36 8.49±1.62 7.80±1.93 0.00* 7.77±2.10 nurses 6.15±2.11 7.48±2.27 7.64±2.43 0.01* 7.26±2.34 p value 0.00* 0.00* 0.00* -0.00* providing information about less common side effects in an understandable language patients 1.10±2.99 2.29±4.07 1.12±2.91 0.17 1.54±3.43 physicians 5.32±0.04 7.06±2.13 6.88±3.04 0.08 6.344±2.67 nurses 4.31±2.83 6.38±2.72 6.22±3.35 0.01* 5.90±3.03 p value 0.00* 0.00* 0.00* -0.00* providing patient access to their medical records and their contents patients 8.79±3.20 7.58±4.23 7.30±4.50 0.23 7.88±4.04 physicians 6.19±3.02 7.79±2.26 6.22±3.30 0.15 7.03±2.76 nurses 5.342±2.41 6.74±3.04 6.85±2.65 0.04* 6.51±2.85 p value 0.00* 0.24 0.70 -0.00* necessity of informing patients about their rights upon admission patients ----- physicians 4.67±2.68 7.32±2.63 6.67±2.00 0.00* 6.36±2.81 nurses 4.62±2.65 7.62±2.35 5.95±3.12 0.00* 6.49±2.91 p value 0.94 0.55 0.51 -0.77 * shows a significant p value. all data are demonstrated as mean (± sd). j med ethics hist med 2012, 5:5 alireza parsapoor et al. page 8 of 8 (page number not for citation purposes) table 3. results concerning the observance of patients’ right for choosing and deciding freely inquired aspect stakeholder type of hospital p value total teaching private public right to choose care-provider (original physician) by patients patients 4.91±4.89 8.51±3.36 4.58±5.03 0.00* 6.15±4.77 physicians 3.79±2.65 8.33±1.65 6.33±3.00 0.00* 6.90±2.88 nurses 3.92±3.22 7.64±2.77 5.54±2.91 0.00* 6.27±3.24 p value 0.51 0.19 0.37 -0.38 seeking the opinion and involving the competent patient in diagnostic and treatment measures patients 2.13±3.84 5.96±4.85 5.20±4.37 0.00* 4.63±4.67 physicians 6.00±2.30 7.94±1.72 7.50±2.00 0.00* 7.22±2.14 nurses 5.35±2.72 7.44±2.21 7.19±2.62 0.00* 6.94±2.56 p value 0.00* 0.01* 0.02* 0.00* possibility of leaving the hospital with personal consent against the advice of the treatment team patients ------ physicians 8.36±1.96 9.75±3.86 8.55±2.20 0.00* 9.81±1.60 nurses 7.40±2.36 9.18±1.34 8.82±2.43 0.00* 8.71±2.05 p value 0.13 1.01 0.73 -0.08 right to consult physicians other than the treating physician by the patient patients ----- physicians 5.00±2.58 8.25±1.62 7.75±2.49 0.00* 7.30±2.58 nurses 5.52±2.75 7.97±2.14 6.24±3.05 0.00* 6.91±2.76 p value 0.50 0.51 0.20 -0.57 * shows a significant p value. all data are demonstrated as mean (± sd). table 4. results on the observance of the patient’s right to follow up their complaints and revealing medical errors inquired aspect stakeholder type of hospital p value total teaching private public active complaint system in the hospital patients 6.67±5.00 5.87±4.94 6.60±4.62 0.88 6.22±4.75 physicians 6.41±2.77 9.11±1.41 7.56±1.66 0.00* 8.13±2.26 nurses 5.80±2.53 8.93±1.51 6.81±2.68 0.00* 7.66±2.50 p value 0.70 0.00* 0.75 -0.00* revealing compensated treatment error by the responsible person physicians 4.76±3.13 5.48±2.47 7.00±3.60 0.13 5.42±2.97 nurses 4.08±2.95 6.67±2.76 5.16±3.58 0.00* 5.71±3.21 p value 0.51 0.05* 0.017 -0.56 revealing compensable (uncompensated) treatment error by the responsible person physicians 5.62±3.15 6.45±2.47 8.50±2.27 0.01* 6.50±2.83 nurses 3.78±2.75 6.77±2.97 5.78±2.98 0.01* 5.86±3.31 p value 0.03* 0.61 0.01* -0.18 revealing no compensable treatment error by the responsible person physicians 4.75±3.68 5.82±3.23 8.00±2.05 0.04* 5.83±3.38 nurses 3.00±2.37 6.26±3.15 4.56±3.35 0.00* 5.06±3.13 p value 0.05* 0.57 0.00* -0.16 * shows a significant p value. all data are demonstrated as mean (± sd). j med ethics hist med 2012, 5:5 alireza parsapoor et al. page 9 of 8 (page number not for citation purposes) references 1. özdemir mh, ergönen at, sönmez e, can io, salacin s. the approach taken by the physicians working at educational hospitals in i̇zmir towards patient rights. patient educ couns 2006; 61 (1): 87-91. 2. lledo r, salas l, gonzalez, et al. the rights of the hospital patient: the knowledge and perception of their fulfillment on the part of the professional. the group in catalonia of the spanish society of care for the health services user. rev clin esp 1998; 198(11): 703-5. 3. chan d, goh lg. the doctor patient relationship: a survey of attitudes and practices of doctors in singapore. bioethics 2000; 14(1): 58-76. 4. kuzu n, ergin a, zencir m. patients' awareness of their rights in developing countries. public health 2006; 120(4): 290 6. 5. merakou m, dalla-vorgia p, garanis-papadatos t, kourea-kremastinou j. satisfying patients' rights: a hospital patient survey. nurs ethics 2001; 8(6): 499-509. 6. mossaddeq rad am, esna ashari p. surveying on awareness of physicians and patients of patients’ rights and their observance in shahid beheshti hospital of isfahan. iranian j educ med sci 2004; 11: 45-53. 7. anonymous. the patients association, survey of the uk public patients' rights main report, december 2005, http://www.patients-association.org.uk /dbimgs/file/the%20public%20perception%20of%20patients%e2%80%99%20rights%20within%20the%20uk.pdf (accessed in 2010). 8. basagaoglu i, sari n. patient attitude about ethical issues confronted during the clinical education of medical students, with emphasis on informed consent. www.ishim.net/ishimj/jishim4_7_8/vol4no7/ibrahim_sari.doc (accessed in 2009). 9. yazici s, eti aslan f, sbuncu h. thoughts about patient admission procedures in inpatient health care institutions. proceedings of the 2nd national nursing congress; 1992; izmir, turkey; ege university publishing; 1992, p. 882-7. 10. keatinge d, bellchambers, h, bujack e, cholowski k, conway j, neal p. communication: principal barrier to nurse consumer partnerships. int j nurs pract 2002; 8(1): 16-22. 11. beisecker ae, beisecker td. patient information-seeking behaviors when communicating with doctors. med care 1990; 28(1): 19-28. microsoft word 16 journal of medical ethics and history of medicine innovations and discoveries of jorjani in medicine saeed changizi ashtiyani 1* , ali zarei2, mohammad elahipour 3 1.department of physiology, arak university of medical sciences, arak, iran. 2.department of biology, payame noor university of abadeh, abadeh, iran. 3.akhtar hospital, shahid beheshti university of medical sciences, tehran, iran. *corresponding author: saeed changizi ashtiyani address: department of physiology, arak university of medical sciences, arak, iran. postal box: 3848176941 e-mail: ashtiyani@sums.ac.ir received: 04 jul 2009 accepted: 15 aug 2009 published: 20 aug 2009 j med ethics hist med. 2009; 2:16. © 2009 saeed changizi ashtiyani, ali zarei and mohammad elahipour; licensee tehran univ. med. sci. abstract keywords: thyrotoxicosis, surgery, zakhire kharazmshahi, jorjani. introduction seyed esmaeel jorjani, one of the most out standing iranian physicians in the history of islamic medicine, was born in gorgan in 434, a.h (1042, a.d.) and died in marve in 531, a.h (1136, a.d) during kharazmshahi dynasty. he was claimed to belong to the second generation of physicians like avicenna, having an important role in the preserva tion and transmission of greco-roman medical heritage (1). zakhireye kharazmshahi is one of the most complete, significant and comprehensive persian medical texts that truly must be recognized as an theologian seyed esmaeel jorjani (1041‐1136), titled zeinoddin and known as jorjani, is one of the most famous iranian physicians. almost one thousand years ago, he did valuable compilations in the history of medicine and many of his medical views are, to a great extent, in line with the recent views. his most famous work is zakhire kharazmsha‐ hi. his innovations and practices in various branches of medical sciences are quite new and unique. jorjani was very efficient in surgery and, in his main book zakhire, he introduced different methods and instruments of surgery in a way that it shows his dexterity and depth of experience. he explained methods of stopping severe hemorrhage by casting them with plaster, treating the obstruction of air canals by tracheotomy, curing the difficulty in urination by catheterization, the exact method of removing apophasis and stitching the spot after cutting and paring in polyp surgery in full details. jorjani also wrote about cancer, its difficulty of treatment, the necessity to avoid inciting it, and the impact of early treatment. in zakhire, he pointed to the relationship between exophthalmos and goiter, and the relationship between outgrowth of thyroid and increase in heart rate; this way, he came to understand about the pathologic toxic reactions of thyrotoxicosis. j med ethics hist med 2009, 2:16 saeed changizi ashtiyani, et al page 2 of 5 (page number not for citation purposes) integrated medical encyclopedia which covers all aspects of medical subjects and branches, including general medicine, anatomy and physiology, etiology of disease, description of health, hygiene, nutrition, health care duties of everyday life, medical procedures such as blood sampling etc, disease symptoms and their treatments, surgical procedures, pharmacology and pharmaceutics. he wrote this book in nine volumes plus a chapter exclusively about herbs; so, altogether, they amounted to ten volumes (1, 2). with almost 700,000 words, zakhireh has made an astonishing summary of the world of medicine. in his book, jorjani has combined repeated experimental methods of rhazes, scattered ways in al-havi, avicenna's classic and logical (and sometimes difficult) descriptions and his own logical, theoreti cal, and applied approach to medicine to create a relatively easy and clear medical source. in other words, he standardized the medical terms in the zakhireh kharazmshahi. jorjani's works are complete examples of medicine (3). edward brown has talked about zakhireh and its significance in arabian medicine and in persian medical history (4). the french ’ s crussol, in his medical thesis discusses jorjani , s views on physiol ogy and ophthalmology given in the zakhireh and al-aghraz. in this thesis, crussol writes: ″jorjani collected and combined the main and specialized points in the medical books of his predecessors, added his own experiences and made a complete medical book″ (2). jorjani used avicenna ’ s canon and referred to it as one of the most important sources, but zakhireh is not merely a translation of canon, rather, it is a complementary to canon and other medical works of the time. jorjani criticized certain details offered by galen and avicenna (5). in the fifth book, jorjani elegantly described three body fluid compartments: intravascular, interstitial and a third compartment within the material of the tissues (intracorporeal). also he was the first to mention the association between goiter and exophthalmia (1). he wrote several works in which he dealt with medicine and natural sciences. jorjani believes on the science of medicine: “medicine is an art that a physician relies on to understand the status of health and disease in man, to keep the healthy condition and restore the health of the sick” (1). according to jorjani, each organ has a special balance and any imbalance in organs would cause disease (2). discoveries of jorjani as we know the diaphragm is a dome-shaped musculofibrous septum which separates the thoracic from the abdominal cavity. it is crucial for breathing and respiration. the two phrenic nerves are made up mostly of motor nerve fibers for producing contractions of the diaphragm during respiration (6). in the physiological study, he described, for the first time, that diaphragm is a unique muscle in an anatomical site but, functional ly, it acts like two separate muscles, because when one of the two phrenic nerves is severed, the related muscle part is paralyzed, but the other part works correctly (1). we know that intercostal muscles are several groups of muscles that run between the ribs, and contribute to the formation and movement of the chest wall (6). the observa tion of jorjani showed for the first time that there are two principal layers; the external intercostal muscles, which aid in quiet and forced inhalation and the internal intercostal muscles, which aid in forced expiration (1). on the anatomy of the optic nerve, jorjani, unlike avicenna, agreed with galen that this nerve at its periphery goes to the ipsilateral rather than the contralateral eye. in zakhire, after mentioning the main theories of the great former scientists, he comes to conclusions and he does this in the clearest and the most appropriate manner and wherever he feels he adds his comments and this makes his work even more specific. his innova tions and practices in various branches of medical sciences are quite new and unique. jorjani was fully efficient in surgery for which he used a nice persian term meaning manipulation. in zakhire, he elaborated on different methods of surgery and the related tools in a way that is quite expressive of the dexterity and the depth of his experience. he also wrote about the needed medications and the types of medical care before and after surgery in the best possible way. it can be claimed that zakhire is the best surgical document of the time after zahravi’s al-tarif and razi’s al havi (1); here we point to some of the surgeries which had been recommended by jorjani: in the case of surgery, other than the usual operations, jorjani also prescribed different kinds of cauterization. based on his experience and practice, he even wrote about its application in tightening and epilating the slots made by different types of hernia. for complete treatment of pustule apothems, at first, he prescribed pharmacotherapy, and, if not being successful, gave appropriate instructions for surgery and operation (2). for stopping severe hemorrhage of wounds, he suggested using plaster casts several centuries before european scientists. in urology, he proposed catheterization for the treatment of patients with difficulty in urination. however, he indicates that if, due to swelling, injury or bladder stone, using catheter is not possible, there will be no way other than ripping up and discharging the obstructive agent (2, 7). in case of the polyp existence, jorjani ex plained how to use a thin sharp semicircular knife for cutting and paring and a curved needle made of metal with a piece of silk string or the hair of horse j med ethics hist med 2009, 2:16 saeed changizi ashtiyani, et al page 3 of 5 (page number not for citation purposes) for stitching and repairing the wound. it is also interesting to know that jorjani indicated that, if the resulted apophasis was hard, distorted in color and accompanied by edema of mortise area, this could be regarded as a possibility for malignancy and cancer (7). jorjani discussed cancer for the difficulty of its treatment, the necessity to avoid inciting it and the relative effectiveness of early treatment. this, somehow, connotes modern chemical treatment as it insists on taking care of the patient’s body. he also referred to high degree of occurrence of breast and uterus cancer among women and throat and bowel cancer among men (7). in a wonderful discussion about tumors, jorjani divided these lesions into soft and hard and called them “saghirus” and “saratan” (= crab / cancer), respectively. he believed that cancers are more common in females, and stated correctly that”the diagnosis of cancer in early stages is not simple and by the time you can diagnose a cancer, it is usually when you cannot treat it.” then he added that if a cancer is far from the vital organs, you should excise it completely with all of its roots, and he explained, in detail, how he resected the breast of a woman with breast cancer (8). jorjani is one of the pioneers in finding an early chemotherapy treatment for cancer in the form of medication which was used as a lotion for covering the cancerous tissue and there have been positive reports declaring its efficacy. jorjani talked about cancers, effectiveness of curing cancer from the very beginning, operating cancerous tumors, and spreading cancer to other organs (metastasis). on cancer and its treatment he wrote “the best method in treating this disease is to avoid operation or cut the tumor and it should be kept intact. cancer may be cured in its early stages, but a deeply rooted cancer is impossible to cure. in many occasions a cancerous tumor appears and grows slowly in body, and the best thing to do is not to remove the cancerous tumor, then it may live in the patient for longer time, otherwise it will kill the patient. some cancerous tumors are small in size and they may not affect body organs. these tumors plus a part of flesh surrounding it can be removed by surgical operations. in this case let the blood bleed, apply ointment and then dress the wound cleanly. in many occasions, cauterization and cutting the cancerous tumor proved to be deadly. it is said that some previous physicians used to cut the cancerous breast of women, but after a while the disease returned to other breast “(2). jorjani pointed out clinical symptoms and me thods of treatment which himself had observed and cured. for instance, in the chapter dedicated to throat diseases, he explained the relationship between protrusion of eyeball (exophthalmos) and goiter. this is what parry came to discover several centuries later in 1825 (9). he also pointed to the relationship between the outgrowth of thyroid glands and the increase in the heart rate. this is how he understood about the toxic reactions of these glands (thyrotoxicoisis). this is one of his most fascinating observations in the discussions of endocrinology. in endocrinology, in particular, jorjani was one of the first to associate exophthal mos with goiter, which was not repeated until parry c, and later robert graves and carl von basedow. ljunggren jg, in 1983 suggestd that jorjani should be credited with recognizing graves-basedow disease having noted the association of goiter and exophthalmos (10). jorjani also established an association between goiter and palpitation in the zakhire (11). in the case of severe diphtheria and the ob struction of air canals, for the continuation of air flow and breathing, he proposed the incision of a glass pipe into the throat. and, in case of asphyxia caused by displacement of a cervical vertebra, he prescribed the insertion of hand or a metal device into the throat (laryngoscope) for fixing the vertebra (2, 11). in eye surgery, he discussed different types of operation among which the treatment of cataract can be mentioned. in the surgery stages, at first he explained situating the patient in a lighted place, holding his head backward, turning his upper eyelid upward, keeping the eye wide open and then using a rod called “mehet” which is made of copper with which incision through iris takes place and the water is drained (2). conclusion nowadays medicine has to be considered as a complex system based on the interaction of formation, research, medical and social facilities, law and ethics. the specific field of the history of science is the study and explanation of the origin and transformation of the structures of scientific knowledge. what is of interest here is the combina tion of approaches used by philosophers and historians in studying medical thinking and their joint relevance for a better understanding of contemporary medical problems. the study of jorjani ’ s works shows his depth of knowledge and great expertise on diseases and their treatments. similar to avicenna and many other scientists’ works, his compilations need careful revisions and preparation of grounds for new research due to the existence of various problems in curing diseases especially in modern medicine. j med ethics hist med 2009, 2:16 saeed changizi ashtiyani, et al page 4 of 5 (page number not for citation purposes) fig 1: the colophon to a copy of the final book of the treasure of khvarazm’shah by jurjani. it states that the copying of the first section (on materia medica) was completed on 8 safar 992 [= 20 february 1584] by qasim ‘ali tajm al‐din mahmud al‐yafaqi. (12) fig 2: treatment of a patient by the physician. (8) j med ethics hist med 2009, 2:16 saeed changizi ashtiyani, et al page 5 of 5 (page number not for citation purposes) references 1. moharreri mr. zakhireye kharazmshahi. tehran: the iranian academy of medical sciences; 2005. [in persian] 2. tadjbakhsh h. alaghraz altibbia val mabahess al-alaiia. tehran: tehran university press; 2006. [in persian] 3. tadjbakhsh h. sayyed esma'il jorjani, founder of persian medicine. j vet res 2007; 62(4): 131-40. 4. brown eg. arabian medicine. translated by rajabnia. tehran: scientific and cultural publications company; 1985. [in persian] 5. newman aj. tashrih-e mansuri: human anatomy between the galenic and prophetic medical traditions. in: vesel z, beikbaghban h, thierry b, (eds). la science dans le monde iranien. tehran: institut francais de recherche en iran; 1998, p. 253–71. 6. standring s. the gray's anatomy: the anatomical basis of clinical practice, 40th edition. churchilllivingstone, elsevier; 2008. 7. jurjani si. zakhireh-i kharazmshahi, photo offset from the original hand written manuscript. edited by saeedi sirjani. tehran: iran cultural publications; 1976. [in persian] 8. zargari o. hakim jorjani and his role in the revival of iranian medicine. dermanities 2005; 3(3). 9. nabipour i. clinical endocrinology in the islamic civilization in iran. int j endocrinol metab 2003; 1: 43–5. 10. parry ch. enlargement of the thyroid gland in connection with enlargement or palpitations of the heart. in: collections from the unpublished medical writings of c. h. parry. london: posthumous; 1825, p. 111-129. 11. ljunggren jg. who was the man behind the syndrome: ismail al-jurjani, testa, flajina, parry, graves or basedow? lakartidningen 1983; 80 (32-33): 2902. 12. schullian s, p. 338 entry p25, where the name of an owner of the volume is misinterpreted as the compiler of the collection. nlm microfilm reel: film 48-136 no. 5. www.nlm.nih.gov/hmd/arabic/e11_e13.html journal of medical ethics and history of medicine organizational behavior of employees of tehran university of medical sciences hossein dargahi associate professor, department of health care management, school of allied medicine, tehran university of medical sciences, tehran, iran. *corresponding author: hossein dargahi address: adjacent to milad tower, shahid hemmat highway, department of health care management, school of allied medicine, tehran university of medical sciences, tehran, iran. tel: (+98) 21 88 62 27 55, (+98) 21 88 62 27 66 fax: (+98) 21 88 62 25 33 email: hdargahi@sina.tums.ac.ir received: 15 jan 2012 accepted: 01 aug 2012 published: 21 oct 2012 j med ethics hist med. 2012; 5:7. http://journals.tums.ac.ir/abs/22269 © 2012 hossein dargahi; licensee tehran univ. med. sci. abstract keywords: organizational behavior, employee, organizational ethics. introduction organizational ethics are generally recognized as an essential component of organizational life. organizational politics strongly influence both formal and informal organizational structures and communications processes between employees, organizational climate, and reward system. most employees are persuaded to participate in the politics of their organizations because of predomi nance of organizational politics (1). there are many definitions of organizational politics in the literatures. one of the definitions is the power utilization to impact decision-making or to guarantee a situation that supports a powerful person. another definition is the coalition of several individuals or groups to control the resources of an organization (2). organizational politics can motivate the em ployees to show political behaviors (3). recent organizational behaviors are commonly acknowledged as fundamentals of organizational life that strongly influence both formal and informal organizational processes, interpersonal relationships, work environments, and pay and promotion policies. the current study aims to investigate political behavior tendencies among employees of tehran university of medical sciences (tums). this cross-sectional, descriptive and analytical study was conducted on 810 tums employees at the headquarters of the tehran university of medical sciences, iran during 2010-2011. the research tool for data collection was a researcher-tailored questionnaire on political behaviors. the validity of the questionnaire was confirmed by seven management professors, and its reliability was tested by a pilot study using test-retest method which yielded a cronbach’s alpha coefficient of 0.71. the respondents were asked to fill the questionnaire and express their perceptions and tendencies to engage in organizational behaviors. the collected data was read to and analyzed by ibm spss environment and correlation analytical methods. overall, 729 respondents filled and returned the questionnaire yielding a response rate of 90%. most of the respondents indicated that they had no tendency to engage in political behavior. moreover, we found that there was a significant correlation between sex, higher education degrees, tenure and the employees’ tendency to engage in political behavior. the participants were not overtly political because of their personal belief, ethical values, and personal characters. non-political and overtly political employees are both prejudicial for all organizations. therefore, it seems that the medium rate of good political behavior is vital and prevalent in iranian organizations. j med ethics hist med 2012, 5:7 hossein dargahi page 2 of 7 (page number not for citation purposes) researches show that many factors develop or increase the political behaviors and therefore all groups or organizations are not equally political. some of these factors are derived from employees’ personal characteristics, and others are conse quences of organizational culture and work environment. both organizational and individual factors can provide political behaviors that cause unfavorable outcomes such as inequalities in pay and reward system and prevention of punishment of employees who show political behaviors (4). it is supposed that political behaviors are associated with power, uncertainty, and constraints within organizations (5). avoiding action, for instance by over conforming, passing the buck, paying dumb, depersonalizing, smoothing, smoothing and stretching, and stalling, avoiding blame through buffing, playing safe, justifying, scapegoating, misrepresenting, and escalating commitment, and avoiding change by resisting change and protecting turf are different political behavior tendencies among employees. moreover, the history of political behaviors within the organizations includes bureaucratic processes, various stressors, individual’s insecurity and anxiety, emotional exhaustion, work alienation, self-monitoring and low self-efficacy (6). vigoda-gadot who examined citizen’s percep tions of organizational politics and ethics in public administration, showed that political behaviors were related to ethics, employee satisfaction, trust in supervisors, and direct or indirect goal attain ment (7). additionally, vigoda-gadot et al. declared that there is a relationship between perceptions of political behavior tendencies and job satisfaction, organizational commitment, and job autonomy and job attitudes (8). valle and perrewe examined political behaviors as a critical, but ignored element within the model of traditional organizations. they found that job environment as an organizational element of political behavior tendencies is preferred to the set of organizational and individual variables in these institutions. finally, the perception of political behaviors demonstrated that these behaviors are mediation effects between previous variables such as employees’ work insecurity and anxiety, and job satisfaction and job commitment (9). our research is aimed to study political behavior tendencies among the employees of tehran university of medical sciences. materials and methods this cross-sectional, descriptive and analytical study was conducted among 810 employees working in the headquarters of tehran university of medical sciences (tums) in tehran, iran during 2010-2011. the research tool for data collection involved a researcher-tailored question naire on political behaviors. the first section of the questionnaire has been devoted to the demographic information, such as sex, age, ethnicity, higher education degrees, work experience, tenure and position. in the second section, the self-assessment of political behaviors has been measured through 26 questions without relevant dimensions. a 2 point scale was used to measure the level of each question of political behavior ranging from agree to disagree. a score rating of 75-100% was defined as the highest agreement rate, a score of 50-75% as a medium agreement rate, and below 50% was defined as disagreement. tums ethics committee approved this study, because all employees were verbally asked to participate and contribute to the self-assessment. the questionnaire was undergone evaluation by 7 management sciences professors in the area of organizational behavior for validity such as clarity, relevance and coherence of the ques tions. for the questionnaire reliability, a pilot study involving 50 randomly selected participants was performed two weeks before the main study. comparing the obtained results from the pilot study with the results of the main study by test-retest method yielded a cronbach’s alpha coefficient of 0.71, which suggests a relatively high reliability. the questionnaires were delivered to the respond ents by five evaluators who explained the aim of this study and philosophy of political behaviors to the participants at the end of administrative time. overall, 729 respondents filled and returned the questionnaires, yielding a response rate of 90%. the collected data were analyzed for correlations by ibm spss environment. results nearly (39.6%) of the employees were 30-40 years old and (55.9%) of them had bachelor of science (bsc) degree. moreover, 73.9% of the respondents were married and while 28% of employees had 0-5 of years of work experience, 28% as the second largest group had 10-15 years of work experience (table 1). the results of this research indicated that ap proximately 70% of tums headquarters employ ees agreed with correction of supervisor’s mistakes by subordinates. only less than 10% of the respondents agreed with misuse of secret infor mation by the employees. the majority (93.7%) of the respondents disagreed with political behavior against the organizations authorities. the majority (97.3%) of the employees disagreed with the misuse of supervisor’s weakness by subordinates. less than half (48.6%) of the respondents believed in power as the most important factor in any organizations. approximately 30% of the employ ees expressed their tendency to engage in political behavior adventurously. the majority (91.9%) of j med ethics hist med 2012, 5:7 hossein dargahi page 3 of 7 (page number not for citation purposes) the respondents showed their respect for organiza tional hierarchy in order to improve organizational goals. the majority (95.5%) of the employees disagreed with using escalating commitment as a political behavior in order to increase individual advantage. approximately 50% of the respondent believed that political behavior was a natural process in organizations. approximately 78.4% of the employees agreed with recognition and use of political skills by their supervisors. more than half (62.2%) of the employees believed that there was a positive relationship between lower tenure of the employees working with supervisors and political behavior. approximately 80% of the employees expressed that there was a negative relationship between political behavior and organizational efficiency and effectiveness, and more than half (66.7%) of the respondents believed that power supervisors should resist political behavior (table 2). moreover, we found that there was significant correlation between the employee’s tendency to engage in political behavior with their education (p=0.034), their sex (p=0.04), and their tenure (p=0.016). but there was no significant correlation with their age (p=0.192), marriage status (p=0.495), years of work experience (p=0.544), and ethnicity (p=0.52). discussion the research presented here is an investigation of political behavior and organizational politics among tums employees. the findings of this research appeared to judge credible human resource management and organizational behavior policymakers and healthcare organizational leaders. political behaviors exhibited by the employees can line up with departmental and organizational objectives as well as with the individuals. some personal characteristics, such as sex, may cause certain individuals to display political behavior (2). larimer and hannagan expressed that male employees had more tendencies to engage in political behaviors than women (10), although dubrin reported no significant difference between males and females in this regard (11). however, much similarity exists between women’s and men’s political behavior in japan, while women are not completely uninterested in political behavior (12). we found that tums male employees had more tendencies to engage in political behavior than women and that tums is compatible with the larimer and hannagan research, but in contrast with that of dubrin and steel’s studies. keith believed that participation in multi-age groups increased efficacy, while age-graded participation decrease political activity (13). nevertheless, we did not find a significant correla tion between the employee’s age and political behavior.we observed no relationship between the respondents’ tendencies to engage in political behavior and their ethnicity. however, ralston et al. conducted a cross-cultural study of ethics on a group of u.s. and hong kong chinese managers aiming to evaluate the effects of different political behaviors on these managers’ organizational goals, and showed that differences were found between these two groups as a result of their varied views on ethical behavior (14). also, vigoda showed that cultural differences bring about different percep tions of conflict and political behaviors, and concepts that have their roots in culture might be a contributing factor to reactions to organizational politics (15). the mexican-american elderly were found to be rather unlikely to engage in political behavior and had little sense of effectiveness (16). torres-gil & becerra suggested a socioeconomic model that presented political behaviors between older black americans, younger blacks, and older and younger whites (17). also, klecka believed that ethnicity can affect political behavior and suggested a new model for understanding the relationship between ethnicity and political behavior due to aging (18). although we could not find a significant corre lation between the employees’ perceptions of political behaviors with their work experience in tums, conner showed that among human resource experts there was a negative relationship between work experience and politics as regards pay, reward and promotions system (19). moreover, based on a multiple regression analy sis, there is a significant correlation between job context factors and hierarchical level with political behaviors (20). similarly, according to our re search, tums employees regard organizational hierarchy of utmost importance to the promotion of organizational goals. we found that most tums employees agreed with correction of supervisors’ mistakes by subordinates but did not agree with misuse of the supervisors' weakness by subordinates. this finding is compatible with poon’s investigation that among employees perceiving low levels of political involvement, there was a positive relationship between trust in supervisors and employees’ willingness to help their colleagues (21). tums employees believed that there was a positive relation between lower organizational tenure of employees working with supervisors and political behavior. although an increase in percep tions of political behavior under conditions of lower tenure working for supervisors is associated with lower attendance, there is no relationship between political behaviors with attendance under higher tenure working for supervisors (22). similar to poon and ferris et al. results (23, 24), most of tums employees stated that improvement of organizational performance depended on nonpolitical and non-stressful environments. while many other studies have linked the effective use of political behaviors to improvement of individual j med ethics hist med 2012, 5:7 hossein dargahi page 4 of 7 (page number not for citation purposes) performance (25), tums employees disagreed with use of political behavior to improve individual performance. however, comer believed that political behavior may not only influence decision making but also reflect organizational objectives and individual interest and inclinations (26). approximately three quarters of tums em ployees agreed with recognition and use of political skills by their supervisors which is similar to kolodinsky et al. investigation that declared there was a positive relationship between rationality and supervisory political skills (27). we found that the majority of respondents in our research disagreed with using political behavior against organizations’ authorities and believed that only cowardly employees were inclined to do so. also, biberman reported that employees with high political tendency score higher on machiavellian ism and are generally less fulfilled and less competitive (28). approximately 70% of tums employees be lieved that political behaviors made their respective organization less efficient. likewise, witt et al. showed that team member’s political behaviors were negatively related to teams’ ratings of effectiveness and team members’ satisfaction and commitment (29). moreover, cropanzano et al. declared there was a negative relationship between political behavior tendencies and employees’ job satisfaction and organizational commitment (30). employees who had high political tendency boasted lower job satisfaction (31-33) whereas there is evidence that job satisfaction may lead to higher levels of political behavior (34). according to one study, in turkish organizations bullying is a political behavior that some employees show in order to promote their own interests (35). although tums employees believed that pow erful administrators should resist political behavior, geisce showed that administrators’ success in achieving desirable results depended greatly on their tendency to exhibit political behavior (36). also gadot found that how employees performed and behaved within their organization was the direct outcome of their organizational politics (37). one of the main limitations of the present study is that it was conducted at one specific point in time. a longitudinal study would have been preferred, although limited resources could have made it difficult. secondly, the employees were surveyed by a questionnaire. although it is possible that this information-collecting process is conven ient for the present research, it might have been introduced into the final results of the research. finally, many other organizational political barriers and constructs, which inhibit the employees from responding to the questions that influence the employees’ perceptions, have not been included in our research. therefore, it might not be accurate to state absolute conclusions regarding the global effects of organizational behaviors on tums employees. conclusion there seems to be a need for human resource development programs to decrease unnecessary political behaviors. human resource policy makers should increase awareness of employees through need assessment, and aim at discouraging political behaviors and encouraging alternate practices. in addition, the human resources programs can help to promote positive organizational behaviors. political behaviors are both subjective and objective and pertain to real political events in an organization. employees, however, have their own personal understanding of reality, and that is what deter mines the manner in which they perform within their organization. the results of our research showed that tums employees were not overtly political and had no tendency to engage in political behavior, because of their personal belief, ethical values and personal characters. non-political and overtly political employees both are prejudicial for all organiza tions. non-political employees are inactive and overtly political employees are exposed to syco phantic and unhealthy political behavior. there fore, it seems that the medium ratings of good political behavior, as a vital tool, are prevalent in tums. however, we suggest iranian human resource management policymakers to provide a number of rules and regulations to guide or suggest norms of political activity to eliminate ambiguous circumstances and define a situation to fit employ ees’ needs and desires. this redefinition of the situation is often considered political behavior. also, we recommend further research on the relationship between tums employees’ political behaviors and their job satisfaction, organizational loyalty, organizational effectiveness and efficiency. ethical considerations ethical considerations including plagiarism, informed consent, misconduct, data fabrication or falsification, double publication, redundancy, etc. have been completely observed by the author. acknowledgements this research was supported in part by a re search grant from the deputy for research of tehran university of medical sciences. the authors declare that they have no conflict of interest. the author would like to thank zahra yarifard for her assistance in the data collection, golsa shaham for her aid in general research program, parvin nazari for typing the manuscript, and anonymous reviewers for their helpful suggestions. j med ethics hist med 2012, 5:7 hossein dargahi page 5 of 7 (page number not for citation purposes) table 1: demographic data of tums staff headquarters’ demographic details n % age (year) 20-30 292 40 30-40 299 41 40-50 109 15 50-60 29 4 total 729 100 degree diploma & associate diploma 131 18 bsc. 422 58 msc. 95 13 phd 81 11 total 729 100 sex woman 549 75 man 183 25 total 729 100 marriage status single 255 35 married 474 65 total 729 100 place of birth tehran 525 72 out of tehran 204 28 total 729 100 years of work experience 0-5 204 28 5-10 109 15 10-15 204 28 15-20 168 23 20-25 8 1 25-30 36 5 total 729 100 j med ethics hist med 2012, 5:7 hossein dargahi page 6 of 7 (page number not for citation purposes) table 2: the perceptions and tendencies of tums staff headquarters row types of questions agree disagree total n % n % n % 1 correction of supervisor’s mistakes by subordinates, not misuse these mistakes 539 73.9 190 26.1 729 100 2 misuse secret information by the employees 53 7.2 676 92.8 729 100 3 help coworkers without expectancy of compensation 551 72.1 177 24.3 729 100 4 neighboring with authorized people 460 61.3 269 36.9 729 100 5 using political behavior against organizations authorities 46 6.3 683 93.7 729 100 6 esteem of coworkers if they esteem mutually 269 36.9 460 63.1 729 100 7 doing supervisor’s private expectations by subordinate 112 14.4 617 84.7 729 100 8 assistance with supervisor’s joking in order to job position improvement 105 14.4 624 85.6 729 100 9 traveling with supervisor instead of being near family 138 18.9 591 81.1 729 100 10 misuse of supervisor’s weakness by subordinates 20 2.7 709 97.3 729 100 11 tendency to engage political behavior compatible with supervisor 289 38.6 440 60.4 729 100 12 notifying to supervisor about their mistakes 204 27.9 525 72.1 729 100 13 believe in this sentences “if you don’t this duty’, it may lead to supervisor’s dissatisfaction 263 36 466 64 729 100 14 familial neighborhood with supervisor in order to job position development 40 5.4 689 94.6 729 100 15 neighborhood to key personnel improvement of job position 184 25.2 545 74.8 729 100 16 believe in power as the most important factors in any organizations 355 48.6 374 51.7 729 100 17 tendency to engage in political behaviors adventurously 243 33 486 37 729 100 18 respect for organizational hierarchy in order to improve organizational goals 670 91.9 59 8.1 729 100 19 using escalating commitment as a political behavior in order to increase individual advantage 33 4.5 696 9.55 729 100 20 believe in political behaviors as a natural process 315 41.4 414 56.8 729 100 21 recognition and use of political skills by supervisors 571 78.4 158 21.6 729 100 22 positive relation between tenure of employees working with supervisor with political behavior 454 62.2 275 37.8 729 100 23 doing running work in nonpolitical organization 526 72.1 203 27.9 729 100 24 political behaviors make 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empirical examination of two competing models. personal rev 2007; 36 (5): 661-83. jmehm-7-11 journal of medical ethics and history of medicine underreporting of medication errors in nursing students: a threat to patient safety mozhgan kalantarzadeh1*, maryam hosseinnejad 2 1msc, department of medical surgical, faculty of nursing and midwifery, islamic azad university, kerman branch, kerman, iran. 2msc, department of community health nursing, faculty of nursing and midwifery, islamic azad university, kerman branch, kerman, iran. corresponding author: mozhgan kalantarzadeh address: dept. of medical surgical, faculty of nursing and midwifery, islamic azad university, kerman branch, kerman, iran. email: klntr@yahoo.com tel: 03413210043 fax: 03413201770 received: 25 feb 2014 accepted: 5 jul 2014 published: 15 jul 2014 j med ethics hist med, 2014, 7:11 © 2014 mozhgan kalantarzadeh et al.; licensee tehran univ. med. sci. abstract medication errors (mes) are among the most prevalent health errors threatening patients’ safety and are regarded as an index for determining patients’ well-being in hospitals. the purpose of this study was to explore the me reporting rate and causes of underreporting among the nursing students in the city of kerman. in this cross-sectional study, 90 nursing students in the seventh and eighth semesters of kerman university of medical sciences and islamic azad university of kerman were selected. data collection tool was a researcher-made questionnaire consisting of three parts: 1) demographic information, 2) types and causes of medication errors, and 3) causes of underreporting. data analyses were performed by descriptive statistics and inferential statistics. the spss 16 statistical software was used in this study and p values less than 0.05 were considered significant. according to the data, 66.7% of the nursing students in this study had made mes, and the rate of underreporting was calculated at 40%. the most important causes of mes were illegible data cards and prescriptions, and the major reasons for underreporting were fear of low evaluation scores, reprimand and punishment. there was no statistically significant relationship between demographic characteristics and underreporting of mes in nursing students (p > 0.05). findings of this study showed that the rate of mes is high among nursing students and that medication errors are a major problem in the field of nursing. patient safety and mes are two important topics in health care, and recognition of the factors contributing to the latter may decrease their frequency and consequently improve patient safety and the quality of care. keywords: medication errors, nursing students, reporting, patient safety mailto:klntr@yahoo.com j med ethics hist med 7:11 jul, 2014 jmehm.tums.ac.ir mozhgan kalantarzadeh et al. page 2 of 7 (page number not for citation purposes) introduction medication errors (mes) are a significant threat to patient safety (1); they are the most common medical errors and among major challenges to the health system (2). twenty one percent of all severe accidents in hospitals are related to medication errors (3). the consequences are rather serious, as 5% of all mes are fatal, while about 50% are preventable (4). the consequences include disability, physical or mental injuries, long-term hospitalization and death (5). an annual 1.5 million patients are harmed due to mes, and the associated costs are estimated at 3.5 billion dollars per year (6). the american institute of medicine defines error as the failure to fully implement the actions planned or application of a defective method to achieve a purpose (7). a large number of health care providers, including doctors, pharmacists and nurses, make medical errors. nurses play a key role in the implementation of medication orders, and are therefore responsible for the greater portion of mes (8). nurses are the second group facing with mes because they play an important role in the administration, preparation, and distribution of medication orders in hospital (9). medical errors are either the result of health care providers’ wrong approach, or their erroneous performance. execution of physicians’ orders is a main component of nurses' duties and an important part of the healing process and patient care (10). the rate of mes made by both nurses and nursing students is rather high. hence, identifying such errors and their causes is of utmost importance for the safety of patients. numerous studies have revealed the risk factors and causes of medication errors made by students to be lack of adequate pharmacological information, drug miscalculation, lack of attention to dosage and errors in transcribing medication to the kardex or drug cards (11, 12). one strategy to reduce mes is to report them, but various studies point to the fact that the reporting rate of medication errors is low (13). most students believe that clinical errors can put the patient's life at risk; however, they generally do not take the issue seriously, and in many cases try to keep them covered (14). as shown by several studies, students do not report their medication errors due to fear of being blamed by doctors, nurses, patient's relatives and trainers, as well as concerns about accusations of incapability, possible impact on their evaluation scores, and legal issues (11, 15). the philosophy behind the safety culture in modern health care perceives errors as a sort of system failure and defect. based on this culture, health care organizations are changing their practice of blaming the individual to identifying the underlying risk factors (16). many health care organizations agree that blame and punishment would not reduce mes. the overall approach to medication errors is determined by the culture of justice and fairness prevalent in the system. in a fair and just culture a balance is established between the need for disciplinary action and the need to learn from errors (17). in such an environment, employees can report their errors easily and without fear of blame (18). nevertheless, several studies indicate that despite the myriad benefits and ethical aspects of error detection and reporting, nurses and nursing students may hesitate to report their errors in order to protect themselves from penalties and administrative laws (19). even though it is inevitable for nursing students to make mes, they are often preventable. therefore, it seems necessary to study the factors underlying these errors in order to take systematic measures in minimizing or preventing them. since reporting medication errors can prevent their recurrence and preserve patient safety, identifying the causes and reporting barriers appears to be essential. it should be noted that once nursing school graduates enter the work force, they will make up the majority of the medical staff in health care centers (20). seeing as this topic has not been investigated in the kerman province so far, the present study was conducted with the aim to determine the causes of medication errors and factors affecting underreporting of mes from the nursing students' perspective in kerman. method this descriptive study was conducted on a total of ninety nursing students in the seventh and eighth semesters of kerman university of medical sciences and islamic azad university of kerman. these students were selected between february and november 2013. data collection tool was a researcher-made questionnaire that had been prepared and adjusted based on literature review and scientific papers (1, 7, 12). the questionnaire consisted of three parts. the first part collected demographic information (age, sex, marital status, and work experience at the same time as attending nursing school) and contained questions related to medication errors (their frequency, witnessing other students make these errors, and reporting them). the second part pertained to factors affecting medication errors including human and organizational factors and drug-related factors. the third part examined factors influencing the underreporting of medication errors. the validity of the questionnaire was confirmed using content validity method and the opinions of 10 academic members familiar with the subject, and their modifying and corrective comments were applied. the test-retest method was used to confirm the reliability of the questionnaire. for this purpose, a group of ten nursing students who met the research subject criteria were interj med ethics hist med 7:11 jul, 2014 jmehm.tums.ac.ir mozhgan kalantarzadeh et al. page 3 of 7 (page number not for citation purposes) viewed and tested in two stages with a ten-day interval using the questionnaire. after data collection, the internal consistency of the last two questionnaires was determined at 0.83 and 0.86 respectively. after determining the validity and reliability of the data collection tool, the questionnaire was distributed among the participants. the purpose of the study and instructions on how to complete the questionnaire were explained to the participants, who were assured of confidentiality and anonymity. they were also told that the results of the study would not be used for evaluations in the internship program. data were analyzed using spss 16 (spss, inc., chicago, il, usa) at an alpha level of 0.05. descriptive statistics (frequency, mean, median, standard deviation) and inferential statistics (chi-square, t-test and mann-whitney u test) were generated for variables. results the majority of the students (84.4%) were female. the mean age of the students was 22.56 ± 1.37, with a minimum of 20 and a maximum of 28 years old. of all participants 74.7% were married, and 11.1% were employed in health care centers while attending nursing school. of the 90 students who participated in the study, 60 students (66.7%) had made mes. the rate of underreporting of medication errors by nursing students was 40%. according to the students, the main factor contributing to medication errors was illegible prescriptions, and the least significant one was infrequent use of certain medications (table 1). the results of the t-test showed that from the students' point of view, most medication errors were due to human and organizational factors (p = 0.0001). among the human factors affecting underreporting of mes, "fear of the impact of mes on student evaluation" and "fear of being blamed by the instructor and the ward nurses" were the most significant ones (table 2). table 1 distribution of the frequency of factors affecting medication errors by nursing students in the city of kerman in 2013 sd mean never no. (%) low no. (%) moderate no. (%) high no. (%) factor 0.949 3.23 6 (6.7) 14 (15.6) 23 (25.6) 47 (52.2) discouragement and apathy towards the nursing profession human and organizational factors 0.842 3.38 4 (4.4) 9 (10) 26 (28.9) 51 (56.7) overwork and fatigue 0.721 3.46 0 (0) 12 (13.3) 25 (27.8) 53 (58.9) performing other tasks at the same time as administering medication 0.897 3.40 5 (5.6) 10 (11.1) 19 (21.1) 56 (62.2) inadequate training 0.937 2.43 14 (15.6) 37 (14.1) 25 (27.8) 14 (15.6) presence of patients’ relatives 0.917 3.03 4 (4.4) 25 (26.7) 6 (6.6) 35 (38.9) inadequate supervision 0.760 3.39 3 (3.3) 6 (6.7) 34 (37.8) 47 (52.2) lack of pharmacological information 0.691 3.50 1 (1.1) 7 (7.8) 28 (31.1) 54 (60) illegible kardex 0.689 3.56 2 (2.2) 4 (4.4) 26 (28.9) 58 (64.4) illegible prescriptions 0.773 3.14 2 (2.2) 15 (16.7) 41 (45.6) 32 (35.6) use of abbreviated names drug-related factors 0.810 3.13 3 (3.3) 15 (16.7) 39 (43.3) 33 (36.7) similarities in drug names 0.846 2.88 4 (4.4) 26 (28.9) 37 (41.1) 23 (25.6) similarities in packaging 0.827 2.30 14 (15.6) 42 (46.7) 27 (29.9) 7 (7.8) infrequent use of certain medications 0.894 2.62 11 (12.2) 26 (28.9) 39 (43.3) 15 (15.6) identical or similar packaging for different doses j med ethics hist med 7:11 jul, 2014 jmehm.tums.ac.ir mozhgan kalantarzadeh et al. page 4 of 7 (page number not for citation purposes) table 2 distribution of the frequency of human factors affecting underreporting of medication errors sd mean never no. (%) low no. (%) moderate no. (%) high no. (%) questions 0.875 3.43 6 (6.7) 5 (5.6) 23 (25.6) 56 (62.2) fear of the impact of mes on student evalua-tion 0.905 3.37 6 (6.7) 23 (25.6) 8 (8.9) 53 (58.9) fear of being perceived as incompetent and untrustworthy as a nursing student 0.911 3.16 7 (7.8) 10 (11.1) 35 (38.9) 38 (42.2) fear of non-cooperation of ward personnel with the student in the following days 0.885 3.12 6 (6.7) 12 (13.3) 37 (41.1) 35 (38.9) fear of the patient noticing the me and his/her negative attitude toward nursing students 0.898 3.41 7 (7.8) 6 (6.7) 21 (23.3) 56 (62.2) fear of being blamed by the instructor and ward nurses 0.925 3.23 5 (5.6) 15 (16.7) 24 (26.7) 46 (51.1) fear of legal issues after reporting 0.828 2.99 4 (4.4) 19 (21.1) 41 (45.6) 26 (28.9) too much concern on the part of the nursing instructor regarding medication 0.984 3.10 8 (8.9) 15 (16.7) 27 (29.9) 40 (44.4) focus of the nursing instructor and head nurses on persons responsible for mes, regardless of other factors involved 0.870 2.91 6 (6.7) 20 (22.2) 40 (44.4) 24 (26.7) insignificance of some mes, such as those involving medications with no side effects 0.825 2.76 6 (6.7) 26 (28.9) 42 (46.7) 16 (17.8) lack of a clear definition for the term “medication error” 0.949 2.44 17 (18.9) 28 (31.1) 33 (36.7) 12 (13.3) forgetting to report mes there was no significant relationship between mes and gender, age, marital status, work experience at the same time as attending nursing school, and the items on the questionnaire pertaining to factors affecting medication errors or underreporting (p > 0.05). discussion the results of this study showed that on average, nursing students reported 60% of medication errors to trainers. in other studies, including one conducted on nursing students in tehran and another similar study in arak, these rates were reported to be 46.6% and 72.2% respectively (11,15). the same rate was 32.7% in a study by ross et al. (21). it is clear that a low prevalence of mes is considered desirable by authorities; however, it should be noted that minimizing the difference between the number of errors and the reporting rate is extremely important. studies show that nowadays mes are among the main problems in health care environments and most importantly, the management and prevention of these errors depend on detailed reporting. executives and instructors should not focus on the undesirable consequences of such reports and simply apply punishment; they must use their means to eliminate the obstacles in the way of reporting and attempt to compensate the damages and resolve the complications caused by nursing errors as much as possible (1,7). for this purpose, aristotle’s views can be applied to foster the principle of honesty among nursing students as a virtue. in this manner, students can be encouraged to view the reporting of mes as a moral task in the patient’s best interest aimed at maximizing benefits (11). among the factors affecting the incidence of mes in nursing students, illegibility of doctors' prescriptions is worth mentioning. in a study on the opinions of educators about mes and their causes and solutions, nearly all participants agreed that bad writing and illegible prescriptions and drug instructions in the kardex or drug card are the major causes of mes in nursing students. they also believed that inadequate pharmacological information and incorrect drug calculations are other important factors contributing to the incidence of mes (22). in several studies with nurses as samples, illegible prescriptions have been reported among the most important risk factors for mes (23 25). shulman et al. and kopple et al. argue that computerized physician order entries would lead to reduced medication errors and improved patient outcome (26, 27). in this study, insufficient training (62.2%) was identified as one of the most common causes of mes. in a similar study, 39.47% of nursing students believed that the credit hours dedicated to pharmacological theory is insufficient and theoretical education on the subject is not in conformity with the students’ practical needs (28). therefore, increasing the credit hours of pharmacology, keeping education consistent with the practical j med ethics hist med 7:11 jul, 2014 jmehm.tums.ac.ir mozhgan kalantarzadeh et al. page 5 of 7 (page number not for citation purposes) needs of students, and offering more extensive training on common drugs used in various wards can be effective preventative measures. given that “nursing principles and skills” is a course that contains many important topics, little time is allocated to medicinal topics and related subjects. nevertheless, increasing the students’ pharmacological knowledge has been introduced as an important strategy to reduce medication errors and patient harm (29, 30). in this study, performing other tasks at the same time as administering medication was identified as one of the most important factors affecting mes (58.9%). based on a systematic review by mansouri et al., inadequate knowledge about medications was the most common reported contributory factor for mes in iran (31).this can be due to various overlapping assignments and functions expected from nursing students because of nursing staff shortage in the wards, which leads to increased workload, burnout lack of focus and frequent medical errors. in several studies with nurses as samples, high workload has been reported as one of the main reasons for medication errors (32, 33). fear of being blamed by the instructor was among the reasons for underreporting of mes in the present study and another one by kohestani et al. (15). according to sanagoo et al. (2012), nursing students’ typical reaction to mes is to "hide" them. disclosure of medical errors has been associated with anger in physicians, nurses, patients’ relatives and trainers, as well as a sense of guilt, fear of low evaluation scores, blame and peer embarrassment (14). in the review by aronson et al., personal fears have been stated as major perceived barriers (34). in several studies it was demonstrated that fear of being reprimanded and punished is the most frequent barrier (35-37). in the present study, similarities in drug names (36.07%) and use of abbreviated names (35.6%) were reported as the most important medicinal factors affecting the incidence of mes. in a study by ghasemi et al., 87.2% of the nurses stated that similar labels and packaging were a major cause of mes. they also believed that pharmaceutical companies and regulatory institutions should monitor the process of naming and packaging drugs with more care, especially in the case of dangerous drugs such as potassium chloride, magnesium sulfate, etc. since errors in their usage can lead to severe injuries and even death (38). quoting john, kohestani et al. writes that the american heart association (2005) has described one of the most important causes of mes in cardiac intensive care unit to be the similarities in the names of medicines such as amrinone, amiodarone, dobutamine and dopamine (12). berman's study showed that 25% of medication errors are due to confusion about medications with similar names, and 33% are the result of similar packaging and labeling (39). enguidanos and brumley also reported the use of medical abbreviations as one of the most important causes of medication errors (25). thus, avoiding the use of less common abbreviations can be effective in reducing the incidence of errors (40). it would be ideal if medical errors did not occur in the first place, but when they do, the manner in which they are handled is of utmost importance (19). many health care organizations agree on avoiding blame and punishment as a strategy to reduce medication errors (17). an individual, nonsystematic approach to human error and the blaming culture reflect the weakness of the system, and will counteract positive, resolving measures. therefore, proper communication between teachers and students, avoiding negative reactions in case of medication errors, and encouraging the students to report errors will have positive and useful outcomes. conclusion this study demonstrates that medication errors are a major problem among nursing students, particularly during the internship period. while it may be inevitable for nursing students to make mes, all individual and system-related factors involved in their occurrence must be identified. thus, appropriate changes and modifications can be made in the education system in order to develop an efficient strategy for reporting and acquire a systematic approach (rather than an individual one) toward the error to prevent future medication errors. the role of nursing trainers is very important in minimizing and preventing mes, especially in higher semesters. moreover, educational content should be designed carefully in order to reduce such errors, even though many of them are negligible and may not cause any serious harm to the patients. reporting medication errors must be considered a moral duty as it is in the patient’s best interest and can maximize health care benefits and improve patient safety. through positive reactions to the reporting of mes, nursing trainers can handle the issue more appropriately and use these reports as a powerful tool for studying the whole process through analysis of causes and effects. acknowledgements we would like to thank the research deputy of islamic azad university, kerman branch for their invaluable financial support and co-operation. authors would also wish to express their sincere thanks to all nursing students who participated in this study. j med ethics hist med 7:11 jul, 2014 jmehm.tums.ac.ir mozhgan kalantarzadeh et al. page 6 of 7 (page number not for citation purposes) references 1. cheragi ma, manoocheri h, mohammadnejad e, ehsani sr. types and causes of medication errors from nurse's view point. iran j nurs midwifery res 2013; 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[in persian] 39. berman a. reducing medication errors through naming, labeling, and packaging. j med sys 2004; 28(1): 9-29. 40. dean c. medication errors and professional practice of registered nurses. collegian 2005; 12: 29-33. hhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh copyright © 2022 tehran university of medical sciences. this work is licensed under a creative commons attribution-non commercial 4.0 international license https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. original article abstract breaking bad news to patients is an essential aspect of the physician-patient relationship, but in iran, this relationship is often disrupted by patients’ families. this study investigates the views of patients' companions on breaking cancer news. in this descriptive-analytic cross-sectional study, we conducted research on 170 cancer patients’ companions and 170 non-cancer patients’ companions. we designed a questionnaire to investigate the subjects’ opinions and used cvi, cvr, cronbach's alpha and icc for evaluation. in order to compare groups, we used mannwhitney, kruskal-wallis, chi-square tests and spearman’s correlation. most participants believed that patients should be informed of their diagnosis. cancer patients' companions were more willing to learn the bad news in case they were diagnosed with cancer and were less likely to choose “despair” as the reason for non-disclosure (71% vs. 44%).there was no difference between the two groups in willingness *corresponding author mojtaba parsa address: no. 23, 16 azar st., keshavarz blv., tehran, iran. postal code: 1417863181 tel: (+98) 21 66 41 96 61 email: mparsa@tums.ac.ir received: 9 mar 2022 accepted: 15 may 2022 published: 1 jun 2022 citation to this article: zardoui a, yekaninejad ms, kazemian a, parsa m. assessing the willingness of patients’ companions to disclose bad news to cancer patients. j med ethics hist med. 2022; 15: 3. to break the cancer news to patients, choosing who should be informed first, and the reasons for nondisclosure. most participants believed the family should be the first to know the diagnosis. in this study, most participants believed that patients should be informed of their diagnosis. however, they preferred to learn about the diagnosis before the patient, which confirms the importance of educating the families about autonomy. keywords: bad news; autonomy; patients’ rights; cancer. assessing the willingness of patients’ companions to disclose bad news to cancer patients 1. researcher, school of medicine, tehran university of medical sciences, tehran, iran. 2. associate professor, department of epidemiology and biostatistics, school of public health, tehran university of medical sciences, tehran, iran. 3. associate professor, department of radiation oncology, cancer institute, tehran university of medical sciences, tehran, iran. 4. assistant professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran; research center for war-affected people, tehran university of medical sciences, tehran, iran; department of medical ethics, school of medicine, tehran university of medical sciences, tehran, iran. arshia zardoui1, mir saeed yekaninejad2, ali kazemian3, mojtaba parsa4* assessing the willingness of patients’ companions to disclose bad news to cancer patients j. med. ethics. hist. med. 2022 (june); 15: 3. 2 introduction bad news is any information that has a severe and undesirable effect on one's future perspectives (1). according to the principle of autonomy, physicians are legally and ethically required to inform patients of their diagnosis, course of illness, and prognosis (2). disclosing cancer news to patients is an important example of breaking the bad news. cancer is one of the leading causes of death, and the 19.3 million cancer cases in 2020 are expected to increase by 47% by 2040. because of the rising occurrence of cancer due to population growth and lifestyle changes, physicians are increasingly finding themselves in situations where they must give their patients cancer news (3). in north america and western europe, autonomy is of utmost importance, and the patient is directly involved in the diagnosis and treatment of the disease. however, in eastern countries, a balance of autonomy and the evident influence of families is the most important factor in informing patients of cancer diagnoses (4). therefore, a significant number of patients do not receive the cancer diagnosis directly from their physician (2, 5, 6). according to some studies, in countries such as japan, saudi arabia and iran, many cancer patients and even physicians agree that the doctor should inform the family first and let them give the news to the patient. as for patients, they have the right to ask not to be informed. still, if a physician tells the family without the patient’s permission, this act will be in direct violation of the patient’s autonomy (6 9). there are several protocols, including spikes and paciente, for breaking bad news to patients (10 12). along with the spikes protocol, a new scoring system has been established to consider individual preferences (13). however, it has been noticed that sometimes following these guidelines does not result in patient satisfaction (14). therefore, in addition to reviewing the existing guidelines, cultural differences between communities should be considered as indigenous guidelines are developed. in iran, the supportive role of families results in the interference of the patient's companions in the doctor-patient relationship; therefore, to adopt appropriate policies, we must study the perspectives of families and their reasons for being against the disclosure of bad news to patients. there are a few studies on iranian patients' attitudes toward receiving bad news, but to the authors' knowledge, there are not enough studies on the zardoui a., et al. 3 j. med. ethics. hist. med. 2022 (june); 15: 3. patient's companions' and family members’ attitudes toward this issue. it is critical to understand the circumstances prior to developing a guideline that is appropriate for our culture and society. as a result of the previously mentioned involvement of patients' families, we believe that investigating the families' opinions is an important step in developing a suitable guideline for breaking bad news in our society. in this study, we assess the willingness of the patients’ companions to break the cancer news and its relationship with different variables. methods this descriptive and analytic cross-sectional study was conducted in imam khomeini hospital complex in tehran, iran, from october 2020 to january 2021. we chose this hospital because it is a major referral center in the capital of iran and patients from all over the country are admitted to this hospital, so our sample could be representative of the whole country. the inclusion criteria consisted of being able to read, consenting to be enrolled in this study, and being older than 18 and a first-degree relative of a patient (parents, siblings, children and spouses). we conducted search of scientific databases such as pubmed, google scholar and sid to develop a questionnaire. based on the previously published studies (2, 6, 15, 16), we aimed to evaluate three factors among patients’ companions: their level of agreement with breaking the cancer news to their patients, their level of agreement with giving the cancer news to themselves if they got diagnosed with cancer, and the reason for their opposition to breaking the cancer news. we used closed questions to obtain clarification and generated a 4item questionnaire. two questions were based on the likert scale (participant’s willingness to break the cancer news to their patient or to themselves if they get diagnosed with cancer), and each item had five possible responses from 1 (strongly disagree) to 5 (strongly agree). the other two questions were multiple-choice questions: the reasons for opposition to breaking the bad news (with possible responses of “patient’s anxiety”, “patient’s fear”, “patient’s despair”, and “not pursuing the treatment"); and the person who should first get informed of the cancer diagnosis (with possible responses of the patient, family members, and both at the same time). the sample size of 323 was calculated based on a previous study (15), considering a 5% accuracy rate and a 95% confidence interval. this sample size was expanded into 340 companions of cancer assessing the willingness of patients’ companions to disclose bad news to cancer patients j. med. ethics. hist. med. 2022 (june); 15: 3. 4 and non-cancer patients (170 for each group) to achieve better results. to assess content validity, a panel of 11 physicians who were medical ethics specialists or clinicians was asked to express their views on grammar, phrasing and phrase placements. based on the method proposed by lawshe, the panel of experts was asked to examine each question based on essentiality, relevancy, simplicity and clarity. next, the content validity ratio (cvr) and content validity index (cvi) were calculated. cvis greater than 0.8 and cvrs greater than 0.59 (based on the number of panelists) were considered valid. thus, all of the questions were shown to have acceptable levels of cvi and cvr (17). to investigate the reliability of the questionnaire, 100 participants, 50 companions of cancer patients and 50 companions of non-cancer patients (mean age = 41.95 ± 12.823 years), completed the questionnaire on day 0 (in person) and day 14 (via telephone). for all four items, cronbach’s alpha and intraclass correlation coefficient were greater than 0.8, which shows a high level of internal consistency and test-retest reliability over time. after assessing the reliability, 120 companions of cancer patients and 120 companions of non-cancer patients completed the questionnaire. using the data of 340 participants (the initial 100 participants were also included), we looked for the frequencies and possible relationships. all statistical analyses were conducted using spss software version 22. mean, standard deviation, median, and interquartile range were used to report quantitative variables, and frequency was used to report qualitative variables. prior to data analysis, the kolmogorov-smirnov test was used to determine the normality of quantitative variables. also, the distributions of two rank variables were compared using the mannwhitney test, and the correlation of two rank variables was estimated by spearman correlation coefficient. kruskal-wallis was applied to compare the distribution of several groups, and the chisquare test was run to determine the relationship between categorical variables. p-values < 0.05 were considered statistically significant. ethical considerations the ethics committee of tehran university of medical sciences approved the study protocol (ir.tums.medicine.rec.1399.840), and all participants were notified about the aim of the study and gave informed consent before completing the questionnaire. zardoui a., et al. 5 j. med. ethics. hist. med. 2022 (june); 15: 3. results we gave the questionnaire to 340 patients’ companions who had agreed to be enrolled in our study. the study population consisted of two groups: 170 companions of cancer patients, and 170 companions of non-cancer patients, including 145 males (42.6%) and 195 females (57.4%) participants. the mean age was 40.58 ± 10.954, ranging from 18 to 85 years old (table 1). out of 170 cancer patients’ companions, 138 (81.2%) stated that the patient was aware of the cancer diagnosis. of these 138, 79 (57.2%) said that the patient had been informed of his/her diagnosis by a physician, 21 (15.3%) said that the patient had been informed by his/her family, and 38 (27.5%) stated that the patients themselves had found out about the diagnosis from their general condition. nobody said that the patient had been informed of the diagnosis by a nurse. table 1. characteristics of the participants variable cancer patients’ companions non-cancer patients’ companions age (mean ± sd, min max) 40.74 ± 11.11, 18 85 40.36 ± 10.8, 18 71 gender male 71 (58.2%) 74 (43.5%) female 99 (58.2%) 96 (56.5%) marital status married 140 (82.4%) 121 (71.2%) not married 30 (17.6%) 49 (28.8%) residence urban 144 (84.7%) 152 (89.4) rural 26 (15.3%) 18 (10.6%) education high school and lower 59 (34.7%) 52 (30.6%) high school diploma 50 (29.4%) 55 (32.4%) associate degree 19 (11.2%) 16 (9.4%) bachelor’s degree 37 (21.8%) 35 (20.6%) master’s degree and higher 5 (2.9%) 12 (7%) in total, 129 (75.8%) of cancer patients’ companions and 125 (73.6%) of non-cancer patients’ companions agreed with breaking the cancer news to the patient. 147 (86.5%) of cancer patients’ companions and 124 (73%) of non-cancer patients’ companions said they wished to learn the news if they were diagnosed with cancer (figure 1). the most reported reason for opposition to assessing the willingness of patients’ companions to disclose bad news to cancer patients j. med. ethics. hist. med. 2022 (june); 15: 3. 6 breaking the cancer news was “patient's anxiety” among cancer patients’ companions’ (53.7%), and “patient’s despair” (71.1%) among non-cancer patients’ companions. “not pursuing the treatment”, on the other hand, was the least reported reason for both groups (figure 2). figure 1. willingness to break the cancer news figure 2. reasons for opposition to breaking the cancer news to patients zardoui a., et al. 7 j. med. ethics. hist. med. 2022 (june); 15: 3. approximately 70% of the participants in both groups believed that the patient's family and relatives should be informed of the diagnosis first, about 17% believed that the patients and the relatives should be informed at the same time, and nearly 10% believed that the patient should be informed of the diagnosis first (figure 3). figure 3. participants’ views on the person who should be informed of the cancer diagnosis first our findings showed that cancer patients’ companions’ willingness to break the cancer news to patients was correlated positively with education and negatively with age (correlation coefficient: 0.216 and -0.191, p-value = 0.005 and 0.013, respectively). non-cancer patients’ companions’ willingness to break the cancer news was higher in unmarried participants (p-value = 0.007) and was positively correlated with education (correlation coefficient: 0.198, p-value = 0.010) (table 2). the participants’ willingness to learn the cancer news in case they were diagnosed with cancer was positively correlated with education in both groups (cancer patients’ companions: correlation coefficient: 0.157, p-value = 0.041; non-cancer patients’ companions: correlation coefficient: 0.296, p-value < 0.001). however, it was negatively correlated with age in companions of the cancer patients (p-value = 0.047) (table 2) assessing the willingness of patients’ companions to disclose bad news to cancer patients j. med. ethics. hist. med. 2022 (june); 15: 3. 8 table 2. the relationships between questions and variables *p-values are significant ρ= spearman’s correlation coefficient questions cancer patients’ companions gender marital status median (iqr) residence education age the willingness to break the cancer news to the patient 0.845 0.253 0.430 0.005* (ρ = 0.216) 0.013* (ρ = -0.191) the willingness to learn the cancer news if diagnosed 0.919 0.850 0.539 0.041* (ρ = 0.157) 0.047* (ρ = -0.152) who should be informed of the diagnosis first 0.815 0.008* 0.883 0.001* 0.129 stating “patient’s fear” as the reason for opposition to breaking the cancer news 0.763 1 1 0.006* 0.741 stating “patient’s anxiety” as the reason for opposition to breaking the cancer news 0.257 1 1 0.893 0.618 stating “patient’s despair” as the reason for opposition to breaking the cancer news 0.006* 0.573 0.118 0.562 0.304 stating “not pursuing the treatment” as the reason for opposition to breaking the cancer news 1 1 1 0.025* 0.217 questions non-cancer patients’ companions gender marital status median (iqr) residence education age median (iqr) the willingness to break the cancer news to the patient 0.989 0.007* married: 2 (2) not married: 1 (1) 0.750 0.010* (ρ = 0.198) 0.543 the willingness to learn the cancer news if diagnosed 0.403 0.227 0.633 < 0.001* (ρ = 0.296) 0.128 who should be informed of the diagnosis first 0.614 0.900 0.473 0.207 0.024* patient: 46 (13) family: 39 (12) both: 37 (11) stating “patient’s fear” as the reason for opposition to breaking the cancer news 0.787 1 1 0.646 0.704 stating “patient’s anxiety” as the reason for opposition to breaking the cancer news 0.236 0.005* 0.608 0.913 0.331 stating “patient’s despair” as the reason for opposition to breaking the cancer news 0.141 0.168 0.308 0.700 0.139 stating “not pursuing the treatment” as the reason for opposition to breaking the cancer news 0.642 1 1 0.816 0.137 zardoui a., et al. 9 j. med. ethics. hist. med. 2022 (june); 15: 3. preference of cancer patients’ companions regarding the first person to be informed of the cancer diagnosis was dependent on two variables: 1) marital status (the patient: 8.6% in married vs. 20% in unmarried; family and relatives: 77.9% in married vs. 50% in unmarried; and both at the same time: 13.6% in married vs. 30% in unmarried, pvalue = 0.008, table 2), and 2) education (p-value = 0.001, respectively, table 3). there was an association between age and the preferences of non-cancer patients’ companions on the first person to be informed of the cancer diagnosis (pvalue= 0.024). also, the median age of participants who believed the patients themselves should be informed first was 46 years old (iqr: 13), the median age of participants who believed family and relatives should be informed first was 39 (iqr: 12), and the median age of participants who believed the family and the patient should be informed at the same time was 37 years old (iqr: 11) (table 2). table 3. the views of cancer patients' companions on the first person who should be informed of the cancer diagnosis, according to the level of education education the patient patient’s family and relatives both at the same time high school 3.4% (2) 83.1% (49) 13.6% (8) high school diploma 10% (5) 74% (37) 16% (8) associate degree 0% (0) 89.5% (17) 10.5% (2) bachelor’s degree 27% (10) 54.1% (20) 18.9% (7) master’s degree 20% (1) 20% (1) 60% (3) p-value 0.001 for cancer patients’ companions, choosing “patient’s fear” as the reason for non-disclosure was associated with education level (high school: 19%; high school diploma: 45.5%; associate degree: 0%; and bachelor’s degree: 100%; p-value = 0.006). choosing “not pursuing the treatment” was also associated with education (high school: 0%; high school diploma: 27.3%; associate degree: 16.7%; and bachelor’s degree: 33.3%; p-value = 0.025). finally, choosing “patient’s despair” as the reason for non-disclosure was associated with gender (63.6% in female and 21.1% in male participants; p-value = 0.006) (table 2). in non-cancer patients’ companions, choosing “patient’s anxiety” as the reason for non-disclosure was associated with marital status (85.7% in assessing the willingness of patients’ companions to disclose bad news to cancer patients j. med. ethics. hist. med. 2022 (june); 15: 3. 10 unmarried and 26.3% in married participants, pvalue = 0.005) (table 2). cancer patients' companions were more willing to learn the bad news in case they were diagnosed with cancer (p-value = 0.011). also, among the reasons for non-disclosure, choosing “patient’s despair” was not independent of the group of participants (43.9% in cancer patients’ companions and 71.1% in non-cancer patients’ companions, pvalue = 0.011). there was no difference between the two groups of companions in the willingness to give cancer news to the patient, choosing who should be informed of the diagnosis first, and choosing “patient’s anxiety”, “patient’s fear”, and “not pursuing the treatment” as the reason for opposition (p-values > 0.1). discussion in this study, 81.2% of the cancer patients were aware of their diagnosis according to their companions, similar to alzahrani et al. (86.27%) (18). most of these patients had heard the bad news directly from their physicians (57.2%). our study showed that 75.8% of the cancer patients' companions were in favor of breaking the bad news to their patients. this rate was 64%, 68%, in studies by alzahrani et al. (18), zekri and karim (15), respectively. jiang et al. showed that about 70% of companions favoured bad news disclosure in the early stages of cancer, while only 34% of companions agreed to bad news disclosure in the late stages (16). this difference may be due to cultural differences across communities. still, the interesting point is that in all these studies, a significant percentage of patients' companions and relatives were willing to inform the patients of the diagnosis. this might be due to increased awareness of patient autonomy, which can act as a positive motive for patients to start or to continue their treatment. we also found that 76.5% of the companions of non-cancer patients were willing to inform the patient of the cancer diagnosis. we think that the reason behind these high rates of disclosure might be the increased awareness of patients’ rights in these eastern countries. we found that the willingness of both groups of companions to break the cancer news to the patients was significantly related to their education level, so that higher education increased the willingness to inform the patient about the cancer diagnosis. this is in agreement with findings of a study in saudi arabia (15). this relationship could come from the fact that educated people may have more information about cancer, the importance of early detection, available treatments for cancer, and the principle of autonomy. previously, alzahrani et zardoui a., et al. 11 j. med. ethics. hist. med. 2022 (june); 15: 3. al. had shown that having prior insight about cancer increases the likelihood of being in favor of disclosure (18). in our study, 86.5 percent of cancer patients' companions wished to know if they were diagnosed with cancer, compared to 73% of non-cancer patients' companions. this significant difference may be because of cancer patients' companions' prior personal experience with cancer in their firstdegree relatives. they are more aware of the importance of notifying the patient of the diagnosis and respecting his/her autonomy, and they have prior knowledge of cancer prognosis and possible treatments. we could not find any article that assessed the relationship between the desire to know the news if diagnosed with cancer, and demographic variables. in our study, the answer was positively correlated to education in both groups and negatively correlated to age in cancer patients’ companions. this association may be due to the awareness of younger and more educated people about cancer, the importance of early detection, available treatments, and the principle of autonomy. also, the remaining years of life may be one of the reasons for younger people's willingness to know their diagnosis. in our study, most of the cancer patients' companions (72.9%) believed that the patient's family and relatives should be the first to be informed of the cancer diagnosis. in a similar study in saudi arabia, this option had the highest prevalence (61%) among cancer patients’ companions’ preferences (15). two other studies conducted in japan/united states and saudi arabia asked the same question of cancer patients themselves and physicians (7, 8). in both studies, 65% of the cancer patients in japan and saudi arabia agreed that the doctor should inform the family first and let the family decide about informing the patient; this was the preference of 80% of japanese physicians and nearly 50% of saudi physicians (7,8). a study in iran also showed that 45% of the patients would like to be informed of the cancer diagnosis by their family (6). ruhnke et al., however, found that patients and physicians in the united states had a different attitude toward this matter. only 22% of the cancer patients and 6% of the physicians agreed that the patient’s family should be the first to know about the diagnosis (7). a systematic review showed that americans of latin, eastern european and asian descent are more willing to learn the bad news than their counterparts outside the united states (5). assessing the willingness of patients’ companions to disclose bad news to cancer patients j. med. ethics. hist. med. 2022 (june); 15: 3. 12 all of the above indicates that education has an essential role in maintaining autonomy in the society. these differences may be because people and physicians in the united states are more aware of autonomy and patients’ rights. also, in eastern countries, these outcomes may be due to a lack of clear rules regarding patients’ rights, the importance of family relationships casting shadows over autonomy, and cancer treatment misconceptions (19). we found a relationship between participants’ preference as to who should be informed of the cancer diagnosis first, and marital status and education level in cancer patients’ companions, and age in non-cancer patients’ companions. 50% of the unmarried participants believed that the patients themselves should be present in the initial encounter with the cancer news (patient alone 20%, and patient with family 30%), but only 22.1% of the married participants believed so (patient alone 8.6%, and patient with family 13.6%). this difference may be due to the new attachments and family relationships that are formed after marriage. 80% of the participants with a master's degree and about 47% of those with a bachelor's degree believed that the patients themselves should be present in the initial encounter with the cancer news. at the same time, this number does not exceed 26 percent in lower education groups. the reason for this observation may be the commitment and belief of most educated people with regard to autonomy, or their previous knowledge about cancer. older participants were more likely to prefer the patient’s presence in the initial encounter with the cancer news, maybe because they rely on their own experience over the years and believe that the patient can handle hearing the cancer news. as mentioned previously, autonomy is the right of all patients, and its implementation is subject to the removal of administrative barriers. patients’ families’ opposition to informing the patient can be a significant obstacle in eastern countries, but one that can be eliminated by knowing the reasons for families' opposition to telling patients about their cancer diagnosis. in our study, “patients' anxiety” was the most common reason for opposition to breaking the cancer news among cancer patients’ companions at 53.7%, and “patients' despair and hopelessness” was the most common reason for opposition among non-cancer patients’ companions at 71.1%. similar studies in china and saudi arabia involving cancer patients only showed that the most common reason for opposition was to prevent the negative impact of bad news on the patient in saudi arabia (77%), and in china, psychological anxiety was the most zardoui a., et al. 13 j. med. ethics. hist. med. 2022 (june); 15: 3. common reason in the early stages of cancer (50.3%). these findings are similar to our study, but in in the final stages, “maintaining the patient's quality of life” was the most common reasons for opposition (16, 18). it can be said that in all these studies, including ours, the concern about the negative effects of disclosure on patients’ mental health (for instance anxiety problems) has been the most common reason for refusing to tell patients about the cancer diagnosis. this indicates that in many cases, by educating families, providing psychological support to patients and reassuring families of the patient's psychological support, they may agree with disclosing the diagnosis to the patient. among the cancer patients’ companions, the female participants mentioned “patient’s despair” more than males (63.6% vs. 21.1%); this difference could be due to psychological differences between genders. the non-cancer patients’ companions mentioned “patient’s despair” more than the cancer patients’ companions as the reason for their opposition (71.1% vs. 43.9%). this can be due to the previous experience of cancer patients’ companions with cancer, and the lack of experience thereof in non-cancer patients’ companions. there were a few limitations to our study. first, for reliability analysis of our questionnaire, the retest was done over the phone because many of the patients would have been discharged during the two-week period. second, this project was run during the covid-19 pandemic in iran, and there were far fewer non-covid hospitalized patients at the time. conclusion few studies have assessed iranian patients' companions’ willingness to break the bad news before. this study provides insight into the patients’ companions' views on informing the patient of the cancer diagnosis. we found that most of the patients' companions agreed with telling the patient about the cancer diagnosis, which may not be consistent with some of our previous concepts. this was significantly related to the level of education. however, most participants believed that family and relatives should be informed of the diagnosis before the patient, which is a violation of autonomy if the physician does so without permission from the patient. this study confirms that people value autonomy more than before, but still the patient may not be the first to learn of the diagnosis in many cases, and a minority of the patients may never know their diagnosis. this problem compromises the credibility of the informed consent forms obtained assessing the willingness of patients’ companions to disclose bad news to cancer patients j. med. ethics. hist. med. 2022 (june); 15: 3. 14 in medical centers. as a result, the need to pursue this crucial right of patients through newer guidelines is growing in importance, and more effective rules and education are required to solve this problem. in this manner, patients will be the first to learn about the diagnosis, course and prognosis of their disease. funding the authors declare no funding for this research. acknowledgements this study was performed as a thesis project in medicine, and we would like to express our gratitude to the participants for their cooperation. conflict of interests the authors declare no conflict of interests. references 1. buckman r. breaking bad news: why is it still so difficult? br med j (clin res ed). 1984; 288(6430): 1597-9. 2. parsa m, bagheri a, larijani b. telling bad news and its various aspects. journal of medical ethics and history of medicine. 2011; 4(6):1–14. [in persian] 3. sung h, ferlay j, siegel rl, laversanne m, et al. global cancer statistics 2020: globocan estimates of incidence and mortality worldwide for 36 cancers in 185 countries. ca cancer j clin. 2021; 71(3): 209-49. 4. borgan sm, amarin jz, othman ak, suradi hh, qwaider yz. truth disclosure practices of physicians in jordan. j bioeth inq. 2018; 15(1): 81-7. 5. larkin c, searight hr. a systematic review of cultural preferences for receiving medical “bad news” in the united states. health. 2014; 6(16): 2162–73. 6. aminiahidashti h, mousavi sj, darzi mm. patients’ attitude toward breaking bad news; a brief report. emergency. 2016; 4(1): 34-7. 7. ruhnke gw, wilson sr, akamatsu t, et al. ethical decision making and patient autonomy: a comparison of physicians and patients in japan and the united states. chest. 2000; 118(4): 1172-82. 8. mobeireek af, al-kassimi f, al-zahrani k, et al. information disclosure and decision-making: the middle east versus the far east and the west. j med ethics. 2008; 34(4): 225–9. 9. kazemian a, parsapour ar. evaluation of physicians ethics about truth telling to terminal ill patients. ethics in science & technology. 2007;1(1: suppl. issue in medical ethics): 61-7. [in persian] zardoui a., et al. 15 j. med. ethics. hist. med. 2022 (june); 15: 3. 10. pereira cr, calonego mam, lemonica l, de barros gam. the p-a-c-i-e-n-t-e protocol: an instrument for breaking bad news adapted to the brazilian medical reality. rev assoc med bras (1992). 2017; 63(1): 43-9. 11. baile wf, buckman r, lenzi r, glober g, beale ea, kudelka ap. spikes-a six-step protocol for delivering bad news: application to the patient with cancer. oncologist. 2000; 5(4): 302–11. 12. kaplan m. spikes: a framework for breaking bad news to patients with cancer. clin j oncol nurs. 2010; 14(4): 514-6. 13. von blanckenburg p, hofmann m, rief w, seifart u, seifart c. assessing patients´ preferences for breaking bad news according to the spikes-protocol: the mabban scale. patient educ couns. 2020; 103(8): 1623-9. 14. seifart c, hofmann m, bar t, knorrenschild jr, seifart u, rief w. breaking bad news-what patients want and what they get: evaluating the spikes protocol in germany. ann oncol. 2014; 25(3): 707-11. 15. zekri j, karim sm. breaking cancer bad news to patients with cancer: a comprehensive perspective of patients, their relatives, and the public-example from a middle eastern country. j glob oncol. 2016; 2(5): 268-74. 16. jiang y, liu c, li jy, et al. different attitudes of chinese patients and their families toward truth telling of different stages of cancer. psychooncology. 2007; 16(10): 928-36. 17. lawshe ch. a quantitative approach to content validity. personnel psychology. 1975; 28(4): 563-75. 18. alzahrani as, alqahtani a, alhazmi m, et al. attitudes of cancer patients and their families toward disclosure of cancer diagnosis in saudi arabia: a middle eastern population example. patient prefer adherence. 2018; 12: 1659-66. 19. khalil rb. attitudes, beliefs and perceptions regarding truth disclosure of cancer-related information in the middle east: a review. palliat support care. 2013; 11(1): 69-78. 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____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ 1 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e © 2019 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. really good stuff volume 12 number 14 october 2019 professionalism workshops tailored for nurses *corresponding author zahra shahvari azad university complex of gachsaran, ferdousy blvd., gachsaran, iran. postal code: 75 81 86 38 76 tel: (+98) 074 32 33 533 email: shahvarizahra@gmail.com received: 14 nov 2018 accepted: 29 aug 2019 published: 21 oct 2019 citation to this article: samadi sh, shahvari z. professionalism workshops tailored for nurses. j med ethics hist med. 2019; 12: 14. shahram samadi1, zahra shahvari2* 1.associate professor, department of anesthesia and intensive care, school of medicine, tehran university of medical sciences, tehran, iran. 2.assistant professor, department of nursing and midwifery, azad university of gachsaran, gachsaran, iran. what was the problem? many studies have attempted to analyze the concept of professionalism in nursing. prior to this study, however, there had been no experience of empowering nurses to train their peers. the context of nursing is different from other professions in the health system. in comparison to physicians, nurses’ exposure to patients is not only more frequent, but also of a kind that urges them to behave in a professional manner that differs from physicians and medical students. practical improvement of professional behavior in a clinical setting requires teamwork and participation of all members of the team. education is the first step in promoting professional behavior (1). despite the great efforts to teach professionalism to faculty members and medical students, there has been no systematic education for nurses as important members of the treatment team. the number of hospitals under the supervision of tehran university of medical sciences and the number of nurses working there are very high, but there are not enough nursing faculty members to educate clinical nurses, and it is not their responsibility to train clinical nurses after all. since a limited number of educators have the required skills and knowledge to teach professional behavior to nurses, it is necessary that such training be offered in special professionalism workshops tailored for nurses. professionalism workshops tailored for nurses 2 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 14 october 2019 what did we do? this project was designed to empower a number of nurses to teach professional behavior issues to other nurses in university hospitals. although no needs assessment study was performed, the difference between the pre-test and the post-test obtained from the participants indicated the need for training. in the first stage, the nursing bureau of tehran university of medical sciences introduced 41 nurses who were active in other university projects or had the potential and motivation to teach professionalism. a workshop about professionalism was organized in which all 41 nurses participated. the purpose of the meeting was to familiarize the nurses with the project. subsequently, 12 volunteers formed 6 pairs and chose 6 topics of professionalism including altruism, responsibility, honor and integrity, respect for others, justice and excellence based on their personal interest. we provided material for study on the chosen topics and asked the participants to design scenarios relevant to the given topics for discussion in the workshop. the scenarios were reviewed and commented on by experts and executives. the first round was planned and implemented in 5 sessions, each lasting 4 hours. in each session, there were a number of nurses, two nursing faculty members, and three medical professionalism experts. three topics were presented by the nurses and were reviewed and evaluated by the juries. two nurses were responsible for each topic and finally 8 nurses presented their lectures. participating nurses received feedback on the presented content, slides, designed cases and how the speeches were delivered, and they improved their products based on the feedback. the speakers presented the previous modified topics in a new session. the second round of the project started in five sessions, each lasting four hours. nurses who still had problems after this stage were invited to the professionalism office and their problems were resolved by members of the office. in the third round, a workshop was held for a number of nurse supervisors to ensure that the speakers were adequately educated and had achieved the necessary capabilities. at the beginning and end of the sessions, participants completed a questionnaire for assessing the effectiveness of the workshop, and another for assessing the teaching method. the assessment forms showed satisfaction of the participants with the workshop. what lessons have been learned? extensive staff training requires an experienced training team. in interdisciplinary fields such as professionalism, it is necessary to ensure that the content and the teaching method are accurate, and holding trainer workshops is a good way to achieve this. after the introduction of capable nursing speakers, the nursing bureau of tehran university of medical sciences decided to hold a two-day workshop on professionalism in 12 hospitals every month. we hope that the workshops will gradually increase the level of knowledge and attitudes of nurses toward samadi sh., et al. 3 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 14 october 2019 professionalism. in this project, it was necessary to increase the number of participants in the initial workshop so that a sufficient number of nurses could gradually become available for teaching. despite their continuous participation in the project, some nurses were not competent speakers due to professional commitment issues, and we found that we should not make initial choices for nurses just based on their interests. therefore, it is recommended that the initial selection of individuals be based on the ability of individuals to teach regardless of their individual interests, and that recruitments continue throughout the project. flowchart 1empowering nurses to teach professional behavior issues to other nurses professionalism workshops tailored for nurses 4 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 14 october 2019 references 1. cruess rl, cruess sr, steinert y. teaching medical professionalism. uk: cambridge university press; 2008. 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____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ 1 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e © 2019 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. case study volume 12 number 10 august 2019 the unlikely legalization of medical cannabis in albania: a case study *corresponding author gentian vyshka rr. dibres 371, tirana, albania. tel: (+355) 5697566130 email: gvyshka@gmail.com received: 31 mar 2019 accepted: 26 may 2019 published: 27 aug 2018 citation to this article: vyshka g. the unlikely legalization of medical cannabis in albania: a case study. j med ethics hist med. 2019; 12: 10. gentian vyshka faculty of medicine, university of medicine, tirana, albania. abstract cannabis abuse has been an issue of major concern for the albanian society in recent years, following the wide illegal planting of the species. legal lacunas, weaknesses from the drug-controlling agencies, and the easiness of harvesting cannabis sativa plants have contributed to the creation of a general negative opinion toward a potential use of its active principles for medical purposes. professionals of the field and policymakers are largely focused on harm reduction activities, thus bypassing the option of legalizing cannabinoids for clinical conditions that might find relief in their use. the discussion of a case suffering from postherpetic neuralgia shows how this negative opinion is depriving albanian patients from an otherwise helpful pharmacological option whose efficacy has been confirmed by an important bulk of research. uncovering the roots of this misperception will help address the issue. clinicians with expertise need to have their say in the debate, since for the majority of countries where medicinal cannabis is legalized, this was due to consumer-led initiatives. ensuring patients’ freedom as implied within the principle of autonomy is also a sound ethical support of such legalization. keywords: medical ethics; cannabis; legalization; tetrahydro-cannabinol (thc); policymaking mailto:gvyshka@gmail.com the unlikely legalization of medical cannabis in albania: a case study … 2 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 10 august 2019 introduction cannabis and marijuana have become an issue of major concern in albania in recent years, mainly due to an unprecedented wave of illegal planting and trafficking. a variety of reasons have led to this phenomenon, including economic hardship, legal lacunas and law enforcement weaknesses, the high quality of the plant in terms of thc (tetrahydro-cannabinol) concentrations, and the easiness of its harvest (1). this situation has rendered very unlikely the option of legalizing medical cannabis, at least in the near future. not only is the public perception of cannabis strongly deformed, but also prejudice and ignorance among policy-makers and professional staff is seriously hampering its legalization. beyond the absent discussions about the clinical adequacy or lack of efficacy of the thc and cannabinoids in certain medical conditions, albanian politicians, professionals and laypersons are conjointly focusing on harm reduction approaches (2, 3). this is obviously related to the fact that cannabis is the most widely abused agent after alcohol, according to recently published data. thus, ethanol apart, it might account for more than 80% of all cases of drug abuse, including illegal agents such as heroin and cocaine, or sedatives licensed for medical purposes (with benzodiazepines on the top of the list) (4). case description an octogenarian with severe post-herpetic neuralgia, unresponsive to all licensed drugs used in albania for pain, neuropathy and chronic painful conditions, was desperately seeking relief. in spite of consultancies and referrals in pain centers, the aching and suffering was relentless, especially at night. conventional antalgics (non-steroidal antiinflammatory drugs), tramadol and oxycodone were sequentially administered with very little success, if at all. after several sessions, visits and examinations, the treating clinician lost contact with the patient. a few weeks later he met by chance the old man’s son, who told the doctor that each evening he was giving his father some drops of handmade hashish oil whose concentration he ignored, but that worked pretty well. in this case, cannabis was not being used under professional supervision, but that does not necessarily mean the treatment was illogical from the medical point of view. the patient’s son was obviously breaking the common law, even facing arrest if caught with whichever quantity of hashish. yet the drug was achieving what had seemed impossible: it was alleviating the unbearable pain of his father. discussion some moral dilemmas might be formulated in relation to this case. the family physician was no more in the position of a treating doctor, since he was unaware of the treatment. the post-factum searching of his opinion could not contradict the efficacy of the drug, especially when all other previous options had failed. turning a blind eye would probably exculpate the doctor from vyshka g. 3 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 10 august 2019 not denouncing a situation of illegal use of prohibited drugs, which seems not the case as long as that happened out of his sight. questioning the morality and the moral basis of offering a therapeutic option to aching patients in painful conditions – in this case cannabis – is an issue that has raised discussions and arguments even among judicial authorities and scholars (5, 6). demonizing cannabis in toto and upholding an aprioristic position of exclusion is mainly due to a defective perception of the plant. this misperception is obviously depriving albanian patients from an otherwise helpful pharmacological option, with the general public equalizing its usage with crime and antisocial behavior in the worst of cases, or exhibiting a sense of phobia in others. politics has largely prevailed over medical reasons, and it seems this is not a local or a localized phenomenon (7). weak and flawed political discussions have hardly helped the progress toward a probable legalization for medical purposes, and after an initial acme during the years 2014 2015, the issue has been almost entirely pushed aside. at that time there were some albanian members of the parliament suggesting a mitigation of legal penalties for cannabis abusers, together with its legalization for medical purposes. with the society having other priorities, and the general public ignoring the quintessence of the discussion, oblivion prevailed in the midst of an ever flourishing illegal harvesting and consumption. uncovering the roots of this misperception will help address the issue, and redress the prejudicial elimination of medical cannabis from being available on the market. very few attempts have been made to uncover the medical values of the plant to the albanian public, whose perception of cannabis consumption remains strongly impregnated with fear and a feeling of doing something wrong, even if not caught and prosecuted. a big deal of this misperception relies on the terminology. in fact, hashish entered the everyday albanian language not directly from the arab language, but rather during the historical period when the country was part of the ottoman empire. the misspelling of hashish (from arabic “grass”) as hashash (the later usage of turkish haşhaş, which means “opium”) has largely served to increase confusion, and made laypersons consider cannabis as strong, dangerous and addictive as heroin itself. on the other hand, latin influences probably have not spared albanian semantics: for most of the latin-derived languages, hashish may have served as an origin to the word assassin, although this still might be an etymological speculation. some authors suggest the term to stem from the order of the haschischins, founded in the sixth century a.d., whose members consumed cannabis deliberately during combat preparations (8). since the chemical extraction of its active principle (thc, tetra-hydro-cannabinol) more than half a century before, attempts toward convincing policymakers in favor of legalizing cannabis for medical purposes have not been systematic and unfortunately not always successful. as one of the thc discoverers and an author on the subject, the unlikely legalization of medical cannabis in albania: a case study … 4 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 10 august 2019 mechoulam has reported his experiences and suggested obvious advantages that produces medical cannabis for patients in need, as an agent already legalized in scores of countries (2, 9). apart from having intrinsic antinociceptive effects, cannabis-derived byproducts (thc and other cannabinoids) might be useful for their antalgic properties, especially when aiming at lowering the dosage of opiates, if not substituting these completely in selected conditions (10, 11). the major drawback of all these debates is that clinicians, i.e. the authorities that will prescribe cannabis once medically legalized, have been largely silent (12). during an accurate analysis of the issue, newtonhowes and mcbride conclude that medicinal cannabis has mostly been a consumer-led initiative, and that the sociopolitical prejudices of the day contribute more toward its prohibition, rather than focusing on the real harms (12). conclusion in an important, delicate issue such as legalizing cannabis for medical purposes, physicians and treating clinicians need to have the final say. clearly, the legal status of cannabis as a drug of abuse must remain separated from the medicinal framework (12). large-scale and multicenter clinical trials that will convince policymakers to opt for marketing medical cannabis are difficult to implement as long as prohibition stands strong. even the contrary perspective, i.e. the view that the prohibition of cannabis can be based on medical reasons, is erroneous (13). to make decisions more simple, comprehensive and logical, one should remember that freedom of individuals as implied within the principle of selfdetermination or autonomy seems a sound ethical reason to allow the use of medical cannabis (13). ethics and the slippery-slope arguments, for instance policymakers’ fear that cannabis legalization will serve as a gateway for stronger and earlier addiction disorders, remain elusive (14, 15). yet this position, so far, is hampering a logical and medicallyoriented ad hoc legislation in albania, when some countries have already advanced in this direction and enacted it accordingly (5, 6, 16). acknowledgements none. conflict of interests nothing to declare. vyshka g. 5 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 10 august 2019 references 1. bruci z, papoutsis i, athanaselis s, et al. first systematic evaluation of the potency of cannabis sativa plants grown in albania. forensic sci int. 2012; 10; 222(1-3):40-6. 2. mechoulam r. plant cannabinoids: a neglected pharmacological treasure trove. br j pharmacol. 2005; 146(7): 913-5. 3. hughes b, wiessing l, des jarlais d, griffiths p. could cannabis liberalisation lead to wider changes in drug policies and outcomes? int j drug policy. 2018; 51:156-59. 4. matua l, muharremi g, petrela e, koçibelli m, vyshka g, xhemali b. the use of psychoactive substances and illegal drugs in the albanian society. curr drug res rev. 2019; 11(1):73-9. 5. blumenson e, nilsen e. liberty lost: the moral case for marijuana law reform. indiana law journal. 2010; 85(1): 279. 6. pfeifer dj. smoking gun: the moral and legal struggle for medical marijuana. touro law review. 2011; 27:339-78. 7. clark pa, capuzzi k, fick c. medical marijuana: medical necessity versus political agenda. med sci monit. 2011; 17(12): ra249-ra261. 8. candela garcía e, espada sánchez jp. una revisión histórica sobre los usos del cannabis y su regulación. salud y drogas. 2006; 6(1): 47-40. 9. mechoulam r, gaoni y. a total synthesis of dl-delta-1-tetrahydrocannabinol, the active constituent of hashish. j am chem soc. 1965; 87: 3273-5. 10. lötsch j, weyer-menkhoff i, tegeder i. current evidence of cannabinoid-based analgesia obtained in preclinical and human experimental settings. eur j pain. 2018; 22(3):471-84. 11. khan sp, pickens ta, berlau dj. perspectives on cannabis as a substitute for opioid analgesics. pain manag. 2019; 9(2):191-203. 12. newton-howes g, mcbride s. medicinal cannabis: moving the debate forward. n z med j. 2016; 129(1445):103-9. 13. hayry m. prescribing cannabis: freedom, autonomy, and values. j med ethics. 2004; 30(4): 333-6. 14. helgesson g, lynøe n, juth n. value-impregnated factual claims and slippery-slope arguments. med health care philos. 2017; 20(1):147-50. 15. de hoop b, heerdink er, hazekamp a. medicinal cannabis on prescription in the netherlands: statistics for 2003-2016. cannabis cannabinoid res. 2018; 3(1): 54-55. 16. reis-pina p. the prescription of medicinal cannabis and the virtue of prudence: without phobia(s) nor philia(s). acta med port. 2019; 32(4): 323-24. ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ 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medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. review article volume 12 number 3 march 2019 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e medical ethics and the trolley problem *corresponding author gabriel andrade no. 23, raeligh quay, georgetown, cayman islands. tel: (+58) 4265651980 email: gabrielernesto2000@gmail.com received: 14 june 2018 accepted: 30 sep 2018 published: 17 mar 2019 citation to this article: andrade g. medical ethics and the trolley problem. j med ethics hist med. 2019; 12: 3. gabriel andrade assistant professor, department of ethics and behavioral science, school of medicine, st. matthew’s university, cayman islands. abstract the so-called trolley problem was first discussed by philippa foot in 1967 as a way to test moral intuitions regarding the doctrine of double effect, kantian principles and utilitarianism. ever since, a great number of philosophers and psychologists have come up with alternative scenarios to further test intuitions and the relevance of conventional moral doctrines. given that physicians routinely face moral decisions regarding life and death, the trolley problem should be considered of great importance in medical ethics. in this article, five “classic” trolley scenarios are discussed: the driver diverting the trolley, a bystander pulling a lever to divert the trolley, a fat man being thrown from a bridge to stop the trolley, a bystander pulling a lever to divert a trolley so that a fat man may be run over, and a bystander pulling a lever so that a fat man falls off from a bridge to stop the trolley. as these scenarios are discussed, relevant moral differences amongst them are addressed, and some of the applications in medical ethics are discussed. the article concludes that trolley scenarios are not the ultimate criterion to make ethical decisions in difficult ethical challenges in medicine cases but they do serve as an initial intuitive guide. keywords: trolley problem; medical ethics; non-maleficence; abortion; euthanasia medical ethics and the trolley problem 2 volume 12 number 3 march 2019 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e introduction the primacy of non-maleficence in medical ethics with some oversimplification, it could be argued that medical ethics is about balancing the four main principles long recognized as central in medical practice throughout the ages: autonomy, beneficence, nonmaleficence, and justice (1). it is commonly agreed that, ever since the beginnings of ethical reflection, non-maleficence has been the most important of all principles, and should be given priority when in conflict with others (2). although hippocrates did not explicitly mention the phrase “first do no harm” in his oath (the original version actually states, “abstain from doing harm”), it is enshrined in the common medical understanding of ethics (3). and indeed, this principle prevails above others. take, for example, the case of a person suffering from minor pain, who asks her doctor for a massive administration of morphine. when considering the principle of autonomy, it would seem that the right thing to do is to, indeed, comply with the patient’s request. but, as much as morphine is a dangerous substance with great abuse potential, the physician should be aware that its administration will ultimately cause great harm. in this case, autonomy would be at odds with non-maleficence, and the doctor must privilege the latter over the former. first, do no harm. although the patient may desire a specific procedure, the physician is required to think about whether or not that particular procedure will be harmful for the patient. if in conscience the doctor does believe that the procedure will be harmful, then it should not be prescribed, even if the patient asks for it. non-maleficence may also be at odds with beneficence. most doctors have the legitimate desire to do good, but as the popular saying goes, the road to hell may sometimes be paved with good intentions. some procedures may appear to be good in the short term, but they could have very prejudicial consequences in the long term (or perhaps even in the short term). again, the prime principle in medical ethics is first doing no harm. if, by trying to address a health problem out of a concern with beneficence, the doctor puts the patient in an even worse condition, then that procedure should not be done. that is why, amongst other things, when it comes to new biotechnologies, most ethicists prescribe a cautionary principle (4). for the most part, we do not have full knowledge of how some of the newer biotechnologies work, and it is therefore better to suspend the administration of those biotechnologies until further knowledge about their workings is gathered. even if those biotechnologies offer good solutions to particular health problems, they may in fact cause even greater harm. justice may also clash with non-maleficence, and again, the latter should take precedence. the just allocation of resources in health care may sometimes imply procedures that will ultimately do more harm to patients. consider, for example, a famous case put forth by philosopher philippa foot and ever since widely popularized: a surgeon has five patients who are waiting for organ transplants. the patients will die if they do andrade g. 3 volume 12 number 3 march 2019 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e not receive the organs, but the organs are not available at the time. the whole prospect changes, however, when a young traveler comes to town and goes in for a routine checkup. the doctor is performing the checkup when he realizes that the traveler’s organs are healthy and incidentally compatible with his dying patients. the young man is the perfect donor, and no one would associate him with the surgeon if he were to disappear (5). the dilemma here is, should the doctor remove the organs from the healthy man in order to distribute them to the dying patients? of-course not. although it may be a more efficient and even just allocation of resources, it would still be a moral monstrosity to authorize such a transplant. the reasoning here is that nonmaleficence takes precedence over the other ethical principles. it is safe to argue, then, in favor of the primacy of non-maleficence, but medical ethicists seldom ask why that should be the case. what authorizes first doing no harm? it seems that much of this reasoning relies on strong intuitive appeals. nevertheless, these intuitive appeals face an important critique, as there may be some additional intuitions illustrated by other cases, in which it does not seem to be so clear that non-maleficence should take primacy. discussion 1. the first trolley case philosophers conventionally call the “trolley problem” a series of bizarre questions and dilemmas that derive from some particular situations that elicit moral responses. they make reference to a trolley because, in the variants, the cases are about trolleys going down the tracks, and on their course, they run down persons who are helplessly tied to the tracks. the purpose of these cases is to test intuitions, so as to decide what actions are morally correct. these intuitions can be extended to cases (mostly medical, although by no means exclusively so, for they may also have military applications) that are structurally similar, and on that basis, we may decide what the proper course of action is. the first trolley scenario was proposed by philippa foot (6), and is about a trolley that is going down the tracks, and is set on course to run down five people who are tied to the tracks. the driver of the trolley has the option to divert the trolley onto another track in which only one person is tied. foot wondered whether or not the driver should divert the trolley. foot answered that, indeed, the driver should divert the trolley. a simple calculation shows why this is so. if the driver keeps the trolley on its tracks, five people will be run over and die. if, by contrast, the driver diverts the trolley, only one person will die. it seems ethically acceptable to kill one person in order to save five. nonetheless, foot herself warned that it is not always ethically fine to kill one person to save five. consider the case of the transplant mentioned above: a surgeon thinks about a healthy person who shows up at a hospital, and five terminally ill patients who can get cured with that person’s organs. should that medical ethics and the trolley problem 4 volume 12 number 3 march 2019 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e person be killed so that the other five survive? surveys show that, overwhelmingly, respondents disapprove of such a transplant (7). foot also disapproved, yet she wondered why in the case of the trolley it is morally acceptable to kill one in order to save five, whereas in the case of the transplant it is not morally acceptable to kill one in order to save five. her answer relied on a distinction between negative duties and positive duties. we have duties not to do certain things, and duties to do certain things (i.e., negative and positive, respectively). in foot’s estimation, negative duties are more important than positive duties, and if they ever come into conflict, negative duties should be given priority. in the case of the transplant, there is indeed the positive duty to help the five patients. however, there is the even greater negative duty of not harming the healthy person. although foot does not address this issue, we may even ask whether the healthy person’s consent would justify killing him in order to transplant his organs to save the five. the standard answer in medical ethics would be that, even in that case, it would be unethical for a doctor to carry on such a procedure. again, non-maleficence overrides autonomy. in the case of the transplant, the dilemma is between killing one and letting five die. foot clearly argues that there is no moral justification to kill the one person, as killing is a greater offence than letting die, even if five are left to die, and only one is killed. the negative duty towards the one is greater than the positive duty towards the five. yet, how is this different from the driver who diverts the trolley, thus killing one in order to save five? foot argues that, in this case, the dilemma is different. it is no longer a dilemma between killing one and letting five die, but rather, between killing one and killing five. by default, the driver’s original action (setting the trolley in movement) will end up in killing five people. he may choose to take another action, and thus kill one. in both scenarios, his action will ultimately kill someone. if that is the case, then it is better to kill one than to kill five. the driver has the duty not to kill anybody. but, given that his actions will ultimately kill someone, the lesser evil is to kill as few people as possible. therefore, he is morally required to switch the trolley onto another track. this first variant of the trolley problem supports the primacy of non-maleficence in medical ethics. the five patients may die as a result of the transplant not taking place, but the surgeon is not ethically at fault since he has done no harm, and that is a doctor’s most important duty. in order to save the five, he would have had to kill the one person. the surgeon wisely refuses to engage in such a procedure in deference to non-maleficence. the driver of the trolley, by contrast, does have the moral obligation to kill one in order to save five, because those five will die as a result of his own initial action. as opposed to the doctor, the driver is not in a position to claim that his duty is to first do no harm. this is because the driver already has done some harm by setting the trolley on course to kill five people. his moral duty is to take additional action to minimize his initial andrade g. 5 volume 12 number 3 march 2019 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e harm. killing one is not better than letting five die, but killing one is indeed better than killing five. foot’s reasoning (and, as a corollary, the primacy of non-maleficence in medical ethics) relies on the assumption that there is a significant difference between omissions and actions, and this corresponds with negative duties vs. positive duties. yet, this has been challenged by some philosophers, notably james rachels (8). foot believes there is an important ethical difference between killing and letting die. rachels, by contrast, believes the difference is not significant. consider the following case as an instance: a woman desires her uncle to die, and administers poison in his coffee. another woman also wants him dead, and is about to give him poison, but then she notices that he drinks poison from another source. she then observes him dying, and withholds the antidote in her pocket. rachels argues that, in this case, neither of the women is worse than the other, and intuitively, he seems to be right. according to rachels, this indicates when it comes to killing and letting die, there is no significant difference. it also proves that there is no major difference between negative and positive duties. rachels thus subscribes the equivalence thesis regarding killing and letting die. if rachels is right, then his claim has big implications on medical ethics, and the primacy of non-maleficence can be put into question. rachels himself has been a defender of euthanasia. medical ethicists conventionally differentiate between passive euthanasia and active euthanasia. passive euthanasia proceeds by letting patients die (for example by withholding treatment or disconnecting artificial ventilators), whereas in active euthanasia death is induced through additional procedures, such as administering specific substances. medical ethicists typically allow for passive euthanasia if the patient consents, but condemn active euthanasia even if the patient consents (9). for the most part, legislations also support this moral stand. in no country is it illegal to withhold treatment if it is the patient’s wish, but in the overwhelming majority of countries it is illegal to actively induce death, even if the patient asks for it. the moral rationale is that there is a difference between killing and letting die, and therefore, this supports the primacy of non-maleficence. yet, if rachels is right and his example is intuitive and powerful enough, the difference between killing and letting die collapses, and as a result, non-maleficence may not be as primal as traditionally thought. sometimes, it may be morally acceptable to actively do harm, for instance by killing someone in order to stop that person from suffering. although rachels’ hypothetical scenario is intuitive, there are plenty of other scenarios that lead our intuitions towards the original idea that killing and letting die are two very different things. there is a fundamental difference between murdering someone and letting hundreds of unfed children die in some third world country due to medical ethics and the trolley problem 6 volume 12 number 3 march 2019 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e indifference. we may have the moral obligation to care for those children, but it seems that that neglect will never be morally equivalent to murder. 2. the second trolley case intuitions, as laid out in foot’s arguments, seem to support the primacy of nonmaleficence, which justifies not killing a healthy person to distribute his organs to five sick patients. even when harm is already done, there is justification to seek the lesser harm, as in the case of diverting the trolley to kill one instead of five. in order to test new intuitions, philosophers have further come up with additional trolley cases. as it turns out, in some cases, it seems like causing harm is the right thing to do. consider, for example, a variant of the trolley problem devised by judith jarvis thomson (10). in this scenario, very much as in the first one, a trolley is going down its path and it will run over five people. there is the option of diverting the trolley onto another track in which one person is tied. however, the difference in this case is that it is not up to the driver, but rather to someone standing by, to switch the trolley by pulling a lever. should the bystander pull the lever? the fact that the decision now has to be made by a bystander and not the driver is of great importance, as the bystander faces a different dilemma. in foot’s analysis, the driver must decide whether he should kill five people or one, and that is why it seems morally acceptable for him to divert the trolley. the bystander, however, was not responsible for setting the trolley on its original course in the first place, and if the trolley runs over five people by going down its original path, it will not be his responsibility. if, instead, he diverts the trolley on the track to kill the one person, then it will be his responsibility. thus, the bystander’s dilemma is not killing one versus killing five, but rather, killing one versus letting five die. we have already established that, putting rachels’ objections aside, there seems to be a significant difference between killing and letting die. that is why killing one is worse than letting five die. this explains well the moral intuitions most people have when it comes to a healthy person being killed so that his organs are distributed amongst five patients. yet, surveys consistently show that in the case of the bystander who has the option of pulling the lever to divert the trolley and kill one person in order to save five, the overwhelming majority of respondents have the intuition that the bystander would be morally obligated to pull the lever (11). somehow in this case, letting five die is worse than killing one. the intuition in favor of the primacy of nonmaleficence, then, does not seem as strong as it originally appeared. perhaps in some cases, the rule of first doing no harm can be relaxed. the bystander would unmistakably be causing harm by pulling the lever and killing the one person on the diverted track, but he would most likely be lauded. yet, even if the principle of non-maleficence may be somewhat relaxed, there is still a need to be precise about when such relaxation can take place. in part, this can be andrade g. 7 volume 12 number 3 march 2019 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e done by trying to find a difference between the case of the surgeon who intends to kill a person so that five patients get his organs, and the case of a bystander who pulls the lever to divert a trolley to kill one person instead of letting five die. in both cases, the dilemma is between killing one and letting five die, yet intuitively, the morally right thing to do is very different. the standard philosophical answer (the one tentatively provided by thomson herself) is that, although in both cases the dilemma is between killing one and letting five die, there is a crucial difference. in the case of the surgeon seeking to kill a person to distribute his organs to five patients, that person is being used as a means to an end. in turn, in the case of the bystander who pulls the lever to divert the train to kill one person, that person would die as an unfortunate side effect of the bystander’s decision, but would not be used as a means to an end. if, somehow, the person in the hospital could escape, the surgeon’s plan to save the five patients would be shattered. in that sense, the person in the hospital becomes a means to save the five patients. if instead, somehow the one person in the track could escape, that would not shatter the bystander’s plan to save the five that are tied to the other track. in that sense, the one person in the track does not become a means to save the other five. this distinction relies on kant’s moral philosophy (12). kant famously argued that part of the moral imperative is never to treat other people as means to ends, even if those ends are praiseworthy. kant’s philosophy is emblematically deontological, as opposed to utilitarian. deontological ethics prescribes that moral agents do the right thing on the basis of duty, regardless of the consequences, or as the poetic phrase goes, “even if the heavens fall” (13). utilitarian ethics, instead, allows for more accommodation, as long as the end results bring about a higher quantity of good; utilitarian ethics are consequentialist, in the sense that the worth of an action is not in its intrinsic moral character, but rather in its consequences. for kant, if some action implies using someone as a means to an end, then that action is wrong, even if it leads to greater good. that is why killing the potential organ donor is wrong, but killing the person tied to the track is not wrong. most legislations follow these kantian principles, and medical ethics is for the most part deontological. the rule of first doing no harm holds most of the time. yet, even in those cases where some harm must be done, the kantian principle still applies: the harm done to someone must never be a means to achieve an end. as an example consider vaccines. although pseudoscientists and popular media often exaggerate (to the point of being grossly irresponsible) (14), it is nevertheless true that vaccination campaigns do cause some harms, sometimes even deaths. vaccinators are responsible for these deaths, yet, by doing so, they are able to save a far greater number of people who would otherwise die of preventable diseases. strictly speaking, vaccinators face the dilemma of killing a medical ethics and the trolley problem 8 volume 12 number 3 march 2019 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e few versus letting many die. if the principle of non-maleficence were to be applied very strictly, then vaccinators should refrain from administering vaccines, because after all, they do cause some harm. yet, vaccines are considered a great moral good. this is because the case of vaccines is of the same class as the bystander who must pull the lever, and of a different class than the surgeon who thinks of killing a person to distribute his organs to save five patients. vaccines are considered a moral good, inasmuch as those few deaths are only side effects, and not the means, to save the greater number of lives. if somehow vaccines could be administered and no deaths would occur as a result, the plan to save more lives would not be shattered. that is how sometimes doing harm may indeed be justified. 3. the third, fourth and fifth trolley cases apart from the kantian approach, philosophers have also devised another important concept as a caveat to the primacy of non-maleficence: the doctrine of double effect. although this doctrine had many antecedents, it was first formally proposed by thomas aquinas in the context of military ethics (15). aquinas is one of the great contributors to the just war tradition, i.e., a philosophical consideration about how and when it is morally acceptable to wage war. aquinas acknowledged that, in every war, innocent lives will be lost, but that need not morally invalidate military actions. civilians’ deaths are morally acceptable, as long as they come as a result of what in military jargon is called “collateral damage”. granted, this rather unfortunate phrase has been abused in recent times by reckless politicians and generals, but it still has a legitimate philosophical use. according to aquinas, some actions may have not just one effect, but rather two, and the moral quality of those effects may vary. a given action may have one set of good effects, and one set of bad effects. again, a strict compliance with the principle of nonmaleficence would require that those actions never be carried out in the first place, because they will cause some harm, and the prime duty is to first do no harm. however, aquinas’ principle of double effect allows for some actions to have bad effects, as long as some conditions are met. first of all, the action itself must be morally good or morally neutral. second, very much as in kant’s formulation, the bad effect must not be the means by which the good effect is achieved. third, the motive must be to achieve only the good effect. and fourth, the good effect must be greater than the bad effect. in its military applications, this doctrine would allow the bombing of the enemy’s bases, and as a result, the death of some civilians. the bad effects (the civilians’ death) are proportional to the good effects (for example, the destruction of the enemy’s air force), and most importantly, the bad effects are not means to the good effects. if somehow the civilians could survive the bombing, the plan would still hold. this is very different from, for instance, the atomic bombing of hiroshima. even if, as sometimes (dubiously) claimed, this atomic andrade g. 9 volume 12 number 3 march 2019 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e bombing brought about the end of world war ii, it would still be considered immoral, because the civilians were directly targeted, and their death became the means to the end. if somehow hiroshima’s civilians survived the atomic bomb, the original plan would not have worked. the bad effects may be foreseen, but never intended. to get back to medical ethics, consider the case of vaccines previously mentioned. a public health official may foresee that, when a vaccination campaign is begun, some people will die as a result of the vaccines themselves. yet, the public health official will never intend such deaths, and he will anticipate that the few deaths caused by vaccines are far fewer than the lives saved by the vaccine, thus complying with the requisite of proportionality. the public health official intends to save a greater number of people from dying of preventable diseases; he does not intend to have a very small number of people die from vaccine administration. can we then rely on the doctrine of double effect? thomson herself came up with yet another trolley scenario, in order to test intuitions regarding this doctrine. consider a trolley that is going on its path, and it is about to run over five people tied to the track. the trolley is about to go underneath a bridge; on that bridge, there is a fat man. if that fat man is pushed over the bridge, his weight will stop the oncoming trolley, he will die, but the five tied to the track will be saved. should the fat man be pushed? when asked about the bystander who pulls the lever to redirect the trolley and kill one person, the overwhelming majority of respondents morally authorize the hypothetical bystander. however, when those same respondents are asked about pushing the fat man, the percentage of approval is much lower (11). this is at first strange, because in terms of numbers, both cases are structurally similar: killing one versus letting five die. however, the doctrine of double effect makes the difference clearer. the bystander foresees the death of the person attached to the track, but does not intend it. by contrast, the person pushing the fat man not only foresees the fat man’s death, but also intends it. the fat man’s death is the means to save the five persons tied to the track. it may be objected that the fat man’s death is not really intended. whoever pushed the fat man only wanted him to serve as a buffer against the incoming trolley, and did not wish his death per se. however, proponents of the doctrine of double effect counter that, if in factual terms an action is intrinsically inseparable from its immediate consequence, then that particular consequence must be considered as intended. in that regard, whoever pushes the fat man to stop the trolley, truly intends the fat man’s death, even if that person claims differently. again, this has implications on medical ethics and the principle of non-maleficence. some medical procedures cause harm, but that need not imply that a physician should refrain altogether from administering such procedures. if the action causes harm but also an even greater good, and if the harm is medical ethics and the trolley problem 10 volume 12 number 3 march 2019 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e foreseen but not intended, then the action can indeed be carried out. this principle has applications in two very delicate subjects in medical ethics: abortion and euthanasia. consider the case of a pregnant woman who has been diagnosed with uterine cancer, and the only way to treat her is by removing the uterus (16). this will end the fetus’ life. yet, even those religious traditions (especially catholicism) that are staunchly opposed to abortion, would allow such a procedure, on the basis of the doctrine of double effect. although the surgeon may foresee that by removing the uterus, the fetus will die, he does not intend it. however, performing an abortion just because the mother’s life is in danger, but directly targeting the fetus, would not be allowed according to catholic standards. again, this would not receive moral approval, because the harm would be intended, and not merely foreseen. similarly, consider the case of a terminal patient whose death is imminent and is in severe pain. in order to alleviate pain, the physician administers a dose of morphine, and as a result, the patient dies (17). is this euthanasia? not strictly speaking. although the administration of morphine did cause the death of the patient, it only came about as a result of a morally neutral action, i.e., administering morphine. the doctor may have foreseen, but never intended, the patient’s death. his intention was not to kill the patient, but to relieve his pain. if the patient had survived the morphine shot, the doctor would have been satisfied. in a case like this, the patient’s condition must indeed be terminal, and her death imminent. after all, death is the greatest harm, and death as a side effect does not seem to be proportional to the action, hence violating the requisite of proportionality. yet, if the patient is about to die anyways, then the patient’s death may be tolerated as an unintended side effect of the pain alleviating action. this would be different from, for example, mercy killing. consider this case, as suggested by tony hope: a truck is on fire, with the driver trapped inside. he cannot be saved, and will soon die. the driver has a friend who is outside the tuck with a gun in his hand. if the driver asks this friend to shoot him, he will die a much less painful death than if he burns alive in the flames (18). hope attempts to make the case that the moral thing to do would be to shoot the driver in order to relieve his desperate pain. yet, according to conventional medical ethics, relying on the doctrine of double effect, killing the driver would be immoral. even if the ultimate intention is the relief of pain, there is the mediating intention of killing the driver. as opposed to utilitarianism, the doctrine of double effect does give its share of importance to intentions. in that regard, such a doctrine is part of the deontological understanding of ethics. harms may be done, but they can never be intended, only foreseen. this case of mercy killing suggests that, perhaps in some cases, the doctrine of double effect should be put on hold, given the desperation of the person who asks to be killed. thomson herself came up with yet another trolley scenario that puts in doubt the relevance of the doctrine of double andrade g. 11 volume 12 number 3 march 2019 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e effect. consider a trolley that, on its path, will run over five people tied to the track. there is a looping track that eventually goes back to the original track. in that looping track, a fat man is tied. if the trolley is diverted onto the looping track, the weight of the fat man will stop the trolley, and thus, the five lives will be spared. should a bystander pull the lever to divert the trolley? surprisingly, most respondents to this question approve of diverting the trolley in this case (11). this is very strange. in this case, the fat man is used as a means to an end. if somehow he escapes, the plan to save the other five is shattered. the fat man needs to die in order to save the others. his death is not merely foreseen; it is actually intended, as it forms an integral part of the plan. nevertheless, the same respondents who typically object to throwing down the fat man from the bridge have no qualms about diverting a trolley to run him over, precisely because he is a means to save the five. this seems to prove that, intuitively, the doctrine of double effect is not as robust as it may appear. in some circumstances, harm can be done, even intentionally so, if it actually leads to a greater good. thomson put forth this scenario in order to challenge the doctrine of double effect. however, she did not really attempt to offer an explanation as to why the case of the fat man being thrown from the bridge seems morally repugnant, but the case of the fat man being run over by the trolley in the looping track seems to gain moral support. indeed, it remains mysterious to most philosophers. perhaps the difference is that in the case of the fat man being thrown from the bridge, the action is deliberately initiated by the person who throws the fat man. however, in the case of the bystander diverting the trolley in order to run over the fat man, the bystander has not initiated the action, but is only intervening in the last minute. the intervention is clearly direct in the former case, but less so in the latter, and intuitively, this seems to be an important moral difference. in other words, the level of participation in the act seems to be relevant here. yet another trolley scenario seems to support this notion. suppose that the fat man is standing on the bridge, but instead of pushing him off to stop the trolley, someone may pull a lever to open a trap underneath the fat man so that he falls off from the bridge and is run over by the trolley. should the lever be pulled? surprisingly, the percentage of respondents who approve such an action is significantly greater than the percentage of respondents who approve of the fat man being thrown by conventional means (19). this seems to support the intuition that a harm being done, even if both foreseen and intended, is still more excusable if somehow the mechanism is not as direct. this may also have important implications in medical ethics, especially in regard to euthanasia. as of now, most legislations disapprove of euthanasia. in euthanasia, the death of the person is intended, and this is seen as a violation of the moral principle of not intending harm. yet, if somehow the means medical ethics and the trolley problem 12 volume 12 number 3 march 2019 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e to bring about the death of the person were not so direct (such as, for example, assisting the patient’s death instead of directly causing it), then perhaps that could receive greater moral approval. the rule about first doing no harm could be relaxed in favor of a rule allowing harm to be done, as long as the means of doing that harm are not so direct. thus, the trap door scenario in trolley discussions should be considered in discussions about physician-assisted suicide. conclusion do intuitions really matter? a considerable number of variations have been tried in trolley problem experiments with surveys, and as a result, psychologists now know better what psychological variables may lead respondents to answer differently. for the most part, it has been established that cognitive overload, reminders of death, and emotional appeals tend to condition subjects to be more deontological in their answers (20). by contrast, exposure to jovial or funny situations tend to condition subjects to be more utilitarian. similarly, subjects with psychopathic tendencies and brain damage in the ventromedial area are also more likely to take actions to save a greater number of people, disregarding kantian or double effect principles (21). utilitarian philosophers have traditionally given little importance to intuitions. not surprisingly, most of these philosophers have some affinity with the analytic tradition, and their approach attempts to be entirely cognitive. cases must be analyzed rationally, regardless of what emotions or intuitions may tell us. this strict reliance on rationality makes utilitarian philosophers much more likely to care about numbers. in their view, the bottom line is, as bentham famously claimed, to achieve the “greatest good for the greatest number” (22). in all the trolley scenarios, utilitarians would favor whatever option in which the greater numbers of lives are saved. the moral value of an action is not in its intrinsic nature, but rather in its consequences. utilitarians do not seem to have much patience with the primacy of non-maleficence, precisely because ultimately, this principle may trump achieving the greatest good for the greatest number. utilitarians disregard the power and relevance of intuitions. in their estimation, morality should be based on a thorough rational approach, and if that implies overriding some powerful feeling, so be it. utilitarians legitimately complain that some needed modifications, in both the ethical and legal understanding of medical practice, are stopped because of emotional repulsion rather than rational analysis. in the utilitarian view, there should be no yuck factor in medical ethics (23). yet, utilitarians may be willing to admit some caveats. perhaps not in every case should an action be done in order to save more lives. according to most utilitarians, actions should be morally judged on the basis of rules, and not acts (24). a particular action may be considered good in a particular situation, but if it is consistently done in the long term, it may turn out to be very bad. thus, perhaps throwing the fat man from the bridge would save more lives in that particular moment, but if fat men andrade g. 13 volume 12 number 3 march 2019 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e were consistently thrown from bridges, great panic would prevail in the society, and the consequences could even be worse. as applied to medical ethics, this caveat is relevant. particular medical procedures should be evaluated for their long-term consequences if they were to become rules. whether they judge actions on the basis of actions or rules, utilitarians still believe that this must be done on a rational basis, not an intuitive one. it is undoubtedly true that intuitions can be very deceiving, and a great number of psychological studies have been done to test people on simple cognitive tasks based on intuition, and getting them wrong (25). however, it is still open to debate whether or not moral intuitions can so easily be discarded. after all, as g.e. moore and other moral non-cognitivist philosophers have long claimed, morality is not about facts (26). in the absence of facts, when it comes to moral judgments, perhaps we ultimately have to rely on intuitions. trolley scenarios are not without critics, precisely because some philosophers see no relevance in intuitions when it comes to making moral judgments (27). other philosophers and psychologists believe the scenarios are too unrealistic to be truly meaningful (28). we may grant that it is extremely unlikely to find five people tied to the tracks of an incoming trolley, and to find a fat man standing on a bridge at that precise moment. yet, these scenarios are not totally unrealistic, because some structural similarities do remain when we compare them to particular cases of medical ethics as discussed above. for that reason, trolley scenarios will not be the definite criterion in order to decide on things such as euthanasia or abortion, but they may certainly be used as a tool in deliberations on medical ethics. acknowledgements the author wishes to acknowledge st. matthew’s university school of medicine for providing the bibliographic resources in order to carry out this research. conflict of interests the author declares that there is no conflict of interests. medical ethics and the trolley problem 14 volume 12 number 3 march 2019 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e references 1. edwards sd. nursing ethics: a principle-based approach. uk: palgrave macmillan ltd; 2009. 2. svoboda t. duties regarding nature: a kantian environmental ethic. new york: routledge; 2015, p. 24. 3. mehring s. first do no harm: medical ethics in international humanitarian law. netherlands: martinus nijhoff publishers; 2014, p. 29. 4. peel j. the precautionary principle in practice: environmental decision-making and scientific uncertainty. australia: federation press; 2005. 5. landsburg s. the big questions: tackling the problems of philosophy with ideas from mathematics, economics and physics. usa: free press; 2010, p. 45. 6. foot p. the problem of abortion and the doctrine of the double effect. oxford review.1967; 5: 5-15. 7. edmonds d. would you kill the fat man? usa: princeton university press; 2014, p. 56. 8. rachels j. killing and letting die. in: becker l, becker c. encyclopedia of ethics. 2nd ed. new york: routledge; 2001, vol. 2, p. 947-50. 9. loewy e. textbook of medical ethics. new york: springer science & business media; 2013. 10. thomson j.j. the trolley problem. yale law journal. 1985; 94(6): 1395-415. 11. tannsjo t. taking life: three theories on the ethics of killing. uk: oxford university press; 2015, p. 58, 63, 75. 12. atwell je. ends and principles in kant’s moral thought. usa: springer science & business media; 2012. 13. barry v. cengage advantage books: bioethics in a cultural context: philosophy, religion, history, politics. new york: cengage learning; 2011, p. 48. 14. hupp s,jewell j. great myths of child development (great myths of psychology). new york: john wiley & sons; 2015, p. 81. 15. reichberg g. thomas aquinas on war and peace. uk: cambridge university press; 2016, p. 175. 16. kelly df, magill g, have ht. contemporary catholic health care ethics. usa: georgetown university press; 2004, p. 112. 17. frith l, dowrick c. general practice and ethics (professional ethics). new york: routledge; 2012, p. 94. 18. hope t. medical ethics: a very short introduction. uk: oxford university press; 2004, p. 15. 19. shaver r. ethical non naturalism and experimental philosophy. in: nuccetelli s, seay g. ethical naturalism. uk: cambridge university press; 2012, p. 194-200. 20. greene jd. dual-process morality and the personal/impersonal distinction: a reply to mcguire, langdon, coltheart, and mackenzie. journal of experimental social psychology. 2009; 45(3): 581-4. 21. raine a, glenn a. psychopathy: an introduction to biological findings and their implications. usa: new york university press, 2014, p. 96. 22. bentham j. an introduction to the principles of morals and legislation. london: new york: courier corporation; 2012. andrade g. 15 volume 12 number 3 march 2019 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e 23. kelly d. yuck!: the nature and moral significance of disgust (life and mind: philosophical issues in biology and psychology). usa: mit press, 2011. 24. lyons d. forms and limits of utilitarianism. uk: oup oxford press; 1965, p. 121. 25. cappelen h. philosophy without intuitions. uk: oxford university press; 2012, p. 53. 26. hamid a. g e moore. new york: mittal publications; 1989. 27. hare rm. moral thinking: its levels, method and point. uk: oxford university press; 1982. 28. button t. the limits of realism. uk: oxford university press; 2013, p. 164. jmehm-7-19 journal of medical ethics and history of medicine ophthalmology in persian medicine seyed mahmoud tabatabaei1, nastaran sabetkish2, seyed mohammad ali tabatabaei3 1 professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran; 2pediatric urology research center, section of tissue engineering and stem cells therapy, children’s hospital medical center, tehran university of medical sciences, tehran, iran; 3postgraduate student, department of periodontics, dental faculty, babol university of medical sciences, babol, iran. corresponding author: seyed mahmoud tabatabaei address: #23, shanzdah azar st, medical ethics and history of medicine research center, tehran, iran. email: smtabataba_md@yahoo.com tel: 98 21 66 41 96 61 fax: 98 21 66 41 96 61 received: 20 sep 2014 accepted: 29 nov 2014 published: 03 dec 2014 j med ethics hist med, 2014, 7:19 © 2014 seyed mahmoud tabatabaei et al.; licensee tehran univ. med. sci. abstract despite the fact that ophthalmology is one of the foremost branches of medicine, conceptualization of the structure and function of the eye barely advanced in ancient western civilizations. at the early recovery of persian civilization (9th century ad) after the extinction of the sassanid empire (7th century ad), translations of greek medical textbooks played an important role in the development of medicine and the emergence of great persian physicians such as rhazes, avicenna and others. rhazes was a leading persian physician whose medical teachings have as yet not been thoroughly explored. in addition to numerous books and articles in various fields, he authored a great medical encyclopedia (al-hawi al-kabir) in 25 volumes. in this article, we are going to compare rhazes’ particular viewpoints about ophthalmology with those of other famous persian physicians and some recent essays and textbooks. for this purpose we reviewed rhazes’ second volume of al-hawi that is dedicated exclusively to ophthalmology and contains some major topics of ophthalmology including anatomy, physiology, pathology, diseases, disorders and treatments. important themes were carefully extracted and compared with the tenets of modern ophthalmology. after collating rhazes’ viewpoints with the latest findings in this field, it was concluded that he had brilliantly written about the signs and symptoms, etiology and treatment of many eye disorders more than a thousand years ago. the amazing point is that there was no accurate equipment at the time to help him in his investigations. this study proved that rhazes’ theories conform to recent knowledge about ophthalmology in many aspects, and could therefore be the subject of further investigations. keywords: rhazes, avicenna, ophthalmology, persian medicine, al-hawi mailto:smtabataba_md@yahoo.com j med ethics hist med 7:19 dec, 2014 jmehm.tums.ac.ir seyed mahmoud tabatabaei et al. page 2 of 6 (page number not for citation purposes) introduction considering the importance of vision as a basic human faculty, it seems that the hygiene of the eye, ocular diseases and their treatments were among the oldest concerns in the history of medicine. hippocratic medicine greatly influenced the advancement of all branches of medicine, including ophthalmology. the influence commenced in rome where galen helped develop this area of medicine (1, 2). according to historical documents, persia had a thousand year history in medicine (35). in the 9th century ad, when persian civilization began to recover after the fall of the sassanid empire two centuries ago, medical literature from different civilizations including greece, india and china reached the arab world and persia. the most important books from the point of view of scientific content and clinical application were dioscorides’ and galen's medical references. these works were translated mainly by leading christian physicians such as stephen, honein (johan), and others who lived in the islamic capital baghdad in the mid 9th century ad. these translations helped the evolution and development of medicine in arab countries and persia, and resulted in the emergence of great persian physicians such as rhazes, avicenna and others (6). muhammad ibn zakariya al-razi, known in western literature as rhazes, was one of the greatest and most influential persian physicians. using his great knowledge of persian, greek and indian medicine as well as his personal observations and discoveries, he wrote about 180 books and articles in various fields of science (7). alhawi, which is in fact a medical encyclopedia written in 25 volumes in the 10th century ad, is one of these books. it is a compilation of knowledge gathered from other works as well as rhazes’ own theories and clinical experiences. in the second volume of al-hawi, which is approximately 400 pages, ophthalmology is discussed exclusively (8). translation of this encyclopedia into persian first began in 1989. overall, four volumes were published, as well as a summary in three volumes entitled synopsis of al-hawi (9, 10). in this article, we aim to investigate the theories and clinical experiences of rhazes, avicenna and some other persian physicians by juxtaposing their viewpoints against contemporary scientific studies in the field of ophthalmology. rhazes' viewpoints about diseases and disorders of the eye disorders of the eyelids adhesion of eyelids: according to rhazes, this condition is categorized in two separate groups: i. adhesion of eyelids to any part of the eyeball that may occur after removal of pterygium or healing of sores. it seems that this phenomenon is known as symblepharon in modern ophthalmology (9-11). ii. adhesion of a part of one eyelid to another. rhazes explains that this condition could happen during sleep or as a result of conjunctivitis recovery. it seems that this phenomenon is known as symblepharon in modern ophthalmology as well (9-11). ectopic cilia: rhazes describes a condition in which cilia are grown along the edge of the eyelid toward the inside causing irritation, abrasion and pain (9, 10). in recent studies, it has been clarified that distichiasis is the abnormal growth of lashes from the orifices of the meibomian glands, while trichiasis is a normally grown cilium that is misdirected toward the eye (12). pediculosis: it is remarkable that rhazes mentions the major cause of this disease to be a low level of personal hygiene (9, 10). according to modern literature, there is a significant association between pediculus humanus corporis or body lice and poor hygiene (13-16). disorders of the conjunctiva conjunctivitis: rhazes defines this disease as the acute inflammation of the conjunctiva accompanied by redness or purulent discharge. he categorizes the risk factors in three groups (9, 10): i. exposure to sunlight, heat, dust or greasy substances. ii. a hot bath in patients who are prone to developing conjunctivitis. rhazes emphasizes that vasodilation due to a hot bath can cause this type of conjunctivitis. iii. red roses. the first and third categories are well-known examples of allergic conjunctivitis where a history of itching may help with the diagnosis (17 20). in the first category, dry eye is induced by an underlying condition that triggers allergic conjunctivitis, while in the third category; allergic conjunctivitis is induced by an allergen. according to rhazes, there are four types of conjunctivitis (9, 10): 1) in the first type a well-known risk factor such as sunlight, heat, dust, smoke or a greasy substance causes the disease. this condition is known today as irritative conjunctivitis. rhazes considers this type of conjunctivitis to be so slight that it can easily be cured through avoiding the agents mentioned above, and this is exactly how this type of conjunctivitis is treated nowadays (20). 2) rhazes believes that an acute inflammation of the conjunctiva could cause the second type of conjunctivitis (9, 10). this is known as epij med ethics hist med 7:19 dec, 2014 jmehm.tums.ac.ir seyed mahmoud tabatabaei et al. page 3 of 6 (page number not for citation purposes) demic keratoconjunctivitis (ekc) and is associated with etiology of adenovirus. in this type of conjunctivitis a remarkable inflammation affects the conjunctiva and makes it irritated. 3) rhazes declares that in both the abovementioned types of conjunctivitis, harmful discharge might cause inflammation, pain, thickness, itching, and redness of the conjunctiva. the third type may be accompanied by lacrimation, excessive redness, and laborious lid movements. modern studies have established the association of ocular itching with allergic conjunctivitis after exposure to certain allergens (17-20). stringy or ropy discharge due to conjunctivitis has also been mentioned in a number of articles (20). 4) the last type of conjunctivitis mentioned by rhazes is cyclic and may occur every day or in intervals (9, 10). this subcategory is known today as seasonal conjunctivitis or vernal keratoconjunctivitis in which patients may experience remissions and exacerbations (20). pterygium: rhazes describes this disorder as a condition in which there is an excessive growth in conjunctiva, usually starting from the inner corner of the eye and extending on the surface of cornea and eventually covering the pupil. it can be soft or hard and its color may be yellow or red (9, 10). in recent studies, it has been indicated that pterygium is a kind of conjunctive epithelial hyperplasia with a high rate of proliferation originating from the bulbar conjunctiva over the cornea (21-25). moreover, it is now classified as fibrous (yellow and hard) or vascular (red and soft). accordingly, rhazes’ classification is similar to the modern categorization. pterygium without inflammation has a white or yellow appearance, but in the presence of inflammation, the condition is called pterygitis and is red in color. keratoconjunctivitis: rhazes also defines a condition in which a thin smoky layer of protuberant blood vessels overlie the cornea and conjunctiva and make the eyeball red and hard. in most cases symptoms such as lacrimation, watery discharge, itching and inflammation arise and the patient cannot see objects in sunlight or other lights (9, 10). this may be a rare condition known today as atopic keratoconjunctivitis in which patients suffer from corneal vascularization, intense itching and redness in the eyes, mucosal discharge, and difficulty in opening their eyes outdoors in prolonged cases (20, 26). considering the fact that vernal keratoconjunctivitis is more prevalent in iran climate, rhazes may have described a condition that induces severe papillary conjunctivitis, giant papillae, gelatinous thickened accumulation of tissue around limbus, and presence of discrete whitish raised dots along the limbus (tranta's spots) (27). disorders of the cornea corneal abrasion: rhazes states that the cause of these abrasions might be the collision of iron, wood or other foreign objects with the cornea, or the inappropriate use of ophthalmic medication (9, 10). corneal melting: rhazes believes that either the first layer or all three layers of the cornea might be affected in this disorder. it is noteworthy that he divided the cornea into three layers (9, 10) without access to the complex equipment that exist today. rhazes describes a disorder in which white or black lesions appear when discharge settles between the layers of cornea (9, 10). according to recent data, this condition is known as superficial punctate keratitis and is characterized by a breakdown of the corneal epithelium in a pinpoint pattern. red eye, foreign body sensation, tearing, photophobia, and a burning sensation are among the non-specific symptoms (9, 10). disorders of the iris rhazes explains that the pupil is opened and closed with the help of a muscle, and visual disorders occur when this muscle is damaged. he classifies iris disorders in four groups (9, 10): widening and narrowing of the pupil: a widened pupil may be the result of an expansion of the iris, or a loose iris that cannot contract properly. the narrowing of the pupil on the other hand may be due to iritis, opium use, or excess light. protrusion of the iris: according to rhazes, the iris might protrude through the damaged part after corneal ruptures. iris rupture: rhazes declares that the first complication of iris rupture is that an aqueous substance spills out and causes other complications. according to modern ophthalmology, iris rupture may induce glaucoma due to a condition named angle recess. nyctalopia and hemeralopia: rhazes points out that some patients do not have accurate vision during the night, and some experience this problem in the daytime (9, 10). today, these patients are known as nyctolopic and hemeralopic respectively. however, these conditions are known to occur as a result of retinal photoreceptors disorder. impairment of eye muscles rhazes explains that when a muscle located near the root of a nerve weakens, the eye will be drawn outward (9, 10). according to rhazes, if the weakness is insignificant, the protuberance of the eye will be negligible and vision will not be affected. these findings refer to phoria or latent deviation (as opposed to manifest deviation). however, if the weakness is significant, it may even lead to blindness. rhazes believes this condition to be the result of a shortening or weakening of the muscles situated on one side of the eye that will terminate in dislocation of the eyeball and its traction to the opposite side (9, 10). these findings refer to j med ethics hist med 7:19 dec, 2014 jmehm.tums.ac.ir seyed mahmoud tabatabaei et al. page 4 of 6 (page number not for citation purposes) amblyopia induced by strabismus, or eye deviation. according to rhazes, if the deviation of the eyeball is upward or downward, diplopia occurs (9, 10). disorders of the optic nerve in cases of blindness or sight diminution where no obvious damage is found during eye examinations, rhazes recommends that optic nerve or even brain damage be taken into consideration. his categorization of the factors causing optic nerve disorders is remarkable (9, 10): i. constitutional changes ii. nerve compression iii. inflammation iv. tumors v. decomposition of organs vi. optic nerve ruptures the importance of the optic nerve rhazes considers optic nerve damage or rupture to be the most important risk factor for blindness or visual disorders (9, 10). according to his theory, when blindness is accompanied by protrusion of the eye, optic nerve has been ruptured or protracted excessively. today, it is known that thyroid ophthalmopathy may be accompanied by optic neuropathy. rhazes specifies that eyeball protrusion and limited vision are symptoms of flabby eye muscles. eye cancer rhazes states that when a malignancy occurs in one of the eye layers, patients experience protraction, redness, and severe pain especially during eye movements. according to rhazes, this condition is incurable, but pain relief should be offered. he adds that the pain is aggravated by hiking and considerable body movements that are usually followed by extensive headaches. he also states that vein dilation can develop in eye cancer. other symptoms also associated with eye cancer in modern ophthalmology include diluted and irritative eye discharge and lack of appetite (9, 10). the origin of eye disorders rhazes categorizes the risk factors in two major groups (9, 10): 1) the first category consists of extracranial causes, most importantly trauma. this category is divided into three subgroups: a) traumas that cause a dramatic disturbance in the function of eye muscles. in these types of injuries, patients do not suffer from any kind of ocular dysfunction or vision loss, but the ability to move the injured eye is decreased. blowout fracture is one of the traumas that can cause this kind of disturbance. in recent articles it has been mentioned that inferior and medial rectus muscles can be pathologically involved in orbital floor fractures, which may be followed by permanent damage of the neuromuscular complex. decreased extraocular motility is a wellknown consequence of such fractures (28). b) traumas in which the optic nerve is torn. these injuries cause total blindness. in modern literature, blunt or penetrating trauma and especially indirect pressure to the head that can cause optic neuropathy are mentioned as a cause of permanent visual loss (29). c) in some other cases, trauma causes a hemorrhage in the eye. as mentioned in some articles, acute retrobulbar hemorrhage that can occur after retrobulbar injections and trauma to the orbit is known as a sight threatening condition. they may also cause subconjunctival, vitreous, and retinal hemorrhages. vitreous and retinal hemorrhages decrease vision while retrobulbar hemorrhages induce compressive optic neuropathies (30-32). 2) in the second category rhazes states that intracranial growths, encephalitis or inflammation of the optic nerve can terminate in complications mentioned below: a) damage of the optic nerve in the brain (cortical blindness). b) damage to the nerves sending signals to the eyeballs (muscular or nerve palsies, like cranial nerves iv, iii, or vi). some recent articles assert that acute demyelination of the optic nerve due to multiple sclerosis or an isolated neurologic disease can result in visual impairment (33-37). viewpoints of avicenna and other persian physicians about ophthalmology in the chapter dedicated to ophthalmology in his famous medical textbook canon, avicenna describes the anatomy, physiology, pathology, diseases and treatments of the eye (38). considering that avicenna lived about 80 years after rhazes, he would have access to rhazes’ works and therefore there is no major difference between their views about ophthalmology. other physicians such as ali ibn sahl al-tabari (9th century ad), ali ibn abbas alahwazi, also known as haly abbas (10th century ad), and syed ismail jurjani (13th century ad) are persian physicians who have described various topics of ophthalmology in their medical textbooks (1, 39, 40). their viewpoints and descriptions are not as comprehensive and methodical as rhazes. the viewpoints of avicenna and the above-mentioned persian physicians about ophthalmology can be a topic of research for future articles. conclusion reviews of ancient persian medical textbooks indicate that the most noteworthy and all-inclusive textbook of ophthalmology has been written by rhazes. the definitions, divisions, and classifications of ophthalmic diseases and disorders have been offered with remarkable precision in this work and have not lost their scientific value even after j med ethics hist med 7:19 dec, 2014 jmehm.tums.ac.ir seyed mahmoud tabatabaei et al. page 5 of 6 (page number not for citation purposes) eleven centuries. issues that have been discussed in this article are excerpts from rhazes’ medical encyclopedia that was written in over 400 pages. it may be added that by reviewing the works of traditional physicians and using advanced technology, modern medicine has been able to identify the topics of ophthalmology defined by persian physicians. it should be noted that these contents have never lost their historical value, and contain important educational and clinical points that are similar to concepts in modern ophthalmology. references 1. al tabari a. [ferdos al hekmah fi al teb]. berlin, germany: aftab press; 1928, p. 161-79. [in arabic] 2. ibn alnadim m. [alfehrest]. translated by tajadod mr. tehran: asatir press; 2001, p. 510-19. [in persian] 3. andalosi qs. [altarif be tabaqat al omam]. tehran: dar al hejrah; 1997, p. 158-63. [in arabic] 4. elgood lc. medical history of persia and the eastern caliphate from the earliest times until 1932. translated by forghani b. tehran: amirkabir press; 1978 p. 25-52. [in persian] 5. najmabadi m. history of medicine in iran before islam, 2nd ed. tehran: university of tehran press; 1992, 2nd vol, p. 93-430. [in persian] 6. discorides p. materia medica. translated by tabatabaei sm. tehran: tehran university press; 1st vol, p. 5-39. [in persian] 7. najmabadi m. history of medicine in iran after islam. tehran: university of tehran press; 1975, p. 324-442. [in persian] 8. rhazes m. [al hawi alkabir fi al tebb], 1sted. india: dakan; 1955, 2nd vol, p. 50-258. [in arabic] 9. rhazes m. [al hawi alkabir fi al tebb]. translated by tabatabaei sm. tehran: alhawi pharmacy co. press; 2000, 2nd vol, p. 11-263. [in persian] 10. tabatabaei sm. [synopsis of rhazes’ alhawi]. mashad: mashad university press; 2008, 1st vol, p. 113-150. [in persian] 11. holsclaw ds. ocular cicatricial pemphigoid. int ophthalmol clin 1998; 38 (4): 89–106. 12. brooks, dennis e. ophthalmic examination made ridiculously simple. proceedings of the 30th world congress of the world small animal veterinary association, 2005. 13. holland bj, siderov j. phthiriasis and pediculosis palpebrarum. clin exp optom 1998; 81(1): 8-10. 14. berkow r. merck manual of diagnosis and therapy. merck and co; 1987. 15. harrison tr, fauci as. harrison's principles of internal medicine, l4th ed. new york: mcgraw-hill; 1998, p. 2549-50. 16. burkhart cn, burkhart cg, morrell ds. infestations, in: bolognia jl, jorizzo jl, schaffer jv, et al, eds. dermatology, 3rd ed. philadelphia: mosby elsevier; 2012, chapter 84. 17. friedlaender mh, okumoto m, kelley j. diagnosis of allergic conjunctivitis. arch ophthalmol 1984; 102(8): 1198-9. 18. bielory l, friedlaender mh. allergic conjunctivitis. immunol allergy clin north am 2008; 28(1): 43-58. 19. wingard jb, mah fs. critical appraisal of bepotastine in the treatment of ocular itching associated with allergic conjunctivitis. clin ophthalmol 2011; 5: 201. 20. friedlaender mh. conjunctivitis of allergic origin: clinical presentation and differential diagnosis. surv ophthalmol 1993; 38: 105-14. 21. balci m, sahin s, mutlu fm, yaqci r, karanci p, yildiz m. investigation of oxidative stress in pterygium tissue. mol vis 2011; 17: 443-7. 22. chao sc, hu dn, yang py, lin cy, yang sf. overexpression of urokinase-type plasminogen activator in pterygia and pterygium fibroblasts. mol vis 2011; 17: 23-31. 23. taylor hr, west sk, rosenthal fs, munoz b, newland hs, emmett ea. corneal changes associated with chronic uv irradiation. arch ophthalmol 1989; 107(10): 1481-4. 24. golu t, mogoanta l, streba ct, et al. pterygium: histological and immunohistochemical aspects. rom j morphol embryol 2011; 52(1): 153-8. 25. chui j, di girolamo n, wakefield d, coroneo mt. the pathogenesis of pterygium: current concepts and their therapeutic implications. ocul surf 2008; 6(1): 24-43. 26. abelson mb, schaefer k. conjunctivitis of allergic origin: immunologic mechanisms and current approaches to therapy. surv ophthalmol 1993; 38: 115-132. 27. kumar s. vernal keratoconjunctivitis: a major review. acta ophthalmol 2009; 87(2): 133-147. 28. joseph jm, glavas ip. orbital fractures: a review. clin ophthalmol 2011; 5: 95-100. 29. levin la, beck rw, joseph mp, seiff s, kraker r., the treatment of traumatic optic neuropathy: the international optic nerve trauma study. ophthalmology 1999; 106(7): 1268-77. 30. krohel g, wright j. orbital hemorrhage. am j ophthalmol 1979; 88(2): 254-8. 31. lee kyc, tow s, fong k. visual recovery following emergent orbital decompression in traumatic retrobulbar haemorrhage. ann acad med singapore 2006; 35(11): 831-2. 32. katz b, herschler j, brick d. orbital haemorrhage and prolonged blindness: a treatable posterior optic neuropathy. br j ophthalmol 1983; 67(8): 549-53. 33. kezuka t, usui y, goto h g. analysis of the pathogenesis of experimental autoimmune optic neuritis. j biomed biotechnol 2010; 2011. j med ethics hist med 7:19 dec, 2014 jmehm.tums.ac.ir seyed mahmoud tabatabaei et al. page 6 of 6 (page number not for citation purposes) 34. sanders ea, volkers ac, van der poel jc, van lith gh. estimation of visual function after optic neuritis: a comparison of clinical tests. br j ophthalmol 1986; 70(12): 918-24. 35. beck rw, cleary pa, anderson mm, et al. a randomized, controlled trial of corticosteroids in the treatment of acute optic neuritis. new engl j med 1992; 326(9): 581-8. 36. trip sa, schlottmann pg, jones sj, et al. retinal nerve fiber layer axonal loss and visual dysfunction in optic neuritis. ann neurol 2005; 58(3): 383-391. 37. trip sa, schlottmann pg, jones sj, et al. optic nerve atrophy and retinal nerve fibre layer thinning following optic neuritis: evidence that axonal loss is a substrate of mri-detected atrophy. neuroimage 2006; 31(1): 286-93. 38. avicenna h. [al qanoon fi al teb]. tehran: aligholikhan press; 1880, 3rd vol, p. 57-76. [in arabic] 39. al ahwazi a. [kamel alsena ah al tebbiah]. translated by ghafari m. tehran: institute of islamic studies, university of tehran; 2009, 2nd vol, p. 194-200. [in persian] 40. jorjani se. [zakhireye kharazmshahi]. tehran: bonyade farhange iran press; 1977, p. 333-362. [in persian] journal of medical ethics and history of medicine perception of consent among dental professionals shaila tahir 1 , farkhanda ghafoor 2* , shaheena nusarat 3 , amanullah khan 1 1.fatima memorial hospital, college of medicine & dentistry, lahore, pakistan. 2.national health research complex, pakistan medical research council, shaikh zayed medical complex, lahore, pakistan. 3.de montmorency college of dentistry, lahore, pakistan. *corresponding author: farkhanda ghafoor address: national health research complex, pakistan medical research council, shaikh zayed medical complex, lahore, pakistan. e-mail: fghafoor99@hotmail.com received: 03 oct 2009 accepted: 18 nov 2009 published: 24 nov 2009 j med ethics hist med. 2009; 2:20. © 2009 shaila tahir et al.; licensee tehran univ. med. sci. abstract keywords: informed consent, dental ethics, dental education. introduction advances in medical procedures, invasive ness, cost and recognition of human rights (both patient’s and medical practitioners’) have realized the application of informed consent in almost all health care disciplines. safeguarding legal and ethical rights of the patients as well as of attending physicians became a part of preliminary steps during the last two decades. it was also aimed at strengthening the level of trust between the patient and the dental surgeon (1). historically some facts link informed consent to hippocrates who eluded to patients rights. in the recent history (18 th century) surgical steps were required to be undertaken after patient’s consent. however world war ii triggered the need for informed consent which was formalized in the 1964 helsinki declaration, in which the main argument was ethics. in the succeeding years of the background: informed consent concept has been recognized in all patient care fields. the contents and wordings of the informed consent are still being debated and experimented. dental care services have considered the role of informed consent since 1980’s, after some legal claims of malpractices. methodology: a cross-sectional analytic study was undertaken involving 375 senior dental students and fresh graduates in their house job. a self-administered questionnaire explored their knowledge, attitude and practices regarding the need and importance of informed consent in dental services. the study instrument was designed keeping in view the content of courses in dental education and international standards. the questionnaire was pre-tested on a small group for assessing the suitability and validity of the responses. results: the data was entered in spss version 16 and cross-tabulated through it. most of the respondents (87%) were aware of the concept of informed consent, 6.9% considered it unnecessary and 21.9% were not practicing it. invasiveness of dental procedure was found to be directly related to the need of including informed consent. major justification for presence of informed consent was to protect the dentist from any legal proceedings. conclusion: dental professionals were aware about the informed consent as a step, but were unaware about its precise significance, content application and practice. j med ethics hist med 2009, 2:20 shaila tahir et al. page 2 of 6 (page number not for citation purposes) 20 th century, lots of additional elements and steps have been added to formalize and standardize informed consent, in public health research, as well as in practice of medicine (2). in the field of dentistry, informed consent gained recognition in the mid-1980s, and over the years this element has been covered in the academic teaching (1). informed consent comprises of implied and expressed consent. implied consent is assumed by patient’s attitude and applied mostly to the non invasive procedures such as consultation, examina tion and diagnosis, whereas expressed consent is a formal type of permission related to more invasive procedures, including nature of decision for the procedures to be undertaken, reasonable alterna tives to proposed interventions, the relevant risks, benefits related to each procedure, understanding of patient about the procedures and his/her acceptance for intervention. in dental practice, verbal consent is one form of expressed consent and used adequately for routine dental treatment such as dental filling, extraction etc., whereas in written consent another form of consent is taken for more extensive treatments such as procedures requiring sedation and analgesia, etc. in case of children under the age of 16 or 18 years, in most part of the world they are presumed incompetent to take part in decision-making process. some children, even less than 10 years of age, are considered better than their parents to grasp the concept of treatment and its conse quences. in pakistan the age limit for children giving consent is 18 years and over. it is still the ethical duty of medical or dental doctor to give importance to the children under the age of 18 years and respect the ideas of child for the treatment. this also helps the dentist to develop good patient-doctor relationship by discussing the treatment modalities with them and their concerns towards treatment. the use of informed consent prevents mal practices or quackery in dental practice; the purpose and benefits of treatment are well unders tood by patients themselves and parents, in case of minor children, to protect patient’s rights from malpractices. this study was designed to assess the gaps in the knowledge and perceived importance of informed consent among dental students/house surgeons who are interacting with patients for their dental treatment. materials and methods this was a cross sectional descriptive study. after the clearance of institutional review board, objectives of the study were explained to dental students of 3 rd and 4 th year and dental house surgeons of government and private dental colleg es/hospitals, (de’montmorency college of denti stry/ dental hospital lahore, fatima memorial college of dentistry/dental hospital lahore and margalla college/dental hospital rawalpindi. pakistan). the subjects of the study had given their willingness to respond to the questionnaire. a group of 125 students each from 3 rd year, 4 th year and dental house surgeons were included in the study on the basis of non-probability convenient sample (appendix-1). statistical analysis a self administered questionnaire was given to each respondent. the data was analyzed by spss version 16. the analysed data was qualita tive and between-groups comparison was made by applying chi square test for assessing significance. results the present study was conducted on 375 den tal field professionals, 250 students of senior dental classes and 125 dentists in house jobs. table 1 show that 84.8% of the respondents were females and 15.2% males. this proportion was almost similar in the three sub groups. on the question of basic knowledge about the type of informed consent, 15.7% knew about the verbal type, 50.9% for written, 20.3% for verbal and written types both, and 13.1% did not know about any of the types of informed consent. the difference between the groups was not found statistically significant. in the third year students, only 2.4% had no knowledge about any type of informed consent, while it was in 12.8% of the fourth year and 8.0% among dental surgeons in house job (table -1). in response to the question, “who should pro vide the informed consent”, the majority (69.9%) mentioned the patients, 22.1% the parents and 7.2% other relatives accompanying the patient. the dental surgeons in house job were the highest, 80%, in mentioning the patient as informed consent provider, and they were the lowest, 12%, in mentioning parents as informed consent providers. these differences were statistically significant (p < 0.05) (table -2). on inquiring about the importance of obtain ing informed consent, the majority, 61.1%, considered it as quite important. however this gradually increased from 52% in the third year students to 74.4% in dental surgeons in house job. almost 7.0% of students did not consider informed consent to be of any importance. none of the dental surgeons in house job considered informed consent to be unimportant (table -2). since most of the respondents were in the clinical practice of dealing with the dental prob lems, it was asked as to how often they were j med ethics hist med 2009, 2:20 shaila tahir et al. page 3 of 6 (page number not for citation purposes) actually taking the informed consent. only 5.3% were taking it mostly, 16% usually, 56.8% some times and 21.9% were not obtaining informed consent. the group not obtaining the informed consent was highest in students (36% and 20.8%) and lowest (8.8%) among dental surgeons in house job. these differences were also statistically significant (table 3). the respondents were given a list of dental procedures and were asked to identify situations where they considered informed consent to be important. surgery (43.6%) and root canal/crown bridge procedures (35.2%) were mainly identified as necessary for informed consent. all other dental procedures were considered as less important for informed consent (table 3). in an answer to mention the person requiring the informed consent, the doctor was considered as protected (68%) through it. some (13.8%) consi dered informed consent to be just as a routine step and only 9.1% thought that informed consent was a patient’s right. similar proportion (9.1%) consi dered informed consent to be a research linked step (table 4). the respondents were asked to identify the information to be included in the informed consent form. ‘describing’, the procedure was the main information considered by the majority (49.3%). this was followed by statements relaxing the patient psychologically (31.5%). other areas like informing about risks, short-and long-term effects were mentioned by less than 10% respondents (table 4). finally they were asked about the source of their information for informed consent. four sources were mentioned in almost equal numbers; for 86 (22.9%) the source was teacher, whereas for 92 (24.5%) it was printed material in form of books/journals, 83 (22.2%) got the information from colleagues and friends and for 114 (30.4%) source was the media. discussion informed consent is the educational process which focuses on patient’s absolute right to understand their status and practioner’s proposed treatment plan. laws regarding informed consent vary from country to country; american dental association’s principles of ethics in this regard states “the dentist should inform the patient of the proposed treatment and any reasonable alternatives, in a manner that allows the patient to become involved in treatment decision (3). in this cross-sectional descriptive study car ried among 3 rd year, final year students of dentistry and dental surgeons doing their house job, a self administered questionnaire comprising of 17 questions to investigate the perception and practic es of dental professionals in matters relating to informed consent were explored. the information obtained suggested that 87% of the respondents were aware of the informed consent; whether verbal or written, and 13% had no knowledge. similarly 92% also knew that either the patient or the parents have to provide informed consent. these suggested that at least the signific ance of informed consent has been included in the academic curriculum. in a survey conducted elsewhere more that 90% of the students had heard about the informed consent, and the consent was understood by 70% 73% of them (4). in current study, by attitude only, 6.9% did not consider informed consent to be an essential step in the dental care services. however to examine, treat, manage or operate upon patient without consent is assault in law, even if it is beneficial and done in good faith (5). in this study, there was a wider gap of 21.9% who still did not obtain informed consent as a routine protocol. this could probably be due to hurry, lack of time or negligence on the part of the dental professionals. however the seniors (house surgeons) were more involved in obtaining informed consent than the juniors, perhaps due to improved realization of its importance. it is also very important that patient or parents in case of minors should completely understand what they are consenting for. in an observational study among 70 parents, it was found that 74% were able to participate fully in survey and 40% of the written consent obtained from parents was not valid (6). in a survey among 232 dental students for identifying the topics in ethics course, which can influence their professional practice, 21% of the students identified confidentiality, 21% identified informed consent and 19% identified obtaining assent from children and adolescent as the most important (7). interestingly in this study, importance of in formed consent was not uniformly realized for all procedures and only more invasive and surgical procedures were considered eligible for obtaining informed consent. maxillofacial surgery and root canal procedures thus were mentioned by 79% of the respondents. in the current study, two thirds of the respon dents considered informed consent to be a safe guard for the doctors mainly and as a right for the patient. there was also diversity about what should be the contents of the informed consent. in another informal survey among 252 dent ists, it was found out that they only obtain written informed consent for the administration of local anesthesia (8). the results of a study conducted in india showed that written informed consent is usually obtained for anesthesia involving sedation or general anesthesia and not for local anesthesia j med ethics hist med 2009, 2:20 shaila tahir et al. page 4 of 6 (page number not for citation purposes) considering it to be extremely safe. however it is important to remember that having a patient sign a written consent form does not excuse the dentist from the responsibility of having adequate discus sion with patient about the proposed treatment and explaining the risks-benefits and possible alterna tives (9). conclusion there is high sensitization about the concept of informed consent but there are many gaps in the realization of its contents, need, application and practice. this calls for better attention of the teachers to stress on the role of informed consent in a systematic way. acknowledgements authors are grateful to mr. aasim jagga and mr. sohail tasawar of nrhc for their support to complete this study. j med ethics hist med 2009, 2:20 shaila tahir et al. page 5 of 6 (page number not for citation purposes) table 1: distribution of subjects by gender and knowledge about main types of informed consent total n= 375 n % p < 0.05 was considered significant table 2: sources of obtaining informed consent & attitude towards informed consent source third year final year house surgeons total n % n % n % n % patients 75 60.0 87 69.6 100 80.0 262 69.9 parents 37 29.6 31 24.8 15 12.0 83 22.1 other relatives 10 83.0 7 5.6 10 8.0 27 7.2 friends or relatives accompanying patients 3 2.4 3 0.8 importance quite important 65 52.0 71 56.8 93 74.4 229 61.1 may be taken 31 24.8 24 19.2 21 16.8 76 20.3 only situational 15 12.0 18 14.4 11 8.8 44 11.7 not very important 14 11.2 12 9.6 26 6.9 gender third year n= 125 n % third year n= 125 n % house surgeon n= 125 n % total n= 375 n % male 19.0 15.2 15 12.0 23 18.4 7 15.2 female 106 84.8 110 88.0 102 81.6 18 84.8 knowledge verbal consent 24 19.2 19 15.2 16 12.8 9 15.7 written consent 75 60.0 62 49.6 74 59.2 91 50.9 both verbal & written consent 23 18.4 28 22.4 25 20.0 6 20.3 neither 3 2.4 16 12.8 10 8.0 9 13.1 total 125 100.0 125 100 125 100.0 75 100.0 j med ethics hist med 2009, 2:20 shaila tahir et al. page 6 of 6 (page number not for citation purposes) table 3: current practice and procedure requiring informed consent practice third year final year house surgeons total n % n % n % n % almost always taken 5 4.0 7 5.6 8 6.4 20 5.3 usually taken 15 12.0 20 16.0 25 20.0 60 16.0 sometimes taken 60 48.0 72 57.6 81 64.8 213 56.8 mostly not taken 45 36.0 26 20.8 11 8.8 82 21.9 procedure scaling & preventive steps 5 2.5 10 3.8 14 4.3 29 3.7 caries & fillings 3 1.5 7 2.7 16 4.9 26 3.4 periodontal diseases 3 1.5 8 3.1 12 3.7 23 2.9 endo dental care 8 4.0 22 8.6 31 9.6 61 7.8 root canal/ crown bridge 70 35.0 92 35.9 112 34.7 274 35.2 dentures 5 2.5 8 3.1 13 4.0 26 3.4 maxillo facial surgeries 105 53.0 110 42.8 125 38.7 340 43.6 table 4: reference need and contents of informed consent (perception) need third year final year house surgeons total n % n % n % n % patient’s right 6 4.8 12 9.6 16 12.8 34 9.1 doctor’s protection 70 56.0 94 75.2 91 72.8 255 68.0 research 5 4 14 11.2 15 12.0 34 9.1 as a routine 44 35.2 5 4.0 3 2.4 52 13.8 content about procedures 60 48.0 65 52.0 60 48.0 185 49.3 about risks/complications 3 2.4 5 4.0 8 6.4 16 4.3 economic involvement 20 16.0 9 7.2 6 4.8 35 9.3 psychological relaxation 33 26.4 40 32.0 45 36.0 118 31.5 long term effects 9 7.2 6 4.8 6 4.8 21 5.6 j med ethics hist med 2009, 2:20 shaila tahir et al. page 7 of 6 (page number not for citation purposes) references 1. seldin lw. informed consent. the patient’s rights. dent today 2003; 22(12): 86-8. 2. katz rv, kegeles ss, kressin nr, et al. the tuskegee legacy project: willingness of minorities to participate in biomedical research. j health care poor underserved 2006; 17(4): 698–715. 3.anonymous. american dental association. principles of ethics and code of professional conduct. http://www.ada.org/prof/prac/law/code/index.asp (accessed on dec 2004) 4. hiroyo k, chuya k, shohei s, izumi h, hidenori y, tooru s. a consciousness survey on “informed consent” in students from 3 private dental colleges. jpn j dent pract adm 2000; 35(2): 142-50. 5. reddy ksn. the essentials of forensic medicine and toxicology, 23rd ed. hyderabad: k. suguna devi; 2005, p 40-1. 6. mohamed tahir ma, mason c, hind v. informed consent: optimism versus reality. br dent j 2002; 193(4): 2214. 7. sharp hm, kuthy ra. what do dental students learn in an ethics course? an analysis of studentreported learning outcomes. j dent educ 2008; 72(12): 1450-7. 8. orr dl 2nd, curtis wj. obtaining written informed consent for the administration of local anesthetic in dentistry. j am dent assoc 2005; 136(11): 1568-71. 9. rai b. informed consent for local anesthesia. internet j law health care ethics 2007; 4: 2. j med ethics hist med 2009, 2:20 shaila tahir et al. page 8 of 6 (page number not for citation purposes) appendix 1. the questionnaire perception of consent in dental professionals date: _ serial no. class of student: 1. do you know what an informed consent is? yes/no/not sure 2. if yes, then do you know what is …? a) verbal consent yes/no/not sure b) written consent yes/no/not sure 3. if yes, where did you learn about informed consent? teachers/books/journals/colleagues/friends/media 4. do you think patient consent is important in your profession? quite important/may be taken/only situationally/not important 5. have you been taking consent from the patient before? yes/no/not sure 6. from whom do you take consent? (encircle more than one, if necessary) patient written/verbal parents written/verbal guardian written/verbal spouse written/verbal others written/verbal 7. for disabled people, who should sign the consent? 8. for which procedures do you take consent? parents/guardian/others extractions crown/bridges endodontic therapy dentures filling periodontal disease fixed/removable orthodontic appliances dental implants maxillofacial surgeries laser whitening 9. does patient’s consent help with the treatment? yes/no/not sure 10. in what way does the taking of consent make the job easier? a) in protecting the rights of the patient b) in protecting the rights of the doctor c) for research purpose 11. do you think it is important to explain treatment plan? before taking the consent? yes/no/not sure 12. when should the patient consent be taken? before treatment/after treatment 13. if informed consent is mutually advantageous for both patient and dentist, which of the following should be ideal? a) verbal consent b) written consent 14. should a record of written consent be maintained? yes/no/not sure 15. should signatures be taken even if it is a verbal consent? yes/no/not sure 16. if informed consent was to be applied, what should be the main area of content in the consent statement? about procedure/about risk/complications/economic costs/psychological relaxa tion/long-term effects 17. should the consent be taken? a) as a routine b) as an ‘when necessary’ c) only if one remembers 18. have you now realized the importance of informed consent more than before? yes/no/not sure 19. in your opinion, what are the major components of consent? journal of medical ethics and history of medicine the necessity of observing ethical liability in bioethics: instruction of the principles of bioethics should be launched from school ata pourabbasi 1* , meysam tavakkoli bina2, mahnaz sanjari 3 1.research fellow, endocrinology and metabolism research center, tehran university of medical sciences, tehran, iran; ehsan educational & cultural institute, endocrinology and metabolism research center, shariati hospital, tehran university of medical sciences, tehran, iran. 2.phd student, sciences and research branch, islamic azad university, tehran, iran; educational & cultural institute, endocrinology and metabolism research center, shariati hospital, tehran university of medical sciences, tehran, iran. 3. research fellow, endocrinology and metabolism research center, tehran university of medical sciences, tehran, iran. *corresponding author: ata pourabbasi address: endocrinology and metabolism research center, shariati hospital, kargar st., tehran, iran. tel: (+98) 21 88 22 00 37 e-mail: atapoura@sina.tums.ac.ir received: 02 oct 2010 accepted: 26 dec 2010 published: 28 dec 2010 j med ethics hist med. 2010; 3:7. © 2010 ata pourabbasi et al.; licensee tehran univ. med. sci. introduction the current students at classrooms and schools are the future doctors and health adminis trators of our country. as a matter of fact, their current learning would lead to better ways of passing the medical and health learning paths. nowadays, high school textbooks are loaded with scientific and technical concepts; the very concepts the students need in order to succeed in entrance exams to medical schools. at high school, the students focus on challenging issues such as reproductive system, development, neuroscience, stem cells science and other challenging issues. these topics contain intense academic load for learners; and at the same time, they are full of spiritual, moral and ethical meanings. when these aspects of learning are neglected, new and im mense moral and ethical challenges emerge. this is especially true in current cultural background of our society; in which moral and cultural challenges are discernible. one should keep in mind that "morality" de void of beliefs and cognitive principles would transform into formal and legal commands. in the absence of supervision, it would lead to a disaster. so far, notable cases have occurred in scientific field. therefore, creating a basis for moral and cognitive beliefs should be considered as a com plementary gesture; the one which should be kept in mind at the outset of any scientific or technolo gical learning process. hence, commitment to the necessary and original principles of religion is one of the prominent methods of institutionalized medical ethics. for example, if the literature for teaching re productive system to students aged 15 to 17 years old is not managed properly, it would transform to a factor of collapse which leads to moral decadence in the society. likewise, concepts related to neuroscience or stem cells research could lead to inconsistencies in beliefs, religious teachings and j med ethics hist med 2010, 3:7 ata pourabbasi et al. page 2 of 3 (page number not for citation purposes) scientific education of the students. clearly, these challenges should be dealt with at a simultaneous level to teaching. consequences of such training methods, regardless of problems and moral outcomes, would be seen in a generation free from any strong cognitive and ethical principles, soon to enter the universities and medical schools. at the same time, the main ethical beliefs should be considered as regularized irrepressible manners. the question is, to what extent such a generation can be receptive to transcendental education on bioethics and medical ethics at universities? the answer is clear. as this introduction suggests, the transfer of ethical values and beliefs should complement the existing scientific concepts in school textbooks. the authors of this article are simultaneously concerned with bio issues and ethical-faith ones. based on a preliminary needs assessment and a designed curriculum for high school students of experimental sciences, the first trial phase of the plan was executed on third-year students of one high school in tehran. the plan was taught in one academic semester; and the program's headings were as follows: “vanity, perfection pest”: pride is always harmful to wisdom; especially when the knowledge is considered necessary for the community and few people can master it. this assumption can be verified in all concepts and courses in experimental sciences; because knowledge may lead to egocen trism among the adolescents. nowadays, one of the ethical issues making an impact on medical community is pride and arrogance against the patient (1). “sanctify the spirit, sanctify the body”: the medical profession deals with the human body or other living creatures. so from a professional viewpoint, body is the original theme of the study; and this may lead to some challenging situations. for example, in autopsy halls of medical schools, one is not far from witnessing indignities towards the human corpse and dignity. some examinations and interventions performed in this regard are not considered as dignifying towards humanity. in this course, students would learn that human body as well as his soul is valued and respected and it must always be appreciated in professional contacts (2). “death, rebirth”: death is a concept that has a major role in ethical teachings of islam. in so many narratives and traditions of our religion, death and remembrance of death is a pivotal instrument in practicing piety and virtue in human beings. occasionally, in scientific field, the concept of death is discussed as a totally natural process. the science tries to explain physical and molecular aspects of this event; but the eminence and importance of death is hidden in our thoughts. if such a phenomenon is presented as only a normal biological process, the moral teachings of the learners would be useless. in this course, the phenomenon of death is regarded as a great numinous event. “intellect is inside the proof”: in our religious believes, human wisdom and some proofs -such as the messengers of godguide human beings towards perfection (3). some debates in areas of neuroscience are trying to simulate the neural processes; in order to illustrate molecular and cellular functions of the nervous system. as mentioned before, such an approach restricts the scientific insight to nerves sciences and mental processes. it would also present the human wisdom as mere collection of chemical reactions. in such a situation, the human mind would not be able to act as a resource of rational principles and regulations; and therefore, commitment to ethical principles would be of no importance. “from gene to god”: genetic concepts act as bilateral topics in faith and moral regulations. on one hand, understanding and thinking about genetic themes is the best method to recognize the creator; and on the other hand, astonishing advances in this area, such as duplication, artificial life, bio robot, etc may lead to unstable mental approaches towards the creator. therefore, transmissions of these themes can play a crucial role in reinforcing the profundity of religious beliefs in young students. such doctrines can be used in promoting ethical and ideological standards of medical community in future. when young people learn that pride is always harm to wisdom; they would have no problem in accepting professional codes of ethics in future. teenagers should learn that the human body is respected by its credible spirit. in doing so, they would not be inclined to vainly injuring even a rabbit in labs and classes. in the same way, they would accept patients' bodies and souls as respect ful; and they would not behave differently in their investigation and studying of human body. when the concept of death is shaped in a stu dent's mind, he/she would not be ignorant to it in his/her professional challenges. so when a patient is in pain, the doctor (the ex-student) would not be able to sit calmly in his room. so the adolescent who learns scientific discoveries should not underestimate the mind authority. relying on this authority would show him/her numerous profes sional ethics in the future. it should not be forgotten that, the science as general and biology as particular are bilateral issues regarding the intellectual teachings. it means that on one hand, it can be consistent with ethical obligations and on the other hand it can be in conflict with it (4). so far, there is no adequate attention to moral-religious training alongside medical education. but the public health needs them both. ignorance towards this particular point would lead to misinterpretations regarding personal j med ethics hist med 2010, 3:7 ata pourabbasi et al. page 3 of 3 (page number not for citation purposes) values and beliefs among young people. to prevent this, scientific studies in eastern world should be suitable to the values of these societies. learning these concepts in adolescence and in schools has a much more lasting effect compared to their learning in an older age. it would be imprinted on teenagers' minds and it would also facilitate the transference of medical ethics' teaching in universi ties and colleges. as it follows, other educational topics are de signed according to scientific concepts and the educational needs of students and they will be presented in the next academic year. the future of this project will be based on accurate professional assessments and designing issues in the academic level and interdisciplinary courses. the emphasis on age and developing period especially in high school is basically meant to modify fundamental of ethics in medical societies. keep in mind that this approach to bioethics' education for students is a new approach and the headings are provided according to assessment needs. since this approach emphasizes the prin ciples of islamic ethics, authors were not able to find similar educational content in the other countries. a number of activities on bioethics' education have been performed in some countries such as china, japan, philippine and india; and all of them have been based on cultural characteristics of the respective country (5). in this approach, innovation provides an op portunity to evaluate the effectiveness of education. after revision, this curriculum would be suitable enough to be distributed, at least among islamic countries. references 1. koleini. kafee principles, 4th edition. tehran: islamieh darolkotob; 1365, vol 2, p. 309-28. (in persian) 2. larijani b. physician and ethical concerns. overview on ethical principles. tehran: baray-e-farda; 1383, vol 1. (in persian) 3. koleini. kafee principles, 4th edition. tehran: islamieh darolkotob; 1365, vol 1, p. 15. (in persian) 4. barbo e. science and religion. translated by khoramshahi b. tehran: university press; 1362. (in persian) 5. macer d. bioethics education for informed citizens across cultures. sch sci rev 2004; 86(315): 83-6. journal of medical ethics and history of medicine genetic technologies and ethics ali m. ardekani reproductive biotechnology research center, avicenna research institute, acecr, shahid beheshti university of medical sciences, tehran, iran. *corresponding author: ali m. ardekani address: reproductive biotechnology research center, avicenna research institute, acecr, shahid beheshti university of medical sciences, velenjak, tehran, iran. tel: (+98) 21 22 43 20 22 fax:(+98) 21 22 43 20 21 e-mail: iranhealth@hotmail.com received: 27 may 2009 accepted: 19 june 2009 published: 13 july 2009 j med ethics hist med. 2009; 2:11. © 2009 ali m. ardekani; licensee tehran univ. med. sci. abstract key words: human genome, ethics. introduction as the new age of biotechnology begins to have its impacts on modern societies in various ways, the application of such technologies in certain areas of human activities are being ques tioned from the ethical stand point. although genetic technologies have a great potential to change the medical practice as we know it, it also has a potential to be misused and lead to further health disparities, discrimination and inequality in the human societies around the world. the devel opment and use of technologies such as robotics, nano-technology, genetic engineering, neurotech nology and synthetic biology in combination is expected to become a lethal force in the hands of governments and non-governmental agents in the future if not regulated by civil and legal institutions around the world. therefore, an effective oversight and control at both national and international levels are needed. although some countries have adopted comprehensive national policies regarding the use of genetic technologies, most have not adopted any policies and are still debating the issues. in this brief article, i have provided a summary of the main categories of concern regarding the applica tion of genetic technologies in medicine around the world, the generalized view of what the world believes to be ethical regarding use of the new genetic technologies in medicine and a summary of what the most developed countries in biotechnolo gy have decided on these issues. there are many new genetic technologies be ing introduced in the world on a monthly basis however; a few have been recognized to have a particular consequence for human societies across in the past decade, the human genome has been completely sequenced and the know ledge from it has begun to influence the fields of biological and social sciences in fundamental ways. identification of about 25000 genes in the human genome is expected to create great benefits in diagnosis and treatment of diseases in the coming years. however, genetic technologies have also created many interesting and difficult ethical issues which can affect the human societies now and in the future. application of genetic technologies in the areas of stem cells, cloning, gene therapy, genetic manipulation, gene selection, sex selection and preimplantation diagnosis has created a great potential for the human race to influence and change human life on earth as we know it today. therefore, it is important for leaders of societies in the modern world to pay attention to the advances in genetic technologies and prepare themselves and those institutions under their command to face the challenges which these new technologies induce in the areas of ethics, law and social policies. j med ethics hist med 2009, 2:11 ali m. ardekani page 2 of 4 (page number not for citation purposes) the world. these new genetic technologies are believed to have a potential to alter human nature and society at the most fundamental levels (1). therefore, special attention has to be paid to their use in all human societies. main categories for application of genetic technologies there are three main categories of concern re garding the application of genetic technologies: 1) human cloning 2) genetic trait selection 3) genetic modification. human cloning refers to the creation of either human embryos or human children that are genetically identical to their living or dead parents. genetic trait selection refers to selection of sperm, eggs or embryos that possess genes which are associated with certain traits. genetic modifica tion refers to changes and manipulation of genes in living human cells (2). human cloning: the two different applica tions of cloning technologies are 1) research cloning 2) reproductive cloning. in research cloning, clonal human embryo is used for experi mental purposes. research cloning is also known as somatic cell nuclear transfer (scnt). in scnt process a nucleus from a somatic cell (e.g. a skin or muscle cell) is transferred into a female egg from which the genetic material has been removed. at the end of this process a clonal embryo is produced (2). reproductive cloning refers to creation of a clonal human embryo, but instead of being used for experimental purposes, it would be implanted in a woman's womb and brought to term as a born child. embryonic stem cell research in some forms involve research cloning, therefore it must be considered in the cloning debate since it does not involve modification or trait selection of genes(3). genetic trait selection: in this process the presence of certain genes of interest are determined in eggs, sperm and early embryos. then, the desired eggs, sperm or early embryos carrying the genes of interest are used to create a child. in this process however, the genetic selection can be used for medically-related purposes or for non-medical purposes. for example, in medically-related genetic selection (a procedure known as preimplantation genetic diagnosis (pgd), a set of single-cell zygotes [created by ivf (in vitro fertilization] are tested for genes causing cystic fibrosis or tay sachs disease and only zygotes free of those genes are allowed to initiate a pregnancy. also in a disease such as duchenne muscular dystrophy that is sex-linked, pgd can be used to ensure that the child born will be of the sex that does not have or carry the disease (4). human genetic modification: genetic modifi cation in humans can potentially take place at therapeutic and enhancement levels. at the therapeutic level, the illness or deficiency in a person is cured. at the enhancement level, the health condition of a person is seeked to become better than average. genetic modification can be done either at somatic (changes of genes in cells of a person's body other than eggs or sperm) or germline (changes of genes in egg or sperm cells) levels. germline modifications can be passed on to all succeeding generations. therefore, in the area of human genetic modification, four possibilities exist: somatic therapy, somatic enhancement, germline therapy and germline enhancement. definitions somatic therapy: in the past decade a number of clinical trials have been underway to cure diseases by somatic therapy (or gene therapy) such as cystic fibrosis and combined immunodeficiency. in these examples, good genes are transferred to body cells to improve cell functions (5). germline therapy: in this kind of therapy it is potentially possible to insert healthy genes into an early-stage embryo that is found to have diseased genes such as cystic fibrosis. although such interventions have not been attempted in humans, the techniques are under development (5). somatic enhancement: in this kind of process for example, a new gene is inserted into muscle or lung tissues of athletes to increase their strength or respiratory capacity. such enhancements have not been attempted in humans yet (5). germline enhancement: in this kind of process, for example, a genetic modification is attempted in muscle or lung-cell genes of an early stage embryo to improve muscular strength or respiratory capacity in the child that results from that embryo. it has been suggested that through this process individuals can be created who have extra cognitive or behavioral traits that would constitute a new version of human species that could not breed with normal humans. therefore, the practice of germline enhancement is viewed as a potentially dangerous approach in treatment of human disease because it has the potential to alter the human species (5). general consensus in the world the issues of cloning, gene therapy, and em bryonic stem cell research have been at the headlines of many newspapers and magazines for over a decade in many countries throughout the world. although some countries have passed laws on these issues, many countries have not adopted any position and do not have any laws regarding the application of genetic technologies.the following generalizations can be made regarding the ethical use of new genetic technologies in the categories discussed (6): j med ethics hist med 2009, 2:11 ali m. ardekani page 3 of 4 (page number not for citation purposes) 1. somatic therapy is widely considered to be ethical and acceptable in the world because it creates hope to treat diseases such as leukemia. 2. somatic enhancement is widely considered to be unethical since it could introduce new forms of inequality. 3. germline therapy is supported by most people because it helps couples at risk of passing on a serious genetic disease, to decide on having a child free of disease by means of medically related trait selection. 4. germline enhancement is widely considered unacceptable throughout the world because it serves no medical purpose. it also could poten tially lead to inequality among one generation over the next without their consent. further more, changing the nature of human beings over the long term may have consequences that can not be predictable at this time. 5. human genetic trait selection is generally supported because it allows a couple at risk of passing on a serious genetically-based illness to their child a chance to avoid it. however, genet ic trait selection is generally opposed for non medical or social purposes such as selection of a desired sex. 6. human reproductive cloning is universally rejected. 7. cloning for research purposes is supported in some countries and others strongly oppose it. 8. embryonic stem cell research is cautiously supported because it is argued that the unused embryos resulted during the ivf procedure should be used for research purposes to gain knowledge about stem cells. policies of countries in many countries around the world, the ethical use of new genetic technologies has been discussed at the highest levels of governmental and non governmental bodies. based on the united nations report (7), out of 192 countries in the world, some have adopted laws allowing or prohibiting the use of new genetic technologies in certain medical practices. the following table (table 1) is a combination of information obtained from the reports by the center for genetics and society (6): the thirty member countries of the organiza tion for economic cooperation and development (oecd) that include turkey, mexico, canada, australia, and the united states together account for nearly 20% of world population and 84% of world gdp and have the most fully developed human biotechnology research sectors (8). the status of the policies of oecd countries regarding the ethical use of new genetic technologies in humans is given below (table 2). table 2 is obtained from the reports by the center for genetics and society (6). council of europe: the 47-member council of europe maintains a bioethics division and has explicitly prohibited inheritable genetic modification, somatic genetic modification for enhancement purposes, social sex selection, and creation of human embryos solely for research purposes. council of europe in 1998 prohibited cloning human beings (9). european union: european union is a 27-member entity and has approved laws regarding the rights to the integrity of the person, and has prohibited human reproduc tive cloning, eugenic practices, in particular those aiming at selection of the persons and making the human body and its parts as a source of financial gain (10). african union: the african union has passed laws regarding the inviolability of the human body and the genetic heritage of the human species. it has also called for supervision of research facilities to obviate selective eugenic by-products, particularly those relating to sex considerations (11). group of eight (g-8): the g-8 countries (canada, france, germany, italy, japan, russia, the united kingdom, and the united states) have called for a worldwide ban on human reproductive cloning and have called for close international cooperation to prohibit the use of somatic cell nuclear transfer to create a child (12). conclusion the evidence provided in this article strongly suggests that many governments and organizations throughout the world have agreed to prohibit human reproductive cloning, inheritable genetic modification and social trait selection. however, the opinion is divided regarding the research cloning and embryonic stem cell research using ivf embryos and medically-related genetic selection. there also appears to be a concern about the somatic genetic enhancement and commerciali zation and commodification of human reproductive practices. in many countries, it is now against the law to pay for women’s eggs for research or assisted reproduction and commercial surrogacy. as the new genetic technologies allow indi viduals to buy genetic materials and rent individu als for reproductive reasons, it is likely that, in the near future, pregnancy itself becomes a job that could be outsourced to gestational surrogates in the poor countries. the recent reports (9) suggest that egg trafficking is on the increase from the poor countries to the rich ones. the issues raised in this article provide the evidence that the law-makers, http://en.wikipedia.org/wiki/canada http://en.wikipedia.org/wiki/france http://en.wikipedia.org/wiki/germany http://en.wikipedia.org/wiki/italy http://en.wikipedia.org/wiki/japan http://en.wikipedia.org/wiki/russia http://en.wikipedia.org/wiki/united_kingdom http://en.wikipedia.org/wiki/united_states j med ethics hist med 2009, 2:11 ali m. ardekani page 4 of 4 (page number not for citation purposes) political, religious and social leaders in the developing countries must quickly address these issues and provide the guidelines to the organiza tions and institutions involved in the practices of genetic technologies for reproductive and research purposes in their respective countries. table 1. policies of countries around the world practice prohibited allowed countries reproductive cloning 59 0 germline modification 44 0 social trait selection 36 0 research cloning 40 14 embryonic scr using ivf embryos 12 44 medically related trait selection 6 30 no policies 133 authorization of cloning 0 scr= stem cell research; ivf= in-vitro fertilization. table 2. the status of the policies of oecd countries practice prohibited (%) allowed (%) reproductive cloning 97 0 germline modification 83 0 social trait selection 77 0 research cloning 63 27 embryonic scr using ivf embryos 13 73 medically related trait selection 10 67 scr= stem cell research; ivf= in-vitro fertilization. references 1. fenton e. genetic enhancement – a threat to human rights? bioethics 2008; 22(1): 1-7. 2. sparrow r. cloning, parenthood, and genetic relatedness. bioethics 2006; 20(6): 308-18. 3. baylis f, robert js. the inevitability of genetic enhancement technologies. bioethics 2004; 18(1): 1-26. 4. sparrow r. therapeutic cloning and reproductive liberty. j med philos 2009; 34(2): 2-18. 5. budinger tf, budinger md. ethics of emerging technologies. new jersey: john wiely & sons; 2006. 6. anonymous. center for genetics and society. www.geneticsandsociety.org (accessed on june 2009). 7. anonymous. unesco, bioethics. www.unesco.org (accessed on june 2009) 8. anonymous. organization for economic cooperation and development (oecd). www.oecd.org (accessed on june 2009) 9. anonymous. council of europe. http://conventions.coe.int (accessed on june 2009) 10. anonymous. european union. http://www.europarl.europa.eu (accessed on june 2009) 11. anonymous. organization of african unity. http://www.africa-union.org (accessed on june 2009) 12. anonymous. group of eight. final communiqué of the denver summit of the eight. http://www.g7.utoronto.ca (accessed in june 2009) journal of medical ethics and history of medicine professional ethical competence in nursing: the role of nursing instructors fariba borhani 1 , fatemeh alhani 2* , easa mohammadi 3 , abbas abbaszadeh 4 1.phd nursing student, tarbiat modares university, tehran, iran. 2.associate professor, nursing department, faculty of medicine, tarbiat modares university, tehran, iran. 3.associate professor, faculty of medicine, tarbiat modares university, tehran, iran. 4.associate professor, faculty of medicine, kerman university of medical sciences, kerman, iran. *corresponding author: fatemeh alhani address: 4 th floor, no.5, nasr bridge, jalal-e-ale ahmad highway, faculty of medicine, tarbiat modares university, tehran, iran. e-mail: alhani_f@modares.ac.ir received: 26 feb 2010 accepted: 26 jun 2010 published: 08 jul 2010 j med ethics hist med. 2010; 3:3. © 2010 fariba borhani et al.; licensee tehran univ. med. sci. abstract keywords: nursing, nursing student, ethics. introduction the purpose of nursing education is not only teaching rational and mental skills but, in this arena, more emphasis is put on promotion of moral, spiritual, and communicative values for serving people (1). in other words, in nursing, simultaneous teaching ethics to nurses leads to their involvement in providing high quality care, enable them to duly encounter ethical issues. one of the key elements of educational systems is nursing instructors. even though lots of studies show the role of instructors in students’ learning, their role in promotion of professional ethics has been attended to less. the objective of this study is surveying the experience of nursing students with respect to the role of instructors in promotion of professional ethics. this qualitative study enrolled 15 undergraduate nursing students from three nursing schools in teheran whom depth interview was performed. the interview was semi structured with open ended questions. the analysis was accomplished by use of qualita tive content-analysis method. data analysis demonstrated 2 main themes and 7 subcategories in regard to the role of instructors in promotion of professional ethics in nursing students including: 1) the effective professional role model 2) facilitating creative learning. the effective profes sional role model encompasses individual characteristics and beliefs, clinical skills and professional commitment of role model. creative learning facilitates by encouraging critical thinking and decision-making, providing supportive learning conditions, providing proper space for sharing knowledge followed by evaluation and creative feedback. the findings of this study provides a background for strengthening the role of instructors in promotion of professional ethics with more emphasis on research which increase capability of instructors at nursing education centers. j med ethics hist med 2010, 3:3 fariba borhani et al. page 2 of 8 (page number not for citation purposes) promotion of both professional ethical competence and technical capabilities are given attention too. teaching ethics leads to train nurses commit ted to and responsible for presenting high quality care (2). most clear-sighted moral theorists insist on the role of education in promoting nurses’ capability in facing with ethical issues (3). nursing instructors are significant elements of education. they can increase students’ capabilities in various fields including their self-esteem (4) and taking advantage of learning opportunities (5). the more the contribution of instructors, as meta-cognitive guides, in teaching ethics, the more is the ethical reasoning and decision-making capability of nursing students (6). according to duquette the nursing instructors are much effective in shaping ethical values of students (7). there are some studies that found nursing instructors affecting the ethical knowledge (2) and moral function (8) of students. although in the process of teaching the nurs ing instructors are more insisting on ethical principles such as justice, beneficence, non maleficence and autonomy, however, problems arise when the students face with the organizational realities of nursing work. therefore, it is required that nursing instructors prepare nursing students for management of ethical context of their work environment (9). regarding the fact that the professional ethical competency is highly con nected to patients care, therefore, one cannot examine ethical competency as context-free (10). in other words, development of professional ethics in relation to different students and educational systems has specific features. this is due to the nature of ethical issues which takes different dimensions in various socio-cultural contexts. thus, examining professional ethical competency in different cultures and work circumstances may lead to discovery of new findings. in iran undergraduate nursing students should pass 135 units including 26 basic sciences course units, 20 general course units, and 89 specialized course units for getting bachelors degree. a course on nursing history, development and ethics equivalent to one course unit was offered since 1983 and then upon reconsideration of the curricu lum a separate course under this title was eliminat ed in 1995; however issues on nursing ethics were included in all specialized courses. despite this emphasis and due to the fact that a successful training depends on various factors including qualification of the instructors, content of the texts, teaching method, individual backgrounds of students and methods of evaluation of professional ethics, the extent of success in learning the ethical topics differs at various faculties. their role as the teachers of ethics has not been attended too much (2). moreover, in the process of education in iran, no adequate investiga tion has been made into the ethical competency of nursing students and, therefore, more qualitative studies are needed for explaining the experience of undergraduate nursing students in relation to the role of instructors especially in this context. this paper reports on the role of nursing instructors, which is one part of a larger study. the aim of the larger study was to explore how nursing students achieve ethical competency. one aspect of the findings was the impact of nursing instructors on students' competencies from their perspective. method we performed this study to survey the role of nursing instructors in nursing students competency from their perspective. the proposal of this qualitative study was approved by the research ethics committee at tarbiat modares university in tehran in 2008. therefore 15 undergraduate nursing students with different levels of education from three nursing faculties in tehran were selected for interview. all participants were informed about the purpose of the study by the first author, both verbally and in writing. the participa tion was voluntary and all the participants were assured regarding their confidentiality and anonym ity. main questions were asked focusing on their ethical sensitivity and practice, their experience of working with instructors, and their view on instructors’ role in fostering ethical competence. after obtaining informed consent, the nursing students were scheduled for interviews at their first convenient. participants were asked to narrate their experience of achieving ethical competence. all interviews started with the question: “please tell me about your experience of achieving ethical compe tence in nursing care?” the students were encour aged to talk freely about their own experiences of learning ethical competence in educational period. during the interviews, the researchers focused on nursing students' experiences of the role of their teachers in this process. each interview was audio taped and lasted between 50 to 75 minutes (with an average of one hour), and then transcribed verbatim and analyzed before the next interview. this process was continued until data saturation occurred. a descriptive design was used incorporating qualitative content analysis. this approach allows the researcher to explain and interpret the data (11) and elaborate the dominant and major themes of the participants' experiences (12). the specific procedure of qualitative content analysis used in the present study was based on methods described by granheme and landman (13). through the interview, the investigator brack eted her own ideas about teachers’ role in achiev j med ethics hist med 2010, 3:3 fariba borhani et al. page 3 of 8 (page number not for citation purposes) ing ethical competence and focused on the expe riences of each participant. the data collection and analysis were con ducted concurrently according to the method of constant comparison. initially, all interviews and the entire diaries were transcribed into texts. then the texts were read several times and the meaning units were identified. a total of 500 meaning units were identified. in the next step, the meaning units were condensed and grouped into categories. during the analysis, the intension was to reduce the number of categories by subsuming similar categories into broader categories. finally, the condensed meaning units were abstracted to an interpretive level to reveal their implicit meanings. the abstractions were read and compared, and those relating to the same content were grouped together. the credibility of data collection and data analysis was established by member checks and peer checks, external audit and prolonged engage ment. the findings were given to all participants, to check for the accuracy of their meaning interpreta tion. three expert supervisors carried out the peer checks and two persons outside the study con ducted a thorough review of the study and reported their opinions about the accuracy of the data of one third of interviews. the prolonged engagement with the data and participants also helped to gain a better understanding of the field of research. the maximum variations of sampling (in terms of the type of school, level of education, and age) provided the data on a wide range of views and perceptions, as well as enhanced the credibility and conformability of the data. results the mean age of the participants was 22 years. data analysis showed two main themes and 7 subcategories related to the effective role of instructors in promoting professional ethics in nursing students including: 1) the effective professional role model including the individual's subthemes and psychological state, clinical skills, responsibility and professional commitment; and, 2) enhancing creative learning which its subthemes including encouraging critical thinking and decision-making, establishing a supportive learning field, having good theoretical knowledge, provid ing opportunity for fair evaluation and feedback. effective professional role model according to the participants view in this study, models play an effective role in practical education of professional ethics and the instructors have been an important behavioral model in this direction. they considered promotion of profes sional ethics dependent on the model-centered role of nursing instructors. they believed that students, by observing ethical behavior of instructors, learn how to act ethically. according to the results, the ethical models are not restricted to instructors and many people can show a role model for them. however, they considered the instructors as one of the most effective models and, from the beginning of their entry to nursing course, have always experienced the influence of the instructors on their function in both technical and ethical fields. from the viewpoint of students, the model role of instructors is reporting as the following subthemes: a) individual characteristics and beliefs of role model most participants in this study considered the individual features such as responsibility, honesty, patience, cheerfulness, kindness, being practical, and etc as the basic elements of the individual features of nursing instructors in promoting professional ethical competence. the second student participating in this study stated: “i remember one of our instructors to be such patient and cheerful that every time they entered the ward, even on being much tired, had a smile and, by this behavior, taught us to be kind and cheerful to patients.” another participant stated concerning the im portance of honesty of nursing instructors: “when the instructor is honest, the student, too, learns to behave appropriately. one of our instructors, in the training session or in the classroom, used to tell us that an instructor may not know all the questions you ask (any time they didn’t know the answer to our question with certainty, honestly revealed that they didn’t know the answer and would need to study about the case concerned). i always remember them as a model of honesty.” the study subjects believed that the nursing instructors should undertake religious principles and values, and establish education based on these values, which help students learn ethical nursing. a participant stated such in this regard: “when the instructor him/herself believes in religious principles, surely does what god ap proves. of course, this belief should be heartfelt and pure not hypocritical. some of our instructors are known to be moral thinking, being both religious-minded and ethical nurses. if the belief is real, training, too, is done correctly.” another student said: “if there are instructors with the idea that god is observing them, training goes on very well. i am satisfied with most of our educators. some may seem to be not so much believing, but when you work with them you find them much committed j med ethics hist med 2010, 3:3 fariba borhani et al. page 4 of 8 (page number not for citation purposes) to some values and emphasis on seeing the god observing our deeds.” b) clinical skills of role model considering the care as the essence of nurs ing, all students considered the necessity of clinical skills for instructors; they also insisted on the model role of the instructors from clinical view point. another participant said: ‘if someone who is teaching knows how to do nursing tasks and is skillful, he/she would be able to teach the students well. when a student becomes skillful, he/she provides good care for patients. when a student does his/her task well, ethical nursing comes into being. for example, if he/she has learned how to insert a catheter into a blood vessel, he/she will not pierce ten points for finding a blood vessel. inflicting no harm is an ethical act. we had instructors who provided such a care for the patients that the medical students came there to learn and we took pride of them.” c) professional commitment of role model according to nursing students participating in the study, the instructors' interest in nursing profession has an effective role in learning. such instructors provide good care by establishing good relationships with patients and spending adequate time on them, which show their responsibility toward patients and provide full-of-commitment care for them. a student participating in the study said: “you know everybody needs a model and se lects this model according to his/her views. in my opinion, the instructors can be very good models. some of these instructors from whom i learned good nursing practice; one of them, for example, remained at ward even after their work; and, if the patient’s care had not been ended, worked for him/her. the students, too, by seeing such a sympathetic instructor, learn good care.” part of the experience of a nursing student in relation to passing a training course with an interested and committed instructor is as follows: “we had an instructor such interested in their work that, as soon as came to the patient’s bed, turned up their sleeve and started work and arranged the surroundings of the patient. they made good relationship with patients and worked with such interest that every uninterested student would change to an interested one by seeing them. ” facilitating creative learning a) encouraging critical thinking and decision making the participants in the study believed that the instructors confront nursing students with ethical issues, are effective in promotion of professional ethical competence by means of different teaching methods and creating learning situations. in this respect, one of the students stated: “if the instructor, at any ward, discusses the ethical problems of each patient, the student will learn more how to face the ethical problems in his/her work afterwards and how to solve them.” the instructors helps in reasoning and deci sion-making capabilities of students, were in the focus of students’ attention. they believed that instructors who confront the students with tough positions increase their decision-making capabili ties. a student expressed his/her experience in this regard: “during the lecturing, one feels sleepy. if, at the end of the class, you ask such student what he/she has caught, the answer will be: nothing. well, it will be better if the materials presented become more applied and understandable. for example, one of our instructors discussed a topic on difficult-to-cure diseases and cancer, and explained on a cancer-afflicted patient whose life was difficult to continue and urged to follow an easy death. by hearing such an example, we had to ask whether we would be allowed to help him/her. such examples help the students contemplate. .” another student, with respect to the instruc tors’ knowledge of different ethics teaching methods said: “when we jointly discuss the topic at class, we learn more. when we learn how to provide the best care, we will have an ethical care. discussion on the subjects, especially ethical issues helping critical thinking, indicates that he/she accepts nothing without reason and contemplates on the subjects. .” b) providing supportive learning conditions the participants stated that the nursing stu dents would have a great role in creating supportive learning conditions. they said that, they provide better care for patients as teamwork. in their opinion, when the instructors allow the students to make mistake without punishment and humiliation, a proper environment full of respect will be provided which facilitates learning. psychological support more prepares learning environment, creativity, increases capability of solving ethical problems and strengthens honesty in students. in this regard, a participant stated: “once i had drawn a drug into the syringe; my instructor came and saw that i had made a mistake regarding the dose drawn. they told me to come out of the patient’s room and reminded me of my mistake and did not humiliate me in front of the patient. then, i thought that we are all members of one family and i must care more such that no harm is inflicted on the patients by my error.” j med ethics hist med 2010, 3:3 fariba borhani et al. page 5 of 8 (page number not for citation purposes) c) sharing knowledge in addition the participants insisted on the in structors’ theoretical knowledge. the participants did not consider the expert’s knowledge of nursing sufficient for promotion of the professional ethical competence, rather more emphasized on co existence of both technical and ethical knowledge. concerning technical knowledge, a student said: “if good and ethical care is to be delivered, the nursing student should enjoy nursing know ledge. in my view, the educators bear a great role in this arena. when the educator has a proper knowledge of nursing, he/she teaches students scientifically at the same time. one of our instruc tors was so informed of cardiac care unit (ccu) and taught it so well that all of us learned it in depth. when we learn a job well and do it properly, it is ethical.” part of the lecture of a participant concerning ethical knowledge is as detailed below: “until the latest semesters, when i was un dergoing practical training with one of the instruc tors acquainted with ethics, i had no knowledge of ethical work. only in our courses and practical training, general issues were mentioned about patients’ rights, respecting patients, good patients’ relationships, confidentiality and privacy. but, when we were undergoing practical training, they explained ethical issues about the cases which we may encounter during our work; i learned ethical principles.” d) evaluation and creative feedback nursing students more emphasized on the ob servance of ethical aspects of care, especially fair evaluation of their work as an encouragement of ethical development and progress. they also determined the role of instructors technical knowledge in assessment of their weaknesses and strength when facing ethical issues, and considered this evaluation as effective. a participant said: “some of the instructors in practical training do not care whether we observe the ethical issues or not. but, some encourage us when we make good relationship with patients or observe their private limits, and influence observance of ethical principles in evaluation. when the students learn that they are evaluated for observing ethical issues, they try to be committed to them and, gradually, observance of professional ethics becomes institu tionalized.” in this respect, another student said: “some of our instructors do evaluate our technical skills and knowledge and, at the same time, have items for evaluation of professional ethics; for example, patients relationship, informed consent, patients privacy, etc. when the student is to be evaluated, he/she will try to observe ethical issues, too.” discussion the findings of this study emphasize the im portance of the role of nursing instructors in promotion of students’ professional ethical competence in the process of nursing education. the importance of the instructors’ role in students’ learning is not limited to the findings of the present research and the statements of the students partici pating in this study; this issue has, also, been referred to previous studies. but, the findings of this study are more perfect ones concerning the effects of nursing instructors on learning ethical matters by students. the students participating in this research considered the role of instructors as a model promoting ethical issues. they reported that the individual’s characteristics such as kindness, flexibility, honesty, etc are important in this process. similar findings were reported by görgülü et al. (14). parsons et al believe that the role of virtue-based morality for education is very effec tive, and consider the role of moral models especially the model instructor as vital for teaching ethics (15). usually, people are inclined to select individuals as role models to share their values and beliefs with (16). spiritual aspects are one of the essentials of ethical competence, to the effect that the more the nurses are spiritual and show their spiritual aspects in their work, the more they succeed in ethical issues. all humans have spiritual nature (17). few works are done in the world lacking value and psychological bases; ethical education is not an exception to this rule. thus, it is necessary that instructors be informed of their own psychological and belief values, making proper use of them in different educational situations (18). according to fahrenwald for moral character development in nursing students, it is essential that the students be involved with instructors who possessing ethical and professional values (19). participants in this study insisted on the role of instructors as clinical models. according to them, instructors’ competence in clinical skills helps nursing students learning their skills properly and not to harm patients due to clinical insufficien cy. the findings of donaldson et al. confirm the finding that the nursing instructors hold an impor tant role as a model for strengthening clinical skills of students. in their opinion, practical education should be associated with teaching clinical skills, explaining what they should do and giving them training opportunities (20). one of the significant consequences of teach ing ethics to students is increasing their capacity for autonomous ethical decision-making (21). j med ethics hist med 2010, 3:3 fariba borhani et al. page 6 of 8 (page number not for citation purposes) according to the participants in this study, the instructors, by use of different methods, help creation of this capability. regarding the fact that the essence of nursing work is patients’ care, the educational methods which can promote both theoretical capabilities and technical skills of students are important. learning only based on experiences means learning from mistakes. lipp refers to different methods in teaching ethics and considers use of these methods as essential in promotion of students’ capabilities of critical thinking and solving ethical problems (22). in recent years, it has been demonstrated that nurses should be knowledgeable doers, not easily accept ing the past routines and blindly follow others’ guides (23). so, the role of instructors in creating such capabilities can be very important. regarding the fact that ethical, legal and professional nursing issues are interconnected in the context (24), the nursing instructors should be careful to confront nursing students with ethical issues in the context of education and teach them the strategies for facing with ethical dilemmas. the findings of benner show that this capability is created in students during experiencing ethical issues. therefore, one should not ignore the role of practical education in ethical training (25). the nursing instructors should ask themselves whether their task is increasing technical skills and know how in students. if so, do these skills prepare students for future work? or, should the instructors try to teach the students other skills such as critical thinking, judgment skills, ethical and social responsibilities? (26). even though, some authors believe that critical thinking cannot be taught (27), but, many authors insist on the role of teaching in increasing critical thinking capability of students; and, particularly, consider the role of instructors as effective in creating this capability (6). one of the interesting findings of this study is the mere fact that the students generally consider the instructors' competence from technical and ethical view points as mixed and interrelated. one can not imagine a nurse to be ethical but not to perform his/her work skillfully and on the basis of scientific principles. therefore, promotion of professional ethical competence requires that the nursing instructors concern necessary nursing knowledge. also, the participants in this study considered nursing and ethical knowledge as essential for nursing instructors and attached importance to this factor in learning nursing ethics. miller et al. believe that good work in nursing includes a technically and scientifically convenient work associated with ethical feeling and social responsibility (28). woods et al. emphasized that, even though the model-centered role of instructors was important for creating ethical attitude of nursing students, but, alongside it, preparing students from the philosophical viewpoint and developing their knowledge in the arena of ethics was an important task of nursing instructors (29). as nursing has a holistic view toward pa tients; in interviews, too, this fact has been consi dered. participants in the study considered the knowledge of instructors as effective in promotion of professional ethical competence in association with ethical knowledge. because, if the instructors consider different aspects of care and organize their teachings based on that, the students not only will concern the technique, but also will pay enough attention to different aspects of care including ethical ones. the first and the most significant factor affecting ethical education are the role of skills and knowledge of nursing instructors (30). bolmsjö et al. take the view that ethical compe tence requires ethical knowledge, carefulness in determining ethical problems and creativity in indicating possible solutions. therefore, holding one-dimensional and technical knowledge is, in their view, not sufficient for teaching ethics, and they emphasize on a mixture of all kinds of skills and knowledge (31). promotion and development of students’ au tonomy is one of the features of good instructors (20). the students in this study believed that if the instructors give freedom of practice to students and, at the same time, keep adequate supervision on and protection for their work, they, in fact, will create proper conditions for their independent work, so they would be able to assume the respon sibility of their acts. the significance of facilitating capabilities of instructors has been referred to in texts. these capabilities include promotion of problem-solving and critical thinking, creation of a positive atmosphere for learning, and interest in helping students in learning (6, 32). moreover, mutual respect, free relationship, demonstrating relationship between ethical principles and beha vior, enhancing the student’s perception of their own behavior and knowing different ethical conditions are fundamental principles in the relationship between instructors and students (8). data resulted from the present study demon strates that repetition and continuation of profes sional ethics requires convenient and fair assess ment of ethical behaviors of students and giving them effective feedback. the students participating in the study of carter et al. expressed their benefits from instructors’ feedback (20). conclusion instructors are one of the important and key elements of developing nurses' ethical competence. this study, conducted on the basis students' experience of their relations with instructors, explains this role properly which seems useful for educational, research and managerial purposes. division of instructors’ roles into two main features j med ethics hist med 2010, 3:3 fariba borhani et al. page 7 of 8 (page number not for citation purposes) of effective professional role model and facilitator of learning and paying attention to the sub conceptions of these two can be effective in attracting the attention of instructors to the devel opment of their model role. on one hand, the descriptive framework presented in this article concerning the nursing instructors’ role can be the basis of other qualitative and quantitative studies for making the issue clearer. and, finally, educa tional management on the basis of the results of this research can be effective in designing the evaluation indexes of the successful nursing instructors in professional ethics and the ways of strengthening these two features. table 1. examples of the process of analysis meaning unit condensed meaning unit subcategory theme if the instructor, at any ward, discusses the ethical problems of each patient, the student will learn more how to face the ethical issues in his/her work afterwards and how to solve them encourage student to discusses the ethical issue encourage critical thinking and deci sion-making facilitating creative learning i had made a mistake regarding the dose drawn. they told me to come out of the patient’s room and reminded me of my mistake and did not humiliate me before the patient. doing fair evaluation providing suppor tive learning condi tions when the educator knows and under stands the nursing knowledge well, he/she teaches nursing students scientifically at the same time. being knowledgeable sharing knowledge j med ethics hist med 2010, 3:3 fariba borhani et al. page 8 of 8 (page number not for citation purposes) references 1. kim ys, park jw, son yj, han ss. a longitudinal study on the development of moral judgement in korean nursing students. nurs ethics 2004; 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13: 1. elaheh mianehsaz1*, seyed mohammad reza tabatabaee2, mohammad reza sharif3, hamid reza gilasi4, hamid reza shojaee far5, behzad nejad tabrizi6 1.assistant professor, department of physical medicine and rehabilitation, faculty of medicine, kashan university of medical sciences, kashan, iran. 2.assistant professor, department of emergency medicine, faculty of medicine, kashan university of medical sciences, kashan, iran. 3.professor, infectious diseases research center, kashan university of medical sciences, kashan, iran. 4.associate professor, department of epidemiology and biostatistics, faculty of health, kashan university of medical sciences, kashan, iran. 5.researcher, student research committee, kashan university of medical sciences, kashan, iran. 6.researcher, student research committee, kashan university of medical sciences, kashan, iran. abstract professionalism is a set of behaviors that build trust in physicians’ relationships with patients and the public. the aim of this study was to assess professionalism among residents in kashan university of medical sciences, kashan, iran. this cross-sectional study was conducted on 139 residents recruited through the census method. data were collected using the american board of internal medicine professionalism questionnaire. the first part of the questionnaire was on residents’ personal characteristics, and the second part contained fifteen items in the three domains of professionalism, namely excellence, honor/integrity, and altruism/respect. the mean scores of the questionnaire and its domains were calculated and their relationships with residents’ personal characteristics were evaluated. the mean scores (± sd) of professionalism and its excellence, honor/integrity, and altruism/respect domains were 4.93 ± 2.4, 5.92 ± 1.85, 4.94 ± 3.39, and 4.35 ± 3.27, respectively (in a range of 0-10). professionalism had significant relationships only with residents’ specialty and gender. the level of professionalism in residents was low, which requires the attention of educational authorities. moreover, the mean score of professionalism among residents in surgical specialties was significantly lower than non-surgical specialties. various factors can be considered in this regard and it cannot be concluded that the lower score means worse professional behavior. keywords: professionalism; residency; surveys; questionnaires; iran professionalism among medical residents in a young second-level university in iran … 2 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 1 february 2020 introduction medical professionalism is a social contract with the society that builds trust in physicians’ relationships with patients and the public (1). its essence is the mutual physician-patient trust. the key characteristic of professional physicians is the prioritization of patients’ needs over their own (2, 3). there is no single, universal definition of physician professionalism. professionalism is commitment to altruism, honesty, confidentiality, excellence, respect for patients' right to autonomy, and having appropriate relationships with them (4). medical residents are among the main providers of healthcare services. after graduation, some of them are employed as medical faculty members and become role models for their peers and medical students. it is clear that any problem in physicians’ professional behavior can compromise patients’ health. several studies showed that medial students and residents who demonstrated limited accountability and professionalism during their university education committed medical errors several times more than their peers after graduation (5 7). therefore, medical residents’ professionalism needs to be continuously monitored and promoted throughout their training program (8). the accreditation council for graduate medical education (acgme) considers professionalism as one of the six core competencies based on which residents are to be regularly evaluated (9). the importance of the issues of professionalism may be differently ranked and valued by different subspecialties (10, 11). there are different instruments for evaluation of professionalism, many of which have not been fully tested for reliability and validity. the most commonly used methods for assessment of professionalism are direct observation, patient assessment, objective structural clinical examination (osce), clinical incident report, resident portfolio, professionalism mini-evaluation exercise, videotape analysis and peer assessment (9, 12, 13). in peer assessment, peers with the same professional position who have been in direct unplanned contact with the intended person and have no superiority over him/her are asked to comment on his/her professional practice. this method provides valuable information about professionalism (14, 15). one of the instruments for peer professionalism assessment is the questionnaire developed by the american board of internal medicine (2). this questionnaire was used in previous studies to assess professionalism among physical medicine residents in the united states (16), medical residents in all specialties in two universities in tehran, iran (2), and physical medicine and rehabilitation residents in iran (17). all previous studies into medical residents’ professionalism in iran were conducted in leading universities (2, 18), and hence, there is limited information about medical residents’ professionalism in other universities. the present study aimed to evaluate medical residents’ professionalism in a second-level university, i.e., kashan university of medical sciences, kashan, iran. this university was established around mianehsaz e., et al. 3 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 1 february 2020 thirty years ago and is considered a young university. most residency programs in this university have a history of less than ten years, and there are no subspecialty fellowship programs at the moment. professors and senior residents are direct role models for junior students and residents. therefore, the present study aimed to assess professionalism among residents in this university. methods this cross-sectional study was conducted between july and september 2017. study setting was kashan university of medical sciences, kashan, iran, and study population comprised all medical residents in this university, including residents in pediatrics, internal medicine, general surgery, neurology, neurosurgery, gynecology, anesthesia, psychiatry, infectious diseases, pathology, and radiology. all residents in the university were recruited to the study via the census method. they were provided with explanations about the aim of the study and confidentiality of their information, and then, their verbal informed consents were secured. residents were included if they agreed to participate. data collection tool was the persian version of the american board of internal medicine (abim) professionalism questionnaire (2). the reliability and content validity of the questionnaire were confirmed at 0.88 by aramesh et al. (2). in the present study, the cronbach's alpha coefficient of the mentioned questionnaire was estimated at 0.878. this questionnaire included two main parts. the first part was related to residents’ personal characteristics, namely age, gender, academic year, residency specialty, familiarity with the concept of professionalism, participation in professionalism workshops, and self-study about professionalism. participants’ specialties were divided into the main two categories of non-surgical specialties (consisting of general surgery, neurosurgery, gynecology, and anesthesia) and surgical specialties (consisting of pediatrics, internal medicine, neurology, psychiatry, infectious diseases, pathology, and radiology). the second part of the questionnaire contained fifteen items on professional behaviors in three domains, namely excellence (four items), honor/integrity (four items), and altruism/respect (seven items). the items of the excellence domain (items 1 4) assessed residents’ beliefs about the availability of good role models in the areas of professional conduct, patient education, and student training. the honor/integrity domain (items 5 8) dealt with residents’ belief in their peers’ honesty and avoidance of nonprofessional practice. for instance, items in this domain were related to the possibility of lying to patients and asking junior residents to extract data from patients’ medical records. the altruism/respect domain (items 9 15) had items on residents’ respect for patients, peers, and hospital regulations, avoidance of wasting hospital resources, and consideration of professionalism among medical residents in a young second-level university in iran … 4 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 1 february 2020 patients’ convenience in performing diagnostic and medical procedures. items were scored from 0 (i.e., “lowest level of professionalism”) to 10 (i.e., “highest level of professionalism”). thus, the possible total score of the questionnaire was 0 150, and the possible total scores of its three domains were 0 40, 0 40, and 0 70, respectively. in order to generate a uniform 0 10 scoring scale for all domains, the total score of each domain was divided by the number of its items. after obtaining the legal and ethical approvals from kashan university of medical sciences, kashan, iran, (code: ir.kaums.rec.1394.146), two research assistants (medical interns who were well aware of the study aims) provided the study questionnaires to participants and asked them to complete them at their convenience. some participants completed and returned their questionnaires on the same day, while others returned their questionnaires days afterwards. participants were reminded to complete the questionnaires through followup personal contact or telephone calls. data analysis study data were analyzed using the spss program (v. 21.0). the independent-sample t-test was conducted to compare professionalism scores based on participants’ characteristics, and it had two levels. similarly, the one-way analysis of variance or the kruskal-wallis test was performed for characteristics with three or more levels. the level of significance was set at less than 0.05. results among all 181 residents in the study setting, four refused to participate and seventeen were in other universities in iran as guest students. thus, 160 residents participated in the study. despite frequent follow-up contacts, twelve residents did not return their questionnaires. moreover, nine questionnaires were partially filled out. thus, 139 questionnaires were entered in the final data analysis (a response rate of 86.87%). around 73% of the participants were familiar with the concept of professionalism, 11.5% had attended professional ethics or professionalism workshops or courses, and 24% had had self-study in this area. participants’ mean score of professionalism was 73.93 ± 36.01 (in the possible range of 0 150). the total mean scores of professionalism and its excellence, honor/integrity, and altruism/respect domains on the 0 10 scale were 4.93 ± 2.4, 5.92 ± 1.85, 4.94 ± 3.39, and 4.35 ± 3.27, respectively. the mean score of professionalism was significantly greater among residents in nonsurgical specialties than in surgical specialties (5.64 ± 2.40 vs. 3.54 ± 1.62; p < 0.001). moreover, female participants’ mean score of professionalism was significantly greater than their male counterparts (p = 0.006). however, there was no significant relationship between the mean score of professionalism and the other personal characteristics of participants (p > 0.05; table 1). mianehsaz e., et al. 5 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 1 february 2020 table 1the mean scores of professionalisms and its domains based on participants’ personal characteristics professionalism characteristics n (%) total score p-value excellence p value honor/ integrity p value altruism / respect p value gender male 67 (47.97) 4.35±2.16 0.006 5.73±1.92 0.24 4.01±3.24 0.22 3.57±2.90 0.001* female 72 (52.03) 5.47±2.50 6.10±1.77 5.79±3.32 4.91±3.49 marital status single 43 (31.08) 4.94±2.30 0.94 5.58±1.95 0.23 5.34±3.09 0.33 4.35±3.26 0.95* married 96 (68.92) 4.89±2.44 6.06±1.80 4.73±3.51 4.32±3.28 specialty nonsurgical 91 (65.54) 5.64±2.43 <0.0001 5.93±1.97 0.96 5.81±3.48 >0.0001 5.37±3.26 0.0001* surgical 48 (34.46) 3.54±1.62 5.91±1.60 3.22±2.46 2.37±2.19 academic year first 46 (33.11) 4.91±2.62 0.42 5.51±1.84 0.13 4.85±3.34 0.28 4.60±3.4 0.27† second 33 (23.65) 5.48±2.40 5.83±1.83 5.86±3.38 5.05±3.32 third 28 (20.27) 4.66±2.27 6.59±1.79 4.53±3.26 3.62±3.25 fourth 32 (22.97) 4.59±2.17 5.92±1.85 4.39±3.55 3.91±2.96 familiarity with professionalism yes 101 (72.97) 4.79±2.40 0.24 6.01±1.86 0.29 4.75±3.44 0.28 4.1±3.28 0.14* no 38 (27.03) 5.31±2.38 5.67±1.83 5.45±3.25 5.03±3.16 participation in workshops yes 16 (11.49) 4.75±2.23 0.77 5.77±2.07 0.67 4.83±3.55 0.58 4.32±3.08 0.97# no 123 (88.51) 4.95±2.43 5.94±1.83 4.99±3.38 4.36±3.29 self-study on professionalism yes 33 (23.65) 4.69±2.57 0.53 5.12±2.23 0.01 4.66±3.56 0.60 4.45±3.42 0.85* no 106 (76.35) 5±2.36 6.17±1.66 5.02±3.35 4.32±3.24 number of learning hours per week 50–60 47 (33.78) 4.87±2.51 0.38 5.86±1.79 0.16 4.91±3.45 0.79 4.28±3.33 0.68 ̂ 61–70 33 (24.32) 4.73±2.14 5.30±2.23 4.49±3.17 3.76±3.08 71–80 25 (17.57) 5.29±2.61 6.52±1.94 5.20±3.64 4.65±3.63 81–90 9 (6.76) 6.15±2.05 6.82±1.45 6.22±2.96 5.73±2.87 > 90 25 (17.57) 4.89±2.45 5.99±1.19 4.70±3.60 4.38±3.31 *: the results of the independent-sample t-test; †: the results of the one-way analysis of variance; ^: the results of the kruskal-wallis test; #: the results of the mann-whitney u test discussion this study evaluated professionalism among medical residents in kashan university of medical sciences, kashan, iran. the total mean score of professionalism was 73.93 ± 36.01 on the 0 150 scale, and 4.93 ± 2.4 on the 0 10 scale. a study on residents in tehran and shahid beheshti universities of medical sciences, tehran, iran, reported a professionalism mean score of 6.12 ± 0.37, professionalism among medical residents in a young second-level university in iran … 6 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 1 february 2020 indicating moderate professionalism (2). all these findings may demonstrate the ineffectiveness of the interventions that have been implemented for promotion of professionalism in recent years. other studies on physical medicine and rehabilitation residents throughout the united states and iran found that their mean scores of professionalism were 7.7 and 7.67, respectively (16, 17). the significantly higher total professionalism scores in those studies compared to the present study may be due to the fact that they were conducted on physical medicine and rehabilitation residents who did not do night shifts and did not attend the operating room, while samples of the present study consisted of residents from different specialties and different work shifts. our findings also showed a significant relationship between the type of specialty and the total mean score of professionalism, so that residents in non-surgical specialties obtained significantly greater scores than their counterparts in surgical specialties. high occupational stress, emergency situations, high frequency of night shifts, lack of sleep, lack of adequate time for selfstudy, and role multiplicity might have contributed to the lower professionalism mean score among residents in surgical specialties. further studies are needed to determine the factors affecting professionalism. the mean scores of the excellence, honor/integrity, and altruism/respect domains of professionalism in the present study were 5.92 ± 1.85, 4.94 ± 3.39, and 4.35 ± 3.27, respectively. thus, the highest and the lowest scores were related to the excellence and the altruism/respect domains, respectively. these findings indicate that participants’ practice was better in terms of prioritizing patients’ needs over their own needs, attempting to broaden their knowledge, and training junior residents compared to their practice in terms of respecting hospital regulations, saving resources, and ensuring patients’ convenience. further studies are needed to provide reasons for such findings. our findings also showed that residents in non-surgical specialties obtained significantly greater professional scores than those in surgical specialties (5.64 ± 2.40 vs. 3.54 ± 1.62; p < 0.001). however, we could not find any study in this area for the purpose of comparison. this finding may be due to the fact that residents in surgical specialties worked in the stressful environment of operating rooms and needed to make prompt clinical decisions in emergency conditions. another finding of the present study was the significantly greater professionalism mean score among female participants compared to their male counterparts. however, there was no significant relationship between professional mean score and the other personal characteristics of participants. similarly, a former study indicated no significant relationship between residents’ professionalism and their personal characteristics (17). findings also indicated that around 73% of the participants were familiar with the concept of professionalism, and 24% had had self-study about it. a study on medical mianehsaz e., et al. 7 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 1 february 2020 students in shiraz, iran, showed that only 40% of them were familiar with the concept (18), and another study reported that only 10% of the residents had had self-study in this area (17). personal attitudes towards professionalism, self-study on the subject, and participation in conferences and workshops can affect residents’ perceptions of their peers’ professionalism. in other words, residents with greater knowledge about professionalism more seriously expect their peers to adhere to the principles of professional practice and may therefore score their peers’ professionalism more strictly and cautiously. similarly, our findings showed that residents who were familiar with the subject of professionalism, had had self-study in this area, or had participated in relevant workshops evaluated their peers’ professionalism more poorly. of course, the difference was not statistically significant. conclusion based on the results, the medical residents in this study had a low level of professionalism. the high score of the excellence domain and the low score of the honor/integrity and altruism/respect domain denote that the residents had a better condition in prioritization of the needs of patients over their own interests, trying to be scientifically updated, and improving education quality compared to respecting hospital laws, avoiding resource loss, and paying attention to patients’ comfort in the treatment procedures. the findings showed that residents in nonsurgical specialties obtained significantly greater professional scores than those in surgical specialties. this may be due to the fact that residents in surgical specialties worked in the stressful environment of operating rooms and needed to make prompt clinical decisions in emergency conditions. recommendations we evaluated the relationship between professionalism and some personal characteristics such as the type of specialty, gender, and marital status. it is recommended that future studies evaluate the relationship between professionalism and other factors such as patients’ conditions, faculty-resident ratio, patient-resident ratio, and workload. moreover, we found that despite having good role models, residents believed that their peers had poor professional conduct. thus, studies are needed to evaluate the reasons behind the insignificant effects of role models on residents’ professional conduct. moreover, only 11.5% of the participants had participated in professionalism and professional ethics workshops and courses; thus, studies are needed to evaluate the effects of such workshops on medical residents’ professionalism. acknowledgements this study was financially supported by the national center for strategic research in medical education, tehran, iran (project number: 960303), and the research and professionalism among medical residents in a young second-level university in iran … 8 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 1 february 2020 technology administration of kashan university of medical sciences, kashan, iran (project number: 94146). we would like to extend our gratitude to these two centers for their cooperation and support. conflict of interests all authors declare that they have no significant competing interests that might have influenced the performance of the work or presentation of the article. mianehsaz e., et al. 9 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 1 february 2020 references 1. büke as, öztürkçü osk, yılmaz y, sayek i. core professionalism education in surgery: a systematic review. balkan med j. 2018; 35(2): 167–73. 2. aramesh k, mohebbi m, jessri m, sanagou m. measuring professionalism in residency training programs in iran. medical teacher. 2009; 31(8): 356-1. 3. lynch dc, surdyk pm, eiser ar. assessing professionalism: a review of the literature. medical teacher. 2004; 26(4): 366-73. 4. asghari f, nikavaran fard n, atabaki a. are we proper role models for students? interns' perception of faculty and residents' professional behavior. postgraduate medical journal. 2011; 87(1030): 519-23. 5. papadakis ma, teherani a, banch m, et al. disciplinary action by medical boards and prior behaviour in medical school. n engl j med. 2005; 353: 2673-82. 6. papadakis ma, hodgson cs, teherani a, kohatsu nd. unprofessional behavior in medical school is associated with subsequent disciplinary action by a state medical board. acad med. 2004; 79(3): 244–9. 7. papadakis ma, arnold gk, blank ll, holmboe es, lipner rs. performance during internal medicine residency training and subsequent disciplinary action by state licensing boards. ann intern med. 2008; 148(11): 869–76. 8. conran rm, powell sz, domen re, et al. development of professionalism in graduate medical education: a case-based educational approach from the college of american pathologists' graduate medical education committee. acad pathol. 2018; 5: 2374289518773493. 9. lee fy, yang yy, hsu hc, et al. clinical instructors' perception of a faculty development programme promoting postgraduate year-1 (pgy1) residents' acgme six core competencies: a 2-year study. bmj open. 2011; 1: e000200. 10. domen re, talbert ml, johnson k, et al. assessment and management of professionalism issues in pathology residency training: results from surveys and a workshop by the graduate medical education committee of the college of american pathologists. acad pathol. 2015; 2(3): 2374289515592887. 11. hoonpongsimanont w, sahota pk, chen y, et al. physician professionalism: definition from a generation perspective. international journal of medical education. 2018; 9: 246– 52. 12. malakoff gl, payne cl, staton lj, kolade vo, panda m. accounting for professionalism: an innovative point system to assess resident professionalism. j community hosp intern med perspect. 2014; 4(2): 10.3402/jchimp.v4.23313. 13. goldie j. assessment of professionalism: a consolidation of current thinking. med teach. 2013; 35(2): e952-6. 14. bryan re, krych aj, carmichael sw, viggiano tr, pawlina w. assessing professionalism in early medical education: experience with peer evaluation and selfevaluation in the gross anatomy course. ann acad med singapore. 2005; 34(8):486-91. 15. arnold l, shue ck, kalishman s, et al. can there be a single system for peer assessment of professionalism among medical students? a multi-institutional study. acad med. 2007; 82(6): 578-86. 16. delisa ja, foye pm, jain ss, kirshblum s, christodoulou c. measuring professionalism in a physiatry residency training program. american journal of physical medicine and rehabilitation. 2001; 80(3): 225-9. professionalism among medical residents in a young second-level university in iran … 10 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 1 february 2020 17. ahadi t, mianehsaz e, raissi g, moraveji sa, sharifi v. professionalism in residents of physical medicine and rehabilitation in iran. j med ethics hist med. 2015; 8: 3. 18. askarian m, ebrahimi nia mj, sadeghipur f, danaei m, momeni m. shiraz medical students' perceptions of their colleagues' professional behavior. j adv med educ prof. 2015; 3(3): 111-6. 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____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ 1 © 2019 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 15 november 2019 review article bioethics: a look at animal testing in medicine and cosmetics in the uk *corresponding author stefane kabene p.o.box 117781, dubai, uae. tel: (+971)565021495 email: stefane@cud.ac.ae received: 21 apr 2019 accepted: 3 nov 2019 published: 12 nov 2019 citation to this article: kabene s, baadel s. bioethics: a look at animal testing in medicine and cosmetics in the uk. j med ethics hist med. 2019; 12: 15. stefane kabene*, said baadel faculty of communication, arts and sciences (fcas), canadian university dubai, dubai, uae. abstract using animals for cosmetics and medical tests has contributed towards a debate based on conflicting interests. despite the efforts in justifying the value of animals in conducting analyses, this study seeks to elaborate whether or not it is rational to use animals as test subjects in medical and cosmetics fields. the value of animal life is at the core of the emotional conflicts that arise when animals become experimental subjects in medical and cosmetics fields. the aim of this study is to determine if there are ethical differences in the use of animal testing in medicine versus cosmetics. the research, through review and content analysis of the existing literature, compares and provides the outcomes of using animals in medical and cosmetics tests by examining studies conducted in the uk. the findings of this research indicated that animal testing is considered acceptable in the medical field only if there are no other alternatives, but is completely unacceptable in the cosmetics field. the study also provides recommendations in the form of alternatives that protect animals from cruelty and may benefit the different stakeholders and the society at large. keywords: animal testing; bioethics; cosmetics testing; medical research bioethics: a look at animal testing in medicine and cosmetics in the uk 2 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 15 november 2019 introduction throughout history, animals have been the subject of experimentation to improve our understanding of anatomy and pathology (1). however, animal testing only became significant in the twentieth century (2). animal experiments are used extensively when developing new medicines and for testing the safety of certain products. recently, the use of animals for biomedical research has been severely criticized by animal rights and protection groups. similarly, many nations have established laws to make the practice of animal testing more humane. there are two positions in animal testing. one is that animal testing is acceptable if suffering is minimized and there are human benefits that could not have been achieved using any other means (3). the second position considers animal testing unacceptable because it causes suffering, and the benefits to human beings are either not proven or could be obtained using other methods. as such, animal testing is a highly controversial subject that often elicits conflicting emotions from supporters and critics alike. it is also a divisive subject as some people support animal testing only in certain cases and oppose its use in other areas. for example, scientists note that significant medical breakthroughs have only been made possible through drug testing on animals. to them and other like-minded people, such achievements are reason enough to keep using animals in the lab (4). animal tests determine if experimental drugs are effective or ineffective on human beings. eventually, the medicine is tried out on a small group of humans through clinical trials before declaring the medicine safe to use. badyal and desai (5) note that these treatments are as beneficial to humans as they are to animals, since some human diseases are found in animals too. therefore, some who support animal testing only advocate its use for medical (but not cosmetics) purposes, arguing that the advancement in human medicine may lead to advancement in animal medicine. while a significant population completely disapproves of animal testing, a faction of people only disagrees with the use of animals for cosmetics testing, arguing that it is despicable and cruel to use animal life merely so that humans can advance their beauty technology. the concern extends to animals used for science, and people want animal suffering to be minimized (6). the discovery of new drugs has for a long time been based on a number of interactions among aspects such as data collected from patients, tissues, organs or cell culture and varied animal species (7). those who oppose the use of animal testing for cosmetics believe it is outrageous and cruel to use animal life for the simple reason of making humans look better, and that the benefits to human beings do not validate the harms done to animals (7). for such reasons, the use of animals for testing cosmetics products has been banned in the uk and all other member states of the european union since 2013 (8). however, other countries like china and the united states of america still continue with the practice (9). linzey adds that about 50 100 kabene s., et al. 3 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 15 november 2019 million animals are used for experiments every year, and that over 1.37 million animals were used for drug experimentation in america in the year 2010 (9). in the meantime, the number of experiments conducted on animals has declined in britain but is increasing in other countries. while experiments involving vertebrates are regulated in most countries, experiments on invertebrates are not (5). the aim of this study is to examine whether or not animal testing is still useful and necessary in the present time, and whether there are ethical differences between animal testing in medical and cosmetics fields. we use the uk as our case study and provide alternatives that can be recommended in place of animal testing. methods this review was based on a cross-sectional survey by clemence and leaman (11) that analysed the importance of animal testing from two different aspects: medicine and cosmetics. the population consisted of individuals residing in the uk, and the sample size was 987 (= 0.03). the research included 496 men and 491 women. the report compared public views with the responses from a similar study in 2014 that had 969 participants (477 men and 492 women). the inclusion criteria were based on numerous strata such as gender, social grade definitions (i.e., professionals such as doctors and architects, people with responsible jobs such as professors, middle rank public servants such as nurses and clerics, skilled manual workers, etc.), respondents’ working status (fulltime, parttime, not working), ethnicity (white, nonwhite), and educational background. this report measured public perception on whether it is ethical to use animal testing for medical or cosmetics purposes. participants were required to state whether they found it acceptable, mostly unacceptable, unacceptable, or were undecided. consequently, the same participants were also tasked to indicate whether they saw conducting animal testing for scientific experimentation as completely necessary, somewhat necessary, not very necessary, completely unnecessary, or they did not know. the study also utilized data from the uk home office (12) to determine which animals were most frequently used for medical and cosmetics research around the world. this report also provided crucial information as to the purposes of animal testing, for instance for medical research, biological testing, regulatory testing, etc. results according to the uk home office (12), in the year 2016, 48.6% of the animal tests in medical research were conducted for genetically oriented studies. moreover, 28.5% of the medical research involving animal testing was for basic biological research, 13.5% was for regulatory bioethics: a look at animal testing in medicine and cosmetics in the uk 4 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 15 november 2019 fig. 1. purposes of animal testing in medicine testing, 8.6% was for translating research from animals to humans, and 0.8% for other trainings. this is summarized in figure 1 below. data from the uk home office (10) indicates that the most commonly used animals for medical and cosmetics research are mice and rabbits (72.8%), fish (13.6%), rats (6.3%), birds (3.9%) and other animal species representing 3.4% of the total test animal population, as indicated in figure 2 below. fig. 2. types of animals used in testing a published report (12) indicated that 17% of the sampled group viewed animal testing for medical research as ‘mostly unacceptable’ if there were no alternative, 17% as ‘not acceptable’, and 65% as ‘acceptable’. this was in stark contrast with testing for cosmetics purposes, to which an overwhelming 80% of the participants responded as ‘unacceptable’. the summary of the results is provided in figure 3 and figure 4 below. fig. 3. animal testing for medical research fig. 4. animal testing for cosmetics research in the same study (12), the participants were asked about the necessity of conducting scientific experiments on animals, which 38% of the respondents viewed as ‘completely necessary’, 23% as ‘somewhat necessary’, 20% as ‘not very necessary’, and 16% as ‘completely unnecessary’. the results are summarized in figure 5 below. genetic studies 49% basic biological research 28% regulator y testing 13% translation … other training 1% mice and rabbits 73% fi… rats 6% birds 4% others 3% acceptable 6% unacceptable 80% undecided 1% mostly unacceptable 13% for cosmetics acceptable 65% mostly unacceptable 17% unacceptable 17% undecided 1% for medical research kabene s., et al. 5 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 15 november 2019 fig. 5. necessity of conducting scientific experiments on animals the application of these methods to evaluate the safety of cosmetics was the most detested as stated by about 80% of the people who were interviewed during the investigation. the sensitivity to human life, on the other hand, reduces the strictness towards utilization of animals to find antiviruses and antibiotics for various diseases. discussion the outcome portrays the essentiality of using animals to determine materials that would help the population to live healthily (13). however, in the past few decades, the number of animals used for testing drugs has been steadily decreasing (14). the data indicates that most of the medical research processes involving animal testing emanate from genetically oriented studies, which constitute 48.6% of the medical research animal testing. experimentation on human genetics presents various legal and ethical challenges to medical and biological researchers, alongside problems in creating experimental procedures using human test subjects. these problems occur partially due to the fact that the experimentation processes involved in these types of studies often lead to extensive gene and physiological damages to the test subjects. such experiments typically involve deliberate presentation of diseases and other gene modifications to the test subjects, usually requiring the euthanizing of the involved subjects (15). the animal testing experimentations involving genetic processes include studies in gene modification and examine diseases believed to hold genetic components, such as cancer and diabetes (16). these experimentation processes typically involve some sort of gene modification that can simulate the presentation of genetically based disorders manifested in human beings to allow researchers to better understand those disorders. the data also indicate that another major application of animal testing in the medical field is in basic research in biological systems and processes, which accounts for 28.5% of the testing categories. this application of animal testing in medical research involves studies in how biological systems function, and the nature and manner of disease transmission in living organisms. the findings accrued through these kinds of studies translate to advancements in the scientific knowledge of human pathology and present opportunities for the derivation and testing of cures, as noted by festing and wilkinson (17). the findings further present that regulatory testing (13.5%) and animal to human translation research (8.6%) account for 38% 23% 20% 16% 3% 0% 10% 20% 30% 40% responses completely necessary somewhat necessary not very necessary completely unnecessary do not know bioethics: a look at animal testing in medicine and cosmetics in the uk 6 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 15 november 2019 significant portions of the application of animal testing in the medical field. the use of animal testing for regulatory testing purposes involves applying new medical findings, procedures and products to animals to see if they meet the thresholds mandated by the medical regulatory bodies. translation of research findings from animals to humans involves conducting research into the possibility of animal pathogens becoming infectious to humans, and identifying potential ways of applying non-human physiology to the improvement of human health. other forms of medical and biological trainings and studies that also engage the use of animals in experimentation in the medical field include elements such as basic physiology and pathogen studies, typically conducted in educational institutions. animal testing in the field of cosmetics generally involves the use of animal subjects in testing new cosmetics products and ingredients. the practice essentially involves the application or forced ingestion or injection of these substances to various parts of test animals to examine their toxicity, irritation of the eyes and/or skin, ultraviolet light-triggered toxicity, and their potential for causing unwanted gene mutations (18). the use of animal testing in the field of cosmetics research and production presents an unethical viewpoint since the findings do not advance human health, and the practice leads to the torture and killing of animals. the humane society (18) also notes that at the conclusion of the experimentation, the animals are usually killed through methods such as decapitation, neck twisting and asphyxiation, often without pain relief. with regard to the ethical principles of animal testing in both fields, a convincing argument should first be presented to the institutional animal care and use committee (iacuc). this is to justify the need for a researcher to conduct animal studies, and to ensure that the research is conducted using the smallest possible number of animals and with minimal suffering. additionally, naderi et al. (19) noted an increased level of legislation on the matter of animal testing, with researchers being required to submit comprehensive proposals to the iacuc to demonstrate procedural compliance with the guiding principles of the organization before conducting animal tests. furthermore, holden (20) highlighted the fact that researchers need to justify to review and ethics committees the use of mice rather than other alternatives in experiments. these issues indicate that researchers should look for alternatives to animal testing before proceeding with animal trials. the issue then remains on the nature and availability of alternatives to animal testing in the medical research field. researchers have undertaken measures to introduce some levels of such alternatives in medical studies. the accrued data indicate that a significant number of people agree with animal testing for medical research, especially when compared to those who agree with animal testing for cosmetics purposes. the data obtained from the studies indicate a slow but perceptible shift in the public opinions regarding animal testing for medical research purposes. people are kabene s., et al. 7 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 15 november 2019 increasingly finding it unacceptable to use animal test subjects even in medical research. however, the majority of the sampled people believed that medical testing procedures should use animal test subjects, but only when there is no other alternative. this indicates that people view animal testing for medical research as ethical, but under certain conditions. the use of animals in research is still relevant because the process is useful in veterinary medicine as it helps the students understand the physiology and anatomy and improves surgical skills (21). the study by badyal and desai (5) supports this perception by highlighting the fact that animal use in laboratory investigation will make new discoveries possible. however, researchers should apply ethical concepts to reduce the amount of pain and unnecessary procedures for the animals. moreover, animal testing to develop new drugs will continue to protect the future existence of humanity. cheluvappa, et al. (22) reiterate that animal experimentation will remain essential to testing future medicine because it helps scientists understand the changes of behaviour, embryology and genetics through dissections that are conducted on the genetically produced animals. animals play an important role in testing human drugs as they have a large number of medical reactions similar to those of human beings. specifically, animals such as dogs, mice and rabbits have an identical dna that cannot be replicated through artificial models. public concern for the increasing use of animals in terms of ethics and safety provokes anxiety among the population. conversely, these uncertainties and unavailability of trustable alternatives show the importance of using animals in medical research as the scientists aim to protect the human race (23). however, the use of animals to test cosmetics is highly limited due to the availability of alternative sources. for instance, the laboratory animals veterinary association (lava) claims that the uk government prohibits any individual from using animals to determine the suitability of cosmetics to the human body (13, 24). in its circular, the european union states that they have succeeded in developing alternative measures that cosmetics firms can apply to test their products without using laboratory animals (25). recommendations: alternatives to animal testing to improve business ethics in cosmetics companies, it is necessary for alternatives to be integrated instead of animals. companies can employ assessment of scientific barriers to find replacements for animal test subjects and to procure the knowledge of correctly using animals for medical and cosmetics tests. sophisticated tests on human cells or tissues, computer-modelling techniques, and experiments on people who volunteer are some measures that can limit acts of animal cruelty by cosmetics companies. companies need to integrate tests that minimize involvement of animals in order to limit the bioethics: a look at animal testing in medicine and cosmetics in the uk 8 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 15 november 2019 possibility of animal cruelty, and consequently improve their business ethics. some of the recommended alternatives are listed here. computer simulation the concept was developed by denis noble, and the system is currently enrolled in clinical settings. these simulations are used to test heart replacements, and are also applied to explore human behavior. various scholars provide that this model is more accurate than animal experiments because it uses human data to analyse diseases and make predictions (26). stem cells stem cells are proper alternatives to the in vitro systems of disease testing and toxin evaluations (27). the experiments involve evaluation of embryonic stem cells that can be grown in petri dishes. the petri dishes can be placed in the cells, and after that the resulting components are placed under evaluation to help in the discovery of new medications. stem cells are essential because they can differentiate into human tissues and make it possible to screen the suspected diseases (26). biochips these materials are majorly utilized in the cosmetics industry to minimize the number of animals used to test the level of toxicity in a product. significantly, investigations showed that human tissues developed in laboratories can be used to assess the allergic responses to the available chemicals (28). these results can then be analysed by comparing reactions, and a bio signature of genes is used to make appropriate interventions. 3d images notably, scientists can take high-resolution pictures of human tissues, which are then analyzed with the help of various computer systems. the advantage of this model is characterized by its ability to customize the parts of the organism under consideration. moreover, 3d images also develop prototype designs and materials that can be used to investigate the existing and future ailments (29). conclusion this study indicates that it is justifiable to use animals in experimentations only when there are no alternatives, and the tests have significant benefits to humans. many researchers are working towards finding options that will help eliminate the use of animals for medical and cosmetics tests. the different natures of tests conducted on animals in the fields of medicine and cosmetics tend to have clear negative implications. for such reasons, it is imperative for organizations to develop practices that endorse business ethics. although animal tests are ideal in establishing whether drugs can be effective in treating humans for various ailments, entities that conduct these tests need to be educated about the gravity of the situation. animals have been extremely useful in conducting genetic studies and for biological systems investigations. however, a comparison between animal tests in medicine and cosmetics reveals that their kabene s., et al. 9 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 15 november 2019 benefits in the field of medicine outweigh those in cosmetics. therefore, animals are essential contributors to scientific experiments that are affiliated with the medical industry. the effects that medical products may have on humans make it ethical to carry out the tests on animals first. after analysing the arguments of both the supporters and opponents involved in the controversial subject of animal testing, it is difficult to determine which direction is right or wrong. however, the agreement is that animal suffering be minimized at all costs. this research concludes that cosmetics companies should adhere to the established laws and principles against the use and abuse of animals in tests and should seek alternative methods to test their products. acknowledgements none. conflict of interests authors declare having no conflict of interest. bioethics: a look at animal testing in medicine and cosmetics in the uk 10 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 15 november 2019 references 1. hajar r. animal testing and medicine. heart views. 2011; 12(1): 42. 2. pound p, bracken mb. is animal research sufficiently evidence-based to be a cornerstone of biomedical research? bmj. 2014; 348: g3387. 3. costa‐pinto a, santos tc, neves nm, reis rl. testing natural biomaterials in animal models. in: neves nm, reis rl. biomaterials from nature for advanced devices and therapies, 1st ed. usa: wiley; 2016, p. 562-79. 4. saeidnia s, manayi a, abdollahi m. from in vitro experiments to in vivo and clinical studies; pros and cons. curr drug discov technol. 2015; 12(4), 218-24. 5. badyal dk, desai c. animal use in pharmacology education and research: the changing scenario. indian j pharmacol. 2014; 46(3): 257-65. 6. frey rg. interests and animal rights. philosophical quarterly. 1977; 27(108): 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[cited 2019 october]; available from:https://ec.europa.eu/growth/sectors/cosmetics/animal-testing_en 9. linzey a. the global guide to animal protection, 1st ed. usa: university of illinois press; 2010. 10. american anti-vivisection society. testing. [cited 2019 october]; available from: http://aavs.org/animals-science/how-animals-are-used/testing 11. clemence m, leaman j. public attitudes to animal research in 2016. [cited 2019 october]; available from: https://www.ipsos.com/sites/default/files/publication/1970-01/sripublic-attitudes-to-animal-research-2016.pdf 12. anonymous. statistics of scientific procedures on living animals, great britain 2016. [cited 2019 october]; available from: https://www.gov.uk/government/statistics/statistics-ofscientific-procedures-on-living-animals-great-britain-2016 13. farnfield b, petrie a, dennison n. use of animals in research. the veterinary record. 2017; 181(7): 178-9. 14. rowan an, loew fm. animal research: a review of developments. in: the state of the animals. usa: humane society press; 2001, p. 111-20. 15. close b, banister k, baumans v, et al. recommendations for euthanasia of experimental animals: part 2. dgxt of the european commission. lab anim. 1997; 31(1): 1-32. 16. venken kj, bellen hj. emerging technologies for gene manipulation in drosophila melanogaster. nat rev genet. 2005; 6(3): 167-8. 17. festing s, wilkinson r. the ethics of animal research: talking point on the use of animals in scientific research. embo rep. 2007; 8(6): 526-30. 18. humane society. cosmetic testing saq. [cited 2019 october]; available from:http://www.humanesociety.org/issues/cosmetic_testing/qa/questions_answers.html 19. naderi mm, sarvari a, milanifar a, boroujeni sb, akhondi mm. regulations and ethical considerations in animal experiments: international laws and islamic perspectives. avicenna j med biotechnol. 2012; 4(3); 114-20. 20. holden j. of mice and medicine: the ethics of animal research. [cited 2019 october]; available from: https://www.irishtimes.com/news/science/of-mice-and-medicine-theethics-of-animal-research-1.2529740 kabene s., et al. 11 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 15 november 2019 21. pereira gdg, diéguez fj, demi̇rbaș ys, menache a. alternatives to animal use in veterinary education: a growing debate. ankara univ vet fak derg. 2017; 64: 235-9. 22. cheluvappa r, scowen p, eri r. ethics of animal research in human disease remediation, its institutional teaching; and alternatives to animal experimentation. pharmacol res perspect. 2017; 5(4): doi: 10.1002/prp2.332. 23. cressey, d. uk funders demand strong statistics for animal studies. nature. 2015; 520(7547): 271-2. 24. daneshian m, busquet f, hartung t, leist m. animal use for science in europe. altex. 2015; 32(4), 261-74. 25. germain, p-l., chiapperino, l., & testa, g. (2017). the european politics of animal experimentation: from victorian britain to ‘stop vivisection’. stud hist philos biol biomed sci. 2017; 64: 75-87. 26. doke sk, dhawale sc. alternatives to animal testing: a review. saudi pharm j. 2015; 23(3): 223-9. 27. stokes ws. animals and the 3rs in toxicology research and testing: the way forward. hum exp toxicol. 2015; 34(12): 1297-303. 28. prot jm, leclerc e. the current status of alternatives to animal testing and predictive toxicology methods using liver microfluidic biochips. ann biomed eng. 2012; 40(6): 122843. 29. sima f, xu j, wu d, sugioka k. ultrafast laser fabrication of functional biochips: new avenues for exploring 3d micro-and nano-environments. micromachines (basel). 2017; 8(2): 40. jmehm-9-20.docx journal of medical ethics and history of medicine original article history of attitudes toward death: a comparative study between persian and western cultures kiarash aramesh associate professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran; phd candidate in medical ethics, center for healthcare ethics, duquesne university, pittsburgh, pa, usa. corresponding author: kiarash aramesh address: 23# 16 azar ave, keshavarz blvd, medical ethics and history of medicine research center, tehran, iran. email: kiarasharamesh@yahoo.com tel/fax: +98 21 66419661 received: 20 nov 2016 accepted: 23 dec 2016 published: 26 dec 2016 j med ethics hist med, 2016, 9: 20 © 2016 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract in his seminal book on the historical periods of western attitudes toward death, philippe aries describes four consecutive periods through which these attitudes evolved and transformed. according to him, the historical attitudes of western cultures have passed through four major parts described above: “tamed death,” one’s own death,” “thy death,” and “forbidden death.” this paper, after exploring this concept through the lens of persian poetic wisdom, concludes that he historical attitudes of persian-speaking people toward death have generally passed through two major periods. the first period is an amalgamation of aries’ “tamed death” and “one’s own death” periods, and the second period is an amalgamation of aries’ “thy death” and “forbidden death” periods. this paper explores the main differences and similarities of these two historical trends through a comparative review of the consecutive historical periods of attitudes toward death between the western and persian civilizations/cultures. although both civilizations moved through broadly similar stages, some influential contextual factors have been very influential in shaping noteworthy differences between them. the concepts of after-death judgment and redemption/downfall dichotomy and practices like deathbed rituals and their evolution after enlightenment and modernity are almost common between the above two broad traditions. the chronology of events and some aspects of conceptual evolutions (such as the lack of the account of permanent death of nonbelievers in the persian tradition) and ritualistic practices (such as the status of the tombs of shiite imams and the absolute lack of embalming and wake in the persian/shiite culture) are among the differences. keywords: history of medicine, death, western culture, persian culture, end of life mailto:kiarasharamesh@yahoo.com j med ethics hist med 9: 20 december, 2016 jmehm.tums.ac.ir kiarash aramesh page 2 of 6 introduction as an inseparable and inevitable part of human life, death has always been a source of reflection, imagination, and inspiration for thinkers, sages, artists, and even for ordinary people. the very questions of the nature of death and what happens after death have been answered in many deferent ways and forms by religions, philosophies, and traditions. these answers along with the reflections, imaginations, and emotions shaped attitudes surrounding the concept and reality of death, and these attitudes have been embodied and symbolized in the death-related rituals and typical behaviors from the times close to one’s death until the funeral, burial, and memorial ceremonies. these thoughts, imaginations, behaviors, and rituals, and in short, these attitudes have shaped their own history throughout the ages (1). western and persian civilizations are two old and large civilizations with their own unique characteristics and attitudes toward existential subjects such as death. it has been argued the speaking of the “western attitude” contains a sort of overgeneralization and ignoring the diversity, which exists among the western cultures (2). however, as showed in the seminal work of philippe aries, which is discussed below, one can find general trends in culture and mentalities in western civilization with a valid methodology and defendable results (1). the same can be said about the persian culture. as described below, in the western history, thoughts and attitudes toward death have been under the influence of their greek/latin roots and then by christianity, medieval schools of thought, enlightenment, and modernity. the persian attitudes, however, have been under the influence of zoroastrianism (ancient persian religion which was the official religion of the sassanid empire before the islamic era), islam and its shi’a denomination, sufism, and modernity. the gist of these attitudes has been mirrored in the persian poetic wisdom. the persian poetic wisdom is a large body of persian poems carrying the collective wisdom and accumulated historical experiences of persianspeaking people with a specific role in transferring culture and morality through generations. in this paper, the most prominent parts of this historical collection have been used for exploring the attitudes of persian people throughout the history. in this paper, through a comparative review of the consecutive historical periods of attitudes toward death between the western and persian civilizations/cultures, the main differences and similarities of these two historical trends are explored. it has been showed that although both civilizations moved through broadly similar stages, some influential contextual factors have been very influential in shaping noteworthy differences between them. historical periods philippe aries, the french author and thinker, in his seminal book titled western attitudes toward death: from the middle ages to the present has discussed the historical periods of western attitudes toward death. this book has been one of the most influential intellectual works about the history of attitudes toward death in the west and has been applauded by many of critics and scholars. philippe aries describes four consecutive periods through which these attitudes evolved and transformed (1). for this purpose, aries uses literature, such as ancient texts, romances, and novels to explore and retrieve the attitudes of people at each age/period he studying. this methodology has been criticized (2). however, it seems to be the best available method to dig the history and find the beliefs and attitudes of people who died hundreds years ago. rooted in the persian empire established in the 6th century bce, the persian culture has mover through a turbulent historical route. the first official religion of the persian culture was zoroastrianism, which replaced by islam after the invasion of arabs in the beginning of the 7th century. consequently, the majority of persians adopted the shi’a (also called shiite) domination of islam by around 16th century. nowadays the majority of people in iran, tajikistan, and afghanistan speak persian also called farsi). persian-speaking people share a common cultural history and heritage. the most important element of this common cultural heritage is the persian poetic wisdom. in this paper, the focus of the study was on the history of iran as the major part and homeland of persian culture. in the medieval persian literature, in the absence of novels and scarcity of long non-poetic romantic narrations, poetry holds almost all the functions of literature for persian-speaking populations. by exploring the persian poetic wisdom, one can retrieve the persian attitudes toward death it the historical evolutions of these attitudes. below, using the findings of aries and the main sources of the persian poetic wisdom, each period is briefly described based on aries’ account of western mentalities and compared with its counterpart in the persian history. tamed death according to aries, this period is characterized by regarding death as an integral part of daily life. the typical picture of dying person is a person laying in his/her deathbed, aware of his/her imminent death and welcoming to it, with his/her family members and friend and neighbors surrounding him, and the priest coming upon the call of the dying person when he/she feels that it is the time, and accepting the death of loved ones without emotional burst and impatience, but with calm and acceptance. in this typical picture, death is witnessed by friends and relatives, even young children (1). the picture of a j med ethics hist med 9: 20 december, 2016 jmehm.tums.ac.ir kiarash aramesh page 3 of 6 deathbed surrounded by friends and family members is also a common and familiar picture in the pieces of the persian poetic wisdom in the medieval era (3). according to aries, the burial places are away from homes and towns and usually are located in the churchyards. in the churchyards, the dead are under the protection of the saints/church and will resurrect at the time of the second coming of/jesus. the nonbelievers simply wont resurrect. they will remain dead (1). in the persian culture and the persian poetic wisdom, although, some sufi thinkers implicitly mentioned that some people wont be resurrected in the afterlife because of their devolution to this world’s pleasures and not noticing spiritual messages, they still believed in the day of judgment and personal responsibility toward ones deeds in the afterlife (4). according to aries/portrayal, churchyards were also places for recreational gatherings of people. graves are not expected to be permanent, and ossuaries are common (1). this period ends around the 12th century. in the ancient persia, before islam, the official religion, zoroastrianism, was greatly influential on the lifestyle and beliefs of people regarding existential issues including death and its related rituals. for protecting the soil, as a pure element, from contamination, zoroastrians did not bury the dead bodies, instead, the left them in special places, namely dakhmeh, to be decomposed by natural forces and eaten by wild animals (5). this kind of ritual is similar to the burial rituals of the tamed death era as described by aries, in not keeping permanent and personal and decorated tombs. the persian religions, however, from the very beginning, either zoroastrianism or islam advocated the god/devil dichotomy which is translated to redemption/downfall dichotomy in the afterlife (6). one’s own death in the period starting around the 12th century, namely the second middle ages, through the gradual and subtle changes of the vulgate, the “personalization of death” takes place. the teachings of the christian church contending that every person will be judged after their deaths and will be rewarded of punished according to their deeds reshaped the western attitudes toward death. therefore, death became more personal. consequently, the ceremonial meaning of deathbed changed from witnessing death to witnessing the moments before judgment in which the behaviors of dying person implies his/her redemption or downfall. in addition, having personal and personalized encrypted tombs became common (1). in this period, the second coming of jesus is considered as the time of redemption for believers and downfall for nonbelievers and sinners; therefore, death is no longer a common and same fate and destiny of all people, but it is the time of salvation for some and devastation for others (1). this period shows the main characteristics of the persian attitudes toward death from the medieval ages until the modern era. the mainstream religious part of the persian culture firmly believes in the day of judgment. the graveyards and cemeteries are outside the cities. one major difference in this regard appeared after dominance of shiite domination in persian-speaking territories. according to sunni islam, decoration tombs and having ceremonies and memorials in the graveyards is forbidden. it is strictly prohibited for women to visit tombs and graveyards (7). in shiite islam, in contrast, visiting and praying in the tombs of innocent imams is part of very emphasized religious rituals. therefore, paying attention to decorating and ornamenting tombs became popular after shiite denomination became the official religion in safavid iran from the beginning of the 16th century. graveyards and cemeteries grown and expanded around the tombs of innocent imams and their offspring (imamzadeh) and became a place for religious and social events and gatherings of people. in medieval towns of iran, tombs and cemeteries were in close distance to the town and people visited them frequently. the dream of a religious shiite common man was (and still is) having a pilgrimage to the tomb of an innocent imam (specially imam hossein in karbala, iraq; imam ali in najaf, iraq; and imam reza in mashhad, iran). some imams are buried in sunni countries, such as the saudi arabia and shiites, cannot build tombs for them and visit their tombs. rituals of deathbed in this period are very similar to arias/description of the first and second periods of western attitudes. in the most seminal and famous book of moral teachings in persian literature, namely golestan (means the garden) that is a major part of the persian poetic wisdom, musleheddin saadi narrates many tales of life advices given by old and wise people to their sons or friends in their deathbeds (3). the pictures of deathbed portrayed by saadi are very similar to the ones depicted in medieval literature of western culture (1). one of the major aspects of similarity between the western and persian medieval cultures is the religious-based belief in the sanctity of life (8). this idea is originated in christianity and islam/sufism in western and persian cultures, respectively (9). stress on giving the utmost values to preserving innocent lives along with condemning killing ones self or others is part of the beliefs surrounding the concept of death in both traditions. thy death beginning from early 18th century, this period, according to aries is characterized by replacing acceptance with fear and witnessing death with mourning for the dead. in this period, death, like sex, is not considered a normal and pretty familiar part of the reality of human’s life, but it is exalted and feared. in this new picture, families and friends around the deathbed are not witnessing death (or the moment before judgment); they are mourning. this j med ethics hist med 9: 20 december, 2016 jmehm.tums.ac.ir kiarash aramesh page 4 of 6 mourning is accompanied by expressing excessive emotions showing intolerance of the death of loved one. this heightened and vivid expression of emotions makes this period a “sentimental era.” this emotional and dramatic mourning continues with preserving the memory of the lost loved ones. consequently, tombs become more ornate and elaborate especially in southern catholic countries of the western europe (1). in the persian speaking countries, the enlightenment theories imported at around the last decades of the 19th century. it seems that exalted expression of emotions is still part of burial and memorial ceremonies though deeply religious people try to refrain from showing excessive emotions while mourning. at this time, new forms of expression were introduced to the persian literature and under the influence of modern western culture and literature, the first novels were created in persian, followed by theatrical pieces and movies (10). forbidden death beginning in the late 19th and early 20th centuries, the last period of western attitudes toward death, according to philippe ares, is demarcated by sex being replaced by death as a taboo in western cultures. the establishment and popularity of the institution of hospital, along with modern and sophisticated health-care technologies, transformed the typical picture of death from “a predicted/expected death in one’s own home and surrounded by friends and family” to “unwanted and fought against death on the hospital bed, while one is unconscious, alone, and tried to eschew death until the last minutes.” in this era, the exalted emotions of the previous period are replaced by ignorance toward death and trying to eliminate it from the picture of normal and daily life. practices such as cremation, embalming and wake, and commercialization of funerals in the form of emergence of funeral directors who market their services and products as “consumer goods” are among the manifestations of this last transformation of the western attitudes toward death (1). persian-speaking societies encountered modernity as a series of imported ideas from the west. they became familiar with the modernized west and the ideas and theories of enlightenment, french revolution, and modernity in the last decades of the 19th century. this acquaintance was accompanied by awareness of their historical backwardness. although some parts of the community tried to adopt the attitudes and lifestyles compatible by modernity, other parts of society were reluctant to accept it because of religious and cultural hesitations. the resulted conflicts have not been solved in these societies yet. actually, the pahlavi dynasty in the 20th century tried to modernize iran and import and advocate different aspects of modern and western life. the 1979 revolution, which ended up in empowering the anti-western shiite clergies, was a major setback of the movement toward western modernization. persian attitudes toward death and the death-related rituals, as a cultural construct, has been largely under the influence of these cultural transformations and conflicts. nowadays, persianspeaking societies encompass an amalgamation of very different lifestyles and cultural attitudes. decorating tombs and showing the wealth and social status of family in the funeral and burial and memorial ceremonies has been more common. as described above, treating death as “consumer good” is also part of the last historical period of attitudes toward death. growth of funeral industry and their marketing effort is a well-known phenomenon in the united states. the similar phenomenon can be witnessed in iran. advertisements for different parts of funeral and burial rituals can be seen now and then. for example, advertisements for filming, food delivery, and artworks on tombstones and also ritual singing (maddahi) at the funeral and memorial ceremonies are part of this highly profitable market. in this era, some intellectuals started a kind of rereading and re-interpreting of the major pieces of the persian poetic wisdom to criticize the traditional religious customs, conventions, and rituals. referring to hafez and khayyam, two of most famous persian poets became very popular. their poems were cited to emphasize a teaching, which is one of the core cultural beliefs if this period according to aries: the centrality of happiness in this life and recalling the inevitability and brutality of death for emphasizing on seeking happiness in the worldly life. because of the influence of shiite islam, practices like embalming and wake have never been practiced in persian speaking societies. these practices are strictly forbidden in shiite islam. according to the islamic teachings, the dead body must be buried as soon as possible and preserving the dead body is strictly prohibited (11). there are just a few exceptions: such as mummifying the dead body of reza shah, the first king of the pahlavi dynasty who died in exile and has to transferred to his permanent tomb in iran and recent permissions of preserving bodies for teaching anatomy in medical schools, of course with emphasis of the priority of using the bodies of non-muslims. conclusion in this paper, for a brief comparison of the western and persian attitudes toward death, two main resources were used: the seminal work of philippe aries on the western attitudes, and the persian poetic wisdom and author’s description of the contemporary iran along with historical resources for exploring the persian attitudes. as described above, the historical attitudes of western cultures have passed through four major parts described above: “tamed death,” “one’s own death,” “thy death,” and “forbidden death.” the historical attitudes of j med ethics hist med 9: 20 december, 2016 jmehm.tums.ac.ir kiarash aramesh page 5 of 6 persian-speaking people toward death have generally passed through two major periods. the first period is an amalgamation of aries’ “tamed death” and “one’s own death” periods and the second period is an amalgamation of aries’ “thy death” and “forbidden death” periods. through this historical comparative study, one can find the main similarities and differences of the historical evolutions of attitudes toward death between these two cultures/civilizations. the concepts of after-death judgment and redemption/downfall dichotomy, and practices like deathbed rituals and their evolution after enlightenment and modernity are almost common between the above two broad traditions. the chronology of events and some aspects of conceptual evolutions (such as the lack of the account of permanent death of nonbelievers in the persian tradition) and ritualistic practices (such as the status of the tombs of shiite imams and the absolute lack of embalming and wake in the persian/shiite culture are among the differences. the above-mentioned similarities show that one can find similar general trends even in difference cultures. studying these similarities can pace the way for constructing and advocating common cultural norms and principles in the era of globalization. acknowledgment the author of this paper would like to extend his very appreciation to professor henk ten have for his so valuable and helpful guidance and comments. j med ethics hist med 9: 20 december, 2016 jmehm.tums.ac.ir kiarash aramesh page 6 of 6 references 1. aries p. western attitudes toward death: from the middle ages to the present. translated by ranum pm. baltimore: the john hopkins university press; 1974, p. 1-26, 31, 55-108. 2. mazlish b. review of western attitudes toward death from the middle ages to the present, by philippe ariès. j interdisciplin hist 1975; 5(4): 751-2. 3. saadi musleheddin. [golestan]. tehran: fararouy; 2006. [in persian] 4. rumi jalaliddin mohammad. [mathnawi]. tehran: elmi farhangi; 1996, vol 2. [in persian] 5. boyce m. a history of zoroastrianism. translated by sanatizadeh h. tehran: gostareh; 2013, vol 1, p. 373-80. [in persian]. 6. ashidari j. [a guide to the religion and teachings of zoroaster]. tehran: farevahar; 2002. [in persian] 7. halevi l. wailing for the dead: the role of women in early islamic funerals. past present 2004; 183: 3-39. 8. temkin o. the idea of respect for life in the history of medicine. in: frankena wa, temkin o, kadish sh, eds. respect for life in medicine, philosophy and the law. baltimore: johns hopkins university press, 1975. 9. keenan jf. the concept of sanctity of life and its use in contemporary bioethical discussion. in: b bayerts k, ed. sanctity of life and human dignity. dordrecht: kluwer academic publishers, 1996, p. 1-18. 10. zarrinkoob a. [with the caravan of silk]. tehran: elmi; 2000, p. 84-108. [in persian] 11. khomeini r. [practical decrees]. ghom: the office of islamic publications; 2010. 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____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ 1 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e © 2019 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. original article volume 12 number 6 june 2019 factors influencing the attitudes of nicu physicians toward care of neonates with very poor prognosis *corresponding author bita ebrahim imam khomeini hospital complex, keshavarz blvd., tehran, iran. tel: (+98) 21 61 19 23 57 fax: (+98) 21 66 59 13 15 email: bitaebrahim@yahoo.com received: 10 sep 2018 accepted: 21 may 2019 published: 11 june 2019 citation to this article: nayeri f, asghari f, baser a, leila janani l, shariat m, tanha k, eabrhim b. factors influencing the attitudes of nicu physicians toward care of neonates with very poor prognosis. j med ethics hist med. 2019; 12: 6. fatemeh nayeri1, fariba asghari 2, ali baser 3, leila janani4, mamak shariat1, kiarash tanha5, bita eabrhim6* 1.professor, family health institute, maternal, fetal and neonatal research center, tehran university of medical sciences, tehran, iran. 2.associate professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. 3.researcher, department of pediatric, arak university of medical sciences, arak, iran. 4.assistant professor, department of biostatistics, school of public health, iran university of medical sciences, tehran, iran. 5.msc, school of public health, iran university of medical sciences, tehran, iran. 6.researcher, family health institute, breastfeeding research center, tehran university of medical sciences, tehran, iran. abstract attitudes of physicians toward neonates with poor prognosis greatly influence their decisions regarding the course of treatment and care. the present study aimed to investigate factors contributing to attitudes of medical practitioners toward poor prognosis neonates. this was a cross-sectional, descriptive-analytic study. questionnaires for assessing subjects’ attitudes toward care of very poor prognosis neonates were administered to all neonatologists, pediatricians, neonatology assistants, and pediatric residents (a total of 88 individuals) working in the nicus of imam khomeini hospital. participants’ attitudes were determined through analysis of responses to seven questions on a 5-point likert scale ranging from “strongly agree” to “strongly disagree”. presence of anomalies incompatible with an acceptable quality of life, birth weight, gestational age, responses to neonatal diagnostic tests, certain types of diseases, parental marital status and practitioner predictions about patient prognosis were the factors contributing to practitioners’ attitude (p-value < 0.005). however, no significant relationship was found in connection with religious beliefs, socioeconomic status, opinions of consulting physicians, hospital treatment protocols, standards of the association of neonatal physicians, and ethics committee expectations (p-value > 0.005). it can be concluded that the attitudes of practitioners toward intensive care of poor prognosis neonates is determined by the medical condition of the neonate rather than socio-demographic characteristics. keywords: invasive procedures; newborns; neonatal intensive care units; prognosis; resuscitation; viability factors influencing the attitudes of nicu physicians … 2 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 6 june 2019 introduction the increase and ease of access to new fertility techniques coincide with an increase in the number of newborn infants requiring special care (1). pregnancies resulting from such techniques are at risk of prematurity, low birth weight and multiple births, and are predisposed to a greater need for resuscitation notwithstanding other factors at birth (2). preterm neonates, especially moderately preterm neonates (mpt, 29 336/7 weeks), are more likely to have higher morbidity rates. studies have shown higher severity of respiratory problems, cognitive disorders, and reduced academic and behavioral performance in children resulting from these pregnancies (3, 4). furthermore, with the proliferation of neonatal intensive care units (nicu) and improvement of nursing practices and practitioner knowledge, it is now possible to preserve the lives of critically ill and severely premature infants. thus, neonatologists are facing new issues such as the necessity for providing aggressive and advanced care to neonates with severely poor prognosis. severe prematurity, advanced asphyxia, congenital anomalies incompatible with life, and advanced congenital metabolic disorders are examples of such cases. there is a lack of specific regulations within national laws and the medical code of ethics in iran regarding whether to initiate, continue or abandon advanced treatments. in some countries, the sanctity of life is a priority and it is therefore mandatory to employ any possible measure for every infant regardless of disease or prognosis (5). other countries, however, support quality of life, allowing refusal of advanced treatment in cases of undesirably low levels of life quality (6). still, others exist on a cline between these two extremes, making decisions based on their own moral and ideological principles as well as departmental policies (7, 8). in some countries, laws have been enacted whereby practitioners and the families involved can mutually decide on whether to continue advanced treatment (9). according to rabiu and sugand, english laws’ tolerance of quality of life judgments infringes on the sanctity of life doctrine, and hence does not allow this doctrine to be considered a law (10). considering the lack of a relevant set of national guidelines or laws in iran, practitioners may decide based on religious or moral beliefs, hospital policies, or consultation with parents. in many cases, the practitioner is faced with the question of the determining criteria for continuing advanced treatment. one question that may arise is whether continuation of treatment will lead to loss and waste of resources in the society. additional questions include: would this not be in contradiction with commitment to medical justice in the society? is allocating part of the limited resources of a society to an individual with a poor prognosis not tantamount to denying a greater number of individuals the access to those same limited resources? regardless, in most cases, medical practitioners are burdened with a great responsibility in their decisions. nayeri f., et al. 3 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 6 june 2019 personal values and beliefs (in other words, the practitioner’s attitude) might play a fundamental role in decision-making and answering the aforementioned questions. considering the fact that the number of nicus is increasing by the day in iran, more physicians encounter ethical challenges when facing critically ill infants. practitioners’ decisions regarding continuation or discontinuation of treatment in incurable cases is of crucial importance, since there is a possibility of treating future infants requiring specialized care with the same attitude. the present study was carried out on medical practitioners employed in the fields related to neonatal medicine and childcare in the nicus affiliated with tehran university of medical sciences. the aim of this study was to investigate attitudes, as well as the factors influencing these attitudes, toward critically ill infants and those with very poor prognoses. method this was a cross-sectional, descriptiveanalytic study conducted from january 2015 to june 2015 (5 months). the study population consisted of all neonatologists, pediatricians, neonatology fellows and pediatric residents working in 9 teaching nicus affiliated with tehran university of medical sciences. these intensive care units had 6 to 30 active beds and 26 to 50 admissions per month. after receiving the approval of the ethics committee, participants were asked to complete a questionnaire consisting of the raines’ questionnaire titled “level of management in neonatal clinical situations” (11) and rebaglioto’s questionnaire (12), translated and merged. the questionnaires were translated and then approved by five experienced neonatologists based on measurement instruments of clinical ethics. subsequently, they were tested on 20 cases and then used (cronbach’s alpha 75%). the final questionnaire consisted of 3 parts: first, participants filled out a demographic questionnaire including their age, gender, marital status, number of children, health status of children, level of education, and work experience. next, three different cases of newborns suffering from severe prematurity, genetic disorder (chromosomal trisomy), and severe asphyxia were presented to participants. it was explained to the subjects that aggressive care treatment was the option for these three cases. the details of the treatment option were described to consist of aggressive care, including all necessary, practical measures that had to be taken to preserve the life of the infants (e.g. mechanical ventilation and invasive procedures). the participants were then asked, “which of the following factors (and to what extent) affect your attitude and decisions regarding aggressive care of critically ill infants with poor prognosis?” the responses included gestational age, infant weight, parents’ marital status, parents’ social and financial status, infant’s disease, results of infant factors influencing the attitudes of nicu physicians … 4 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 6 june 2019 diagnostic tests, practitioner predictions regarding patient prognosis, presence of anomalies incompatible with an acceptable quality of life, opinions of consulting physicians, hospital treatment protocols, standards of the association of neonatal physicians, ethics committee expectations, and moral and religious beliefs. finally seven 5point likert scaled questions was used for the evaluation of respondents’ pro-life attitude. the pro-life beliefs questions are presented in table 3. in order to evaluate respondents’ pro-life attitude, seven 5-point likert scaled questions ranging from “strongly agree” to “strongly disagree” were used. the pro-life attitude of participants was defined as the sum of the points attributed to responses to these questions. since there were seven questions, the range of scores varied between 7 and 35. it should be noted that in rating points, the highest score was given to "strongly agree" and the lowest score to the "strongly disagree" option. as for the concepts of questions, the first four questions and question number 6 highlighted the importance of sanctity of life, whereas numbers 5 and 7 had reversed concepts. with respect to the categorization of the answers, there were two opposing groups: the "agree" and "strongly agree" options were regarded as pro-life, while "neutral ", "disagree", and "strongly disagree" responses comprised the negative opinions. the seven questions and analysis of the responses are presented in table 3. the questionnaire was anonymous and did not require the participants to take any responsibility for the care of infants, or to cover any expenses. furthermore, the study did not involve the treatment of infants. the study was approved (as a subspecialty thesis) by the research council of tehran university of medical sciences. the new version of the statistical package for social sciences (spss) is not readily available in iran due to sanctions, so spss version 11 was used for statistical analysis. to describe demographic data, descriptive statistics (i.e. frequency, mean, and standard deviation) were used. frequencies (percentages) and mean (sd) were utilized to report categorical variables and continuous variables. chi-square and fisher’s exact tests compared the intergroup distribution of qualitative variables. in order to determine the association between variables, logistic regression was utilized. the significance level was considered as pvalues bellow 0.05. the continuous variables were analyzed by one-way anova, with a p-value bellow 0.05 designated as the statistically significant level. results eighty-eight physicians from 9 different medical centers participated in the study. participants' characteristics are presented in table 1. nayeri f., et al. 5 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 6 june 2019 table 1characteristics of the study population no. (percent) gender male 61 (69.3) female 27 (30.7) age < 30 17 (20) 30 45 60 (70.6) > 45 11 (9.4) marital status married 70 (80) single 18 (20) children (married subjects) yes 50 (71.4) no 20 (28.6) profession pediatric resident 45 (51.1) pediatrician 23 (26.1) fellow of neonatology 10 (11.4) neonatologist 10 (11.4) work experience (years) < 5 42 (47.8) > 5 46 (52.2) twenty-seven of the responding physicians (35.1%) supported the use of aggressive measures in scenarios involving neonates with poor prognosis. factors contributing to practitioners’ attitude toward aggressive care and participants’ decision about aggressive care in poor prognosis infant scenarios are presented in table 2. table 2 – factors contributing to practitioners' attitude toward aggressive care physicians’ agreement with aggressive care factors influencing physicians’ decision on aggressive care disagree no. (percent) agree no. (percent) p-value gestational age disagree 12 (24.5) 37 (75.5) 0.011 agree 14 (53.8) 12 (46.2) birth weight disagree 14 (28.6) 35 (71.4) 0.031 agree 14 (53.8) 12 (46.2) parents’ marital status disagree 31 (64.6) 17 (35.4) 0.033 agree 22 (88.00) 3 (12.00) factors influencing the attitudes of nicu physicians … 6 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 6 june 2019 physicians’ agreement with aggressive care factors influencing physicians’ decision on aggressive care disagree no. (percent) agree no. (percent) p-value socioeconomic status disagree 35 (72.9) 13 (27.1) 0.253 agree 22 (84.6) 4 (15.4) type of disease disagree 3 (6.3) 45 (93.8) < 0.001 agree 17 (68.00) 8 (32.00) diagnostic tests disagree 10 (20.4) 39 (79.6) < 0.001 agree 18 (69.2) 8 (30.8) prognosis disagree 11 (22.9) 37 (77.1) < 0.001 agree 17 (68.00) 8 (32.00) anomalies incompatible with an acceptable quality of life disagree 10 (20.4) 39 (79.6) 0.033 agree 11 (44.0) 14 (56.00) consulting physician’s opinion disagree 11 (22.9) 37 (77.1) 0.062 agree 11 (44.0) 14 (56.00) therapeutic protocols disagree 30 (62.5) 18 (37.5) 0.686 agree 11 (42.3) 15 (57.7) neonatology association disagree 17 (36.2) 30 (63.8) 0.250 agree 13 (50.0) 13 (50.0) ethics committee disagree 33 (68.8) 15 (31.3) 0.280 agree 14 (56.00) 11 (44.00) religious beliefs disagree 29 (60.4) 19 (39.6) 0.136 agree 11 (42.3) 15 (57.7) presence of anomalies incompatible with an acceptable quality of life, birth weight, gestational age, responses to neonatal diagnostic tests, type of disease, parental marital status and practitioner predictions about patient prognosis were factors contributing to practitioners’ attitude. however, no significant relationship was found in connection with religious beliefs, socioeconomic status, opinions of consulting physicians, hospital treatment protocols, standards of the association of neonatal physicians, and ethics committee expectations. practitioners' attitudes toward aggressive care in terms of their pro-life beliefs are shown in table 3, according to which the mean score was 20.96 ± 3.93 out of 35. the minimum score was 7 with the maximum being 27. the pro-life attitude scores of nayeri f., et al. 7 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 6 june 2019 participants who agreed and those who disagreed with aggressive care were significantly different (p-value = 0.025). the mean attitude score of participants who agreed with aggressive care was 22/22 ± 3/96, and 20/18 ± 3/36 for those who disagreed. the practitioners' attitudes toward aggressive care in terms of their pro-life beliefs are presented in table 3. table 3 – practitioners' attitudes toward aggressive care in terms of their pro-life beliefs questions used for the evaluation of respondents’ pro-life attitude number and valid percent due to the sanctity of life, every possible measure must be taken to preserve the infant’s life, even in case of poor prognosis. disagree 34 (43.6) agree 44 (48.9) even in the presence of severe physical disability, survival is better than death. disagree 56 (72.7) agree 21 (27.3) limiting special care in a specific case or select cases creates the opportunity for exploitation, leading to more cases of exploitation. disagree 44 (57.1) agree 33 (42.9) every infant must be provided with the maximum level of care and treatment without consideration of the end results, since such cases can lead to improved treatment for future patients. disagree 33 (42.9) agree 44 (48.9) increased therapy and rehabilitation costs for preterm infants and disabled children do not give us the right to treat patients without consideration of the end results. disagree 36 (46.8) agree 41 (53.2) my religious beliefs, especially in terms of islamic justice, do not allow me to discontinue special care in specific cases or consider limitations in providing special care. disagree 55 (71.4) agree 22(28.6) my moral beliefs, especially in terms of preserving healthcare justice, allow me to discontinue special care in specific cases or consider limitations in providing such care. disagree 51 (66.2) agree 26 (33.8) the evaluation showed no significant correlation between the socio-demographic characteristics of the practitioners and their decision regarding aggressive courses of treatment. discussion this study was conducted with the aim of investigating factors contributing to attitudes of neonatologists and pediatricians towards care for poor prognosis neonates in nicus affiliated with tehran university of medical sciences. physicians’ attitudes toward sanctity or quality of life and factors contributing to such attitudes assume the main role in their decisions and performances in initiation, denial, and factors influencing the attitudes of nicu physicians … 8 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 6 june 2019 discontinuation of advanced treatment measures for infants with poor prognosis. in the ghaffari et al. study, factors influencing practitioner decisions regarding discontinuation of resuscitation included the number of children in the infant's family, pressure on hospital employees, requests by the infant's parents, infant’s gender, insufficient hospital facilities or resources, history of infertility, financial status of the family, and religious beliefs (13). in the studies by rebaglioto et al. and cuttini et al. (2000 2006) in ten european countries, the following factors had an effect on attitude: greater belief in higher quality of life, being female, not having children, being a protestant, lacking a religious background, disregard for religious beliefs, greater professional experience, and working in wards with higher admission of infants with very low birth weight (12, 14). age, duration of work experience, and attention to religious beliefs were considered contributing factors in non-treatment decisions by physicians in the cuttini et al study (15). in this study, 48.9% of physicians agreed that due to the sanctity of life, every measure must be taken to preserve the life of an infant, even with poor diagnosis. in rebagliato et al study the views of physicians differed depending on the country where they worked (12). in estonia and lithuania, practitioners believed they had to implement any measure necessary for saving the patient regardless of the cost, whereas in sweden and the united kingdom, physicians’ decisions were based on quality of life. physicians living in countries with higher socioeconomic status (such as sweden and the united kingdom) were more inclined toward quality of life. conversely, in countries with lower socioeconomic states such as lithuania, the view of sanctity of life held greater sway (12). in a coordinated manner, romanian practitioners had no tendency to deny or discontinue special care for infants even with very poor prognoses (16). in the present study, 72.7% of the physicians disagreed with the statement that despite any physical disability, survival is better than death. thus, in this case they favored quality of life over the alternative. in a study of 10 european countries, presence of mental disability, as opposed to physical disability, had a greater effect on the attitudes of most physicians. overall, most practitioners in various countries considered severe mental disability to be equivalent to or even worse than death, while there was less agreement on severe physical disability. presence of mental disability had a greater effect on the attitudes of most physicians compared to physical disability in many countries (11). in the present study, however, mental disability was not specifically investigated. it must be noted that despite evaluation of the correlation coefficient of the questions (0.613) as well as their conformity with each other, a conflict is observed in the responses of practitioners to the first two questions. this conflict is due to the fact that in the first question, the practitioners preferred to preserve the life when they were to choose between life or death. in the second question, however, among survival despite severe physical disabilities, multiple disabilities and death, they opted for death. nayeri f., et al. 9 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 6 june 2019 in the present study, 57.1% of the physicians disagreed that limiting care in certain cases could lead to increased possibility of exploitation. a significant percentage of practitioners in spain, germany, hungary, lithuania, france and italy agreed that treatment limitations might create an opportunity for exploitation. many even believed that the reverse of this line of reasoning could also lead to maltreatment, specifically overtreatment. most physicians agreed with a set of limitations in aggressive interventions due to very severe neurological prognosis (11). in the present study, 48.9% of the physicians agreed that all infants must be provided with the maximum level of care due to the impact this may have on the treatment of future patients. in the euronic study, most practitioners claimed that they had encountered at least one situation where treatment measures were limited due to an incurable condition. in a few cases, treatment was limited due to poor neurological prognosis (15). in more than half of the countries in the baltic region, legal restrictions prevent decisions to limit treatment, whereas in a low percentage of cases in sweden (3%) and france (5%), it is possible to make decisions regarding limitation of treatment. a significant number of practitioners in lithuania (54%) and italy (29%) agreed with treating every infant regardless of the results, in order to gain clinical experience and benefit future generations (11). on the other hand, 46.8% of the physicians in our study disagreed with the statement that increased cost of treatment is an acceptable reason to limit care for infants based on their prognosis. in the european study, most physicians did not believe that the costs of healthcare affected decisions for treatment. however, in france, the united kingdom, and the baltic states, a quarter or more agreed that such costs did in fact affect decisions. furthermore, costs of healthcare and clinical experiences played a lesser role in decision-making for legislators in enacting legal restrictions (11). moreover, 71.4% of the physicians in our study believed that religious beliefs should not affect the decision to continue or discontinue care, while 66.2% believed that the decision to discontinue care should not be based on moral beliefs. in a european study, the attitude scores regarding quality of life were significantly lower among physicians whose religious beliefs were important to them (italy, hungary, and the baltic countries) compared to countries where religious beliefs were not as important (14). cuttini et al. state that in some countries, limitations in special care exist due to moral reasons (15). however, identification of the conditions necessitating limitation of treatment and decisions that are made in such conditions differ in various countries based on culture. at the same time, however, legal considerations certainly have an influential role. in most countries, the decision to deny treatment to infants who will die despite medical intervention is acceptable. however, limiting special care based on future quality of life is still a controversial issue. in most countries, factors including practitioners’ religious factors influencing the attitudes of nicu physicians … 10 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 6 june 2019 beliefs and personal attitudes toward the value and meaning of life influence decision-making (14). zamboni expresses that neonatologists make their decisions based on their personal beliefs (17). in italy, even though a physician is obligated to obey the professional and medical codes of ethics, which refute aggressive care, italian law strongly supports preservation of the lives of infants and opposes any type of discrimination based on abnormalities or poor prognoses. in addition, the law requires resuscitation of a preterm infant even when birth is caused by a late abortion. zamboni stresses the importance of accepting differences in decision-making since many disabilities may be accepted by the society, which may possess the moral progressiveness to support its weakest members (17). the american academy of pediatrics (aap) supports abandonment of treatment when it is not in the infant’s favor. it allows deciding on discontinuing treatment for neonates and infants only in the following cases: (1) when the infant is in an irreversible coma; (2) when the treatment only prolongs the process of death; (3) when the treatment is futile and inhumane (18). the aap supports joint decision-making with parents concerning resuscitation and intensive care of infants born at extremely low gestational age (< 25 weeks). in such cases, both the infant and the family face the possibility of permanent, severe neurodevelopmental risks and costly health care, and therefore measures to help the infant to merely “survive” will not be justifiable (18 19). in conclusion, considering the results of the present study, attitudes towards intensive care of poor prognosis neonates are correlated with their medical conditions rather than socio-demographic characteristics. furthermore, due to the lack of special regulations within national laws and the medical code of ethics, most practitioners are trapped in a sort of legal vacuum. thus, it seems necessary to legislate laws that clearly determine cases requiring initial denial of treatment and the conditions for discontinuing such treatment. additionally, the pain and suffering of infants need to be considered, and parents must be given sufficient privileges to determine the course of action that is in the best interests of their child. acknowledgements this article has been prepared based on the results of a subspecialty thesis. conflict of interests the author declares that there is no conflict of interests. nayeri f., et al. 11 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 6 june 2019 references 1. tough sc, greene ca, svenson lw, belik j. effects of in 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[bioethics, deontology, and law in neonatal intensive care]. pediatr med chir. 2002; 24(5): 346-51. 18. kathryn l, weise kw, alexander l, et al. guidance on forgoing life-sustaining medical treatment. pediatrics. 2017; 140(3): e20171905. 19. cummings j, committee on fetus and newborn. antenatal counseling regarding resuscitation and intensive care before 25 weeks of gestation. pediatrics. 2015; 136(3): 588–95. jmehm-7-20 journal of medical ethics and history of medicine status of human dignity of adult patients admitted to hospitals of tehran fariba borhani1, abbas abbaszadeh2, soolmaz moosavi3 1assistant professor, department of nursing ethics, medical ethics and law research center, shahid beheshti university of medical sciences, tehran, iran; 2professor, school of nursing and midwifery, shahid beheshti university of medical sciences, tehran, iran; 3msc, medical ethics and law research center, shahid beheshti university of medical sciences, tehran, iran. corresponding author: soolmaz moosavi address: no 8, shams alley, tavaneer cross, valiyeasr st, tehran, iran. postal code: 1516745811. email: moosavi.soolmaz@yahoo.com tel: 98 21 88 78 10 36 fax: 98 21 88 77 75 39 received: 15 mar 2014 accepted: 22 oct 2014 published: 01 dec 2014 j med ethics hist med, 2014, 7: 20 © 2014 fariba borhani et al.; licensee tehran univ. med. sci. abstract maintaining dignity and respect is among patients’ most fundamental rights. the importance of patient dignity, the status quo, patients’ needs, and a shortage of survey studies in this area were the underlying incentives for conducting this study. this was a cross-sectional descriptive study in which data were collected through patient dignity inventory (pdi). the questionnaire was completed by 280 inpatients in 2012 to determine their perspectives on their personal state of human dignity. in this study, the mean score of patients’ dignity was 1.89 out of 5 (sd = 0.81). results indicated a significant relationship between type of hospital and the distress caused by disease symptoms, peace of mind, and social support (p < 0.05). there were also relationship between type of ward and dependency (p < 0.05), type of disease and dependency (p < 0.05), gender and social support (p < 0.05), household size and peace of mind (p < 0.05). the person’s satisfaction with household income showed significant relationship with symptom distress, dependency and existential distress (p < 0.05). results showed a significant inverse correlation between age and patient dignity (p = 0.005, r = 0.166). however, the relationship between employment status, health insurance, education level and the above factors were insignificant. studies indicate that there is a relationship between patients’ dignity and mental distress, and therefore policy makers and health services officials should establish and implement plans to maintain and enhance patients’ dignity in hospitals. educating the health team, particularly the nurses can be very effective in maintaining patients’ dignity and respect. keywords: patient dignity, nursing care, nurse-patient relationship mailto:moosavi.soolmaz@yahoo.com j med ethics hist med 7: 20 dec, 2014 jmehm.tums.ac.ir fariba borhani et al. page 2 of 8 (page number not for citation purposes) introduction dignity is a complex, yet important issue in patient care that has many dimensions rooted in emotions, behavior, appearance, and privacy (1). for many patients, dignity and respect is the last and most significant thing that they may request of their relatives and caregivers, especially if their disease is acute and life-threatening (2). today, important issues associated with spiritual health and respect for patients’ human status and dignity are becoming the main concept in care centers, particularly in adult care departments, nursing homes and hospices (3). human dignity and respect is a complex, vague and multi-faceted concept interrelated with respect for patients’ wishes, maintaining their privacy, selfesteem and control, reducing their shame, and similar issues (4, 5). although these concepts are an important part of our daily lives, people are not comfortable talking about them (4). simply put, dignity is an inherent and non-negating value that a person possesses by virtue of being human. this value is manifested in a person’s existence and in relationship with others. illness, disability, neediness, reduced power and choice, decreased privacy, treatment, palliation and hospitalization can all affect a person’s dignity. limiting patients’ dignity can affect their body, spirit, mood, and spirituality, and expose them to stress (6). in literature there is reference to five behavioral standards in health center staff that are indicators of their regard for patients and a high quality of care. these five standards include: a) respect, meaning that all hospital staff should respect patients in all circumstances; b) attitude, meaning that all hospital personnel should exhibit a positive attitude toward their patients; c) behavior, meaning that the entire treatment team should exhibit professional behavior in dealing with patients; d) communication, meaning that the entire treatment team should communicate with patients in a manner that expresses sensitivity to their needs and preferences; and e) privacy and dignity, meaning that the entire staff must maintain patients’ privacy and dignity in all circumstances (7). nursing literature frequently observes that dignity is highly valued by patients (7). taking a humanistic approach, nursing theorists consider respect for patients and maintaining their dignity as central and of high priority in nursing care. they also assert that maintaining patient dignity is among nurses’ fundamental roles and may even be more important than providing health care (4). nevertheless, there are many issues related to the subject of patient dignity that remain unresolved and require clarification (7). studies conducted on patient dignity define it as a feeling of peace, control and value, and a special type of behavior. circumstances that can negatively affect patient dignity include loss of privacy, and the hospital staff’s commanding and domineering behavior. furthermore, creating an atmosphere that enhances patient dignity can improve a culture of respect for patients (8). many qualitative and quantitative studies have examined the subject of patient dignity. in qualitative studies that attempted to explain participants’ perspectives on patient dignity among the nursing home elderly, the themes included being ignored, fragility and dependence, inner strength, and togetherness (9). in another qualitative study conducted by forming an elderly focus group, attributes such as kindness and sympathy, respect for human values, and observing patients’ rights were found to be important in preserving dignity (2). likewise, results of dwyer et al study using qualitative content analysis revealed that to enhance the dignity of the elderly, nurses require commitment, supervision and training. based on the findings of the same study, nurses are preoccupied with what they can do to maintain patient dignity and perform what is expected of them (9). to assess the level of human dignity experienced by patients hospitalized in various wards, chochinov et al. created a tool that has also been used by many subsequent studies in this area. in the model adopted by these studies, the patient dignity construct is assessed in three categories: dignity in relation to the disease, actions for maintaining dignity and respect, and social respect. these studies have generally reported threatened patient dignity (10). a cross-sectional study found that 7.5% of patients in end-of-life stages experience an intense lack of dignity. a follow-up of these patients over a 6-month period revealed that compared to other patients, this group exhibited more mental distress, physical stress, dependency, and disinterest in life. these findings demonstrate the close relationship between human dignity and a variety of distresses in patients (11). a review of the studies conducted on the subject in iran found that they were largely theoretical and review studies, and none had used any particular tools to assess patient dignity. in a study titled “dignity in medicine”, avizhgan and mirshahjafari stressed the importance of maintaining patient dignity in the last stages of life through patientoriented communication. the above-mentioned study asserted that this communication must involve telling the truth, giving the patient correct information, an appropriate method of conveying bad news, maintaining privacy, confidentiality, reliability, the right to choose and decide, dealing with inappropriate treatment demands, euthanasia, j med ethics hist med 7: 20 dec, 2014 jmehm.tums.ac.ir fariba borhani et al. page 3 of 8 (page number not for citation purposes) and unconditional respect (12). similarly, sadeghi and dehghan nayeri stated that observing patient dignity and respect is a patient’s right and comprises maintaining privacy, confidentiality, and nonexposure (13). considering the importance of patient dignity and a shortage of survey studies in this area that indicate the current state of affairs and patient needs, the present study was conducted to examine the issue further. method this was a cross-sectional descriptive study conducted in tehran during 2013 to investigate the perspectives of adult patients in hospitals affiliated with shahid beheshti university of medical sciences on their personal state of human dignity. sample size was calculated based on a pilot study, and considering mean, standard deviation (0.42), and 0.05 error, 280 patients were selected from surgical and internal medicine wards. quotas were based on the number of hospital beds, and patient availability power associated with the determined sample size was 0.80. study exclusion criteria were: inability to speak persian, absence of full consciousness, mental problems, and lack of physical readiness. data were collected using patient dignity inventory (pdi) designed by chochinov et al. (10) in 2008 to measure the sources of distress associated with patient dignity. the questionnaire was translated into persian using the backward-forward method. its content validity was confirmed by 10 nursing faculty members, and its reliability was determined in a pilot study of 19 patients through internal consistency of 0.87 (cronbach's alpha). this questionnaire contained 25 items including five factors: symptom distress (items 3, 5 9), peace of mind (items 15 17), dependency (items 1, 2, 20), social support (items 21, 22 25), and existential distress (items 4, 11 14, 18). given the number of items in the questionnaire (25 items), and the 5-point likert scale responses, total score ranged from 25 to 125, and mean score ranged between 1 and 5. scoring in previous studies (10, 14) had been as follows: not a problem (1), a slight problem (2), a problem (3), a major problem (4), an overwhelming problem (5). the items of pdi have negative load (written negatively), so higher scores mean more problems associated with dignity. samples were selected using convenient sampling method and all eligible patients completed the questionnaire. the questionnaire was completed as self-report by patients, and illiterate patients were assisted by one of the researchers. the study proposal was approved by the ethics committee of the research and technology department at shahid beheshti university of medical sciences in march 2013. participants were informed of the study objectives, voluntary participation, data confidentiality and anonymity, and were assured that non-participation would in no way interfere with their treatment and care. data analysis was performed using spss 18 statistical software. frequency, percentage frequency, mean and standard deviation were used to identify descriptive parameters, and t-test, anova and pearson’s correlation coefficient were used for the analytical parameters. results data were collected from four general hospitals affiliated with shahid beheshti university of medical sciences in the department of internal medicine (neurology, nephrology, endocrinology, gastroenterology, pulmonary, obstetrics, cardiology, etc.) and the department of surgery (orthopedics, neurosurgery, vascular surgery, urology, etc.). the majority of the study populations were men (59.6%), and women comprised 40.4% of the participants. patients’ mean age was 46.9 (sd = 16.7), ranging from 15 to 90 years. table 1 presents the patients’ demographic details. table 1patients’ demographic details mean (percent ) variables * marital status 73.9 % married 17.9 % single 1.8 % divorced 6.4 % widowed * employment status 10.7 % unemployed 45.4 % employed 12.5 % retired 31.4 % housewife * education level 22.5 % illiterate 67.5 % high school diploma or higher 9.6% bachelor's degree or higher j med ethics hist med 7: 20 dec, 2014 jmehm.tums.ac.ir fariba borhani et al. page 4 of 8 (page number not for citation purposes) * disease type 49.3 % internal ward 50.7 % surgical ward * health insurance 26.8% uninsured 73.2% covered * satisfaction with household income 62.5 % low 35.8% average 1.8% increased the mean overall score of human dignity was 1.89 out of a possible 5 (a lower score indicating a better evaluation), and 2.09 (sd = 0.92) for symptom distress, 1.88 (sd = 0.96) for existential distress, 1.89 (sd = 1.01) for dependency, 1.91 (sd = 0.97) for peace of mind, and 1.60 (sd = 0.89) for social support dimensions. table 2 presents the relationships between demographic details and the dimensions of dignity. table 2 the relationship between the dimensions of human dignity and demographic characteristics dependency symptom distress existential distress peace of mind social support variables p=0.329 p =0.204 *p=0.008 *p=0.003 *p=0.004 hospitals *p=0.006 p=0.786 p=0.710 p=0.984 p=0.984 type of ward p=0.966 p=0.083 p=0.767 p=0.203 *p=0.031 gender *p=0.049 p=0.790 p=0.83 p=0.807 p=0.346 type of disease p=0.54 p=0.22 p=0.87 p=0.9 p=0.91 insurance status p=0.31 p=0.96 *p=0.02 *p=0.004 p=0.21 household size *p=0.005 *p=0.000 *p=0.001 p=0.05 p=0.05 satisfaction with household income p=0.434 p=0.083 p=0.816 p=0.833 p=0.442 education level p=0.196 p=0.828 p=0.891 p=0.510 p=0.801 marital status p=0.466 p=0.078 p=0.345 p=0.555 p=0.215 employment status tables (2 and 3) reports a significant relationship between hospitals and existential distress, peace of mind, and social support. significant relationships also existed between type of ward and dependency, type of disease and dependency, gender and social support, household size and peace of mind and existential distress. the relationships between satisfaction with household income and symptom distress, dependency and existential distress were significant.mean of human dignity and its dimensions in patients participating in the study based on demographic variables are shown in table 3. the relationships between age and peace of mind, and symptom distress were significant (table 4). no significant relationship was found between employment status, insurance status or education level and the five factors (table 2). table 3 the mean of human dignity and its dimensions based on demographic variables variables mean ± sd peace of mind symptom distress existential distress social support dependency gender female male 1/90 ± 0/61 1/88 ± 0.87 t = 1.62 df = 1 p= 0.20 t = 3.06 p = 0.08 t = 0.08 p = 0.76 t = 4.68 **p = 0.03 t = 0 p = 0.99 ward type internal surgical 1/68 ± 0/72 1/91 ± 0/86 t = 0 df = 1 p = 0.98 t = 0.07 p = 0.78 t = 0.13 p = 0.71 t = 0.22 p = 0.63 t = 7.8 **p = 0.006 hospital a b c d 2/1 ± 0/91 2/09 ± 0/91 1/85 ± 0/83 2/26 ± 0/82 f = 4.76 df = 3 **p = 0.003 f = 1.54 p = 0.20 f = 4.01 **p = 0.008 f = 4.52 **p = 0.004 f = 1.15 p = 0.32 j med ethics hist med 7: 20 dec, 2014 jmehm.tums.ac.ir fariba borhani et al. page 5 of 8 (page number not for citation purposes) household size < 5 people > 5 people 1/86 ± 0/77 2/09 ± 1/08 t = 8.49 df =1 **p = 0.004 t = 0.002 p = 0.96 t = 5.11 p = 0.025 t = 1.54 p = 0.21 t = 1.01 p = 0.31 satisfaction with household income low average increased 2/04 ± 0/85 1/65 ± 0/66 1/41 ± 0/33 f = 2.91 df = 2 p = 0.056 f = 8.12 **p = 0.000 f = 7.59 **p = 0.001 f = 2.99 p = 0.052 f = 5.46 **p = 0.005 *p < .05; ** p < 0.01; *** p < 0.001 table 4relationship between age and dimensions of human dignity age dignity dimension social support peace of mind dependency existential distress symptom distress total dignity pearson’s correlation coefficient 0.099 0.215 0.115 0.115 0.166 0.169 p-value 0.09 *0.000 0.05 0.05 *0.005 *0.005 according to the table 4, patient dignity was lower in older people. discussion the present study investigated patients’ perceptions of their personal state of human dignity. the results demonstrated that patient dignity was properly observed in the study hospitals with an overall mean score of 1.89 out of a possible 5 and a lower score indicating a better state of human dignity. a study by hack et al. on cancer patients in canada found that the majority of patients reported a suitable state of human dignity (15). however, other studies found an inappropriate state of human dignity (1, 4, 16). participants in another study by thornock and kelleher conducted on icu patients also reported a low sense of dignity, which may have resulted from these particular patients’ special conditions, including loss of control, autonomy and privacy, and lack of information and awareness. the decreased dignity of patients suffering from urological conditions in baillie’s study could have resulted from loss of privacy, use of treatment equipment and catheters, and bodily exposure. factors affecting human dignity may pertain to the hospital (environment and staff behavior) or the attributes and attitudes of patients (acceptance of the disease, rational thinking, mood or sense of humor). in this study, the good-feeling factor induced by the participating patients’ state of human dignity could be attributed to the fact that they were relatively young (46.9%), had been admitted to surgical and internal medicine wards, had health insurance (72.5%), and the majority did not suffer from critical conditions. results also demonstrated that hospitals directly affect patient dignity. patients in shahid modaress hospital experienced a better state of dignity. the difference may be attributed to the hospitals’ physical and mental atmosphere. according to investigations conducted by the researcher, hygiene and sanitation, air conditioning, physical appearance and size of rooms were more favorable in shahid modaress hospital compared to the other hospitals. another factor that can affect patients’ perception of themselves is the manner in which they are perceived by other people. when people accompany a patient to the hospital, there is a change of atmosphere and everyone begins to adapt psychologically to the new conditions. most patients experience less dignified feelings due to the fear of loss of control, autonomy, and personal space. therefore, the physical and psychological environment of the hospital or a ward can reduce or increase feelings of dependence, peace of mind, and mental distress (4). evidence demonstrates that factors such as poor location hygiene, noise, and lack of respect for privacy can threaten patient dignity. conversely, treating patients respectfully and giving them information, respecting their right to choose, obtaining informed consent, involving patients in treatment and care decisions, an increased level of patient autonomy, and above all nurses’ attention to patients can enhance dignity (1, 17 20). studies indicate that patients’ self-control and accountability significantly influence their daily activities and decisions, and that nurses play a particularly important role in maintaining these values in patients. nurses can balance patients’ feelings of autonomy and dependence through understanding their needs and requirements, and by treating them respectfully (21). certain researchers assert that shortages in hospital facilities (personnel, space and equipment) may affect the dignity of the treatment team, making them feel disrespected within the organization and thus affecting their ability to maintain and enhance their patients’ dignity (4). in the present study, type of disease correlated significantly with patient dignity (dependence j med ethics hist med 7: 20 dec, 2014 jmehm.tums.ac.ir fariba borhani et al. page 6 of 8 (page number not for citation purposes) factor), and patients in internal medicine wards were in a better state overall. this may be due to the fact that patients awaiting surgery face problems such as treatment costs, dependence on the treatment team and family members, loss of control, anxiety, and depression more than other patients. previous studies have also found a relationship between type of disease and the status of dignity (4). anxiety, fear, loss of sense of control, dependence, invasive procedures and anesthesia affect patients’ perceptions of themselves and their expectations of others, especially the treatment team (4). in the present study, a significant relationship was found between type of disease and dependence. the state of dignity was better in patients in internal wards. furthermore, criticality of disease, lack of confidence in treatment, and inability to think rationally reduced the sense of control, thus creating a feeling of dependence on others and a threatened state of patient dignity (1). the present study found a significant relationship between gender and dignity, with women feeling generally less dignified, and this relationship was pronounced in the social support dimension. previous studies have also indicated the existence of a relationship between gender, social support, and depression (22). the women in this study suffered from depression and mental distress more than men. women’s social role and negative stresses, like social conflicts, and the negative responses they receive from their social networks increases their vulnerability to the adverse effects of stress. these factors explain the difference in mental disorders between the sexes (23). the importance of social relationships as a feelgood factor in humans has been proven. social support is a well-known concept in social sciences, health services and so on, and many studies have associated it with reduced mental disorders, emphasizing the role of gender as a social parameter (22). hospitalization is associated with numerous physical and mental problems, which cause a feeling of need for more support. in iran, most women are not employed outside of their homes and have limited access to social support networks, and thus feel they enjoy less support than men. research indicates that reduced social support also affects physical health, and it may even increase mortality rate and functional impairments (24, 25). one factor that may cause women’s perception of social support to differ from that of men is the type of support that they receive from each other when faced with stressful situations and health problems. a study by neff and karney also demonstrated that in stressful situations, women support their spouses more (26), and women have a greater tendency to preserve family relationships and provide support for family members (27, 28). compared to men, women are more sensitive to lack of support, and naturally benefit more when they receive positive support (23). results of the present study demonstrated significant relationships between the level of patient satisfaction with household income and symptom distress, existential distress and dependency. socioeconomic status is one of the most essential social aspects of diseases (29). people in lower income brackets experience greater feelings of dependency and existential distress due to disease symptoms, and reduced feelings of social support and peace of mind. brock asserted that poor physical health is both the cause and effect of disease, poverty, and poor lifestyle. sick people become poor and even poorer with the loss of their jobs and income (30). the existential distress of patients with low income may result from the fact that poverty is associated with feelings of incapacity (31). fear, insecurity, dependency, depression, anxiety, shame, despair, isolation, and powerlessness are non-quantitative emotions expressed by low-income patients (32). low income equates to the inability to access food sources, obtain health services, and find employment; it further correlates with increased divorce and crime rates, and lack of skill and training (30), which can affect certain dimensions of human dignity. some studies associate low family income with symptoms such as high blood pressure (29). the present study found that poor patients suffered increased symptom distress. it also found that low income strongly correlates to lower quality care and reduced respect, and people with lower incomes are forced into early discharge from the hospital regardless of the due course of treatment. thus the vicious cycle of hospitalization, discharge, and prolonged illness continues (32, 33). the present study found an inverse relationship between household size and peace of mind, so that peace of mind increased with reduced household size. peace of mind and feelings of physical and mental well-being greatly affect both physical and mental health. although results of other studies indicate that marriage can increase peace of mind and provide mutual support between spouses, having children and the consequently larger household sizes have no effect (or a negative effect) on peace of mind and the feeling of wellbeing (34). kandel et al. found that couples without children or with children that are independent have better mental conditions than parents in larger households. large household size reduces adult patients’ feelings of well-being and peace of mind (especially when ill or hospitalized) in two ways: first, a larger number of people in the family means more financial burdens and less economic welfare; second, it reduces parents’ emotional support of one another (35). ross et al. found that in the presence of sufficient family income and proper supports and services, a higher number of children and consequently larger household size can j med ethics hist med 7: 20 dec, 2014 jmehm.tums.ac.ir fariba borhani et al. page 7 of 8 (page number not for citation purposes) positively affect parents’ mental status. furthermore, this study asserted that at a similar income level, more populated households bear higher economic pressures, which increases depression in both men and women. poor socio-economic status and a high number of children cause a low level of social support, which in turn increases depression and other psychological problems. all of these factors can reduce patients’ feelings of well-being and peace of mind and increase their psychological distress (36, 37). the present study further observed an inverse correlation between age and the status of dignity. there is strong evidence that dignity is a serious concern for older people, as it is a multifaceted concept, encompassing identity (self-esteem, selfrespect, and honesty), human rights (equality, choice), and autonomy. consequently, when drastic changes are accompanied by increasing age, the aforementioned factors get involved (20). social role, status and the smaller presence of older people in the society lead to reduced feelings of dignity in the elderly. stratton and tadd demonstrated that older people considered old age a period of deterioration in physical, mental, economic, and independence states (38). loss of self-esteem may occur because of lack of support or decisionmaking rights, sentiments related to being treated as an object, or absence of social uniformity resulting from the inability to trust others (20). therefore, national and international social and health care policies for the elderly must emphasize observation of their rights and maintaining their dignity, including increased public awareness and support services. in this regard, respectful treatment of patients by hospital staff, especially nurses, is extremely important (38, 20). current study results can serve to inform health policy makers about the appropriate planning and training of staff, especially nurses, to observe the following while providing health services; consideration for human dignity; respect for values, cultural and religious beliefs; honesty, justice and good manners; freedom from various forms of bias, including ethnic, cultural, religious, disease type, and gender; and current knowledge and practices. moreover, the education of health service practitioners on preserving patient dignity must include in-depth learning opportunities. one limitation of the present study was that the researcher had to complete the questionnaires for illiterate patients, which may have affected participants’ responses, especially in areas of economy and insurance, where people may have overstated their answers. another limitation was that this study was conducted in hospitals affiliated with one university, and therefore the results may not be generalized to patients in other facilities. thus, we recommend further studies in wider dimensions. conclusion results of this study revealed an almost favorable status of human dignity in hospitals affiliated with one of the largest universities in iran. appropriate treatment setting and the proper behavior of hospital staff, especially nurses, are influential in increasing patients’ feelings of self-esteem and respect. inappropriate patient dignity can affect patient outcome, the recovery process, and return to normal life, and therefore we recommend that maintaining human dignity and the factors influencing it be considered in the treatment of patients. acknowledgements the authors thank all participating patients. they also wish to thank the research deputy of shahid beheshti university of medical sciences for providing the funds for this study. references 1. baillie l. patient dignity in an acute hospital setting: a case study. int j nurs stud 2008; 46(1): 23-37. 2. chochinov hm. dignity-conserving care -a new model for palliative care: helping the patient feel valued. jama 2002; 287(17): 2253-60. 3. lam kk. dignity, respect for dignity, and dignity conserving in palliative care, palliative medicine doctors’ meeting. hkspm newsletter 2007; 3: 30-35. http://www.fmshk.org/database/articles/dignityrespectfordignityanddignityconservinginpall.pdf 4. ruth matiti m, trorey g. perceptual adjustment levels: patients’ perception of their dignity in the hospital setting. int j nurs stud 2004; 41(4): 735-44. 5. macklin r. dignity is a useless concept. bmj 2003; 327(7429): 1419–20. 6. walsh k, kowanko i. nurses' and patients' perceptions of dignity. int j nurs pract 2002; 8(3): 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1992, 20 march 1997 and 20 march 2002 ali jafarian 1 , alireza parsapour 2 , amirhasan haj-tarkhani 3 , fariba asghari 4 , seyyed hassan emami razavi 5 and alireza yalda 5 1.professor, imam khomeini hospital complex, tehran university of medical sciences, tehran, iran. 2.researcher, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. 3.associate professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. 4.assistant professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. 5.professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. *corresponding author: alireza parsapour address: no. 21, 16 azar ave., keshavarz blvd., medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. tel: (+98) 21 66 41 96 61 e-mail: aliparsa@tums.ac.ir received: 18 feb 2009 accepted: 07 may 2009 published: 02 jun 2009 j med ethics hist med. 2009; 2:9. © 2009 ali jafarian et al.; licensee tehran univ. med. sci. abstract keywords: medical error, patients’ rights, malpractice. one of the most important occupational tensions a physician encounters in his/her practice is the complaints lodged against him/her by the patients. the purpose of this study is examining the complaints against physicians and dentists entering the medical council organization of tehran in the years ending on 20 march 1992, 20 march 1997 and 20 march 2002 from the viewpoint of number, dispersion and inducing factors. the present study was performed as a descriptive and retrospective one with the aid of a questionnaire containing concerned data. filling in the questionnaire or studying the file was accomplished by a trustee expert of the medical council organization and the data obtained were analyzed after classification. during a 3‐year period, 832 complaints were lodged against physicians and dentists. the complaints against physicians in the years ending on 20 march 1997 and 20 march 2002 were 70% more than that in the year ending on 20 march 1992. 83.1% of the physicians and dentists of tehran that were sued had not been convicted until the date of the performance of the study, on the basis of the contents of the files, and had no malpractice from the vantage point of the medical council organization. the most common causes of complaints from the viewpoint of complainers were therapeutic errors (38%), neglect (30.2%), financial affairs (25.4%) and the physicians’ lack of skill (17.7%). on the basis of this study, with the increase of the doctor’s practice track record and experience more than 15‐20 years, the number of the complaints decreases and most of the complaints are against the middle‐aged doctors/dentists with 10‐20 years of experience. most physicians and dentists of tehran having been sued have not committed any wrong from the vantage point of the medical council organization experts and a large part of the complaints are a consequence of doctor‐patient inconvenient interactions. a behavior based on professional commitment of the physician/dentist vis‐à‐vis the patient can hinder a major part of complaints. j med ethics hist med 2009, 2:9 ali jafarian et al. page 2 of 6 (page number not for citation purposes) introduction the responsibility of physicians is outstanding in proportion to the respect and honour paid to them by the society. in other words, when a person proudly wears the white coat, the society sees itself bound to treat him/her with great respect and he/she, too, sees her/himself bound to observe specific dignities in the society. one of the most important occupational tensions a doctor encounters in his/her own practice is the complaints lodged against him/her by the patient. when a doctor encounters judicial complaints made by patients, he/she sees all the beliefs and dignities shaken and his/her social prestige at shake. this induces anxiety, tension, depression, isolation and, even illness (1). this tension is not merely limited to cases wherein the doctor is wrongdoer, but, even when the patient’s complaint emanates from his/her misunderstanding or bad intention, the doctor is compelled to sustain undesired circumstances. therefore, any complaint causes significant mental tension and negative feelings in the doctor and directly influences his/her function in addition to being time consuming for him/her. on the other hand, surveys have demonstrated that the increased rate of complaints in some medical specialties causes a downward trend in volunteers’ inclination to choose such professions, on one hand, and decrease of adopting measures with more risk in practice and, consequently, increased probability of complaints, on the other (1 , 2). on the basis of a study, complaints filed against gynaecologists & obstetricians have escalated in recent years (3). this increase of complaints in the west has led to less inclination of doctors toward this field and increased cesarean section cases and non-acceptance of high risk patients (2). in any way, nowadays, complaint against doctors is one of the most important tension producing factors in professional career of doctors, and, disregarding the factors causing them leads to imposition of undesirable effects on the quality of services presented by the doctors and indirectly influences the health system. identifying the factors affecting the complaints rate and the process of complaint lodging may be applicable in prevention and education of various medical professions. the purpose of this study is surveying the complaints filed against doctors and dentists entering the medical council organization of tehran in the years ending on 20 march 1992, 20 march 1997 and 20 march 2002 from the viewpoint of number, dispersion and inducing factors. materials and methods this study was performed as a descriptive and retrospective one. for this purpose, after preparing the questionnaire, including the desired data, by coordination with the medical council organization of tehran, all the complaint files of the years ending on 20 march 1992, 20 march 1997 and 20 march 2002 were examined. the questionnaire includes general data on patients (age, gender, illness, complications and mortality), the causes behind the complaints from the viewpoints of patients, the professional particulars of the treating doctors, and the result of expert works on the files considered. after surveying the validity of the questionnaire with regard to 20 files and influencing necessary amendments, the collection of the data commenced. filling in the questionnaires was performed, after studying the files, by a trustee expert of the medical council organization of tehran. in order to observe the confidentiality principles, the data were registered without mentioning the names and other particulars of the individuals; and the medical council registration numbers (mc reg no) of the doctors, too, were registered limitedly. the data were analyzed using spss software. results out of a total of 1090 files examined, 832 cases were related to doctors, the distribution data of which appear in table 1. out of 832 complaints examined in three time periods mentioned above, 421 cases (50.6%) concerned the male patients and 403 cases (49.4%) were related to female ones. in 8 cases, the gender of the patients was unknown. the incidence frequency of the complications and the death type (based on the patients’ words) in the files examined are mentioned in table 2. as is seen, the rate of the complaints in this decade has not changed significantly with the incidence of complications but significant changes in mortality have been observed in the years ending on 20 march 1997 and 20 march 2002. the causes of the complaints have been arranged in eight groups as follows on the basis of the contents of the patients’ complaints: therapeutic error, inattention (refraining from examination, non-attendance, refraining from visiting, and neglect), financial problems, doctor’s lack of skill, diagnostic errors, inconvenient approach, lack of adequate explanation to the patients with respect to the measures taken and non-observance of governmental regulations. j med ethics hist med 2009, 2:9 ali jafarian et al. page 3 of 6 (page number not for citation purposes) in table 3, the relative frequencies of the mentioned complaints in the files examined have been specified as per the years concerned and in general. the only significant difference between theses time periods is related to the therapeutic errors (less incidence in the year ending on 20 mar 1997) and inconvenient approach (less incidence in the year ending on 20 mar 2002). in other cases, the cause pattern of lodging complaints during 1970s shows no significant difference. regarding the lack of full accessibility to and the limited numbers of the files relating to the year ending on 20 mar 1992, the results of the expert examinations at the preliminary and higher committees of the medical council organization in the years ending on 20 mar 1997 and 20 mar 2002 were analyzed. overall, 831 files, examined in the light of the verdicts of the preliminary and higher committees, had the following particulars: 1) 146 cases contained the verdicts of both the preliminary and higher committees. the results of the verdicts of the files examined in the years ending on 20 mar 1997 and 20 mar 2002 contained the verdicts of the preliminary and higher committees have been mentioned in table 4. 2) 187 files contained no preliminary or higher committee verdicts. it appears that these files are either in the examination phase at the preliminary committee or have been terminated due to mutual compromise. of course, some of these files have been referred by the judicial system for advisory opinion and contain no verdict. 3) 498 cases only contained the verdicts of the preliminary committee (395 acquittal cases and 103 malpractice ones). it appears that, in these cases, objection to the verdicts of the preliminary committee have not been followed with mutual agreement of the parties of the files and have not been referred to the higher committee. less likely, the said files may still be on examination in the higher committee. as is noted, the rate of reversal of the verdicts of the preliminary committee has been 26.4% with regard to malpractice and 6.7% with respect to acquittal. it is to be mentioned that out of 146 files containing verdicts of both preliminary and higher committees, 119 cases (81.5%) contained similar verdicts and 27 cases (18.5%) had contradictory one. overall, out of 146 files examined at both preliminary and higher committees, 64 cases (43.8) were discerned as malpractice by both committees. in the year ending on 20 mar 2000, the rate has been 50% in the studies performed at the forensic medicine organization (4). for examining the correlation of complaints with the medical track record of individuals, the relative frequency of the number of complaints, differentiated in 6 groups on the basis of the mc reg no of the doctors, were surveyed, as mentioned in table 5. classification of doctors in these 6 groups has been performed on the basis of the approximate track records estimated based on the mc reg no of the doctors. discussion it appears that lodging complaints against health service providers have been done only by patients having been damaged or having objection against the services provided. this means that exclusive survey of the complaints files is not in itself indicative of the essence of all difficulties of the health service recipients. in other words, lots of difficulties are not set forth due to various reasons, including lack of tendency of the patients to file complaint, the complainers’ lack of knowledge or lack of access to legal authorities or taking consent from the complainants by the health service providers or their colleagues. furthermore, a number of complaints have not been examined here due to having been referred to the judicial authorities. on the basis of a study by harvard university, only 2% of patients having been damaged by care system, to any extent, legally file complaint. therefore, the present study is only indicative of part of the existing problems of the health service providing system, although, it appears that it is, in general, a convenient indicator of the objects of the complaints filed. the amount of the complaints in the years ending on 20 march 1997 and 20 march 2002 was 2.5 times more than that of the year ending on 20 mar 1992, which, taking into account the increased rate of the number of complaints being much more than the increased population; and so it is indicative of the extension of the culture of lodging complaint against doctors. from the similarity between the acquittal rate in the complaints that have led to passing verdict by the preliminary committee in the years ending on 20 march 1997 and 20 march 2002 and, the relative frequencies of the objects of complaints based on the complaints texts in the years ending on 20 march 1992, 20 march 1997 and 20 march 2002, it is inferred that the types of complaints and the results of judgments have not been significantly different in this time interval. on the other hand, taking into account the constancy of the pattern of the causes of complaints, one may conclude that no important measures have been taken in the direction of educating the doctors in order to decrease this risk. the ratio of malpractice to complaints lodged with the preliminary committee in this study is about 30%. a study conducted by harvard university shows that, for each malpractice confirmed in the judicial system, 7 complaints have j med ethics hist med 2009, 2:9 ali jafarian et al. page 4 of 6 (page number not for citation purposes) led to acquittal (5). regarding the findings of this study, it is not possible to analyze the data like the study in harvard university; perhaps because of the lower level of the expectations of the society and patients of medical community. therefore they only lodged complaints in the cases having led to more serious consequences or the more convenient interaction of the medical community with the patients, and less misunderstanding. more accurate survey of this matter entails planned studies in this arena. on the basis of this study, most of the doctors and the dentists of tehran who have been sued, had not committed any malpractice, from the viewpoint of the medical council organization of tehran. the following results may be obtained by examining the findings of table 3: 1) most of the complaints including therapeutic errors, diagnostic errors, lack of skill and inattention on the part of the doctor/dentist, while, it appears that the confirmed malpractice cases are not congruent with this ratio. it appears that a major part of these cases, contrary to the mentality of the patients, emanate from the natural consequences of therapeutic actions taken for them. in such cases, lodging complaints may be due to the poor relationships between patients and doctors/dentists and lack of explaining the problems by the doctors/dentists to patients (5). a study conducted by entman et al, assessed by a specialist committee, shows that the quality of the treatments rendered by the sued gynecologists and uncharged gynecologists is significantly different. also other studies demonstrated that the quality of the treatment is an important factor in making complaints by the patients and their relatives (6). paying more attention to and spending more time for the patient by the doctor/dentist and rendering adequate information regarding the illness of the patient, the therapeutic methods and the positive and negative aspects of each method increases the knowledge of the patient with respect to the treatment provided and the circumstances for occurrence of therapeutic errors diminishes. 2) in this study, financial issues were the cause of only one fourth of cases. therefore, contrary to the primary imaginations, financial issues were not the main cause of lodging complaints. the omission of the direct financial correlation between doctor and patient may be an effective way to decrease the tension between them. the above said target will be achieved through strengthening social insurance in country, providing fair and reasonable medical tariffs by the relevant authorities and efficient supervision on the observance of those tariffs. at present, when these circumstances have not been realised, explaining this relationship by the doctor/dentist to the patient can, to some extent, prevent the occurrence of dissatisfaction. undoubtedly, the primary purpose of providing medical services is not making a profit but helping the needy patients. this must be manifested in the doctor’s behavior. in surveying the information related to the doctors, it appears that, with the increase of practice track record and experience more than 15 20 years, the number of complaints filed decreases. this can be a consequence of their more experience or a decrease of their therapeutic activity. however, the doctors with moderate experience (between 10 20 years) have been sued more than others. this finding can be considered a as consequence of more activity of the middle-aged doctors after obtaining specialization, gaining more fame and more clients and/or a result of their more self esteem and use of more invasive procedures. the complaints rate regarding the newly-graduated doctors follows a downward trend which may be another manifestation of the above reasoning. what appears definite anyway is that the middle-aged doctors in the culmination of their practice are more exposed to being sued and it is necessary that they pay more attention to their relations with the patients. conclusion lodging complaints, a matter of meager importance or rare for doctors in the recent past, is now an important and serious matter. on the basis of the findings of this study, many complaints are not indicative of actual errors and, thus, it may be possible to prevent them from occurring by improving the doctor-patient relationship. what appears necessary is the patients’ perception of beneficence, imposing no harm on patients (non malfeasance) and respecting their autonomy by the doctors. these ethical principles which manifest in the frame of professional behavior in the doctors’ interaction with patients can lead to doctors’ tranquility and a decrease of risk of complaining. j med ethics hist med 2009, 2:9 ali jafarian et al. page 5 of 6 (page number not for citation purposes) table 1. distribution of the files examined in medical council organization of tehran year number of complaints per year (%) 20 mar 1992 20 mar 1997 20 mar 2002 total against doctors and dentists 74 (69) 405 (79) 353 (75) 832 (76) against other medical professionals* 33 (31) 108 (21) 117 (25) 258 (24) total **107 513 470 1090 *these complaints were related to the health centres, laboratories and the like. ** lack of access to all files of the year ending on 20 mar 1992 because of computerized registration since 1994; so 107 files out of 200 were examined. table 2. the incidence frequencies of complications and death damage 20 mar 1994 20 mar 1997 20 mar 2002 total p value complications incidence (%) 46 (62.2) 228 (56.3) 202 (57.2) 476 (57.2) 0.64 death (%) 3 (4.1) 69 (17) 52 (14.7) 126 (14.9) 0.016 not mentioned events 25 (33.7) 108 (26.7) 99 (28.1) 232 (27.9) -- table 3. relative frequencies of the causes of complaints from the viewpoint of complainers causes of complaints 20 mar 1994 20 mar 1997 on 20 mar 2002 total p value chi 2 1 therapeutic errors 54.9 30.1 45.3 38 0.00 20.7 2 inattention 21.7 30.7 31.7 30.2 0.36 2.0 3 financial problems 24.3 23.5 27.8 25.4 0.39 1.9 4 doctors’ lack of skill 16.2 20.2 15 17.7 0.16 1.9 5 diagnostic errors 13.5 10.4 13.3 11.9 0.41 1.7 6 inconvenient approach 12.2 15.6 6.5 15.6 0.00 15.3 7 lack of adequate explanation to patient 4.1 5.2 4.2 4.7 0.88 0.4 8 non-observance of governmental regulations 14.1 3 1.4 2.4 0.24 2.8 table 4. the verdicts issued by the preliminary or higher committee of the medical council organization preliminary committee/higher committee ‘acquittal’ in the preliminary committee ‘malpractice’ in the preliminary committee total ‘acquittal’ in the higher committee 55 (93.3) 23 (26.4) 78 ‘malpractice’ in the higher committee 4 (6.7) 64 (73.6) 68 total 59 (100) 87 (100) 146 table 5. relative frequency of complaints in terms of the mc reg no mc reg no on 20 mar 1992 on 20 mar 1997 on 20 mar 2002 p value complaint rate* complaint rate* complaint rate* less than 10000 (>15) 38.6 (>20) 23.2 (>25) 15.9 0.028 10001 to 20000 (5-15) 46.7 (10-20) 37.5 (15-25) 26.3 0.004 20001 to 30000 (2-5) 12.6 (7-10) 15.8 (12-15) 25.2 0.00 30001 to 40000 (0-2) 2.1 (4-7) 5.4 (9-12) 8.2 0.054 40001 to 60000 (0-4) 5.2 (5-9) 10.2 -- 60001 to 80000 (2-5) 5.7 -- mc reg no not mentioned 12.9 8.5 -- total 100 100 100 -- *the approximate practice track records of each group are in parentheses. j med ethics hist med 2009, 2:9 ali jafarian et al. page 6 of 6 (page number not for citation purposes) references 1. nobakht haghighi a, zali mr, mahdavi ms, noroozi a. a study of the reasons of patient’s complaint from physicians in patients referred to tehran medical council. j med counc islam repub iran 2000; 4: 295-303. (persian) 2. yahwn b, wellever a, hartley d, casey m, krein s, moscovice i. availability of rural minnesota obstetric services: is it a problem? j rural health 1995; 11 (3): 192-203. 3. badakhsh mh. malpractice claims of gynecologists received by medical council, tehran, 1992-96. feyz kashan univ med sci health serv 2003; 24(6): 76-81. (persian) 4. amooei m, soltani k, kahani ar, najari f, roohi m. study of medical negligence sues referring to lmo in 1999. j leg med islam repub iran 2001; 21(6): 15-23. (persian) 5. mahfoozi a, taghadoshi nejad f, abedi khorasgani h. a 6 years’ study on anesthesiologist’s medical malpractice cases referred to tehran medicolegal commission (1994-99). j leg med islam repub iran 2002; 26(8): 4-10. (persian) 6. entman ss, glass ca, hickson gb, githens pb, whetten-goldstein k, sloan fa. the relationship between malpractice claims history and subsequent obstetric care. jama 1994; 272 (20): 1588-91. ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ 1 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e © 2019 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. original article volume 12 number 2 march 2019 a study of the validity and reliability of the questionnaire entitled “physicians' approach to and disclosure of medical errors and the related ethical issues” *corresponding author bagher larijani no. 10, jalal al-ahmad st., next to shariati hospital, chamran hwy, tehran, iran. tel: (+98) 21 88 63 12 97 email: larijanib@tums.ac.ir received: 02 sep 2018 accepted: 25 feb 2019 published: 06 mar 2019 citation to this article: mohammadi m, larijani b, tabatabaei sm, nedjat s, yunesian m, nayeri fs. a study of the validity and reliability of the questionnaire entitled “physicians' approach to and disclosure of medical errors and the related ethical issues”. j med ethics hist med. 2019; 12: 2. mohammad mohammadi1, bagher larijani2*, seyed mahmoud tabatabaei3, saharnaz nedjat4, masud yunesian5, fatemeh sadat nayeri6 1. phd candidate in medical ethics, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran; department of medical ethics, school of medicine, tehran university of medical sciences, tehran, iran; faculty of medicine, department of medical ethics, mashhad university of medical sciences, mashhad, iran. 2. professor, endocrinology and metabolism research center, endocrinology and metabolism clinical sciences institute, tehran university of medical sciences, tehran, iran. 3. professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. 4. professor, knowledge utilization research center, tehran university of medical sciences, tehran, iran; department of epidemiology and biostatistics, school of public health, tehran university of medical sciences, tehran, iran. 5. professor, department of research methodology and data analysis, institute for environmental research, tehran university of medical sciences, tehran, iran; department of environmental heath, school of public health, tehran university of medical sciences, tehran, iran. 6. professor, maternal-fetal and neonatal research center, tehran university of medical sciences, tehran, iran. abstract medical errors are among the major challenges that threaten patients’ health worldwide. the aim of this study was to design a valid and reliable questionnaire to investigate the status of medical error disclosure by physicians. a preliminary questionnaire was developed based on the extracted results from 37 interviews with specialists. to test the validity of the questionnaire, 20 medical practitioners and medical ethics authorities were asked to evaluate the relevance and clarity of each item. to measure the instrument’s reliability (the intra-class correlation coefficient and cronbach’s alpha), a test-retest study was conducted on 20 randomly selected physicians twice with a 2-week interval. statistical analyses were performed using spss software version 20. the overall relevance and clarity of the instrument, with an average approach, were measured at 97.22 and 94.03 percent respectively. the cronbach’s alpha, which presents the internal consistency was satisfactory (0.70 0.79) for various domains of the questionnaire. the range of intra-class correlation coefficients for the items in all domains of the questionnaire was 0.76 to 1.00. regarding the validity and reliability of the questionnaire, it can be an appropriate instrument in the assessment and monitoring of the status of medical error disclosure by physicians. keywords: medical errors; disclosure; beneficence; nonmaleficence; personal autonomy a study of the validity and reliability of the questionnaire … 2 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 2 march 2019 introduction error is an integral part of human life (1), and medical errors are among the major challenges to patients’ health worldwide (2). regardless of how skilled, committed, or careful they are, people commit errors, and healthcare team members are no exception (3, 4). the occurrence of medical errors is inevitable due to factors such as the complexity of medical knowledge, time constraints, and the need for action despite inadequate and uncertain information (5). a medical error has been defined as an act of omission or commission, which is either a failure to fully implement the planned measures or to use of a wrong method to achieve a goal, with or without any harm to the patient (6). medical errors are also regarded as unintentional and unexpected but preventable adverse events in medical care (7 9). based on some classifications, there are three types of medical errors: serious, minor and near-miss. a serious or major error is one that gives rise to permanent or transient injuries that may be life-threatening, whereas a minor error brings about harms that are neither permanent nor potentially life-threatening. finally, a near-miss error is one that could have inflicted harm but did not, as a result of timely intervention or through sheer luck (10). recent studies have indicated an increase in the rank of mortality due to medical errors in the united states. it is estimated that more than 250,000 deaths every year are due to medical error, which has risen in rank from the eighth cause of death in 1999 to the third in 2013 (11, 12). empirical studies have shown that patients tend to be aware of medical errors, the causes and associated complications, and preventive measures to avoid their repetition (13). medical error disclosure actually falls under the category of respect for patient autonomy and health, and provides the possibility to obtain informed consent from the patient for the treatment of error-induced damages (6). from an ethical point of view, patients have the right to receive information about diagnostic or therapeutic measures before their implementation, and as a result are entitled to know the consequences of such measures (14). moreover, in cases of medical error, patients’ healthcare takes priority over commitment to organization (15). several studies have demonstrated that the majority of patients prefer to be informed when errors are made, but physicians are mostly reluctant to disclose errors and tend to provide no or inadequate information (16 19). with regard to physicians’ commitment on error occurrence, opinion 8.12 of the code of medical ethics of the american medical association asserts physicians to “disclose medical errors if they have occurred in the patient’s care, in keeping with ethics guidance” (20). error disclosure reflects physicians’ honesty and truthfulness, which can reduce patients’ discomfort, cultivate trust and confidence, and evoke their positive emotional response; it also fulfills their need to get informed about the quality and manner of their care and promotes awareness of their current mohammadi m., et al. 3 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 2 march 2019 status, which will in turn facilitate obtaining informed consent for the treatment of errorinduced damages and a peaceful compensation (6, 21). it is difficult to get an overall picture of medical errors in developing countries (22), which may be due to absence of a proper recording and reporting system and limited research studies in this area (23). there have been few studies about the attitudes of physicians toward medical errors and the proper manner to deal with them. studies on the subject are rather difficult to conduct due to ethical issues and an absence of a valid and reliable questionnaire to assess physicians’ approach to and disclosure of medical errors. although many studies have been conducted on medical errors in iran, this is the first one, to our knowledge, that attempted to deal with the construction and validation of a questionnaire on medical error disclosure. this study aimed to design a valid and reliable questionnaire to investigate the practices of iranian physicians and their colleagues in dealing with medical errors, especially disclosure and the manner in which it is done, as well as the related ethical issues. methods this study was conducted in two phases. in the first phase, the questionnaire was designed, and in the second, its reliability and validity were measured. phase i: questionnaire design initially, a semi-structured interview was performed with 37 medical specialists about medical error disclosure. the main questions of the interview explored the attitudes, concerns, experiences and practices in dealing with medical errors (either by the physicians themselves or their colleagues), as well as medical error disclosure, recording and reporting, and legal issues. the number of interviews were calculated to be 24 based on the opportunistic maximum variation sampling approach. the variables included gender (male and female), age (less than 45 years and more than 45 years), duration of medical practice (less than 20 years and more than 20 years), and type of specialization (internal medicine, surgery, and other specialties). data saturation was achieved with 37 interviews (table 1). table 1the characteristics of interviewees variables variable characteristics n type of specialization internal medicine 15 surgery 14 other specialties (four pediatricians, one psychologist, one radiologist, and two forensic medicine practitioners) 8 gender male 11 female 26 the mean period of practice (years) 21.25 ± 10.27 a study of the validity and reliability of the questionnaire … 4 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 2 march 2019 in the first round, open coding was conducted and 93 codes were obtained, which were assigned into four categories. then, during axial coding, the characteristics and the ranges of their values were presented in subcategories (table 2). table 2the development of categories and subcategories after interview analysis category 1: the nature and theoretical foundations of medical error subcategories definition and types of medical errors consequences of medical errors ethical/philosophical foundations legal issues category 2: medical error management subcategories medical error disclosure obstacles to medical error disclosure apology compensation for medical errors responsibility systematic approach category 3: colleagues’ medical error management subcategories informing colleagues colleagues’ medical error disclosure to patients dealing with colleagues’ errors category 4: documentation of medical errors subcategories medical error recording (on patient medical records) error reporting (to the health system) as the next step, two researchers familiar with the notions of medical errors and medical ethics extracted factors, components and concepts related to medical errors from the categories and subcategories (including characteristics and the ranges of their values). at the end of this round, 48 items were obtained based on which 48 questions were designed. in the second round, based on the aims of the study, the preliminary questionnaire was revised using the comments of a panel of experts familiar with questionnaire design. the panel consisted of two medical ethicists, two medical specialists with academic and managerial background of iranian medical ethics centers, and one epidemiologist. the most important aspect of the questionnaire content was physicians’ attitudes toward medical error disclosure by themselves and their colleagues, and the manner of disclosure. other items such as physicians’ practices in dealing with errors and their recording and reporting were also mohammadi m., et al. 5 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 2 march 2019 included, as documentation and a kind of medical error disclosure to the organization. moreover, three categories of medical errors were identified: serious (major), no harm (minor), and near-miss. finally, after the review, deletion, merging, and summarizing of previous items and questions, 36 new items were obtained, based on which the preliminary version of the questionnaire was designed. phase ii: reliability and validity of the questionnaire a. content validity (relevance and clarity) in the next round, we investigated relevance, clarity of questionnaire items, and comprehensiveness of the instrument in order to measure content validity. for external validity, the items were evaluated in terms of appropriateness for the target population (including 20 general practitioners and medical specialists), considering subject assessment, format and appearance of the questionnaire. a fourpoint likert scale with responses ranging from undesirable, somewhat desirable, desirable, and very desirable was used to evaluate the relevance and clarity of each item separately. item content validity index (i-cvi) and scale content validity index (s-cvi) were used to analyze the participants’ views in terms of the relevance and clarity of each item or the scale, respectively. the i-cvi was calculated by the proportion of participants who had chosen the responses “desirable” or “very desirable” to the total number of participants, and the s-cvi was the mean of the i-cvis for all items on the scale (24 27). the instrument was also assessed for comprehensiveness. corrective remarks were discussed individually with the participants, and constructive comments were taken into consideration. subsequently, the questionnaire was revised and necessary amendments and modifications were made while retaining the original content. b. reliability to measure the instrument’s reliability, a test-retest was conducted with 20 randomly selected physicians twice with a 2-week interval. internal consistency was determined using the cronbach’s alpha, and for the test-retest, the intra-class correlation coefficient (icc) was calculated. at this stage, the items in each domain were examined, and the responses to some items were reversed so they would be aligned in each domain. cronbach’s alpha coefficients were obtained for each item, and in order to estimate intra-class correlation, the total score for each domain was evaluated. ten items that were in line with the objectives of the research were not categorized in any of the domains because they were presented as single questions and were not related to other items in different sections of the questionnaire. cronbach’s alpha was therefore not obtained for such items, and only the reliability coefficient based on intra-class cluster correlation was calculated. spss software version 20 was used for data analyses. the final version of the questionnaire was constructed in three parts. the first part a study of the validity and reliability of the questionnaire … 6 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 2 march 2019 provided definitions of medical error, its types, and issues pertaining to medical error disclosure, the second part included items related to the three domains of medical error, and the third presented demographic information. ethical considerations this study and the accompanying questionnaire were approved by the ethics committee of tehran university of medical sciences before they were completed by the physicians in the test-retest step (ir.tums.vcr.rec.1395.1535). participation in the study was entirely voluntary. results the final version of the questionnaire in the second part comprised 36 questions categorized in three domains (table 3). table 3domains of items in the medical error disclosure questionnaire domain number of items number of items in subdomain physicians’ practices in dealing with medical errors 9 22 disclosure 1. medical error disclosure (either it was committed by the physician or other colleagues) 2. medical error recording and reporting 7 2 11 2 manner of medical error disclosure 8 8 items with no categorization 10 10  number of questions or items in each domain. some questions or items investigated two or three parameters (subdomains). for example, the physicians were asked, “have you committed a medical error within the past 6 months?” about three types of errors, that is, serious (major), no harm (minor) and near-miss.  the sum of these parameters (subdomains) is presented in the second column. given that in the questionnaire, medical errors were investigated from several aspects, each domain was separately evaluated in the validity and reliability tests. in the content validity phase, the participants consisted of 10 ethicists (all physicians) and 10 specialists. the results of the study showed that the relevancy and clarity of each item (i-cvi) was at an acceptable level (above 80%), as can be seen in table 4. the overall relevancy and clarity of the instrument, with an average approach, were measured to be 97.22 and 94.03 percent, respectively (s-cvi). the comprehensiveness of the instrument was also excellent (100%). it should be added that three questions had to be improved in terms of language with content preservation. mohammadi m., et al. 7 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 2 march 2019 table 4the relevancy and clarity of each item in the medical error disclosure questionnaire clarity relevancy item no. i-cvi the number of observed agreements i-cvi the number of observed agreements 95 19 95 19 1 95 19 90 18 2 95 19 100 20 3 95 19 100 20 4 100 20 100 20 5 100 20 95 19 6 95 19 95 19 7 80 16 95 19 8 95 19 100 20 9 90 18 90 18 10 95 19 95 19 11 95 19 100 20 12 95 19 100 20 13 95 19 95 19 14 90 18 95 19 15 90 18 100 20 16 90 18 95 19 17 95 19 95 19 18 85 17 100 20 19 95 19 95 19 20 100 20 100 20 21 95 19 95 19 22 100 20 100 20 23 100 20 100 20 24 95 19 95 19 25 100 20 100 20 26 100 20 100 20 27 95 19 95 19 28 85 17 90 18 29 85 17 95 19 30 95 19 100 20 31 95 19 100 20 32 95 19 100 20 33 90 18 100 20 34 95 19 100 20 35 95 19 100 20 36 a study of the validity and reliability of the questionnaire … 8 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 2 march 2019 in the test-retest phase, participants included 12 men and 8 women (9 general practitioners and 11 specialists). participants’ ages ranged between 35 and 60 (44.85 ± 8.25) years, and their mean period of practice was 15.35 ± 8.86 years. the results were satisfactory in all domains of the questionnaire (cronbach’s alpha: 0.70 0.79). the range of icc for the items in the domain of “physicians’ practices in dealing with medical errorˮ was 0.76 to 1.00, and that of “medical error disclosure (either it was committed by the physician or other colleagues)” was 0.79 to 0.98. icc ranged between 0.87 and 0.95 for the items in the domain of “medical error recording and reporting” and between 0.87 and 0.97 for the items in the domain of “manner of medical error disclosure”. table 5cronbach’s alpha coefficients and test-retest reliability of items in three domains of the medical error disclosure questionnaire domain cronbach's alpha icc¶ icc range physicians’ practices in dealing with medical errors 0.76 * 0.76 1.00 disclosure 1. medical error disclosure (either it was committed by the physician or other colleagues) 0.74 0.95 0.79 0.98 2. medical error recording and reporting 0.79 0.92 0.870.95 manner of medical error disclosure 0.70 0.72 0.87 0.97 items with no categorization * 0.90 1.00 ¶ intra-class correlation coefficient * since the icc could not be calculated in the domain of practice due to the lack of scores for each item and, consequently, there was no total score, the icc of each item was separately calculated twice (test-retest), in which correlation of all items exceeded 0.7. pearson's correlation was performed for each item and was higher than 0.7. table 5 presents the values of cronbach’s alpha coefficients and test-retest reliability in each domain of the questionnaire. the values of cronbach’s alpha coefficients and the test-retest reliability of each item are demonstrated in table 6. at this point, the appropriateness of the final version of the questionnaire was confirmed considering the acceptable results of the statistical tests. mohammadi m., et al. 9 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 2 march 2019 table 6the icc¶ and cronbach’s alpha of each item in the final version of the questionnaire # items icc of each item cronbach's alpha if item is deleted 1 have you committed a medical error within the past 6 months? 0.92 0.77 2 have you noticed a medical error by your colleagues over the past six months? 0.99 0.71 3 have you ever disclosed a major medical error to your patients? 0.96 0.74 4 have you ever disclosed a minor medical error (no harmful event) to your patients? 0.98 0.78 5 have you ever apologized for your medical error? 1.00 0.78 6 have you ever been sued for a medical error by a patient who has been notified of the error through sources other than yourself? 1.00 0.75 7 have you ever been sued for a medical error by a patient after you informed him/her of the error? 0.97 0.72 8 have you ever recorded your medical error? 0.93 0.69 9 have you ever reported your medical error to your organization? 0.76 0.65 10 what percentage of patients do you think may complain about their physicians when they are informed of a medical error through sources other than their physicians? 0.99 * 11 what percentage of patients do you think may complain about their physicians after error disclosure by the physicians? 0.99 * 12 to whom should a medical error be disclosed? 0.99 1.00,* 13 who should disclose the medical error to the patient? 1.00 1.00,* 14 in general, it is ethically necessary to disclose a medical error to a patient? 0.95 0.34 15 in general, it is ethically correct to disclose a colleague’s medical error to his/her patient? 0.95 0.75 16 in general, it is ethically correct to document a medical error (committed by yourself) in the patient’s medical record? 0.94 0.61 17 in general, it is ethically correct to report a medical error (committed by yourself) to your organization? 0.87 0.67 18 in any circumstance, the physician must inform the 0.79 0.85 a study of the validity and reliability of the questionnaire … 10 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 2 march 2019 patient of his/her medical error. 19 talking honestly and frankly about an error that i committed is acceptable in my workplace. 0.92 * 20 error non-disclosure must be reasonably justified and approved by an impartial individual or group (for instance the ethics committee). 0.95 * 21 if the patient does not become aware of a medical error, it is not necessary to disclose it to him/her. 0.96 0.58 22 it is not mandatory for the physician to disclose the error until the patient inquires about it. 0.92 0.60 23 error disclosure to the patient should be made sincerely, honestly, and with a regretful expression. 0.88 0.64 24 error disclosure should be made with an explanation of this preventable event, error-induced damage, prognosis and possible treatments. 0.95 0.67 25 the physician should apologize to the patient and assure him/her that the same error will not occur to another patient in the future. 0.97 0.76 26 details of medical error disclosure to the patient must be documented. 0.87 0.68 27 it is not necessary to disclose the error to the patient, but his/her treatment should be carried out/continued by the physician until complete resolution of the errorinduced complications. 0.92 0.66 28 it is not necessary to disclose the error to the patient, but the physician must bear the costs of treatment for the medical error. 0.97 0.72 29 until the judiciary condemns the physician to pay compensation (diyah) for the damages, such costs should not be paid by the physician. 0.94 * 30 if a colleague commits a medical error, we should ask him/her to inform the patient. 0.92 0.68 31 if our colleague fails to disclose his/her error to the patient and we are aware of it, we should disclose the major medical error to the patient. 0.91 0.63 32 avoiding colleagues’ error disclosure might jeopardize the medical profession and dignity of the medical community. 0.97 0.66 33 physicians committing errors repeatedly should be referred to competent authorities by their peers to resolve the issue. 0.96 0.74 34 medical errors and the underlying reasons should be discussed with peers in order to devise strategies to minimize their occurrence 0.83 * mohammadi m., et al. 11 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 2 march 2019 35 medical errors and the underlying reasons should be analyzed by managers and physicians in order to devise strategies for their reduction. 0.88 * 36 identify three main reasons for medical error nondisclosure to the patient. 0.9 1.00 * ¶ intra-class correlation coefficient * items with no categorization  kappa coefficient was calculated for these items. discussion the need for a valid and reliable questionnaire to explore the practices of iranian physicians and their colleagues in dealing with medical errors, especially disclosure and the manner in which it is conducted, as well as the related ethical issues urged us to conduct the current study. the existing questionnaires have only addressed some aspects of medical error and its disclosure. in a study conducted in turkey on 652 members of a general hospital medical staff during 2010, cronbach’s alpha coefficient for the participants’ attitude toward medical errors was 0.66 (28). they had used a questionnaire with 16 items in three domains of ‘perception of medical errors’, ‘approach to errors’, and ‘reasons for errors’. over 50% of the questions overlap with those in our study, although we also explored their history regarding committing medical errors, error disclosure, recording and reporting, as well as physicians’ attitudes toward medical errors, manner of disclosure, and physicians’ approach to their colleagues’ errors. moreover, our instrument showed a higher validity and reliability compared with their study (28). in another study by kim et al., healthcare professionals’ attitudes toward teamwork and safety in south korea were explored. a part of their questionnaire deals with medical errors, and there are two sections entitled ‘error/procedural compliance’ and ‘error management’ consisting of 11 items. these items examine participants’ attitude toward the nature of medical errors, the causes, the approach of institutions and other physicians to medical errors, committing medical errors, and prevention of their recurrence. in comparison with our more comprehensive questionnaire, they only used a small number of questions in a limited number of domains, and the cronbach’s alpha coefficients for ‘error/procedural compliance’ and ‘error management’ were 0.212 and 0.156, respectively (29). in their study on 831 physicians in 2002, blendon et al. used a 29-item questionnaire that addressed issues such as medical error experience (errors made in their own or their family members’ care), the frequency and causes of medical errors, and the effectiveness of possible error-reduction strategies. some of their questions overlap with those of our questionnaire, but they did not address the physicians’ attitudes toward a study of the validity and reliability of the questionnaire … 12 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 2 march 2019 medical errors, manner of disclosure, and the approach to colleagues’ errors (30). in iran, there have been few studies on medical errors and design of an appropriate questionnaire in this regard, and we found none that focused specifically on the validity and reliability of such a questionnaire. moreover, all existing literature overlaps with certain sections of the present study. thus, our attempt was to design a valid and reliable questionnaire to measure medical error disclosure and related issues. in a 2013 study by tagaddosinejad et al. in iran, a questionnaire containing 20 questions was used. the questionnaire examined the occurrence of medical errors by physicians and their attitude toward disclosing the types of medical errors to patients, reporting medical errors to authorities and colleagues, prosecution following disclosure of medical errors to patients, and the reasons for nondisclosure of errors by physicians. in this study, medical errors were categorized as major, minor and near-miss errors. the items related to the rate of occurrence of medical errors in our questionnaire are similar to those of tagaddosinejad et al., although we only investigated the six previous months. our study also examined physicians’ attitudes toward the manner of medical error disclosure and their colleagues’ errors, which have not been addressed in the study by tagaddosinejad et al. (31). our findings are in line with some studies that obtained similar icc and cronbach’s alpha values. in a 2011 study about medical errors conducted on 80 iranian general practitioners in the city of zabol, at the testretest stage, the correlation coefficient was 0.80 (32). this questionnaire consisted of 19 questions, which evaluated the rates, types and preventive factors of medical errors, physicians’ attitudes toward them, and the factors involved in their non-disclosure. in our study, aside from medical error preventive factors, other issues were evaluated, and along with the manner of medical error disclosure, the approach of physicians in dealing with their colleagues’ errors was also taken into account. in a pilot study about medical error disclosure on 273 medical residents and interns in kerman university of medical sciences, the reliability of the questionnaire calculated by cronbach’s alpha was 0.80. this study examined the medical error experience, the type of error (major, minor, or near-miss), the reasons for concern about medical error disclosure, and the attitude of the participants toward medical errors (33). our study examined all of the above issues more extensively and had other aspects, as discussed earlier. another study on the subject was conducted by ghalandarpoorattar et al. on 53 faculty members and residents of hospitals affiliated to tehran university of medical sciences. it investigated the physicians’ attitudes toward two types of major and minor medical errors, the level of willingness to disclose errors, effects and barriers pertaining to error disclosure, and participants’ practices regarding their own errors. despite similarities in the general topics, in the study by ghalandarpoorattar et al., the questions in each domain differed from those in our mohammadi m., et al. 13 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 2 march 2019 study, and they reported no reliability testing (34). thus, the various questionnaires used in the above-mentioned studies only partially investigated our intended points of the issue, which justifies our construction of the present questionnaire. however, we do not claim that our instrument is a comprehensive questionnaire covering all aspects of medical errors, although it can be useful in investigating the status of medical errors, particularly ethical considerations. medical error recording and reporting systems, whether in paper or electronic form, and with either optional or compulsory approaches to document, follow up, and manage errors, are supposed to prevent their reoccurrence. although the guideline for management of this adverse event has been communicated to medical universities, there is currently no system for recording or reporting errors in iran, so the incidence of medical errors is relatively unknown. therefore, this questionnaire may not only be helpful in measuring the incidence of medical errors, it can also be used to investigate other factors related to medical errors, including physicians’ attitudes toward dealing with errors and their disclosure, and the manner in which they are disclosed. none of the available questionnaires could simultaneously examine these issues, and to use related questionnaires in international studies, localization and psychometrics of the instruments needed to be performed. in conclusion, awareness of physicians’ attitudes toward medical errors through identification of the strengths and weaknesses will assist policy makers and healthcare managers in planning to enhance physicians’ professional skills to improve relationships. it can also improve the quality of health care provision and support patient autonomy, and develop and maintain trust in the patient-physician relationship. thus, a valid and reliable questionnaire is necessary to explore the status of medical errors by physicians, their approach in dealing with such errors, and their attitude toward medical error disclosure. acknowledgements the present study was part of a thesis submitted by the first author for a phd degree in medical ethics and was funded by tehran university of medical sciences. the authors are grateful to all the medical ethics professors and physicians for their valuable participation in this study. we would also like to express our gratitude to the technical support staff of tehran university of medical sciences, and we are grateful to ms. m. hassanpour for editing the manuscript. conflict of interests all authors declare that they have no significant competing financial, professional, or personal interests that might have influenced the performance or presentation of the work described in the manuscript. a study of the validity and reliability of the questionnaire … 14 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 2 march 2019 references 1. pinto a, brunese l, pinto f, reali r, daniele s, romano l. the 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[in persian] 34. ghalandarpoorattar sm, kaviani a, asghari f. medical error disclosure: the gap between attitude and practice. postgrad med j. 2012; 88(1037): 130-3. journal of medical ethics and history of medicine iranian nurses' perception of spirituality and spiritual care: a qualitative content analysis study gholamreza mahmoodishan 1 , fatemeh alhani 2* , fazlollah ahmadi 3 , anoshirvan kazemnejad 4 1.phd nursing student, faculty of medicine, nursing department, tarbiat modares university, tehran, iran. 2.associate professor, faculty of medicine, nursing department, tarbiat modares university, tehran, iran. 3.associate professor, faculty of medicine, nursing department, tarbiat modares university, tehran, iran. 4.professor, faculty of medicine, biostatistics department, tarbiat modares university, tehran, iran. *corresponding author: fatemeh alhani address: nursing department, medical sciences faculty, tarbiat modares university, jalal al-ahmad street, tehran, iran. postal box: 14115-331 tel: (+98) 21 82 88 38 98 e-mail: alhani_f@modares.ac.ir received: 03 sep 2010 accepted: 02 oct 2010 published: 20 nov 2010 j med ethics hist med. 2010; 3:6. © 2010 gholamreza mahmoodishan et al.; licensee tehran univ. med. sci. abstract keywords: evaluation, content analysis, nurses' spirituality, spiritual care, nurses' lifestyle. introduction spirituality is particularly an intangible (1), highly subjective and multidimensional concept (2) manifested in the human lifestyle (3). it is recog nized as a key to people health. it has been adopted by the world health organization (who) as a principle of promoting health (4). there is no consensus on the definition of spi rituality (2, 5, 6), but it is generally agreed that spirituality is a highly subjective, personal, and the purpose of the present study was to explore nurses’ perception about spirituality and spiritual care. a qualitative content analysis approach was conducted on 20 registered nurses interviewed using unstructured strategy in 2009. three themes emerged from the data analysis: 1) “meaning and purpose of work and life” including ‘spiritualistic view to profession’, ‘commitment and professional responsibility’, and ‘positive attitude’; 2) “religious attitude” including ‘god approval’, ‘spiritual reward’, ‘taking advice’, ‘inner belief in the supreme being’, ‘faith-based interactions and altruism’; 3) “transcendence-seeking” including ‘need for respect’ and ‘personal–professional transcendence’. therefore, the spirituality produces maintenance, harmony and balance in nurses in relation to god. spiritual care focuses on respecting patients, friendly and sympathetic interactions, sharing in rituals and strengthening patients and nurses’ inner energy. this type of spirituality gives a positive perspective to life and profession, peaceful interactions, a harmonious state of mind, and acts as a motivator among nurses to promote nursing care and spirituality. j med ethics hist med 2010, 3:6 gholamreza mahmoodishan et al. page 2 of 8 (page number not for citation purposes) individualistic concept. integrative reviews of spirituality concept analysis have identified some themes such as meaning, purpose, connectedness, relationship, transcendence, hope, existential experiences, power, force and energy (7). spirituality and religiousness are two separate concepts (2), but they are used interchangeably (8). many authors identified a fusion between spiri tuality and religiosity (9). it is suggested that spirituality can be seen as the summation of our values, which determines the process of how we interact with the world; whereas religion is seen as a pathway to follow practices and thoughts that are appropriate to god or gods of a particular faith (10). while spirituality may be related to religion for certain individuals, for others it may not be; for example, the spirituality of an atheist or an agnostic may be centered on a strong belief in significant relationships, self-chosen values and goals instead of a belief in god (8). in addition, spirituality has rarely been dis cussed from nurses' perspectives (11-13). mc sherry et al. interviewed 12 nurses in a study. they described spirituality as a universal concept that applied to both religious and non religious matters and a force that permeated every aspect of their life and human being (14). the concept of spirituality depends on cul tures and beliefs that are important in the under standing of meanings and dimensions of spirituali ty. hence, it is essential to accomplish a qualitative investigation in regard to nurses’ spirituality views. consequently, the findings clarify the themes and may help in the promotion of spiritual nursing care in the concerned context. it also helps to develop spiritual conceptions for nurses and spiritual care. nurses' spiritual needs at work spirituality is important to staff nurses. it can be used as an intervention strategy and a supportive force at work and in the care of clients (12). nurses are exposed to many stressors related to the workplace such as work overload, rotating shifts, high work demands, conflict at work, sudden death, unexpected and rapid changes in patients’ conditions, patients’ violence and daily physical and verbal abuse that may lead to physical and psychological problems (15, 16). ebadi et al. suggested that spirituality is a coping method which could be a source of comfort, strength and support during stress (17). hence spirituality helps nurses by harmonizing and balancing their inner resources (17, 18). spittles found that maintaining a spiritual practice clearly enhances physiological, psycholog ical, intellectual and creative functioning. it was correlated with improved work performance, improved relations with coworkers and supervisors, increased work satisfaction and decreased turnover propensity (19). nurses’ perception of spirituality can directly affect how they behave, how to deal with their patients and how to communicate with them in regard to the provision of spiritual care (18). according to the literature, nurses' knowledge about their own religious, spirit, and attention to such needs are limited and further research about religious and spiritual aspects in different cultural contexts is needed (20). the suggestion that nurses ought to explore their own spirituality has also been made by many authors. being in touch with one’s own spiritual dimensions may be the first step in being able to recognize and support the spiritual nature of the others (21). although some nurses are willing to pay attention to patients' spiritual needs, there is lack of agreement in nurses' interpretation of spirituality and spiritual care (18). therefore, the extension of knowledge of spirituality in different cultural contexts should be explored. moreover, the interpretation and understand ing of spirituality among iranian nurses may not be similar to other cultures, because of differences in nurses’ background and clinical context. therefore, the purpose of this study was to explore nurses’ perception of spirituality and spiritual care. iranian background iran is a religious (muslim) society (10) and, the majorities of nurses are muslim and believe in god. almost 2% percent of iranians belong to the religions of judaism, christianity, zoroastrianism, etc, who believe in god as well. although the majorities of nurses have ac cepted the spirituality as a valuable element in their lifestyle, there are a few studies on nurses’ percep tion of spirituality and spiritual care for patients in iran, which one of them reported that nurses ordinarily spent their time for managing their routine tasks and performing religious activities (22). method this qualitative study was a part of an exten sive investigation about nurses’ lifestyle by using conventional content analysis approach. qualitative content analysis is the analysis of the content of narrative data, and it is a flexible method to identify prominent subthemes and patterns among themes (23, 24). at the conditions of lack of enough knowledge about a phenomenon (such as spirituality) or knowledge fragmentation, the inductive approach is recommended (24) in order to explain and interpret the data and elaborate the dominant and major themes of participants’ experiences (25). http://www3.interscience.wiley.com/cgi-bin/fulltext/118598301/main.html%2cftx_abs#b9 j med ethics hist med 2010, 3:6 gholamreza mahmoodishan et al. page 3 of 8 (page number not for citation purposes) setting and participants the participants were selected by purposeful sampling because it was suitable for conducting a qualitative study. the participants were registered nurses; (14 female and 6 male). the majority of them (45%) aged between 25 and 35 years old. they had the experience of working as nurses from 3 to 29 years in different hospital wards. all of participants were muslim. the study was carried out in 2009 in iran. data gathering was done in three teaching hospitals in gorgan city (iran). the interview was carried out in free and relaxed environment according to nurses’ preferences (in hospitals). data collection was continued until no new data was gathered, and the researchers reached to the point of saturation. data collection unstructured interviews were conducted as the data gathering tool. the major foci of the questions were “can you explain the spirituality in your professional lifestyle?” the interviews lasted between one and half an hour in average. some participants were interviewed twice, (in two separate parts, in order to improve the depth of data gathering). it means that according to the findings, the next interview was carried out to the point of completing the data. the total number of partici pants was 20 nurses, but totally, 24 interviews were performed. the first participant was selected by the hospitals’ supervisors in order to facilitate the selection of the participants followed by using snow ball method for selecting the nurses. the maximum variation of sampling was considered with the participants’ gender, age, nursing expe riences and nursing wards. the interviews were subsequently tran scribed, read, re-read, and analyzed by the team of researchers. ethical considerations the study was approved by the research council of medical sciences faculty, tarbiat modares university, which corroborated its ethical consideration. the study ethical considerations were anonymity, informed consent, withdrawal from the study, and recording permission. prior to the study, the nurses were informed verbally about the aim of the study. it was mentioned that they could withdraw from the study at any time without being penalized. then informed consent was obtained from the nurses who willingly participated in the study. to protect the privacy, confidentiality and the identity of the participants, interviews were conducted only with the participation of the interviewer and the interviewee. data analysis the interviews were recorded on tapes. the interviews were subsequently transcribed, read, re read, and analyzed by the research team. the overt and covert messages and transcribed texts were analyzed by qualitative content analysis approach. the approach focuses on subject and context, differences and similarities within categories and themes (26, 27). inductive content analysis was made in dif ferent steps. at first, the content of each interview (the text) was repeatedly read to obtain an overall understanding of the data and to gain ideas for further analysis. then all the texts were divided into meaning units (each one containing several words, sentences and phrases) related to the aim. then the meaning units were condensed into open coding (26, 28). the data was organized in the next step. this process included open coding [notes and headings were written in the text while reading it (extracted from meaning units)], and creating categories and themes. the written text was read through again, and as many headings as necessary were written down in the margins to describe all aspects of the content. the headings were collected from the margins onto coding sheets and categories were generated at this stage (24). the lists of categories were grouped under higher order headings. categories were grouped as main categories or themes. the purpose of creating categories was to provide a means of describing the phenomenon, to increase understanding and to generate knowledge (28, 29). at this stage, we obtained 11 sub-themes and three final themes. all researchers were engaged in the process of analyzing and synthesiz ing the data. throughout the entire analysis process, subcategories, categories and themes were compared with the original texts until consensus among all authors was attained. therefore, the total process of analysis was briefly carried out as transcribing each interview, and dividing it into meaning units, open coding, subcategories and themes (table 1). credibility of the data was established through member checking. the report of the analysis was given to the participants in order to get assurance that the researchers were presenting their ideal worlds. in addition, nursing faculty members performed member checking of the transcripts, subcategories, and final categorization or themes. maximum validation of sampling helped to establish dependability and credibility of the data. results three themes emerged from the data analysis: 1) “meaning and purpose of work and life” j med ethics hist med 2010, 3:6 gholamreza mahmoodishan et al. page 4 of 8 (page number not for citation purposes) including ‘spiritualistic view to profession’, ‘commitment and professional responsibility’, and ‘positive attitude’; 2) “religious attitude” including ‘god approval’, ‘spiritual reward’, ‘taking advice’, ‘inner belief in the supreme being’, ‘faith-based interactions and altruism’. 3) “transcendence seeking” including ‘a need for respect’ and ‘personal–professional transcendence’. meaning and purpose of work and life this theme consisted of three sub-themes (table 1). spiritualistic view to profession this sub-theme involves affective-spiritual responses of the nurses to caring, acceptance of nursing as a sacred profession and effect of the job on their lives. the participants described nursing as a divine blessing. a participant said: "nursing is an effective job, a spiritual job; actual nursing is very difficult, but, i think it is a divine blessing; i don't suppose that it is only a job." [nurse 2] another one said: "in my opinion, spirituality is the foundation of nursing; i selected this profession due to the spiritual issues." [nurse18] commitment and professional responsibility according to the nurses' views, they are re sponsible to god for their practices. they believe that someone who is religious should work exactly, carefully and correctly. according to a participant: "however, the individuals who are more faithful and believe in god should be more responsible for the client, because they are god-fearing and don't want bad things to occur to god's creatures." [nurse15] therefore, they believed that the spirituality is a kind of internal commitment. the internal commitment is related to god or conscience. "i always remember i must work in a manner that reveals my commitment to the people."[nurse 17] ″i'm responsible to god about the patient's life. so, i suppose to be responsible to god in the future life.″ [nurse 3] positive attitude (positive view) positive view was the other sub-theme men tioned. a participant said "i attempt to have a positive view in my life, i think positive to what occurs to me. my ward was changed, now i am working in a new one, it is better to me. i think the chief nurse in the new ward will be match with me." [nurse 16] another one said "i have a good life; i think it is due to my job, i always attempt to resolve patients' problems" religious attitude this theme contains six sub-themes: god approval (approval of the spirituality) god approval is based on the personal prac tice (behavior) and naturally depends on individu al's behavior, honest working, and ritual practice for clients and so on. a participant said: "i made an effort to do my duty honestly for god approval; furthermore, it may increase my supervisors respect. i work so hard, but my intention isn't to enjoy the attention or encouragement of the supervisor at all, rather i want to gain god approv al." [nurse 3] also, they supposed nursing equal to worship, so a participant said: "now, i am happy; that is, if i get another job offer, i will certainly prefer nursing as my job. i always give thanks to god." [nurse 2] although nurses are facing with many problems, he still has a tendency to remain in the job. another one said," i always say a sentence of allameh tabatabaie (a philosopher and worshipper scholar) to my colleagues, who said, “i never exchange the value of taking care of a patient during a night with seventy years of worship“; it means how worthy and important nursing care near god is." [nurse 17] "the nurse needs to be patient to gain god approval." [nurse 16] spiritual reward the nurses stated that they will be rewarded in different ways by god which consists of being helped in life in secret and so on. a participant said: "it has been ascertained that everybody who performs his/her duty very well, god does not bring loss to him and helps him." [nurse 6] "when i am working honestly for patients and people, obstacles in my life will be removed; god will help me in many circumstances." [nurse 2] taking advice this subtheme focused on advice in relation to the patients' problems. nurses observe patients' problems, then, they will perceive the value (importance) of health and conclude that health is a gift of god. therefore they must be thankful of god and attempt to protect health. "you know that these events may occur to you –it is easy for god-; therefore, you will attempt to understand and find out the power of god and spirituality in these events." [nurse 7] inner belief in the supreme being some of the nurses believed that internal mo tivation with religious context is helpful in caring for patients. "the religious beliefs have created a situation in which i do my duty well. i became more responsible for patients" [nurse 4]. according to nurses' opinions, the supreme being permanently supervises over everyone's j med ethics hist med 2010, 3:6 gholamreza mahmoodishan et al. page 5 of 8 (page number not for citation purposes) actions. although, they try to help recovery of the patients, but results depend on the willing of god. "i do care for patients, i use all of my power to care, but the results depend on god’s willing, ultimate healing comes from god." [nurse 7] "i do my duty, because i know there is a per manent supervisor. he (god) pays attention to me all the time …" [nurse17] thus, the belief that there is a kind of supervi sion over human beings everywhere and every time produces a confidence and precision in performing one's duty. faith-based interactions the participants said that nurses interact with patients, families and others in a friendly manner, but those nurses who are religious and prayerful, interact in a more friendly and sympathetic manner. one participant said: "the nurses that are religious and prayerful are better in practice and behavior toward patients." [nurse 2] another nurse said the following about faith-based relationship: "i communicate friendly with my colleagues and patients’ family. i like ill persons as much as i like my family members; i attempt to have a sympathet ic relationship. of course, the relation of a nurse with a patient depends on his/her nature and beliefs.” [nurse 7] praying is usual in the community and clients would like to pray when encountering problems, but most of the time, it is impossible in the ward. therefore, the nurse as a providing spiritual care says: "i prefer to keep the ward quiet, so i could talk with my patients about themselves and their problems. i like to pray with the patients altogether on friday night. this brings calmness to the patient and me.” [nurse 14] altruism the last subtheme was altruism. a nurse said "it must be done as an affair, an action that you are able to do, because the patient is a trust (and the nurse is a trustee). therefore you must do your duty honestly.” [nurse 15] the patient is a human, i like all people, therefore, if i am permitted, i would work to the utmost within my ability." [nurse 7] this subtheme is a general view, but it is im portant and prominent in the nurses’ spirituality. a participant said: "the nurse must love patients. he/she must know that the patient, who is the present client, as a human needs support and help." [nurse 8] "you must spend energy and time, you must honestly work for a man (human) and spend time to save him/her…i think working for an ill person, an elderly, is worship, and induces a good feeling." [nurse 19] transcendence seeking the third theme has two subthemes: a need for respect feeling transcendence influences the interper sonal interactions, personal quality of working, mental and spiritual calmness. a participant said: “i attempt to have a good communication with my colleagues. interpersonal respect is very important to me." [nurse 15] personal –professional transcendence nurses work in a dynamic environment. they learn and achieve new professional experiences and knowledge. that leads to personal–professional excellence. a nurse said: “i always try to learn everything, do all works …, this produces a good feeling in me." [nurse 3] also a nurse who was eager to self develop ment said "from the scientific viewpoint, i always study, i teach students, and i participate in instruc tion and clinical education." [nurse 18] discussion in this qualitative study, the participants were muslim nurses. in general, iran is almost a reli gious society; therefore, a usual person performs religious rites. moreover, there were no non muslim nurses in the hospitals in this study. however, three themes emerged that is disputable. the first theme was meaning and purpose of work and life. it consisted of three subthemes. one of them was spiritualistic view to profession. according to the participants, nursing was an effective job and a divine blessing. naturally, this view of nurses caused honest and satisfactory delivering of services to patients. moreover, such a nurse would tolerate the difficulties in caring and role performance. his/her mood would not quickly deteriorate due to complaints. it seemed that spirituality was an obstacle to relinquishment of job for the mere reason of a high level of stress. when a nurse assumes nursing as a "divine blessing" then he/she keeps his/her calmness and copes with problems. rays and mcgee stated that spiritual health organizes values, relationships, meaning and purpose of our lives (12). moreover, spirituality provides a personal sense of meaning and life purpose, which is not confined to the beliefs and practices of a particular religion (18, 30). however, spirituality can play a positive role in coping with changes and life-altering events (12). also, it is argued that spiritual needs are met through the individual’s relationship with god, and we are still far from having a universal agreement as to what is meant by the concept of spirituality; also, it is argued that spirituality is possible without the concept of god (31). the second sub-theme was responsibility. the nurses were responsible for the patients, but they were basically responsible to god. they would be j med ethics hist med 2010, 3:6 gholamreza mahmoodishan et al. page 6 of 8 (page number not for citation purposes) audited ultimately in this world and the next world. this perspective induces nurses self control at work and in life. however, the spirituality and religion have been mixed by nurses life, so that, all of the nurses’ intentions and functions are to gain god approval and, consequently, patients satisfaction. therefore, the more faithful nurse is the more responsible to patients. spirituality is important to staff nurses. it in creases quality of work and care of clients (12). religion provides the content for spirituality. it shows us the character of god, the meaning of life, and how we are to live (7). the second theme was religious attitude. in this theme, god approval and spiritual satisfaction was related to the individual's behavior such as honest working, ritual activities for clients and spiritual satisfaction that provided enjoyment and calmness for the nurses. the nurses who believed nursing is equal to worship of god, sought god approval and their own enjoyment. the nurse, patient and community would benefit from this belief. so that, the iranian philosopher “tabata baie" had said about the reward of a night caring for a patient near god: "i never exchange the value of taking care of a patient during a night with seventy years of worship"; this indicates that patient care is very valuable. hence, a nurse that has achieved such a belief undoubtedly cannot be affected much by problems of the work and daily life. they are less involved in disharmony or mental disorder. but they would be happy, fresh and pleased with their work. wong et al. stated that for christians and muslims, spirituality is directly related to religion (18). nurses' perception of spirituality can directly affect how they behave, how to deal with their patients and how to communicate with them in regard to the provision of spiritual care. he or she listens to a patient's spiritual thoughts and concerns with spiritual feelings. spiritual reward was a subtheme. according to islam, god is free of need but he donates reward in this world and the next world to someone who gives service to humans (32). the participants believed that positive and good events in their life had been due to their compassion and honesty. god helps everyone who is beneficent. this idea prevents from any damage to clients even though the boss neglects employees' rights. of course, a nurse must be praised by head nurse or supervisor when he/she tries truthfully. another subtheme was "to take advice" from events. however, the nurses could not completely control occurrence of the events and sickness. a nurse, who believes in a divine entity, supposes that many calamities and illnesses do not come to him/her because of god's kindness. that is, if someone is ill, it may happen to everyone. then a nurse must be grateful of god that he/she is healthy and does not suffer from illness. someone, who is conscious of the human life, will take advice for correction and improvement of his/her life. tongprateep found that the beliefs shaped patterns of thinking and practices in daily life. the participants believed that good or evil actions are related to cause some effects not only in the present life but also in the future life. they hoped that, if they accumulated meritorious acts in their lives, they would get good results both in this life and the future life (33). inner belief in the supreme being, one of the subthemes, is necessary for action; because it is a motivator and produces energy for performing. indeed, inner belief must be present for the sense of spirituality. also, according to participants, inner belief leads to more responsibility. the belief in the presence of the supreme being and a permanent supervisor helps nurses to have a supportive power that everything depends on his/her willing. "ulti mate healing comes from the almighty". thus, the belief that there is a kind of supervi sor everywhere and every time produces confi dence in nurses. pesut et al. stated that spirituality, for us, be gins with recognizing god, whose spirit infuses and sustains all creatures, but who has the capacity to exist independently of the creation. the charac ter of god is what dictates the ideal life. we agree that spirituality is a form of power but, its origin is located within the almighty. daily, we make choices that bring our power closer to or further away from that character of goodness (7). altruism was another subject and since partic ipants were muslims, it is necessary to identify human value in islam. human is the highest creature in the world. according to islam, human is a great, valuable entity and very important (32). hence, a nurse is responsible for care of such an entity. if a nurse loves god, he/she will love this highest creature as well. a nurse is responsible for human care. the participants mentioned that "the patient is a trust, the patient is a human, i like all people, i love patients." these statements indicated that the humans are very important for nurses. therefore, they honestly spend energy and time to save them. the third theme was transcendence-seeking with two subthemes. basically, increasing the human excellence enhances spiritual feeling. doing honor and respecting others and ourselves is a virtue that is related to human spirituality. a nurse, willing to achieve new experiences, skills, and knowledge, gets away from stagnation; conse quently, he/she excels in life and at work. it seems that these help growth of spirituality in nurses. also rays and mcgee stated that self development helps nurses in feeling well about j med ethics hist med 2010, 3:6 gholamreza mahmoodishan et al. page 7 of 8 (page number not for citation purposes) themselves (12). it is a way that promotes human fulfillment (18). finally, while the findings of some investiga tions indicate that spirituality is related to religion, but some others do not agree. for example, they focus on the purpose of life. in this study, "profes sional commitment and responsibility related to god" and "god approval (spiritual satisfaction)" were the new sub-themes that were not present in other studies. both themes lead to a harmonious state of mind in nurses and peaceful interactions with others. conclusion spirituality is a dimension of human health. in this survey, the connection between the concepts of spirituality to religious believes was found. the spirituality produces maintenance, harmony and balance in nurses in relation to god approval and inner belief in the supreme being. this type of spirituality creates a positive perspective in life and profession, peaceful interactions, harmonious state of mind in all situations and connectedness with god. under the religious and, consequently, spirituality influence, the nurses are motivated to deliver care, especially spiritual care. therefore, professional problems and adversity would be sustainable and acceptable to nurses. spirituality prevents from abandonment of job. therefore, according to the nurses' view, spi rituality is meaning and purpose of life, honest care of patients, attainment of god approval and patient’s satisfaction, and attempt to achieve transcendence. also, spiritual care focuses on respect for patients, friendly and sympathetic interactions, sharing in rituals and strengthening patients and nurses’ inner energy. spirituality in nurse's lifestyle has also impli cations for the nurse him/herself, other healthcare providers and ultimately people as clients, probably other muslims or other people who believe in god. it is necessary to investigate in different cultures and beliefs throughout the world to identify similarities and differences and, ultimately, establishing local and general models to recom mend proper behavior. acknowledgement this manuscript extracted from phd thesis that supported financially by tarbiat modares university faculty of medical science. the authors are grateful to all who helped in conducting the present study. table 1: the trend of condensation-abstraction process for themes (sample) meaning units (instances) open coding (condensed meaning units) subcategories (sub-theme) main catego ries/ themes “truthful nursing is very difficult. i think it is a divine blessing, i don't suppose it is only a job” [nurse 2]. nursing is a divine blessing spiritualistic view to profession m e a n in g a n d p u rp o se o f w o rk a n d l if e “i've got a job and i'm responsible for the patient's life. so, i suppose to be responsible in the other world” [nurse 3]. feeling of commitment and responsibility to god. professional commitment and responsibility “there is some delay in my overtime work payment, but i think i have to care well of patients, this is my problem, not for pa tient”[nurse 15]. care of patients without being affected by delay in payment. positive attitude (positive view) page 8 of 8 (page number not for citation purposes) j med ethics hist med 2010, 3:6 gholamreza mahmoodishan et al. references 1. greenstreet w. synchronicity and dissonance: nursing, spirituality and contemporary discourse. spiritual health int 2007; 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of medical ethics and history of medicine original article moral sensitivity and its dimensions in iranian nursing students fariba borhani 1 , abbas abbaszadeh 2 , mohammad javad hoseinabadi-farahani 3 * 1 associate professor, medical ethics and law research center, shahid beheshti university of medical sciences, tehran, iran; 2 professor, department of medical surgical nursing, school of nursing and midwifery, shahid beheshti university of medical sciences and iranian academy of medical sciences, tehran, iran; 3 phd student, department of nursing, university of social welfare and rehabilitation sciences, tehran, iran. corresponding author: mohammad javad hoseinabadi-farahani address: koodakyar ave, daneshjoo blvd, evin, postal code: 1985713834 email: j.hoseinabadi@gmail.com tel/fax: 98919 215 8179 received: 25 sep 2016 accepted: 18 dec 2016 published: 27 dec 2016 j med ethics hist med, 2016, 9: 21 © 2016 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract as future providers of health services, nursing students should learn about ethical concepts over the course of their education. these concepts are currently taught in nursing schools, yet the degree of moral sensitivity in nursing students before entering clinical settings is a topic of controversy. this was a cross-sectional study on the nursing students studying for a bachelor’s degree in qazvin university of medical sciences selected through census sampling (n = 205). data were collected by lutzen's moral sensitivity questionnaire and analyzed through statistical tests using spss 16. the level of significance was p < 0.05. in order to conduct the study, permission was obtained from the ethics committee of shahid beheshti university of medical sciences. the mean of moral sensitivity was found to be 66.1 + 8.1, which is a moderate level. of all the dimensions of moral sensitivit y, "expressing benevolence" had the highest (16.9 ± 4.04) and "structuring moral sense" had the lowest (5.2 ± 1.45) mean scores. among demographic variables, age was found to have a significant positive correlation with the score of moral sensitivity (r = 0.2, p = 0.01). nursing students are relatively familiar with the ethical concepts of patient care, but that does not seem to be sufficed, as moral sensitivity is an extremely crucial factor in care. it is therefore recommended that the necessary training be provided to develop moral sensitivity in nursing students both in educational and practical environments. keywords: ethics, moral sensitivity, nursing, nursing students j med ethics hist med 9: 21 december, 2016 jmehm.tums.ac.ir mohammad javad hoseinabadi-farahani et al. page 2 of 7 introduction healthcare systems across the world have experienced extensive changes in recent years. some instances include technological advances, the discovery and incidence of emerging diseases, new diagnostic techniques and tools, developments in care processes and medical interventions, population growth, increased rate of migration, and shortage of nurses. in line with these changes, awareness of patients’ rights has also increased within healthcare organizations (1-3). as an integral part of healthcare systems, the nursing profession focuses on care and the promotion of community health (4). understanding ethics as a profound and complex process lived by people is a basic nursing action. at first glance, nursing practices and competencies may appear as clinical procedures occurring independently of ethics; however, ethics and clinical procedures are practically inseparable (5-7). as future health care providers, nursing students should learn about ethical concepts related to nursing practice over the course of their education. the purpose of teaching ethics to students is to foster nurses who are able to apply ethics to their care and to develop and promote ethical decision-making skills in the face of ethical dilemmas (7-9). according to lutzen et al., ethical decision-making comprises four components: 1) moral sensitivity; 2) moral judgment; 3) moral motivation; and 4) moral character (10). of these four components, moral sensitivity is the most important, since it enables nurses to identify ethical problems in providing patient care, to make the most ethical decision and to achieve ethical sensitivity (11-14). like other developing countries, nurses in iran are faced with various challenges, including job dissatisfaction, poor social standing, shortage of nurses, and the gap between theory and practice. each of the above-mentioned problems can affect the quality of nursing care (6) and lead to wrong decisions resulting from work pressure. ethical decision-making is not only contingent upon nurses’ proper management of clinical ethical issues (15-17), but also necessitates moral sensitivity (18, 19). in fact, the latter is a prerequisite for ethical decisionmaking (20). moral sensitivity and reasoning are considered crucial nursing skills required for ethical decisionmaking and problem-solving and their dimensions in clinical settings (19, 21). for an effective application of ethics, nurses should develop their powers of ethical reasoning, understanding and analysis as well as their moral sensitivity (22). moral sensitivity is an attribute that enables the individual to recognize ethical conflicts, to have a sensory and intellectual understanding of people in vulnerable situations, and to develop an awareness of the ethical consequences of making decisions about others. moral sensitivity requires care providers to recognize and interpret the spoken and non-spoken behaviors and signs expressed by patients so as to recognize their needs (23-27). as future providers of health services, nursing students should learn about ethical concepts over the course of their education. these concepts are currently taught in nursing schools; however, the controversial issue is the degree to which nursing students possess moral sensitivity before entering clinical settings (28, 29). studies conducted in iran as well as other countries on moral sensitivity in nurses have indicated different levels of this moral concept (30-32). ahn and yeom reported poor levels of moral sensitivity among korean nursing students and argued that teaching morality and promoting moral sensitivity in nursing students should be further emphasized in korea (33). park et al. reported higher levels of moral sensitivity among the senior students in their study compared to the freshmen and asserted that moral education in nursing programs should target the promotion of moral sensitivity and reasoning (21). comrie studied moral sensitivity in both undergraduate nursing students and nursing graduates and noted the importance of emphasizing moral concepts, especially moral sensitivity, over the course of education (19). karimi also demonstrated that nursing students in iran have moderate levels of moral sensitivity and argued that this moral concept plays a major role in providing ethical nursing care (32). considering that moral sensitivity is a fundamental issue in nursing care that has not been sufficiently investigated, the present study was performed to determine the level of moral sensitivity and its dimensions in iranian nursing students in 2015. method the present descriptive study was conducted between april and june 2015 in qazvin, a city in northern iran, about 150 km west of the capital (tehran). study subjects consisted of eligible undergraduate nursing students from qazvin university of medical sciences selected through census sampling. the census method was chosen because the goal was to determine the level of moral sensitivity in all the undergraduate nursing students of qazvin university. for this purpose, a list of nursing students was obtained from the deputy of education, and the questionnaires were distributed among the students on the list. study inclusion criteria consisted of being an undergraduate student and having passed at least one academic term. incomplete or inconsistent information on the questionnaires resulted in exclusion from the study. of the total of 205 questionnaires distributed among the students, 175 were properly completed and were thus collected for further analysis. participants' data were collected using a demographic questionnaire containing items on age, j med ethics hist med 9: 21 december, 2016 jmehm.tums.ac.ir mohammad javad hoseinabadi-farahani et al. page 3 of 7 gender, marital status, current academic term, nursing work experience, interest in the nursing profession and previous attendance in ethics classes. current academic term referred to the semester in which the students were studying at the time of the research by self-report, and work history was concurrent employment in clinical settings. participants’ moral sensitivity was measured using lutzen's moral sensitivity questionnaire (msq), translated by abbaszadeh. this questionnaire was developed by kim lutzen in sweden and later modified by comrie. it contains 25 items on moral sensitivity and is scored based on a likert scale from 0 (totally agree) to 4 (totally disagree) with a minimum total score of zero and a maximum of 100. a total score between 0 and 50 signifies a low level of moral sensitivity, while scores of 50 to 75 indicate a moderate, and 75 to 100 a high level of moral sensitivity. the validity of the questionnaire was measured using the content validity method through implementing the modifications proposed by ten faculty members of qazvin university of medical sciences who reviewed the items. the reliability of the questionnaire was confirmed using the internal consistency method and by measuring the cronbach's alpha value (α = 0.82). the research team began collecting the data after obtaining the necessary permissions and approvals from the ethics committee of shahid beheshti university of medical sciences (no. 6440, dated 11/29/2015). the participating students were briefed on the study objectives and methods of completing the questionnaire before receiving their copy. they were also ensured of the confidentiality of the data and the voluntary nature of participation in the study. all the participants read and signed informed consent forms. the collected data were analyzed in spss 16, and the normal distribution of the data was verified using the shapiro-wilk test. descriptive statistics including the mean, percentage and standard deviation were used to describe the data. moral sensitivity was analyzed through descriptive tests such as the mean, percentage and standard deviation. pearson’s correlation coefficient was used to determine the relationship between age and academic term, and the relationship between moral sensitivity and the other variables was measured by the chi-square test. the level of statistical significance was set at p < 0.05. results the mean age of the participating students was 21.9 with a standard deviation of 2.82. a total of 60% of the participants were female, and the majority were single (90.3%) and had no previous nursing experience (78.9%). only 6.3% of the students had taken ethics courses before, and the majority (57.7%) had chosen nursing out of interest (table 1). the mean score of moral sensitivity was 66.1, with a standard deviation of 8.1. the majority of the students (88%) possessed moderate levels of moral sensitivity (table 2). of the demographic variables examined, only age was found to have a significant positive correlation with the score of moral sensitivity (r = 0.2 and p = 0.01). as shown in table 3, of all the dimensions of moral sensitivity, "expressing benevolence" had the highest mean score (16.9 ± 4.04), while "structuring moral meaning" had the lowest (5.2 ± 1.45); moreover, "relational orientation" was the only dimension that had a significant positive correlation with age (r = 0.2 and p<0.01). table 1the demographic variables of participants variable number percentage variable number percentage gender male 70 40 previous attendance in ethics classes yes 11 6.3 female 105 40 no 164 93.7 marital status single 158 60 academic term second 32 18.3 married 17 9.7 third 25 14.3 interest in nursing yes 101 57.5 fourth 31 17.7 no 74 42.3 fifth 22 12.6 nursing work experience yes 37 21.1 sixth 27 15.4 no 138 78.9 seventh 10 5.7 eighth 28 16 table 2the absolute and relative frequency and the mean score of moral sensitivity in the study participants variable level of moral sensitivity number percentage mean overall score standard deviation moral sensitivity low 4 2.3 66.1 8.1 moderate 154 88 high 17 9.7 j med ethics hist med 9: 21 december, 2016 jmehm.tums.ac.ir mohammad javad hoseinabadi-farahani et al. page 4 of 7 table 3the mean overall score of the dimensions of moral sensitivity in the study participants dimension mean standard deviation experiencing moral conflict 8.26 1.91 following the rules 12.5 2.01 relational orientation 15.38 2.62 expressing benevolence 16.9 4.04 modifying autonomy 7.96 1.62 structuring moral meaning 5.11 1.45 discussion the present study was conducted to determine the level of moral sensitivity and its dimensions in nursing students. the nursing students in this study showed a moderate level of moral sensitivity, which is consistent with the results obtained in previous researches (19, 32-34). the levels of moral sensitivity among nursing students were found to be moderate by comrie and abbaszadeh et al., and low to moderate by ahn and yeom. these findings suggest that nursing students are relatively familiar with the ethical concepts of patient care, but due to certain barriers, they lack the required sensitivity and suffer from confusion and indifference in relation to moral issues. therefore, nursing students require further training on ethical concepts in order to be able to apply ethical principles to patient care in their future career. of all the dimensions of moral sensitivity, "expressing benevolence" received the highest, and "structuring moral meaning" the lowest scores. in the msq, "expressing benevolence" refers to such concepts as honesty, trust between nurses and patients, considering the patients’ reactions to care, and the patients’ insight and knowledge about their disease. as consistent with the present findings, "expressing benevolence" also received the highest score in a study conducted by abdou et al. (18) in the study by comrie, "following the rules" received the highest and "experiencing moral conflict" the lowest scores (19). nursing students appear to have a greater sensitivity toward "expressing benevolence" because they are still in apprenticeship and therefore pay more attention to theoretical issues and their application in clinical settings. "structuring moral meaning" is a dimension of moral sensitivity related to issues about which decisions are made without the patient’s participation. this dimension received the lowest score in the present study, which suggests that students still have problems in this area and do not have the right attitude toward the issue. in other words, they do not consider it necessary to involve patients in their medical care decisions. the fact that patients have no defined role in making decisions about their medical care and that the majority of decisions are made by the healthcare personnel including doctors and nurses, may be attributed to the paternalistic view still is dominating the iranian healthcare system (35, 36). of the demographic variables examined, only age had a significant positive correlation with the score of moral sensitivity, as the older students received higher scores. age was also positively and significantly correlated with "relational orientation", since the older students received higher scores in this area, which includes issues such as the patient-nurse relationship and the patients’ involvement in care. aging and the subsequent mental maturity of the students, on the one hand, and the greater presence in clinical settings after having passed more courses and moved up the academic ladder, on the other, add to the students’ clinical experience. the outcome is a heightened awareness of the effect of ethics on the quality of nursing care and the best means of building a relationship with the patients, thus increasing nursing students’ level of moral sensitivity (9, 37). the present study was conducted only on nursing students in qazvin university of medical sciences, and the data were collected through self-report. therefore, similar studies are needed to be conducted in other nursing schools to establish the generalizability of the results. conclusion the moderate level of moral sensitivity in nursing students is indicative of their knowledge about and attention to moral principles in the profession. however, this level of moral sensitivity is not sufficient for providing satisfactory patient care, and promotion of moral sensitivity should therefore be a priority for the nursing system. holding regular courses on the principles of nursing ethics during the students’ education can certainly enhance their moral sensitivity. moreover, identification of other factors that can affect the level and dimensions of moral sensitivity is clearly essential. acknowledgements the present study is the result of a research project supported by the sbmu medical ethics and law research center (melrc) and in collaboration with qazvin university of medical sciences. hereby, the authors would like to express their sincere gratitude to all the directors and participating students who helped conduct this study. conflict of interests the authors declare no potential conflicts of interests j med ethics hist med 9: 21 december, 2016 jmehm.tums.ac.ir mohammad javad hoseinabadi-farahani et al. page 5 of 7 with respect to the research, authorship, and/or publication of this article. funding the authors received financial support for this research from medical ethics and law research center (melrc) affiliated to shahid beheshti university of medical sciences. j med ethics hist med 9: 21 december, 2016 jmehm.tums.ac.ir mohammad javad hoseinabadi-farahani et al. page 6 of 7 references 1. range lm, rotherham al. moral distress among nursing and non-nursing students. nurs ethics 2010; 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http://www.ncbi.nlm.nih.gov/pubmed/?term=mohamadi%20e%5bauthor%5d&cauthor=true&cauthor_uid=26419438 http://www.ncbi.nlm.nih.gov/pubmed/?term=ghasemi%20e%5bauthor%5d&cauthor=true&cauthor_uid=26419438 http://www.ncbi.nlm.nih.gov/pubmed/?term=hoseinabad-farahani%20mj%5bauthor%5d&cauthor=true&cauthor_uid=26419438 http://www.ncbi.nlm.nih.gov/pubmed/26419438 ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ 1 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e © 2019 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. original article volume 12 number 17 december 2019 professional socialization: an analytical definition *corresponding author leila afshar no. 115, school of traditional medicine, shams dead-end, opposite tavanieer, vali-e-asr st. tehran, iran. tel: (+98) 21 88 77 35 21 email: leilaafshar@sbmu.ac.ir received: 29 sep 2018 accepted: 27 nov 2019 published: 7 dec 2019 citation to this article: sadeghi avval shahr h, yazdani s, afshar l. professional socialization: an analytical definition. j med ethics hist med. 2019; 12: 17. homa sadeghi avval shahr1, shahram yazdani2, leila afshar3* 1.phd candidate in medical education, school of management and medical education, shahid beheshti university of medical sciences, tehran, iran. 2.professor, school of management and medical education, shahid beheshti university of medical sciences, tehran, iran. 3.associate professor, department of medical ethics, school of traditional medicine, shahid beheshti university of medical sciences, tehran, iran. abstract professional socialization is defined as a process through which a person becomes a legitimate member of a professional society. this will have a great impact on an individual’s professional conduct and morality. the aim of this study was to clarify this concept and reduce the ambiguities around it. this was a qualitative research through which the concept of professional socialization was analyzed using walker and avant’s eight-step approach. the review of literature for this concept was done using electronic database without any time limitation. the overall search produced about 780 articles, and after reviewing these articles, 21 were selected purposefully. based on concept analysis, we propose the following analytical definition: professional socialization is a nonlinear, continuous, interactive, transformative, personal, psychosocial and selfreinforcing process that is formed through internalization of the specific culture of a professional community, and can be affected by individual, organizational and interactional factors. this definition is in accordance with the interactionism perspective. existence of a particular profession and getting involved in a community of practice are the antecedents of this process, and formation of professional identity and professional development are its consequences. a case model, as well as borderline and related cases, has been introduced for this concept. the results of this study can be used to design useful educational interventions to conduct and facilitate the process. keywords: professional socialization; concept analysis; education; medical students; professionalism professional socialization: an analytical definition … 2 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 17 december 2019 introduction socialization is the process through which individuals acquire the knowledge, skills, attitudes, values, norms and appropriate actions of their community (1). socialization begins by learning the norms and roles of the family, subcultures and self-concept, and continues throughout a person’s whole life. by growing older and joining new groups, people will take on new roles and learn new norms, and will refine their self-concept. professional socialization is a process that people who want to enter a particular profession must go through (2). it is part of the lifelong socialization process, although in much of the existing literature, the concepts of socialization and professional socialization have been used interchangeably (3). professional socialization is like a journey that leads to the transition from marginal to full participation in a professional society (4). it should be noted, however, that professional socialization is different from mere education. in any profession, training is the learning of knowledge and the related skills, while socialization combines this knowledge with the changed sense of oneself (5). professional socialization is essential for a successful academic graduation experience, and its inappropriate formation may lead to dissatisfaction and dropping out of school (6). until the 1940s, this concept was relatively uncommon, but after world war ii, it attracted the interest of many researchers and scholars of various disciplines and interdisciplinary studies and entered dictionaries and scientific works such as the talcott parsons theory (7). since then, this concept has repeatedly been used in scientific literature with different terminology such as acculturation (8, 9); adaptation (10 13); assimilation (14); social assimilation (15); organizational socialization (16, 17); and a variety of definitions. given the diversity in defining the concept of "professional socialization" in scientific literature and the use of different terms by researchers, policymakers and educational experts in the medical community, it would be useful to clarify this concept. therefore, providing a good analytical definition for this concept through disambiguation could provide opportunities for improving educational programs and supporting strategies in this process. the aim of this study was analyzing the concept of professional socialization and proposing an analytical definition for it. methods talking about concepts helps researchers of a discipline to reach consensus on their own specific perceptions and avoid using them unconsciously (18). concept analysis is a well-known strategy for developing an analytical definition of a concept. in this process, the concept is first decomposed into its main elements and reviewed to better define and explain its attributes, and will finally be reconstructed. walker and avant's approach is one of the most common methods of conceptualization and development of concepts, and is a simplified form of wilson's classical method. this logical positivistic approach aims to develop a theory through simplifying and clarifying a concept (19). in this study, the concept of sadeghi avval shahr h., et al. 3 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 17 december 2019 professional socialization was analyzed by using this approach, which has eight basic, continuous steps (table 1), table 1the walker & avant′s model of concept analysis (19) concept selection 1 determining the purpose of the analysis 2 identifying the uses of the concept 3 determining the defining attributes of the concept 4 identifying a model case 5 identifying the borderline, related and contrary cases 6 identifying the antecedents and consequences 7 defining the empirical referents with regard to the first step, it is worth noting that despite the many researches in this field, the concept is neither well-defined nor completely understood. as for the second step, the purpose of analyzing the concept of professional socialization is determining the key features in order to clarify the meaning and provide a theoretical definition that can be used for educational purposes in the medical field. as the third step of walker and avant's approach, in order to identify all the scientific uses of the concept and find the defining attributes, a comprehensive electronic search without any time limitation was done (through nov. 2017). the search strategy has been shown in figure 1. the search for literature continued until full saturation and repetition of the data. in order to enhance the credibility of the study, the opinions of two experts in the field were used for the audit. results in total, 21 published documents including 16 articles, and 5 theses containing fairly complete information about the concept of professional socialization, were selected for analysis. the rejected articles did not meet the criteria for entering the study (english language, full text access), were repetitive, or did not provide the necessary information for concept analysis because of issues related to ethics, professionalism, and educational methods and measurements. after reviewing the selected articles, the nature, attributes and other relevant features of the concept were identified, analyzed and categorized. defining attributes of professional socialization concept according to walker and avant’s method, the characteristics of a concept are the attributes used when discussing that concept, and have a key role in differentiating it from similar ones (19). at this stage, after carefully reviewing the selected literature, all the phrases involving the attributes, sub constructs, goals, or everything revealing a certain aspect of the concept, were specified in the form of direct quotes, and then the potential definitional attributes were developed through a deductive and inductive process. after that, the necessity and sufficiency tests were done. test of professional socialization: an analytical definition … 4 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 17 december 2019 necessity indicates whether the defining attributes are essential characteristics of the concept and their elimination leads to a defect or not. by using a sufficiency test, the researcher is reassured that the entire list of defining attributes has been considered (20). in this study, six conceptual areas were identified for the concept of professional socialization: identity, attributes, verbs, contents, outcomes, and affecting factors (table 2). . sadeghi avval shahr h., et al. 5 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 17 december 2019 table 2conceptual areas identified in concept analysis of professional socialization definition al areas potential definitional attributes citation main pdas identity process 3, 33 40, 43, 45, 47, 48, 50, 53, 57 process attributes interactive 33, 47, 48, 50 interactive nonlinear 40, 48 nonlinear developmental 38, 40, 45, 47, 48, 53 developmental continuous 34 continuous transformative 38, 59 transformative personal 48 personal psychological 57 psychosocial social 57 self-reinforcing 30 self-reinforcing verbs internalizing 48 internalizing contents culture 3, 33, 34, 38, 43, 57 culture outcomes development of professional identity & professional development 3, 47, 48, 57 professional identity development professional development (later outcomes: job satisfaction, organizational commitment, and becoming an effective member of the profession) affecting factors age 3, 37 individual race 33, 45 gender 3, 30, 33, 37, 45 family 35, 47 friends 30, 43, 47 experiences 3, 30, 33, 35, 36 38, 40, 48 socioeconomic status 36, 45, 50 culture 30 motivation 34, 35, 43 curriculum 30, 33 organizational learning environment 3, 48, 30, 37 system structure& climate 33, 36, 48, 30 role models 57, 36, 47, 30 peers 30, 35, 40, 43, 47, 50 patients 30, 36, 47, 57 personnel 57 mentoring 30,36, 48, 50 practitioners 53 others in healthcare roles 36, 43, 47 interpersonal, gender, mentor & faculty social interactions 3, 30, 33, 35, 37, 40, 50, 57 interactional building a model case a model case is an example that has all the defining attributes of the concept, and helps to further clarify the concept and increase its validity (20). professional socialization: an analytical definition … 6 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 17 december 2019 ms. “a” is a final year medical student. ever since she was a child, she wanted to be a doctor. after admittance into a medical school, she sees herself at the beginning of a long journey, has only general and stereotypical information about the profession, and her expectations of the role are more idealistic. early on in her studies, especially in the first and second years, she uses every moment to learn specialized terminology and content knowledge by attending the theoretical classes. she is an active and interested student, and upon entering the clinical environment, gradually becomes familiar with the power structure and the hierarchy in the profession. she tries to acquire the necessary information about the new role and adapt to it through personal observations and interactions with the professional community. initially, through observation, participation, repetition and practice, and ultimately taking the role, she emulates what is expected of someone in the role. over the next few years, she tries to analyze and interpret her environment to stabilize her professional goals and adjust her continuing professional growth by looking for positive feedback. she has now become a familiar face in the program and receives tacit and informal principles of the profession through communicating with faculty and peers. now she feels more confident in the new role, and after observing and participating in some surgical processes, develops an interest in this field and decides to continue studying it. by having a positive attitude toward the role, her personality is integrated with the social structures of this role, and now she sees herself as part of the professional community. alternative cases according to walker and avant, identifying and presenting the most prominent attributes of a concept is difficult, because it may overlap with some related concepts. examining cases that are not exactly the same as the studied concept, but are similar or contrary to it, in some ways helps the researcher to make a better understanding and assessment about attributes that have the best fit. these additional cases include: related, borderline, and contrary cases (19). in this article, however, the contrary case, which does not include any of the main attributes of the concept, and indicates what the studied concept is not (19), was not mentioned, because it does not play an important role in identifying the desired concept. borderline case a borderline case is an example of a concept that includes only a few, but not all, of the attributes of the concept. in this research, the concept of “organizational socialization” emerged as a borderline concept. organizational socialization is a process through which a new entrant into a particular work environment acquires knowledge and skills considered by the organization and its members as essential for that particular organizational role (20). although there are similarities between organizational and professional socialization in certain cognitive, behavioral, ethical and emotional elements, and structural variables such as employees, the organization's power structure, role models, and important sadeghi avval shahr h., et al. 7 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 17 december 2019 emotional experiences, these two processes are not the same. when a person chooses a profession, he/she must first enter the process of professional socialization, during which formal education is provided to individuals. therefore, professional socialization happens prior to organizational socialization. as the next step, the person can choose an organization for employment, and that is when the process of organizational socialization begins. entering an organization as new workforce, one tries to overcome one’s uncertainty and anxiety through seeking information and reassessment of one’s own assumptions. professional socialization is in fact a kind of preparation that a person receives through formal education, while organizational socialization is the context in which the newcomer should start working as new workforce, and may play a more important role in shaping the performance of the newcomer compared to professional socialization (20). an organization's field of work may often conflict with what individuals acquired through formal education, and in such cases, organizational socialization is considered more pervasive for individual development. in organizational socialization, one must be accountable to a particular organization, while professional socialization is wider and not limited to a specific organization and administration. in the latter case, the person defines oneself as a member of the profession, not a specific organization (21). related case a related concept is somewhat similar to the concept being studied, and therefore may be misunderstood or confused with it. therefore, in order to prevent this, the related concept, its differences with the concept under consideration, and the degree of distinction should be determined (22). in our study, professionalism is considered as the related concept of professional socialization. although there are similarities between the two in terms of some attributes and definitions, they differ from each other. professionalism is based on a social contract between the society and the members of a profession, and suggests professional behaviors that originate from professional norms. despite the presence of similar elements such as cognitive, behavioral, emotional, moral and symbolic elements, professional socialization also has the dimension of internal adaptation, which is formed through symbolic, intellectual and psychological transformation of an individual during the process of professional socialization. in other words, the concept of professionalism is not related to independent principles such as the development of a value system and self-perception that is related to the psychological dimension of professional socialization (23). antecedents and consequences antecedents are events that must exist prior to the occurrence of the concept, and identifying them can be very helpful in clarifying the areas of intervention. consequences are the events that occur as a result of the occurrence of the concept (19). the development of professional socialization firstly requires the existence of professional socialization: an analytical definition … 8 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 17 december 2019 a particular profession as the starting point of the process. secondly, it is necessary to get involved in a community of practice consisting of integrated educational programs, good role models, supportive educational structures, opportunities for work experience, and constructive feedback. the professional identity and professional development that are the main products of professional socialization could result in some long-term outcomes and impacts including adaptation to professional roles, job satisfaction, professional and organizational commitment, and becoming an effective member of a professional community. empirical referents according to walker and avant (19), the concepts and their attributes are abstract, and therefore cannot be good empirical indicators. empirical referents are recognizable features of the concept that facilitate its identification and measurement, and help generate research tools. some empirical referents for professional socialization are as follows: active participation in learning; a positive attitude to the profession (24); the students’ motivation for learning (determined by their requests for guidance and assistance in educational environments such as the skill lab); social solidarity; good rapport with colleagues and others (25); acceptable role performance (26); professional qualification approval through comprehensive qualifying exams such as 360 degree assessment and portfolio assessment; and long term outcomes including job maintenance and satisfaction. the analytical definition of professional socialization after going through the steps of concept analysis, we propose the following analytical definition of the concept of professional socialization: professional socialization is a nonlinear, continuous, interactive, transformative, developmental, personal, psychosocial and self-reinforcing process, which is formed in newcomers through internalizing the specific culture of a professional community, including expectations, values, beliefs, customs, traditions, and unwritten rules of the profession, as well as understanding the hierarchy and power structure, and the responsibilities. the initial and main outcomes of this process are the formation of professional identity and professional development. various factors can affect this process, which are grouped into three categories: individual factors (gender, age, race, religion, nationality, culture, personality traits, socioeconomic status, marital status, personal experiences, and motivation); organizational factors (explicit and tacit curriculum, formal and informal learning environments, role models, and the system structure); and interpersonal relationships (interpersonal relationships with professors, peers, customers and clients, other staff, family and friends, and also receiving feedback and guided reflections). sadeghi avval shahr h., et al. 9 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 17 december 2019 discussion the main approaches to the process of professional socialization there are two major perspectives in relation to this process in the literature: structural functionalism and symbolic interactionism (27). from the structural functionalism perspective, professional socialization is the product of newcomers acquiring the values and attitudes of a society (27). holding this view requires adoption of a step-by-step approach to the concept, as well as acceptance of the passive and reactive behaviors of newcomers. meanwhile, in the view known as symbolic interactionism, professional socialization is seen as a process, and interactivity is its main feature. therefore, contrary to the previous view, here, the new entrants are actively involved in the formation of this process and play an important role in its formation and development (27). many studies have addressed this concept with a functionalistic approach, but a review of recently published literature in this field shows a tendency among researchers toward interactionism (27 31). according to the analytical definition proposed in this study, professional socialization is a highly personal process, and individual factors such as characteristics, motivations, sociocultural status, and previous experiences have powerful influences on its formation. accordingly, the professional socialization process cannot be interpreted from the perspective of functionalism, which is described by atkinson and cited by ongiti (32) to consider new entrants as tabulae rasae (blank slates) that should be filled with essential knowledge and skills in a passive, linear, and uniform process in order to be accepted as members of a profession. on the contrary, individuals getting through this process make an active choice how to respond to the socialization process and adopt it psychologically, as viewed from the perspective of interactionism. the most important features of the professional socialization process non-linearity is an important attribute of this concept that has been mentioned in many studies (33 38). in these studies, features such as being cyclic (24), indirect (39), and iterative (33, 35 38) have also been noted, which all indicate that this process is not linear or sequential. for instance, medical students’ exposure to some events in the early stages, such as their first encounter with cadavers or death of a patient, can make major changes to this process (40). meanwhile, there is no direct relationship between chronological time and the strength of professional socialization outcomes, and the elements of the outcomes are not all of the same weight (27). being cyclical means that by increasing one’s competency, one obtains more selfconfidence and improves one’s capabilities through a self-reinforcing process (24). professional socialization is a lifelong process (28, 41, 42) and does not stop when the period of formal education ends. according to the interactionism theory, the process of professional socialization can be considered as a role-taking process, which requires a continuous modification of one's professional socialization: an analytical definition … 10 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 17 december 2019 role, as one enters different working environments with different facilities and challenges (43). this modification occurs to different degrees in various individuals. therefore, the process can be seen as a highly personal experience that is dependent on the degree of one’s ability to interact with others (44), the degree of self-reflection ability (43), the composition of initial identity (45) and previous personal experiences and individual characteristics (table2). most studies in this area have seen professional socialization as a developmental process (32, 34, 39, 41, 42, 46). according to eyres, loustau, and ersek, as cited by clark (43), in this process, individuals try to link the "ways of knowing" and "principles of behaving" together within a unified framework that is in accordance with the cognitive and moral developmental theories. the development of professional identity is a very important aspect of becoming a professional, and for achieving this, trainees should think, act, and feel like members of the profession (47); doing this requires individuals to negotiate with themselves, that is, to go through the stage of internal adaptation, which forms the psychological dimension of professional socialization (5). professional socialization is a transformative process involving a symbolic, ideational and psychological transformation during which an individual’s meaning system and perspectives are transformed in order to legitimize authority to meet the public’s expectations (48). the most important attributes of this process as proposed in this study that are consistent with aforementioned literature in this areas seemed to be: transformative, developmental, continuous, and personal. professional socialization through internalizing culture internalizing the professional culture includes understanding and accepting the hierarchy and the power structure, responsibilities, expectations, values, beliefs, customs, traditions and unwritten rules of the profession, and occurs through formal and informal processes. the major part of formal socialization happens in basic educational programs, and the remaining part, which is often informal, occurs incidentally and subconsciously in educational and practical environments through unplanned observations and interactions with important others. the formal aspect of the process can transfer certain dimensions of professional culture, such as beliefs about the characteristics of a responsible professional who is committed to adherence to the ethical codes (49). however, transmitting the professional culture through informal situations of socialization, and the implicit effects at the organizational and structural level known as hidden curriculum, also have a significant impact on the formation of trainees' professional values and behaviors (50(. therefore, the adoption of a new approach to this important process, through facilitating the path that leads to appropriate formation of professional identity of future professionals, can help to enhance and facilitate its formation. factors affecting professional socialization as can be seen in table 2, several factors sadeghi avval shahr h., et al. 11 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 17 december 2019 can influence the professional socialization process that were grouped in three categories of individual, organizational, and interactional factors. nonetheless, all of these factors do not have the same weight in terms of impact on the process of socialization, and the roles of mentors and role models (5, 30, 39, 46, 50), previous experiences (31-34, 51), field and work experiences in the community of practice (3, 27, 31, 34, 52, 53), and reflection (5, 30, 33, 54,55, 56,57) are more prominent. mentorship is one of the “key processes” in socializing individuals into nursing and education (58). mentors are like the “linchpin of students’ experience in becoming socialized” who keep various elements of the practical and educational environment together, which is conducive to the students’ socialization (59). reflection and the students’ ability to adapt to the innate culture within the practical settings is fundamental for socialization (54). reflection through integration of personal beliefs, attitudes and values into the professional values helps the development of professional identity (52). it seems that there is a close relationship among the three aforementioned essential elements of role modeling, personal experience and reflection. by observing role models, learners imitate and practice the role, and through guided reflection on their experience, consciously acquire effective knowledge, attitude and competence. furthermore, students subconsciously receive the unwritten rules and culture of the profession and then internalize it consciously through self-reflection. in this manner, they ultimately will be socialized in the professional community and develop a proper professional identity. conclusion professional socialization has been introduced in the literature using surrogate terminology such as professional preparation, professional adaptation, acculturation, assimilation and professional absorption. it is the process through which a layperson gradually becomes a professional, and adapts to a reference point for the particular values and behaviors of the role. clarifying this concept and its elements, which was the mission of this study, can provide an important clue to future studies about the prerequisites, facilities and proper strategies for guiding students to form appropriate professional identity. acknowledgements this paper was part of a thesis, submitted by the first author for a phd degree in medical education, and was funded by shahid beheshti university of medical sciences. the authors would like to thank mr. ibrahim saadatjoo in particular for his support and providing access to intended literature. conflict of interests none declared. professional socialization: an analytical definition … 12 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 17 december 2019 references 1. henslin jm. essentials of sociology: a down-to-earth approach, 11th ed. boston: pearson; 2015, p.71. 2. brinkerhoff db, white lk, ortega st, weitz r. essentials of sociology, 9th ed., canada: cengage learning; 2014, p.71. 3. page g. professional socialization of valuation students: what the literature says. 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[dissertation]. uk (glasgow): glasgow university; 1997. journal of medical ethics and history of medicine aids and drug rationing pooneh salari sharif 1* , mahshad noroozi 2 1.assistant professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. 2.researcher, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. *corresponding author: pooneh salari sharif address: no.21, 16 azar ave., tehran, iran. tel: (+98) 21 66 41 96 61 e-mail: poonehsalari@gmail.com received: 19 jan 2010 accepted: 07 mar 2010 published: 16 mar 2010 j med ethics hist med. 2010; 3:1. © 2010 pooneh salari sharif and mahshad noroozi; licensee tehran univ. med. sci. abstract keywords: aids, ethics, rationing, pharmacist. introduction fairly distributing scanty and /or costly medi cations is considered a major challenge in health care. in a perfect world, providing all effective medicines for all human beings who need them shall be a routine. but financial shortfalls put every health care provider on a dilemma about providing the best medical interventions for the most deserv ing patients and at the real time. with continuously increasing numbers of human immunodeficiency virus (hiv)-infected patients, resource limitation plays a major role in community health. financial shortages limit the number of patients who are eligible for anti-retroviral therapy (art) even in the most conservative arena. making decision in such situations is called rationing which was considered for scarce resources. the excess of demand versus supply, makes rationing inevitable. developing countries are dealing with the availa bility of art as a major public health concern. as long as financial shortfall is a major problem, drug rationing is a rational decision; however, some critic the uneven resource allocation (1). the aim of this paper is challenging ethical and practical issues of drug rationing in hiv positive patients and presenting the other ways which help us treating patients in the best way and at the proper time. epidemiology according to the united nations joint pro gramme on hiv/aids (unaids) report on global financial shortage in resource-limited and poor countries restricts treatment in hiv infected patients especially in poor countries. higher hiv prevalence in poorer countries makes drug rationing a real concern. different countries solve the problem with different methods regarding who guidelines, but fairness and equity should be a major considera tion in drug rationing. this paper is aimed at reviewing different strategic approaches to drug rationing in aids treatment and then discusses pharmacists’ role. in conclusion, there is no fair and equitable strategy, and in each society, cultural, ethical and socioeco nomic issues along with considering a critical role for pharmacists must be taken into account. j med ethics hist med 2010, 3:1 pooneh salari sharif and mahshad noroozi page 2 of 7 (page number not for citation purposes) acquired immune deficiency syndrome (aids) epidemic, it was estimated that there were 33 million people living with hiv all over the world in 2007; and 2.0 million people died due to aids in 2007. south african countries have the highest incidence of hiv infections and the highest rate of death (35% of hiv infections and 38% of aids deaths in 2007) in the world. unaids estimated the number of people receiving antiretroviral drugs in low and middle income countries in the end of 2007 to be 3 million individuals (2). regarding the high rate of hiv positive pa tients as well as the high rate of death in this population, especially in low-income countries, providing the most efficient treatment modalities is necessary. this led to establish the “3 by 5” initiative of the world health organization (who) in order to put 3 million people on treatment by 2005 (3). at the close of 2008, who estimated the number of aids patients in need of treatment about 9.5 million people, from whom only 42% had access to treatment (4). considering the latest who reports in sep 2009, scaling up priority hiv interventions, led to 36% increase in receiving art in one year. in iran, according to the ministry of health and medical education's report in january 2008, the number of people with advanced hiv infection and the number of people receiving art was 8730 and 829 individuals, respectively, while the percentage of hiv positive patients, who received antiretroviral therapy, was only 9.5%. also the number of hiv-positive pregnant women in 2006 and the number of pregnant women who received art for prevention of mother to child transmission was 220 and 22, respectively (5). treatment modalities today we are passing 13 years since market ing potent arts which led to a significant decrease in aids and a change in the quality of life and survival of aids patients (6, 7). in this setting, resource shortage led to rationing medications; therefore, only the first line therapy can usually be ordered (8, 9). first line medications consist of a combination of a non-nucleoside reverse transcrip tase inhibitor (nnrti) and two nucleoside analogue reverse transcriptase inhibitors (nrti). second line treatment is often offered after treatment failure with first line medications and a proton pump inhibitor (pi) is recommended which is more expensive. unfortunately, a high propor tion of hiv infected patients develop treatment failure with first line treatment and need a pi (10). therefore, it is tough to decide when to start second line treatment and how to provide it. regarding the who guidelines, art can be used when the patients’ immune system is highly jeopardized (cd4 cell count of 200 cells per μl or showing constitutional symptoms) (11). actually, there is a question under debate about the best outcome and the time of treatment initiation. medical criteria alone are not useful in starting art and socioeconomic contributory factors should be taken into account. in one study in south africa, the researchers found that if the treatment begins at a less conservative cd4+ count (350 cells per μl as guided by us department of health and human services); the percent of eligible patients for therapy escalated from 9.5% to 56.3% (12). abbas et al. found art benefits for infected subjects as well as the uninfected individuals by decreasing mortality and disease transmission respectively (13). they reported larger individual and population advantage in early diagnosis and treatment which is in agreement with former findings (14). the last who guideline considers treatment initiation at cd4+ count 200-350; however, the stage of the disease should be taken into account for decision-making (15). taken these into consid eration, the question is “how we can ration art in the best possible way?” how to overcome the complexities scientific facts and ethical judgment are needed for solving the problem. the nature of the disease in addition to the specific features of hiv positive patients (addiction, having dangerous sexual behaviors) and patients compliance are major points which have to be regarded for rationing medications. the scaling up priority includes hiv testing and counseling (free hiv testing is possible through public sector in some countries), preventive measures to limit mother-to child transmission, and drug availability by lowering prices of the most first line regimens by 10-40% between 2006 and 2008, while the second line regimen is still expensive (16). different methods of rationing drug therapy will have different socioeconomic consequences particularly in the high risk populations. obviously, there is no unique method which can consider all contributory factors, so different approaches should be impli cated in different situations and the mentioned methods may be regarded at the beginning. in continuation, some points should be considered a light shed to predict the pitfalls and prevent them. therefore, the treatment efficacy should be defined at first as suppressing viral load or increasing cd4+ count in a continuous manner. adjusting care models making provisions for maintaining access to art in developing countries needs adjustment of care models regarding the actual facts of these j med ethics hist med 2010, 3:1 pooneh salari sharif and mahshad noroozi page 3 of 7 (page number not for citation purposes) regions. different countries manage the problem in different ways. while some are negotiating for receiving additional funds, others develop special policy in reprogramming patients’ access to drugs. limiting patients’ access to medications such as protease inhibitors or other antiretroviral medica tions, and keeping patients in the waiting lists are some examples (17, 18). some countries compile policies and pro grams to determine the prior patients for treatment. the most known program is mother-to-child transmission (mtct) mtct-plus, which prefers hiv-positive mothers of new infants in addition to skilled workers. the reasons behind this program are preventing mother to child transmission and preserving economic growth. some governments prioritize health care workers while some others prefer treating poor patients (19, 20). sometimes, programs and policies do not consider special socioeconomic group, but impede drug availability in the areas with high rate of hiv-infected patients, or oblige patients to make copayments (16). targeting high risk group of patients impose some limitations because, mostly, their identification is not easily possible and this term in high prevalence populations like african countries does not make sense (21). some consider virological core groups who have a high viral load. these patients may belong to the late stage of the disease or early infected subjects. they suggest the advantages of this method as increasing treatment equity, the epide miologic efficiency, and feasibility (21), but providing access to potent medications too late ( patients at the stage iii/iv, very low cd4 counts) may result in patients’ death in the first 6 month after drug initiation (22, 23). however, the early mortality suggested as being multifactorial includes severe immune deficiency, new or undiagnosed opportunistic infections, nutritional deficiencies, etc (24). economical solutions in every threatening infectious disease, policy of healthcare system about distribution of scarce or expensive medications is highly critical because the system encounters two groups of people: patients and healthy people who are exposed to the danger. in the recent years, the increasing number of hiv positive patients has imposed additional economic burden on the low income governments. some governments consider aids treatment as a major priority which forces them in absorbing international funds to increase the number of treated patients. after 2002 on, fund mobilization into art treatment by governments and interna tional donor contributions were considered to be useful ways of treating hiv positive patients especially in african countries. however, this high amount of money paid in this way, confronted countries with lack of financial resources for treating other medical conditions (25). resource allocation can be viewed from dif ferent points. as it is a determinant factor in successful treatment and prevention of the disease in especially poor countries, it should be noted that many contributory factors can affect its efficacy. zaric et al, defined the way of resource allocation and its proportion to hiv incidence and prevalence as a determinant in hiv preventive medicine (26). they designed a multilevel allocation in the following study by considering the role of decision makers (27). practical obstacles providing art at a late stage or using expen sive medications after treatment failure create many practical difficulties which need special attention. while scaling up treatment raised issues about drug resistance, detecting primary and secondary drug resistance seems to be a public health challenge (28, 29). drug resistance has potential impact on the outcome and patients’ compliance and their socioeconomic standing can affect it (30). lack of budget for referring to the aids clinics for receiving medications, doing lab tests, and also the low patients compliance and adherence to treatment, raise the issue of resistance more seriously. there is a significant difference in patient’s adherence to therapy between developing and developed countries (31) and it can play a crucial role in emerging resistance. however, walensky et al. studied the impor tance of resistance surveillance as a guide in treatment plans, but they found drug costs and efficacy as a major influencing factor on treatment policy rather than resistance (32). in this field, the type of medication seems to be crucial. it is noteworthy that failure of pi-based regimens causes slower disease progression than nnrti regimens (33, 34). this phenomenon may be due to the differences in basic immunologic response of the patients to these two classes of drugs (35, 36). in addition lateness treatment modification after failure of nnrti regimens increase risk of immunologic failure and mortality (37). ethical issues the most critical issue in the hiv drug ration ing and also medical interventions is observing ethical issues which give legitimacy to the act. along with the four ethical principles: beneficence, non-maleficence, justice, and autonomy; patients’ dignity and patients’ right should be regarded as the most significant ethical issues in health care. j med ethics hist med 2010, 3:1 pooneh salari sharif and mahshad noroozi page 4 of 7 (page number not for citation purposes) scaling up hiv treatment, equity, justice and fairness enjoys special importance while human rights and its international norms, standards and instructions are taken into account more specifical ly. regarding the who and unaids recom mendations, efficiency and fairness are two main fundamental issues in treatment initiation in resourcelimited settings (38). no doubt, drug therapy in hiv-infected patients have great profits for both patients and the society, while the time of initiating drug therapy more complicates the balance between beneficence and non-maleficence. but as discussed before, and according to the who criteria, in rich regions, the medical treatment does not delay until cd4+ count of ≤200 or late stage of the disease. starting treatment at these conditions not only renders difficulties in patients’ improve ment, rather brings resistance and opportunistic infections into account. therefore, the principles of beneficence and non-maleficence more affirm the necessity of starting treatment as soon as the disease is diagnosed. also treating hiv-positive pregnant women at the right time and by proper medications more emphasizes patients beneficence. but we should be aware of the best approach for drug rationing in order to minimize harms. as far as delayed or restricted availability of hiv treatment demolish patients’ survival in all age groups, children are notably sensitive. in adults, the transit time from hiv infection to aids is about 8-10 years, while, without effective treatment, more than half of all hiv positive infants pass away before their second birthday (39, 40). early hiv diagnosis and treatment was con firmed by researchers (41, 42) while some of the studies could not find any higher survival with highly active antiretroviral therapy (haart) initiation at cd4 counts of above 350 cells/μl (43). also the probability of recovering cd4 counts to high levels increased when haart starts during primary hiv infection (phi) in comparison to chronic infection (44). therefore, the need for further evaluation and possible revision of who guidelines is fairly advisable. also the term of justice might be considered in patients’ selection. justice in patients care is defined as making provisions for providing identical patient care facilities when there is insufficient supply. in resource-limited settings, patients do not have the right to take all their health care needs, however, there is a limitation. morally, health care providers’ duty is to provide the health services as much as possible in order to preserve patients’ health and function. therefore each limited chance for living should be respected. in this setting, patients prioritizing are an important issue and should be done based on the disease severity, prognosis, etc, as well as preventive measures which more complicates the dilemma. daniels et al. presented the justice framework of accountability for rationality. he defined special situations in which the equitable decision is made; therefore, the decision will be accepted by the majority. instead of discussing about disagreements on decision making, he verifies the bases of it (45). taken together, justice should be considered in the center of moral judgment. in terms of autonomy and limited resources, time shortage for diagnosis more confirms the negligence of patient’s autonomy (46). other than the above-mentioned criteria, fea sibility, economic efficiency, equity, rationing potential on disease transmission, ethical issues and sustainability should be respected in each rationing system (25). supporters of scaling up art treatment be lieve that there should be no charge on art. in some poor areas, the patients cannot pay the cost of even transfer to a doctor’s or they have to stay waiting for physicians/ pharmacists visit. there fore, there are controversial views about the balance between equity and sustainability. clinical pharmacist’s role the critical role of pharmacists in health care system has to be considered as a unique duty which is mixed with ethical concerns. a pharmacist who dispenses medications can modify the drug rationing in the best way which helps both patient and the health care system. although lowering drug costs is one of their responsibilities in the world, the propagatory role of pharmacists in protecting pharmaceuticals profits weakened their crucial duty (47). this type of conflict of interest is always questionable and yet has not been resolved. instead, it can be expected that pharmacists always play their primary role as patients’ supporter which necessi tate their active contribution in promoting health interests. using combination products is a useful method in reducing drug costs and increasing patients’ adherence to therapy. reviewing drug regimens thoroughly, and regularly by a pharmacist may assist in choosing the best candidate for drug therapy according to the patients status, compliance and adherence; deter mining treatment failure, side effects, and making sure about the right medication. by reviewing drug regimens, drug resistance and side effects will be diagnosed earlier which prevents money wasting or imposing more economical burden on patient or community. the complexity of hiv-treatment because of existence of the other opportunistic infections in aids such as tuberculosis, pneumo nia, etc makes drug interactions a serious matter of concern. evaluating patients profile will help determine any drug interactions especially with j med ethics hist med 2010, 3:1 pooneh salari sharif and mahshad noroozi page 5 of 7 (page number not for citation purposes) hiv medications which are a potent drug class influencing enzymatic metabolism of drugs. reducing the dose of art and/or particularly pi is another method which reduces the costs of art. several studies and clinical trials have been conducted all over the world, which show promis ing results even in patient’s tolerance, but it needs more evaluation (48-50). conclusion finally the important things that has to be fig ured out in treating hiv-infected patients success fully, are providing medications accessibility with low cost, reducing the long-term effects of hiv on socioeconomic development, and putting all eligible patients under treatment. patient’s eligibili ty should be evaluated by scientific facts and moral judgment. thus, the importance of ethical issues in hiv drug rationing should not be ignored or underestimated. taken together, drug rationing must be consi dered as a rational way for treating hiv-infected patients in resource-limited settings; however, many criteria should be considered and/or revised for rationing and no method is completely fair and multilateral. putting all principles (scientific and ethical) together increases the intricacy and debates around the matter. while regarding ethical judg ment seems necessary in finding the best way of scaling up art with the least harm, illuminating, and assessing health care systems output deem advisable. j med ethics hist med 2010, 3:1 pooneh salari sharif and mahshad noroozi page 6 of 7 (page number not for citation purposes) references 1. bayer r, 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inhibitor, protease inhibitor, or both in initio: open-label randomized trial. lancet 2006; 368: 287-98. 11. anonymous. world health organization. scaling up antiretroviral therapy in resource-limited settings: treatment guidelines for a public health approach to 2003 revision. geneva: world health organization, 2003. http://www.who.int/hiv/pub/prev_care/en/arvrevision2003en.pdf (accessed on oct 2009) 12. auvert b, males s, puren a, taljaard d, carael m, williams b. can highly active antiretroviral therapy reduce the spread of hiv? j acquir immune defic syndr 2004; 36: 613-21. 13. abbas ul, anderson rm, mellors jw. potential impact of antiretroviral therapy on hiv-1 transmission and aids mortality in resource-limited settings. j acquir immune defic syndr 2006; 41: 632-41. 14. rowley jt, anderson rm, ng tw. reducing the spread of hiv infection in sub-saharan africa: some demographic and economic implications. aids 1990; 4: 47-56. 15. anonymous. world health organization. prioritizing 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inflammatory reactions in hiv-1 infected persons after initiation of highly active antiretroviral therapy. ann intern med 2000; 133: 447-54. 25. rosen s, sanne i, collier a, simon jl. rationing antiretroviral therapy for hiv/aids in africa: choices and consequences. plos medicine 2005; 2(11): 1098-1104. 26. zaric gs, brandeau ml. optimal investment in a portfolio of hiv prevention programs. med decis making 2001; 21(5): 391-408. 27. zaric gs, brandeau ml. a little planning goes a long way: multilevel allocation of hiv prevention resources. med decis making 2007; 27: 71-81. 28. anonymous. world health organization. draft guidelines for surveillance of hiv drug resistance. geneva: world health organization; 2003. http://www.who.int/3by5/publications/guidelines/en/execsumm.pdf (accessed on oct 2009) 29. spacek la, shihab hm, kamaya mr, et al. response to antiretroviral therapy in hiv-infected patients attending a public, urban clinic in kampala. clin infect dis 2006; 42: 252-9. 30. orrell c, bangsberg dr, badri m, wood r. adherence is not a barrier to successful antiretroviral therapy in south africa. aids 2003; 17: 1369-75. 31. stevens w, kaye s, corrah t. antiretroviral therapy in africa. bmj 2004; 328: 280-2. 32. walensky rp, weinstein mc, yazdanpanah y, et al. hiv drug resistance surveillance for prioritizing treatment in resource-limited settings. aids 2007; 21: 973-82. 33. baker jv, peng g, rapkin j, et al. poor initial cd4+ recovery with antiretroviral therapy prolongs immune depletion and increases risk for aids and non-aids diseases. j acquir immune defic syndr 2008; 48: 541-6. 34. ledergerber b, lundgren jd, walker as, et al. predictors of trend in cd4 positive t-cell count and mortality among hiv-1-infected individuals with virological failure to all three antiretroviral-drug classes. lancet 2004; 364: 51-62. 35. deeks sg, grant rm. sustained cd4 responses after virological failure of protease inhibitor-containing therapy. antivir ther 1999; 4(suppl 3): 7-11. 36. deeks sg, wrin t, liegler t, et al. virologic and immunologic consequences of discontinuing combination antiretroviral-drug therapy in hiv-infected patients with detectable viremia. n eng j med 2001; 344: 472-80. 37. petersen ml, van der laan mj, napravnik s, et al. long-term consequences of the delay between virologic failure of highly active antiretroviral therapy and regimen modification. aids 2008; 22: 2097-2106. 38. anonymous. world health organization. guidance on ethics and equitable access to hiv treatment and care. geneva: who; 2004. http://www.who.int/ethics/en/ethics_equity_hiv_e.pdf (accessed on oct 2009) 39. morgan d, mahe c, mayanja b, et al. hiv-1 infection in rural africa: is there a difference in median time to aids and survival compared with that in industrialized countries? aids 2002; 16: 597-603. 40. prendergast a, tudor-williams g, jeena p, et al. international perspectives, progress, and future challenges of paediatric hiv infection. lancet 2007; 370: 68-80. 41. violari a, cotton mf, gibb dm, et al. early antiretroviral therapy and mortality among hiv-infected infants. new eng j med 2008; 359: 2233-44. 42. puthanakit t, aurpibul l, oberdorfer p, et al. hospitalization and mortality among hiv-infected children after receiving highly active antiretroviral therapy. clin infect dis 2007; 44: 599-604. 43. jevtovic dj, salemovic d, ranin j, dulovic o, ilic d, brmbolic b. the prognosis of highly active antiretroviral therapy (haart)-treated hiv infected patients in serbia, related to the time of treatment initiation. j clin virol 2009; doi: 10.1016/j.jcv.2009.11.017 44. egger m, may m, chena g, philips an, ledergerber b, dabis f, et al. art cohort collaboration. prognosis of hiv-1 infected patients starting highly active antiretroviral therapy: a collaborative analysis of prospective studies. lancet 2002; 360: 119-29. 45. daniels n, sabin j. setting limits fairly: can we learn to share scarce medical resources? cambridge: oxford university press; 2002. 46. liss pe. hard choices in public health: the allocation of scarce resources. scand j public health 2003; 31: 156-7. j med ethics hist med 2010, 3:1 pooneh salari sharif and mahshad noroozi page 8 of 7 (page number not for citation purposes) 47. eaton ml. pharmacy ethics. in: singer pa, viens am (eds). the cambridge textbook of bioethics. cambridge: cambridge university press; 2008. 48. cressey tr, leenasirimakul p, jourdain g, et al. low-doses of indinavir boosted with ritonavir in hivinfected thai patients: pharmacokinetics, efficacy and tolerability. j antimicrob chemother 2005; 55: 1041-4. 49. mootsikapun p, chetchotisakd p, anunnatsiri s, boonyaprawit p. efficacy and safety of indinavir/ritonavir 400/100 mg twice daily plus two nucleoside analogues in treatment-naïve hiv-1-infected patients with cd4+ tcell counts<200 cells/mm3: 96-week outcomes. antivir ther 2005; 10: 911-16. 50. duvivier l, myrto m, marcelin ag, et al. efficacy and safety of ritonavir/indinavir 100/400 mg twice daily in combination with two nucleoside analogues in antiretroviral treatment-naïve hiv-infected individuals. antivir ther 2003; 8: 603-9. journal of medical ethics and history of medicine humanity in medicine pankaj gupta resident medical officer, department of preventive and social medicine, seth g. s. medical college and k.e.m hospital, mumbai, maharashtra, india. *corresponding author: pankaj gupta address: a-9, landmark chs, plot no. 2-1 and 2-8, sector 14, vashi, navi mumbai, maharashtra, india. postal box: 400703. e-mail: pankajgupta85@rediffmail.com received: 09 jan 2011 accepted: 20 feb 2011 published: 27 feb 2011 j med ethics hist med. 2011; 4:3. © 2011 pankaj gupta; licensee tehran univ. med. sci. “to most physicians, my illness is a routine incident in their rounds, while for me it’s the crisis of my life. i would feel better if i had a doctor who at least perceived this incongruity” – anatole broyard (former new york times critic) (1). my first brush with the issue of humanity in medical field was when i read this quote, a few months back, put up by a prestigious international journal for an essay writing competition. as i read that quote, it stirred my conscience. and although i almost instantaneously quelled the desire to write on it, thinking my chances of winning an essay contest too slim to bother with, it set me thinking. the idea behind this quote is thought provoking. it challenges those of us in the medical field to remember what it feels like to be on the other end of the stethoscope — to remember that there is a person and not just a pathogen infecting a host. the purpose behind my presenta tion of ideas on this platform is to reinforce upon us, healthcare professionals, the importance of rekindling and keeping alive the desire of service to mankind with which many of us had gone into the medical profession. my experiences with humanity in medicine: my father, on my first day of medical school, had put his arm around my shoulder and said “son, always remember that the secret to the care of the patient is in caring for the patient”. i, an exuberant 17 year old, with admission letter in my hand and an innocent heart overflowing with an overpower ing desire to “serve the mankind”, made quick mental note of what my father had to tell me. little did i realize that a couple of years later the patients i wanted to “serve” would be reduced to “an excellent hemiplegia case” or “a great hernia case”. by saying “excellent” and “great”, i was not, in any way, wishing ill for the patient. i was just describing my visceral reaction to a case which i could learn new concepts from. from a medical perspective, when we are faced with routine everyday conditions, something unusual and dramatic is, well really cool. to the patient, however, it is anything but that. but who cares? once the “excellent” case was presented to the lecturer in the all important “clinic”, the “case” was forgotten in haste. over to the next case!!! after struggling through the arduous final year exams, i finally became an intern, (a surrogate term for blood sucking vampire, because the only work remotely related to medicine i did was blood sample collection). my entire world centered on “veins”, so much so that patients were subcons ciously classified as those having “good veins” and those having “difficult veins”; and those who “cooperated” and those who “did not cooperate”; and those who were “screamers” and the sweet ones who were “non screamers”. it was the sheer drudgery of the job which sucked out all feelings from me and forced me to think so. the emergency room is another such place where there is an inadvertent neglect of humanity. when your work involves the dying and those who grieve for them, the skill of keeping the humor alive becomes vitally important. we do indulge in humor all the time in the emergency room (er), and if the general public could see it, they would be horrified. we would look like insensitive people j med ethics hist med 2011, 4:3 pankaj gupta page 2 of 4 (page number not for citation purposes) who feast on pain. again there is no malicious intent here on the part of the doctor; it is a simple defense mechanism. we doctors explain it as, “i’m laughing to keep from crying.” it helps keep you somewhat whole and functional, and allows you to carry on and do your job – questionable in terms of taste and professionalism, but necessary and actually helpful on the whole. if you were a blubbering wreck because you just had to amputate someone’s limb due to gangrene, you would be less able to help the next patient in line. disappearing humanism in medical practice: why? hippocrates had said “medicine is an art”. whether i believe him or not is no issue, but the examiner who sets the paper for the entrance exam in medical field surely doesn’t think so. if he did, why does he want to know how much of inorganic chemistry, botany and mechanics, i am aware of? shouldn’t an aspiring doctor be assessed about his emotional intelligence and sensibilities, rather than carrying out futile exercises to quantify his capability to mug up vague theories? pre-medical exams do not develop scientific logic and skill; they only encourage and identify competitive memorizers. the science-only policy is not only restrictive but also selects many candidates with limited aptitude for medical practice. in medical school, the fashionable focus on biology and the reduced emphasis on social determinants of health make physicians short sighted and leave them without an understanding of long-term solutions to common diseases. the spotlight on pathology and disease with a failure to understand illness and patient reality often leads to problems in communication, patient dissatisfaction and doctor shopping. the absence of communica tion and counseling skill training in the curriculum makes it difficult for doctors to convey bad news about diagnosis. the lack of training in negotiation skills for discussing treatment plans often results in poor compliance and medico-legal problems due to discrepancies between the views of patients and doctors on clinical reality. the “science” of medicine is thus well taught in medical schools but the “art” of medicine is given a step motherly treatment in the medical curriculum. no student has ever got an extra mark in his case presentation for his friendly, polite and endearing mannerism towards the patient! and we in the medical fraternity can never think beyond marks!! humanity in medicine – my perspective writing in academic medicine in 2009, sha piro et al. observed that there is an “ongoing lack of clarity on what exactly the medical humanities comprise, and how they should be integrated into medical education.” they proceeded to offer a narrowly “pedagogical” definition: the medical humanities use the methods and concepts of one or more of the humanities disciplines, teach students critical reflection aimed toward a more humane practice, and are by nature interdisciplinary and collaborative (2). another approach was suggested in 2008, when evans identified three “manifesta tions” of medical humanities: as an academic field of intellectual inquiry, as a dimension of medical education, and as “…a source of moral and aesthetic influence upon the daily praxis of organized clinical health care” (3). way too complicated for a person like me with a juvenile horizon of thinking!!! my heart gives me a better definition of humanity in medicine – it is caring for a patient as one would care for his or her loved one. i am sure to find acknowledgement from the nobel laureate, bharat ratna mother teresa. she once had a foreign visitor who remarked that he would never touch a leper’s wounds even if he was offered a million dollars. mother lovingly replied that even she wouldn’t do that for a million dollars; she would do that only because of her love and service for jesus christ. if we accept that medicine is an interpretive science and that the most reliable patient with clear-cut symptoms is a potentially uncertain field of knowledge, then it follows that attention must be given to patients' cultural, social, and family contexts. this allows a more nuanced interpretation of the patients' narratives, the meaning they attribute to their experiences, their values, and their beliefs, and it helps to ensure a successful therapeu tic relationship. medical humanities provide anthropological, historical, and literary tools that allow us to use the underlying cultural context to identify the range of possible interpretations of a given situation. humanity in medicine shares an intimate connection with the concept of physician-patient relationship. societal changes and ethical issues in health care have been responsible for the evolution of the models of the physician-patient relationship today. the role of the physician is to maintain patient autonomy, maintain and/or improve health, promote good, do no evil, and to create a relation ship based on trust. the key ethical principles of respect for persons, autonomy (self-determination), beneficence (do good), non-maleficence (avoid evil), justice (allocation of resources), and veracity (truthfulness) should be inclusive in the physician patient relationship. the quality of this relationship is important to both, doctors and patients. the better the relation ship in terms of mutual respect, knowledge, trust, shared values and perspectives about disease and life, and time available, the better will be the amount and quality of information about the patient's disease transferred in both directions, enhancing accuracy of diagnosis and increasing the j med ethics hist med 2011, 4:3 pankaj gupta page 3 of 4 (page number not for citation purposes) patient's knowledge about the disease. where such a relationship is poor the physician's ability to make a full assessment is compromised and the patient is more likely to distrust the diagnosis and proposed treatment, causing de creased compliance to actually follow the medical advice. in these circumstances and also in cases where there is genuine divergence of medical opinions, a second opinion from another physician may be sought or the patient may choose to go to another doctor. our work in medicine often exposes us to the darker side of human existence. on virtually every shift we get exposed to the seamy underbelly of life. there is homelessness, drug addiction, abuse, neglect, trauma, and lots for our psyche to absorb. this is to say nothing of the strokes, pneumonias, heart attacks, fractures, miscarriages, and more common daily woes that plague our species. keeping a humane outlook amidst all this is indeed a difficult job, but that’s what humanism in medicine is all about! what can be done? i am convinced of the need of incorporation of humanities in the medical curriculum. the “why” part has already been discussed; more pertinent now is to ask “how” – how do we go about this amalgamation of humanities training in medical schools. i am hugely impressed with the training program designed by university of geneva school of medicine (4). the training program has the following goals directed to developing the following skills among medical students:  contextualizing a patients clinical condition in the background of his socio-demographics, family and culture  developing personal reflection and judgment which can sharpen, cultivate, or revive students' curiosity, and enhances intellectual and rela tional capacities  encouraging imagination to gain a better understanding of how others perceive and expe rience things  offering specific ways to improve the quality of the therapeutic relationship by creating explicit links between the first three goals and day-to day medical practice tools which can be used are seminars, role plays and internships. seminars and role plays should cover the dynamics of medical consultation, repercussions of illness on the patient, family and society; handling a dying patient and also handling of personal frustrations and pressures of the doctors themselves. providing textured demonstration of humanis tic values through methods such as critical incident reports (5) and creative projects (6), as well as the use of humanistic connoisseurs (7) to mentor and formatively evaluate learners are some suggested measures to gradually incorporate humanities in medical curriculum. it is well established in the research literature that role modeling is among the strongest influences on medical students' learning (8). medical humanities faculty can play a key role in helping interested physicians become more effective in manifesting humanistic skills and values in their teaching, by serving as role models (9). it would be pretentious to believe that such a program alone will change medical practice. however, the vision is to provide students with tools that are specific to humanities so they can strengthen their own judgment, listening skills, open-mindedness, creativity, and curiosity. these attributes are needed to ensure that the therapeutic relationship will be satisfying for both doctors and patients. final thoughts the process of writing this article has drawn my attention to the advice of my mother. she says that the medical values of doctors should be based on ‘nishkama karma’, expounded by bhagvadgita (ancient indian religious text). nishkama karma, or self-less or desireless action is an action performed without any expectation of fruits or results, and the central tenet of path to liberation according ancient indian ideology. only through “nishkama karma”, we will be able to truly nurture and nourish humanity in our profession. only then can we hope to give a resounding answer to voltaire’s caustic comments on doctors “doctors are men who prescribe medicines of which they know little, to cure diseases of which they know less, in human beings of whom they know nothing.” page 4 of 4 (page number not for citation purposes) j med ethics hist med 2011, 4:3 pankaj gupta references 1.broyard a. doctor talk to me. the new york times. 1990. http://www.nytimes.com/1990/08/26/magazine/doctor-talkto-e.html?pagewanted=5 2. shapiro j, coulehan j, wear d, montello m. medical humanities and their discontents: definitions, critiques, and implications. acad med 2009; 84: 192-8. 3. evans hm. affirming the existential within medicine: medical humanities, governance, and imaginative understanding. j med humanit 2008; 29: 55-9. 4. louis-courvoisier m. medical humanities: a new undergraduate teaching program at the university of geneva school of medicine, switzerland. acad med 2003; 78(10): 1043-7. 5. misch da. evaluating physicians' professionalism and humanism: the case for humanism connoisseurs. acad med 2002; 77: 489-95. 6. branch wt jr. use of critical incident reports in medical education. a perspective. j gen intern med 2005; 20: 1063-7. 7. rucker l, shapiro j. becoming a physician: students' creative projects in a third-year im clerkship. acad med 2003; 78: 391-7. 8. jones ws, hanson jl, longacre jl. an intentional modeling process to teach professional behavior: students' clinical observations of preceptors. teach learn med 2004; 16: 264-9. 9. wright sm, kern de, kolodner k, howard dm, brancati fl. attributes of excellent attending physician role models. n engl j med 1998; 339: 1986-93. ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ 1 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e © 2019 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. letter to editor volume 12 number 16 november 2019 the need for a practitioners' social media code of conduct in iran *corresponding author ahmad sofi-mahmudi no. 10, al-e-ahmad and chamran highway intersection, tehran, iran. postal code: 1411713136 tel: (+98) 21 88 63 12 93 email: a.sofimahmudi@gmail.com received: 10 oct 2019 accepted: 26 nov 2019 published: 1 dec 2019 citation to this article: ahmad sofi-mahmudi a. the need for a practitioners' social media code of conduct in iran j med ethics hist med. 2019; 12: 16. ahmad sofi-mahmudi researcher, non-communicable diseases research center, endocrinology and metabolism research institute, tehran university of medical sciences, tehran, iran. there is a need for a social media code of conduct for dental (or in general, medical) practitioners in iran. with the growing use of the internet and social networks in iran, many dentists use social media, mainly instagram, as an advertisement tool. there are almost no restrictions on their advertisements; they not only expose their patients’ identities and therefore violate the principle of confidentiality, but also sometimes use inappropriate ways and styles, which may injure dentists’ reputation in the society (1). another problem is the increasing number of fake accounts that belong to individuals who introduce themselves as dental/medical practitioners. this problem is more evident in twitter, where a huge number of students and practitioners tend not to use their real names. sometimes they make medical recommendations or use inappropriate words that may make other users cynical about the profession. moreover, others can take advantage of this situation by claiming to be dental/medical practitioners, which has happened several times. in the latest dentistry curriculum in iran, there are no instructions for use of social media in the “medical ethics” course. however, tehran university of medical sciences has developed a guideline for professional behavior in cyberspace in august 2017. it is a good step, but we need an upstream and nationwide action. it is also advisable to adopt other countries guidelines as they may have more experience in this regard. the need for a practitioners' social media code of conduct in iran 2 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 16 november 2019 for example, the general dental council and the general medical council (gmc) of the uk, and the australian health practitioner regulation agency have produced policies and guidelines regarding the use of social media (1). the uk's general medical councils “doctors' use of social media” (2) is a useful document, and its original and persian translation are freely available on the web. this can help students and practitioners see that social media is not a part of their private life and they need to be careful while using social media. references 1. holden a. social media and professionalism: does the profession need to re‐think the parameters of professionalism within social media? aust dent j. 2017; 62(1): 23-9. 2. general medical council. doctors’ use of social media. [cited 2019 november]; available from: https://www.gmc-uk.org/-/media/documents/doctors-use-of-social-media_pdf58833100.pdf?la=en&hash=61bdc9eaa79fe4f877797d8c76515ea39bc8d516 journal of medical ethics and history of medicine nurses awareness of patients rights in a teaching hospital esmaeil mohammad nejad 1* , jamaloddin begjani 2 , ghasem abotalebi 3 , amir salari 4 , seyyedeh roghayeh ehsani 5 1.instructor, msc in nursing training, islamic azad university, aliabad katoul branch, aliabad katoul, iran. 2.instructor, msc in nursing training, islamic azad university, iranshahr branch, iranshahr, iran. 3.instructor, msc in nursing training, islamic azad university, ardabil branch, ardabil, iran. 4.msc of nursing, imam khomeini clinical and hospital complex, tehran university of medical sciences, tehran, iran. 5.bsc of nursing, imam khomeini clinical and hospital complex, tehran university of medical sciences, tehran, iran. *corresponding author: esmaeil mohammad nejad address: first floor, no.9, kavusi alley, urmia st, south eskandari st, tehran, iran. tel: (+98) 21 66 93 66 26 e-mail: asreno282@yahoo.com received: 07aug 2010 accepted: 13 feb 2011 published: 26 feb 2011 j med ethics hist med. 2011; 4:2. © 2011 esmaeil mohammad nejad et al.; licensee tehran univ. med. sci. abstract keywords: nurses, patients rights, teaching hospital. introduction despite of presentation of medical ethics as a new science in academic teaching, the ethical concepts have been alongside the medicine, and its antiquity back to the medicine history. for in stance, literatures such as hippocratic oath letter, liturgy of ibn maymun, and shirazi ethics ordin ance are the old literatures in which the principles such as the necessity of patient preference defender patients’ rights observance is one of the effective measures of patients’ satisfaction of health care services. we performed this study at the aim of evaluation of nurses’ awareness of patients’ rights in a teaching hospital in tehran. this cross-sectional study was conducted in 2010. in this study 156 nurses were randomly selected. two-part questionnaire was used for data collection. the validity and reliability of questionnaire was determined and then it was distributed between subjects. the data were analyzed by spss version 15 using descriptive and inferential statistics. our results showed that %58.33, %39.10 and % 2.56 of nurses have good, medium, and poor levels of awareness respectively. we observed a significant relationship between nurses aware ness and work experience (p=0.008) and concurrent work in public and private hospitals (p=0.01). the most of the nurses (%95.51) were aware of "right to privacy protection and ensure confidentiality of information” and the least of them (%33.97) were aware of "right to receiving necessary information about the health care providers, the rate of tariff and insurance coverage". according to our survey it is concluded that implementation of patients’ right charter in this hospital is accompanied by some limitations which necessitates promotion of the nurses’ awareness about patients’ rights. taken together in order to enhance nurses’ awareness special measures and strategies should be considered. j med ethics hist med 2011, 4:2 esmaeil mohammad nejad et al. page 2 of 6 (page number not for citation purposes) on the physician and observing the principle of confidentiality have been emphasized. however, in the past literature using "physician's commitment and pledge" term was more common rather than "patient rights" (1-3). human being is a creature with physical, mental and spiritual dimensions which has rights during the health and illness. patient rights are the very expectations he has from the health care services and must encompass his physical, mental, spiritual and social needs which are manifested as criteria, standards, rules and laws (4, 5). emphasis on patient rights in the health care services particu larly maintains patient dignity as a rank of a human, and is considered important especially when patient's vulnerability easily expose him to the violations and weaknesses of the health care system (6). considering that health is the most important existence aspect of every person and according to the article 29 of the constitution, providing health is the most important commitment of the government of islamic republic of iran; because of this, in 2002, for the first time the patients’ right charter was developed in iran and was notified by department of health, treatment and medical education (7). the patients’ right charter of iran was approved by health policy council with a new and comprehensive viewpoint aimed to clarify the rights of the health services recipients and observance of moral standards in the treatment and medical fields in november 26th, and in december 1st it was communicated to the relevant centers (1, 8, 9). in this charter patient satisfaction is considered as one of the characteris tics of hospital effectiveness (9). today, the issues related to the quality of health care services, attention to the patients as customers and accom plishing their satisfaction are the main priorities and are of high importance. one of the important factors in patient satisfaction is regarding their demands and observing their rights and providing care along with respect (6). awareness of the patients rights and observing them accomplishes more satisfaction of the patient, physician and other medical team and hospital staff and will lead to the spread of good morals among patients and medical team; so eventually the moral status of all the individuals such as patients and medical team will be upgraded, but otherwise provided not observing these rights, it would lead to distrust to health care team. if there is no trust between medical staff and patients, it would lead to damages and losses for the patient and the medical team. furthermore, it would lead to terrible and unpleasant occurrences which are difficult to compensate and would be followed by the legal prosecution (5, 10). protect ing the patient rights by the nurses only will be possible when they have gained necessary know ledge about it and suitable conditions be provided for respecting these rights (11). appropriate care and observing patient rights require nurses’ knowledge which would be possible through different ways such as side studies, retraining courses, and academic courses during education (5). in the studied researches about the nurses’ level of knowledge from patient rights, several aspects were mentioned. nasiriani et al (5) and houshmand et al (11) reported good nurses’ level of knowledge in yazd hospitals and teaching public wards of tehran hospitals respectively. mohammadi et al. observed moderate and parsinia et al obtained weak nurses knowledge in tehran and karaj hospitals respec tively (10). the clinical researchers in different wards of teaching hospitals have reported that the patients’ rights have been ignored or have not been considered seriously due to shortage of nursing staff, high number of patients in the hospitals, psychological pressures and etc. taken together, we decided to evaluate the nurses’ knowledge about patients’ rights in one of the teaching hospitals of tehran city. method this was a descriptive cross-sectional study in which the nurses’ knowledge about patient rights was determined. . the study samples consisted of 156 nurses who have been selected randomly from one of the teaching hospitals of tehran. the inclusion criterion was having more than 6 months work experience. the data collection instrument was a two-part questionnaire; the first part included the demographic information (age, gender, marital status, work experience, educational level, etc.); the second part consisted of 10 questions according to the 10 section of patients’ rights charter of iran (11). this part determined the following areas about patient rights: 1. right to receive essential information about health care providers, rate of tariff, target insurance coverage if sent to the other medical centers. 2. right to give informed consent for participa tion in educational and research activities. 3. right to receive respectful and quick treatment and care regardless of cultural and racial factors. 4. right to recognize the admission location and the health care staff. 5. right to access to the health care team during hospitalization, transmission and discharge. 6. right to know essential information about the diagnosis, treatment and disease progression process. 7. right to know about the probable complica tions, treatment options and participate in the ultimate treatment choosing. 8. right to make a decision about the presence of those who are not directly involved in the treatment process. j med ethics hist med 2011, 4:2 esmaeil mohammad nejad et al. page 3 of 6 (page number not for citation purposes) 9. right to announce personal satisfaction from ending the treatment and referring to other centers, and 10. right to preserve privacy and being ensured about confidentiality of all of the medical informa tion. the answers of the study subjects to the ques tions were quantified by measuring a three-score scale; "good" (3 scores), "moderate" (2 scores) and "weak" (1 scores). the maximum score in the questionnaire was 30 scores which were considered 21-30 as high knowledge, 10-20 as moderate knowledge and less than 10 as weak knowledge. the validity was done using content validity i.e. the questionnaire was given to 10 faculty members of universities of tehran and after collecting the comments, the relevant comments were applied. the reliability was done using retest. the validated questionnaire was given to 10 eligible study subjects for reliability and in both stages the questionnaire was completed with a 10 day interval and the required correlation of the first and second answers and confidence was obtained r = 0.90 and finally these people were excluded from the study population. the questionnaires were completed during two weeks by direct referring of the researcher to the wards. in order to observe ethics, confidentiality and integrity, the mentioned questionnaires were anonymous and in all stages of the study the information were collected confiden tial and were kept by the researcher. all the data were analyzed using spss software version 15. results the review of the demographic variables in dicated that the majority of the nurses were females (76.28%) with mean age of 34.31 ± 7.3. most of them (91.2%) had bachelor degree and were married (62.82%). in terms of employment and work experience, almost half of nurses (47.43%) were contractual, 46.79% had 6-10 years of work experiences, 30.99% never passed any course about "patient rights" and 30.99% of them had the simultaneous experience in public and private sectors. no association between the variables of gender, age, degree and marital status and nurses’ knowledge about patient rights was found. there was no significant difference between them in terms of work section, work experience and simultaneous work in the public and private sectors, however there was a significant difference between their level of knowledge about patient rights and simultaneous work in the public and private hospitals and work experience (table1). the findings of the study about the nurses level of knowledge in different areas indicated that the highest level of knowledge (95.51%) was in the area of "right to preserve privacy and being ensured about confidentiality of all medical information" and the lowest level was "right to receive essential information about health care providers, rate of tariff, target insurance coverage if sent to the other medical centers". discussion observing patients rights is the most impor tant ethical issue in a hospital which should absolutely be considered. regarding patients’ rights and respecting them are two main factors for patients’ care. it is important that medical staff pay enough attention to its various aspects. observing patients rights means the accountability of all health care staff to the patients at the time of treatment and care giving (12,13). promoting patients rights is a multidimen sional issue and in order to achieve it, comprehen sive efforts should be done. world health organi zation has offered some strategies such as active participation of health care recipients and provid ers’ policy making and extending educational programs for health care providers and entire community (11). the findings of the study showed that nurses’ level of knowledge about patients’ rights in terms of the variables such as type of the hospital, work experience, degree, age and gender was good, moderate and weak in 58.33%, 39.10%, and 2.56% of them respectively. in the studies conducted in karaj hospitals (10) and the public wards of teaching hospitals of tehran (11) also the nurses’ level of knowledge reported as weak. today patients are more aware of their rights and physi cians' responsibilities and commitments and also hospitals' managements regarding their rights (14) and they are more insisting on their principle rights (2). therefore it is highly needed that nurses with low level of knowledge, and the other health care providers be aware of patients right charter and increase their knowledge. mohammadi et al. determined the reasons of the nurses low level of knowledge as lack of institutionalization and regulation of the rights (12); lack of adequate time for studying and researching due to various obstacles such as poor economic conditions; lack of positive vision in selecting nursing profession; tough job conditions in the hospitals such as large number of the patients versus staff shortages, and lack of necessary facilities such as adequate and suitable libraries (5). the results indicated that there was a signifi cant and direct association between level of knowledge and simultaneous jobs in the public and private hospitals (p=0.01) i.e. the nurses who provided services simultaneously in the public and private hospitals had higher level of knowledge. the reason might be due to regulations and rules which are performed more in the private hospitals compared to the public hospitals i.e. no implemen j med ethics hist med 2011, 4:2 esmaeil mohammad nejad et al. page 4 of 6 (page number not for citation purposes) tation of patients right charter which may be followed by punishment. the findings of the present study indicated that in the area of "right to preserve privacy and being ensured about confidentiality of all the medical information", the nurses had the highest level of knowledge. in the patients right charter codified in 2009 it says observance of the principle of confidentiality is necessary about all the information related to the patient except for the cases the law excluded (1). in a comparative study about the patients’ right charter in the selected countries with iran in 2007, it was indicated that regulations of iran for the right of the confidentiali ty of the patient information and medical records is similar to the other countries such as hungary, hong kong, new zealand, united states, south africa, european union and lithuania (14). unlike the above results, in canada it was indicated that 84% of the medical staff did not have enough knowledge about commitments and obligations of the law about confidentiality of the information and privacy of the patients’ information (15). our findings indicated that there was a direct and significant association between level of knowledge and work experience (p= 0.008) and the level of knowledge of the study subjects from patients rights charter was increased by increasing work experience which was in accordance with the studies of nasiriani et al. and parsinia et al. (5, 10). in addition, the study indicated that there was no association between level of knowledge and degree and increasing degree had no effect on the level of knowledge. in a study in karaj it was mentioned that the level of knowledge of the technicians was higher in comparison with supervisors and matrons and the most important reasons were sense of job security, professional status and disregardness of matrons and supervisors to the important tasks (10). the findings indicated that nurses in the area of "right to receive essential information about health care providers, rate of tariff, target insurance coverage if sent to the other medical centers" had the lowest level of knowledge. the patients right charter codified in 2009 states that information must be given to the patient at the right time and appropriate condition by considering individual characteristics such as language, degree and perception; however the patient has the right to access all the information recorded in his/her clinical records (16, 17). in the patients’ right charter of some countries such as canada and united states unlike the other countries such as iran, hong kong, new zealand, africa, european union, lithuania, "right to ask for explanation about the costs" has been discussed (14). the results indicated that 66% of the nurses was aware of the “right to access to the health care providers during hospitalization", instead of 90% of turkish nurses (17). nowadays ethical and legal concepts such as patient rights are included in the educational curriculum of greek and turkey (18, 19). accord ing to the considerable gap between development and realization of the patient rights (20) and the increased knowledge, claims and demands of the patients and also the results of this study, in order to observe patients right the following solutions are suggested: encouraging the nurses to consider patients’ right charter seriously. establishing and empowering the sanction of patients’ right charter more emphasizing on concepts of professional ethics and patient rights in teaching nursing students attending expertise meetings with presence of beneficiaries for evaluating barriers and presenting strategies in order to implement the patients right charter as soon as possible providing periodic educational programs for health care providers and patients about patient rights conclusion generally, since 41.6% of the nurses of the study had not a proper level of knowledge about patient rights and considering the fact that aware ness and knowledge can be the base of nurses’ performance and also patients increasingly are getting informed about their rights, the implemen tation of patients right charter is highly recom mended. this wills increase nurses knowledge about patient rights. holding educational programs, seminars, workshops and academic panels for nurses, and nursing students help overcome difficulties. page 5 of 6 (page number not for citation purposes) j med ethics hist med 2011, 4:2 esmaeil mohammad nejad et al. table1. demographic data of the nurses from knowledge about the patient rights statistical indicators variables number (percent) statistical test sex female 119 (76.28) t = 0.102 p = 0.37 male 37 (23.71) marital status married 98 (62.82) t = 0.08 p = 5.38 single 58 (38.17) educational level high school graduated 7 (4.48) f = 2.56 p = 0.407 technician 3 (1.92) bachelor 142 (91.02) master 4 (2.56) employment status recruitment plan 26 (6.66) f = 2.56 p = 1.93 contract corporate 13 (8.33) contract 74 (47.33) official 43 (27.56) type of hospital public 103 (69) t = 1.31 p = 0.017 private-public 53 (30.99) work experience (year) 1-5 43 (27.56) f = 5.34 p = 0.008 6-10 73 (46.79) 11-15 22 (14.10) > 16 18 (11.53) hospital ward intensive 33 (21.15) f = 1.68 p = 0.19 emergency 52 (33.33) surgery 21 (13.46) internal 31 (19.87) orthopedics 19 (12.17) page 6 of 6 (page number not for citation purposes) j med ethics hist med 2011, 4:2 esmaeil mohammad nejad et al. references 1. parsapoor a, bagheri a, larijani b. patient’s right charter in iran. j med ethics hist med 2010 (supplement): 3947. 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[in persian] ancient time efstathios drampalos 16-9-93 journal of medical ethics and history of medicine the influence of theory on the formation of the infirmary during antiquity and the middle ages in the west efstathios drampalos1, vasileios stogiannos2, panagiotis psyllakis3, mohammad sadiq4, ioannis michos5 1department of orthopedics, wrightington hospital, uk; 2department of history and methodology of science, univerity of athens, greece; 3department of orthopedics, bristol royal infirmary, bristol, uk; 4department of orthopedics, manchester royal infirmary, manchester, uk; 5΄δ orthopedic department, asklipieion voulas hospital, athens, greece. corresponding author: efstathios drampalos address: hip center, wrightington hospitan, hall lane, appley bridge wigan, lancashire, wn6 9ep, uk email: edrampalos@yahoo.gr tel: 00441942 244000 fax: 00441257 256352 received: 03 may 2014 accepted: 12 aug 2014 published: 10 dec 2014 j med ethics hist med, 2014, 7: 21 © 2014 efstathios drampalos et al.; licensee tehran univ. med. sci. abstract the modern infirmary is the evolutional product of the dialectic interface between medical theories at each time and the outcome of their application in clinical practice. the infirmary as we know it today did not exist during antiquity, but the different precursors of the modern hospital emerged as a result of the interaction between medical theory and practice. during antiquity the hippocratic work decisively contributed to the creation of the asklipieion, an institution with predetermined structure created to heal diseases. later in antiquity new types of infirmaries appeared along with the evolution of private practice for physicians. establishment of the first modern hospitals was an outstanding contribution of islamic medicine during reign of the islamic empire. although there was little progress in the development of medical theory in medieval west, evolution of the infirmary continued and was mostly influenced by christian religion and charity. in constantinople large medieval infirmaries were built, but patient care was frequently offered in monasteries by clergymen. later on medicine and treatment of diseases were taken over by physicians and taught in universities, and medical theory continued on its course of evolution. it is obvious that the modern infirmary is not only a place for treating diseases, but rather the upshot of a series of advancements in science, the relations between people or even countries, and the way humanity perceives its nature and the future. our research is focused on the interactive relationship between the evolution of medical theory and the infirmary as an institution during antiquity and the middle ages with particular emphasis on the western world. keywords: infirmary, medical theory, antiquity, middle ages, west mailto:edrampalos@yahoo.gr j med ethics hist med 7:21 dec, 2014 jmehm.tums.ac.ir efstathios drampalos et al. page 2 of 6 (page number not for citation purposes) introduction the modern infirmary is the evolutional product of a process consisting in the dialectic interface between the medical theories about illness at each time and the results of their application in clinical practice. the hospital is the most advanced type of infirmary comprised of a block of buildings and the surrounding environment in urban structure. hospitals have a particular architectural morphology and functionality, and are built using specialized methods, specifications and materials. in a hospital there are the main spaces for treatment called the wards, as well as theatres, laboratories, and the areas for ancillary use, that is, galleys and warehouses. from the point of view of function and purpose the modern hospital is a place where medicine is practiced in order to cure patients based on approved methods. the present work aims to show that the formation of the infirmary has mainly been influenced by views about illness and health that shaped the relative theory in this area. the term “infirmary” refers to a place for medical practice and includes the geographic position, topography and morphology of the ground, design and layout, functionality and purpose, equipment, furnishing, tools, type of construction materials used in the structure, and other elements that can influence therapy, diagnosis or prevention of illness. “medical practice” refers to a set of procedures that are considered to cure or prevent illness or even contribute to research at the time of implementation. the term “theory” is used for an idea, conviction, or recognized and accepted practice related to the medical practices of each time, even if it is not considered medical theory in the modern sense. the idea of the interaction between medical theory and the formation of the infirmary is quite recent. even though there have been several articles, publications and lectures regarding medical theory and the infirmary, there is no relevant research that describes the influence of theory on the formation of this institution. method our search did not produce any articles or books focusing on the interaction between medical theory and the formation of the infirmary. the research was conducted in different stages. textbooks and lectures from the department of history and methodology of science of the university of athens (uoa) and other relevant departments of greek universities were consulted. it should be mentioned that one of the main authors was a graduate of the aforementioned department and had the opportunity to formulate the basic idea and organize the research using the insight of experienced lecturers of medical history. for this purpose, works that contained descriptions of the infirmary as an institution or other valuable information were used, even if they were not directly related to the topic of our research. among them were the works of hippocrates, euripides, homer and other famous personalities such as philosophers, historicists, physicians and so on. in order to collect relevant information, the keywords “infirmary”, “medical theory”, “ antiquity”, “medieval”, “hospital”, “west” and “asklipieion” were searched on google, pubmed and wikipedia. in the course of the study, no articles could be found on the influence of theory on evolution of the infirmary. therefore, the research question involved the existence of the infirmary in different forms, for instance the ancient asklipieion, the roman infirmary or the most recent form, the medieval infirmary. the present paper evaluated the infirmary as an institution as well as medical theories of various historic eras, and aimed to establish a correlation between the two. antiquity in ancient greek mythology we find the first references to treatments for various diseases and this confirms the presence of a theory since theory comes before observation and application (1). in greek mythology, melampus was a legendary soothsayer and healer, originally from pylos, who ruled at argos. he was the first to cure diseases with medicine and purifications without the divine help (2). furthermore, hercules was cured from the mania that the queen of the gods, hera, had inflicted upon him by drinking an infusion of a herb called helleborus (3). the oldest known theory about illness and therapy revolves around the divine origin of diseases, the therapeutic power of nature, and treatments sent by the gods, and is chronologically placed around the fifth century bc. god apollo was the doctor of gods and the sun, and his son asklipios was the doctor of humans. this theory configures the type of infirmary known as “asklipieion”, blocks of spacious, buildings in the forest with peri styles and gardens, and at the center the temple of god asklipios or god apollo. the most famous infirmary of this type is that of epidaurus, which was built around 320 bc in ancient greece. in the “asklipieion” healing procedures were mystic and priesthood was hereditary. the patients entered the infirmary after sunset, took the purifying bath at the area called “tholos”, offered sacrifice to god asklipios and finally entered the area called “avato”. the latter was the sanctuary where the procedure of “enkoimisis”, a type of therapeutic sleep, was completed. the goal was not just a therapeutic dream, but a course of purification j med ethics hist med 7:21 dec, 2014 jmehm.tums.ac.ir efstathios drampalos et al. page 3 of 6 (page number not for citation purposes) aiming to bring the patient in contact with the divine. during the night the priest-doctor and his assistants, accompanied by a dog or a snake, visited the patient and cured the disease. it is known that hippocrates formulated a lot of his medical theories based on concepts from the “asklipieion” (4). medicine developed a more rational, scientific and professional status with hippocrates (fourth fifth century bc) who adopted the theory of humorism, which was based on the four humors (black bile, yellow bile, phlegm, and blood) and the four temperaments (wet, dry, cold and hot), and through which he attributed illnesses to natural causes (5). according to the theory of humorism the human body is filled with four basic substances, called humors, which are in balance when a person is healthy. all diseases and disabilities supposedly result from an excess or deficit of one of these four humors. for the first time illness was associated with the patient’s predisposition (i.e. altitude, humidity). therapy was personalized and considered to be the nature’s work, and the goal was to restore the balance of the humors by applying the principle of treating with the opposite. the doctor and the infirmary simply provided the appropriate environment for the patient. furthermore, there were different types of treatment which included: a) diet for acute and chronic illnesses; b) medication (there were almost 400 different kinds); c) surgery (traumatology, orthopedics, and bandaging); d) gynecology; and e) special treatments (cauterization, purification or evacuation of bowels, phlebotomy and exsanguination) (5). in “hippocratic collected works” or in tests of galen there is no mention of any form of institution or building where patients would be admitted for treatment (6). considering the nature of popular therapies and the briefly formulated suggestions and recommendations about the organization of the infirmary in a book by hippocrates entitled “on the workshop of a doctor” (7), it can be deducted that the hippocratic theory decisively contributed to the formation of the infirmary as a place dedicated specifically to therapy. according to the above-mentioned book, in the infirmary there should be a room with adequate light (natural or artificial) and special instruments for surgical procedures, with enough room for the patient, doctor, assistants, equipment and the bed. there should also be a room for bandaging and application of splints, which corresponds to the modern plaster room. hippocrates has another work entitled “on the things pertaining to women” (8) that emphasizes the peculiarity of a woman’s nature, indicating that in the hippocratic infirmary there was a special room for gynecological examination. the nature of the treatments available at the hippocratic infirmary (6, 7) indicates presence of the following areas in this type of institution: a) a special place for keeping medicine, since there were almost 400 kinds; b) a special place for purification or evacuation of bowels; and c) hygiene facilities such as toilets, bathrooms, water supply systems and a sewer system. considering all the aforementioned characteristics it is safe to presume that the hippocratic infirmary was the first rationally organized infirmary in the history of medicine. research on human body using cadavers was mainly performed by herophilus and erasistratus in alexandria for the first time during the third century bc, and continued with the roman kelso (first century ad) and tertullien (second century ad), and the greek galen in rome during the second century ad (9). the advancements in anatomy during the third century ad in alexandria were due, among other factors, to the support of the ruler ptolemy i soter i (283 bc – 367 bc), who permitted the anatomic dissection of cadavers and funded anatomic research. anatomy probably contributed to the development of proper instruments and medical facilities such advancements are not directly reported in ancient texts but their emergence is rationally deducted from the necessity for a specific place to perform dissection and house the means for the procedures and practices (instruments, beds and so on). out of the need for medical care for soldiers during military campaigns emerged military medicine, which is first mentioned in homer’s iliad. in iliad there are descriptions of how the sons of asklipios, machaon (surgeon) and podilarios (dietician-pathologist) heal the soldiers’ wounds and cure their diseases. there are no reports about the military infirmary in iliad, but it is reasonable to presume that it was in the form of a tent (10). later, in the roman military organization we find medical professionals skilled in the treatment of wounds (known as medici), and there is also an infirmary in each legion consisting of tent-rooms. the medici were regular soldiers who had received some medical training and looked after the wounded and the sick on the march and at “valetudinaria”. the term refers to temporary military hospitals dedicated to treatment of rather serious injuries and ailments (11). establishment of the valetudinaria was a significant contribution of the roman military system to the empire’s healthcare structure. the early versions of roman hospitals were more like “flying military camps” described in de munitionibus castrorum (12) as a minimally equipped structure that could accommodate about two hundred men. the valetudinaria soon evolved into wellequipped structures made of stone and wood that provided medical care to soldiers, slaves, and gladiators. there is little doubt as to the existence of these hospitals, although they may not have been j med ethics hist med 7:21 dec, 2014 jmehm.tums.ac.ir efstathios drampalos et al. page 4 of 6 (page number not for citation purposes) quite so widespread. this is due to the fact that ruins of many of these hospitals were recognized based on the design of building remains, and not through investigation of surviving records or unearthed medical instruments (13). physicians offered their services initially in infirmary-sanctuaries, like the asklipieion or the anfiareion in oropos and later in academies, like the ones in the greek island of kos or in the city of knidos in cyprus. private practice developed gradually and mainly in ancient rome, where greek doctors like galen, the physician of marcus aurelius, treated roman officials (13). private practice contributed to the formation of a new type of infirmary, a picture of which was unearthed during excavations in pompeii. the picture shows rooms intended for the doctor’s private usage, including the dining room, kitchen, archive, library, bedroom and the doorkeeper’s room. all these rooms are located around the atrium. the examination room is connected both to the street and the atrium. here the doctor passes most of his time and receives his patients (14, 15). near the port of pompeii is the so-called house of the surgeon, built around the fourth or third century bc, where interesting surgical instruments were discovered (15, 16). the middle ages during the middle ages of western history the first modern hospitals were established in the east as a result of advancements in islamic medicine. . in this contest physicians and scientists of different origins (including india, egypt, greece and the middle east) and cultures were invited at the famous school of jundishapur (17). when the arab muslims conquested the persian city of jundishapur in 638 ad, a major center for the dissemination of ancient manuscripts was born (18) playing an important role in the birth of islamic medicine (19). among the accomplishments of this era were: training physicians in basic sciences; establishment of a curriculum for clinical training in internal medicine and surgery, and licensing of physicians (17, 20). islamic medicine contributed greatly to the development of better hospitals (20, 21). there were separate wards for male/female patients and for different diseases in these hospitals together with teaching of medical students. drugs were provided free of charge. also, for the first time records of patients were kept and special clothing was given to inpatients. health services were free, and all patients were given five gold pieces at the time of discharge to help them support themselves until they could go back to work (17). during the islamic time many hospitals are funded as independent institutions or as religious trusts frequently in the contest of personal charity (17). later on, these institutions provided the model for hospitals in medieval europe. by the 14th century ad there were numerous hospitals in the islamic empire. the important ones were placed in damascus (was built in 706 ad), baghdad, jundishapur, cairo, tunisia, jerusalem, morocco and granada (17). hippocrates, galen and dioskorides were among the leading figures in western medicine during the middle ages, and a major part of medical research has been dedicated to commentaries on their works. during this era there was little progress in medical theory in the west, although one significant evolution was the emergence of new types of infirmaries. the most important factors involved were: a) christian charity; b) appearance of monasteries and cathedral institutions in western europe; c) the dominant theory about the spiritual nature of illness; d) epidemic diseases; and e) establishment of medical schools and universities. christian charity gives birth to the first infirmaries organized in special buildings, with doctors, nurses, use of animals for carrying patients and also care for the companions of the patients. the foundation of the first christian infirmary is attributed to saint basil the great. called the "basilias", this was a city-like complex which consisted of several buildings for different classes of patients as well as lodging for doctors and nurses (22). justinian also builds several infirmaries in constantinopole (11). with the predominance of christianity in europe health care was passed on to the church and members of christian orders, and monasteries took over medical care. for this reason medieval infirmaries were religious institutions where christian morality was dominant, and their primary goal was to provide food and shelter to those in need (23). after the christian conquest of jerusalem in 1099 and during the first crusade, members of the religious community who took over st. john’s hospital (also known as hospitallers of st. john of jerusalem) reorganized the infirmary based on the byzantine prototype. due to the executive position of jerusalem, st. john’s hospital was known throughout the european continent. the hospitallers built several hospitals in italy and south france. these hospitals had regulations for their function, for instance the presence of at least 4 doctors was mandatory in order to admit patients. thus the hospital in jerusalem served as a model for the modern western hospital and contributed to the transformation of the infirmary into a foundation specialized in the treatment of diseases (5). in christianity medicine is considered charity and every christian is bound to charity. the idea of charity as a religious duty and the need to help the diseased provided the motive to built guesthouses for pilgrims that later evolved into typical christian infirmaries (14). during the middle ages mysticism prevailed in christianity, and although the tests of galen were j med ethics hist med 7:21 dec, 2014 jmehm.tums.ac.ir efstathios drampalos et al. page 5 of 6 (page number not for citation purposes) often taught in academies and universities, medical theory was dissociated from the naturalistic models of hippocrates and galen. diseases were believed to have spiritual causes and could be cured only through god’s will, a concept similar to evangelical descriptions of jesus christ’s miraculous cures. healing could therefore be achieved only through invocation of god’s help and chrism, prayer and imposition of the hands took the place of medicine. a circular of the tour synod of 1163 entitled “the church detests blood” deprived clergymen of practicing surgery (23). exsanguinations, teeth extractions and surgery in general were undertaken by barber-surgeons whose shops were transformed to resemble infirmaries. exsanguinations were also performed in public baths, which were a popular place of therapy (14). the epidemics that appeared in the falling roman empire and generally in western europe during the middle ages found the existing medicine inadequate, and, a big part of the urban population was lost. according to the galenic theory transmission of disease from human to human is not possible because disease has an internal cause, that is, the imbalance of the four humors. nevertheless, the authorities of big cities took drastic measures in order to contain the epidemics. consequently, in 1377 the authorities of ragusa (known as dubrovnik in modern day croatia) decided to isolate those who arrived at the city port from areas afflicted with the plague for 30 days in a nearby island. in 1397 the duration of the isolation was extended to 40 days (quaranta, hence the term quarantine). in milan whenever a new case of the plague was observed in a house, all the residents were locked in and left to die. although seemingly barbaric, this measure limited mortality from the plague to 15% in milan, compared to 25% in the rest of europe and 60% in florence alone. the quarantine in its modern sense as an institution for disease control through isolation of patients owes its existence to the epidemics of the middle ages and the decisions of political authorities of the time (5). at the height of the plague there were over 200 institutions for treating the diseased in england and scotland, and around 2000 in france (14). specialized institutions were also built for the treatment of hansen’s disease called the leper colonies, which were something between infirmaries and places of isolation (14). the medical school of salerno was founded in the eleventh century by four professors according to tradition: a latin, a greek, an arab and a jewish master, symbolizing the interaction of these civilizations. in the twelfth century ad universities were established with four faculties of medicine, law, arts and theology in bologna (1180), paris (1200), oxford (1200) and other cities (24). these universities were in fact unions of professors and their main characteristic, as opposed to monasteries and cathedral schools, was the recognition and awarding of degrees (25). recognition of university degrees started in 1224 when frederic ii issued an edict stating that physicians who wanted to practice in the kingdom of naples had to have a degree from the university of salerno and the approval of the professors (hippocratic school) (14). in order to obtain a university degree, students had to attend anatomy lectures mainly on galenic anatomy and perform anatomical dissections of human and animal cadavers. this was similar to the established practice in the anatomy dissection halls of modern universities. although christianity was dominant in medieval europe, astrology, magic, alchemy and other superstitions were also practiced. the royal touch as a cure for scrofula (tuberculous lymphadenopathy) (23), itinerant lithotomy (removal of stones from the head of psychiatric patients), spells from priests and other healing ceremonies are examples of such superstitions. towards the end of the 13th century the first pharmacies were founded in italy. they were designed after the al-qairawan hospital and mosque in tunisia (26), which had been built under the aghlabid rule in 830. al-qairawan was a simple structure but adequately equipped with halls organized into waiting rooms, a mosque, and a special bath. pharmacies were initially part of monasteries, but later evolved into private stores that physicians frequented not only to buy medicine, but also to meet colleagues and even to examine patients. the chemist himself was often an astrologist and alchemist at the same time (14). gradually chemists formed a separate guild while they followed the advice of the local doctor and even performed some medical procedures. in this way the pharmacy became a new type of infirmary. during the middle ages insanity was considered a manifestation of “divine punishment” or the consequence of sin, and psychiatric patients were confined to home under the care of their families. these patients were later detained in abandoned towers, fortresses or monasteries where epileptics, criminals and orphans were also held (for example fools’ towers in germany). such institutions were mostly intended for detention rather than treatment. in london bethlem royal hospital was founded around 1247 ad and devoted to st. mary of bethlehem with the initial prospect of reinforcing relations between england and the holy land. around 1403 ad it started hosting ill, insane and elderly people and by the mid 15th century was transformed into an insane asylum, and that is why the name bedlam refers to a mental institution (27). conclusion the infirmary as we know it today did not exist during antiquity and the middle ages, but the various precursors of the modern hospital evolved due to the interaction between medical theory and j med ethics hist med 7:21 dec, 2014 jmehm.tums.ac.ir efstathios drampalos et al. page 6 of 6 (page number not for citation purposes) practice. these institutions were influenced by and at the same time influenced the production of new theories about the origins and treatments of diseases. during antiquity the hippocratic work and the theory of humorism as well as several other books decisively contributed to the creation of the asklipieion, an institution with predetermined structure and specialized rooms, instrumentation and personnel created to help the diseased. mobile military infirmaries were set up by ancient greek and roman soldiers and along with this kind of infirmary, military medicine also evolved. later in antiquity new types of infirmaries appeared alongside the private practice for physicians. during the middle ages the first modern hospitals were developed as a result of the advancements in islamic medicine. although there was little progress in medical theory during medieval times, evolution of the infirmary continued. some crucial elements influencing the process were christian religion and charity. large medieval infirmaries were built in constantinople, but caring for patients was mostly the responsibility of clergymen in monasteries. later in medieval west priests stopped practicing surgery and gradually physicians and universities took over medicine and treatment of diseases. medical theory started evolving again and science played a crucial role in the process. soon in renascence the infirmary and medical theory started on a rapid course of evolution and acquired their modern characteristics. considering all the above it is evident that the modern infirmary is more than a place for treatment of diseases. it is the result of a long process of scientific development, the relations between people or even counties and the way humanity perceives its nature and the future. references 1. chalmers af. what istthis thing called science. indianapolis: hackett publishing company incorporated; 2013. 2. apollodorus a. the library of greek mythology. oxford: oxford university press; 2008. 3. gray a. the hercules furens of euripide. cambridge: cambridge university press; 1910. 4. gouni o. ancient greek “asklipieions”. http://www.ionianet.gr/olgagouni/epidaurus.htm (accessed in 2014). [in greek] 5. lindberg dc. the beginning of the western science: the european scientific tradition in philosophical, religious, and institutional context, prehistory to a.d. 1450, 1th ed. chicago: university of chicago press; 1992. 6. miller ts. the birth of the hospital in the byzantine empire. usa: johns hopkins university press; 1997. 7. hippocrates. on the workshop of a doctor. athens: zitros publishing; 2001. [in greek] 8. hippocrates. pertaining to the woman’s nature. athens: kaktos publishing; 1992. [in greek] 9. lloyd g. the greek science after aristoteles. crete: crete universrity press; 2007. [in greek] 10. homer. iliad. athens: deagostini publishing; 2005. [in greek] 11. byrne eh. medicine in the roman army. classic j 1910; 5(6): 267-72. 12. allason-jones l. health care in the roman north. britannia 1999; 30: 133-146. 13. baker p. the roman military valetudinaria: fact or fiction. abstract book of the annual conference of the theoretical archaeology group. university of birmingham: 1998. 14. margotta r. history of medicine. darby: diane publishing co.; 2001. 15. ellis s. archaeology’s interactive dig: the house of surgeon. http://interactive.archaeology.org/pompeii/field/11.html (accessed in 2014). 16. capriceci ac. pompeei: 2000 years ago and today. firenze, bonechi publications; 2007. 17. larijani b, zahedi f. an introductory on medical ethics history in different era in iran. daru 2006; (suppl 1): 10-16. 18. magner ln. a history of the life sciences. new york: crc press; 2002, p. 66-76. 19. simon j. men and medicine in the middle east: a factual and pictorial assessment of what 20 countries are doing to raise their peoples health standarrds and how the world health organization (who) is assisting them, 1th ed. the who regional office for the eastern mediterranean; 1967, p. 35. 20. syed ib. islamic medicine: 1000 years ahead of its times. j islam med assoc north america 1981; 13: 6-13. 21. lyons as, petruccelli rj. medicine: an illustrated history. new york: h. n. abrams; 1978, p. 295–317. 22. 22. mcgrew r. encyclopedia of medical history. usa: mcgraw hill; 1985, p.135. 23. 23. lecca v. introduction to the history of medicine. athens: national and kapodistrian university of athens publications; 2011. [in greek] 24. 24. papadopoulos g. notes of the history of medicine. athens: national and kapodistrian university of athens publications; 2009. [in greek] 25. 25. grant e. physical science in the middle ages. cambridge: cambridge university press; 1971. 26. 26. hamarneh sk. health sciences in early islam. texas: zahra publications; 1983, vol 2, p. 102. 27. 27. lecca v. history and theory of psychiatry. athens: national and kapodistrian university of athens publications; 2011. [in greek] http://www.ionianet.gr/olgagouni/epidaurus.htm http://interactive.archaeology.org/pompeii/field/11.html journal of medical ethics and history of medicine the compatibility between shiite and kantian approach to passive voluntary euthanasia soroush dabbagh 1 , kiarash aramesh 2* 1.assistant professor, iranian institute of philosophy, tehran, iran. 2.assistant professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. *corresponding author: kiarash aramesh address: no. 21, 16 azar ave., tehran, iran. tel: (+98) 21 66 41 96 61 e-mail: kiarasharamesh@tums.ac.ir received: 17 jul 2009 accepted: 16 dec 2009 published: 24 dec 2009 j med ethics hist med. 2009; 2:21. © 2009 soroush dabbagh and kiarash aramesh.; licensee tehran univ. med. sci. abstract keywords: kantian ethics, shiite ethics, euthanasia. introduction euthanasia is one of the most controversial topics in current medical ethics. euthanasia which means mercy killing, "involves someone doing something to bring about someone else's death-in particular, killing or letting die-with the intention that the person die because the death is in the best interests of the person who will die"(1). there are six types of euthanasia which have to be distin guished from each other as follows: active volunta ry, passive voluntary, active non-voluntary, passive euthanasia is one of the controversial topics in current medical ethics. among the six well known types of euthanasia, passive voluntary euthanasia (pve) seems to be more plausible in comparison with other types, from the moral point of view. according to the kantian framework, ethical features come from 'reason'. maxims are formulated as categorical imperative which has three different versions. moreover, the second version of categorical imperative which is dubbed 'principle of ends' is associated with human dignity. it follows from this that human dignity has an indisputable role in the kantian story. on the other hand, there are two main theological schools in islamic tradition which are called: ash’arite and mu’tazilite. moreover, there are two main islamic branches: shiite and sunni. from the theological point of view, shiite's theoretical framework is similar to the mu'tazilite one. according to shiite and mu’tazilite perspectives, moral goodness and badness can be discovered by reason, on its own. accordingly, bioethical judgments can be made based on the very concept of human dignity rather than merely resorting to the holy scripture or religious jurisprudential deliberations. as far as pve is concerned, the majority of shiite scholars do not recognize a person’s right to die voluntarily. similarly, on the basis of kantian ethical themes, pve is immoral, categorically speaking. according to shiite framework, however, pve could be moral in some ethical contexts. in other words, in such contexts, the way in which shiite scholars deal with pve is more similar to rossian ethics rather than the kantian one. j med ethics hist med 2009, 2:21 soroush dabbagh and kiarash aramesh page 2 of 4 (page number not for citation purposes) non-voluntary, active involuntary and passive involuntary (2). considering the distinction between killing (active euthanasia) and letting die (passive eutha nasia), it seems that the latter is less challenging in comparison with the former, intuitively speaking. in fact, the willful act of killing is absent in the latter. moreover, voluntary euthanasia seems more plausible in comparison with the involuntary and non-voluntary ones, as it is in accordance with the principle of respect for autonomy. therefore, we are inclined to conclude that passive voluntary euthanasia (pve) is more plausible in comparison with other types. in this paper, we are going to compare the mu'tazilite and kantian approach to pve. the structure of the paper is as follows: the mu'tazilite theological approach and its similarity with the shiite framework are discussed. then, the main themes of kantian ethics are talked about and the similarities and differences between shiite mu'tazilite approach and kantian perspective, as far as pve is concerned, are explored. finally, some implications of the mentioned comparison are explained. shiite and mutazilite theological frameworks many people in all over the world look for the answers of their fundamental questions with regard to life and death, in their believed religion. this is true in islamic countries as well. one of the fundamental issues, brought about by modern medical technologies, is euthanasia. the exact approach of islam towards this very issue has a crucial role in the life and death of many people in such countries. the islamic world can be divided into two main branches: shiite and sunni, each with similarities and differences in religious jurispruden tial, theological and ethical school(s). while the majority of the muslims (about 90%) are sunni, the majority of iranians (again, about 90%), on the other hand, are shiite. moreover, the shiite islam shapes the majority of the populations in azerbai jan, bahrain and iraq, as well as considerable minorities in other muslim countries such as lebanon, kuwait, afghanistan and pakistan. shiite muslims, like other muslims, follow qur'an and the teachings of the prophet muham mad. nevertheless, in contrast to other muslims, they believe that the prophet's family (ahl al-bait), including a certain chain of his descendants known as imams, have special spiritual rule over the community. likewise, there are two main theological schools in the islamic tradition which are called: ash’arite and mu’tazilite. from the theological point of view, shiite theoretical framework is similar to the mu'tazilite one (3). according to ash’ariyyah thoughts, there is no such thing as intrinsic and essential moral goodness and badness, because reason and its products cannot stand on their own feet in a way that they have not epistemic justification at all. rather, they should be taken into account in the light of scripture and the prophetic tradition in order to grasp their own epistemological value. on the other hand, according to the shiite-mu’tazilite perspective, moral goodness and badness can be revealed by reason, on its own. hence, bioethical judgments can be made based on reasoning rather than purely resorting to the holy scripture or jurisprudential deliberations. of course, today, the mainstream of shiite scholars believe that reason has a hermeneutical role, according to which one has to do his best to understand the exact meaning and the implications of the scripture, the prophetic tradition and the imams' one. furthermore, they rely on reason, on its own, in the cases in which reason arrives at decisive conclusions (ghat'). thus, according to shiite ethical and jurisprudential framework, ethical judgments should be made based on both the holy scripture and reason. moreover, nowadays, a movement which can be dubbed ' reviving mu'tazilite thought' emphasizes on the indisputable role of reason in arriving at justified religious jurisprudential and ethical judgments (4). kantian ethical framework kantian ethics is the most influential and con troversial version of classical deontologism. according to this deontologistic account, there is no such thing as moral value in the phenomenal world. however, it does not follow from this that we cannot give a plausible account of the way in which we arrive at justified moral judgments, from the philosophical viewpoint. rather, the idea of categorical imperatives and good will which are associated with the idea of noumen in the kantian sense gives an account of morality. it follows from this that kantian ethics is non-empirical and a priori. according to kant, to the extent that moral subject exercises his freedom; the idea of normativ ity which we are looking for in the realm of morality emerges. moreover, categorical impera tives and its different versions which are the product of the exercising of good will is what has to be taken into account in order to arrive at justified moral judgment. in other words, several moral properties like goodness, badness, and moral principles such as:'thou shall not lie', 'thou shall not kill' which are not taken from the external world, could be gleaned from three different formulations of categorical imperatives. in fact, moral principles which are categorical, have to be applied in http://en.wikipedia.org/wiki/azerbaijan http://en.wikipedia.org/wiki/azerbaijan http://en.wikipedia.org/wiki/bahrain http://en.wikipedia.org/wiki/iraq http://en.wikipedia.org/wiki/lebanon http://en.wikipedia.org/wiki/kuwait http://en.wikipedia.org/wiki/afghanistan http://en.wikipedia.org/wiki/pakistan http://en.wikipedia.org/wiki/qur%27an http://en.wikipedia.org/wiki/muhammad http://en.wikipedia.org/wiki/muhammad http://en.wikipedia.org/wiki/shi%27a_imams j med ethics hist med 2009, 2:21 soroush dabbagh and kiarash aramesh page 3 of 4 (page number not for citation purposes) different ethical contexts in order to arrive at tenable moral judgments (5). let us see different versions of categorical imperatives in details at this stage. according to the first formulation, one has to treat others in a way that he requires others to treat him. this formula tion is dubbed ‘universalizability’ thesis. second formulation deals with human dignity and empha sizes that one has to take into account others in the realm of morality not only as means but also as ends. this formulation is dubbed 'principle of ends'. the third formulation talks about the way in which moral agents have to be engaged in the process of legislating in a community. in fact, what is issued by an autonomous moral agent in different ethical contexts would be justified and tenable. this formulation is categorized as 'kingdom of ends' (6). furthermore, we have to bear in mind that kantian ethics is a substantive rather than a formal one. in fact, as far as normative ethics is concerned, kant does not say anything straightforwardly. rather, formulations of categorical imperatives have to be concretized in different contexts in order to arriving at tenable moral judgments. moreover, these three formulations of categorical imperatives talk about one thing, though from different perspectives. shiite/ kantian approaches to pve there are three main schools which are dis cussed in current normative ethics: deontologistic ethics, consequentialistic ethics and virtue ethics. it seems that these thoughts can be found within the islamic tradition as well (7). let us make the point clearer at this stage. the way in which eternal reward and punishment is categorized in several verses of qur'an is associated with the conse quences of acting or avoiding to do something which is morally relevant. for instance, 'telling lie' is forbidden, since the one who lies will receive punishment in his eternal life. in contrast, 'truth telling' is morally justified, as a result of which, one will receive reward in her eternal life. moreover, this account which covers the ethical attitude of the majority of muslims is not the only way of reading the tradition, from the moral point of view. moreover, as far as islamic philosophical tradition is concerned, virtue ethics’ thoughts are more justified and plausible. the ultimate purpose of being engaged in morality is arriving at virtuous person who acts morally without any reservation. on the other hand, the way in which moral conscience is discussed in islamic scripture in a way is similar to that in the deontologistic account (8). as we have seen the very idea of duty and moral obligation is elaborated in a transcendental and non-empirical sense in the kantian ethics, nevertheless this notion does not have the same metaphysical background in islamic ethics. rather, it is said that 'conscience' is internalized in human beings by god. however, the deontologisitc ethicists and their counterpart proponents in islamic tradition are similar in saying that in order to arriving at tenable moral judgment we have to disregard the consequences of the supposed action and just go ahead according to moral codes which are the requirements of our conscience . as we have in the above, the second version of the kantian ethics which is dubbed 'principle of ends' is associated with human dignity. bear in mind those moral maxims which originates from categorical imperatives in the kantian story are a priori. it follows from this that the idea of human dignity has to be understood in the transcendental and non-empirical sense. moreover, it is only related with practical reason in the kantian sense which, on its own, issues moral maxims, regardless of god and his commands which are revealed in the scriptures. on the other hand, human dignity is empha sized and talked about in the holy qur’an. for example: “we have honored the sons of adam; pro vided them with transport on land and sea; given them for sustenance things good and pure; and conferred on them special favors, above a great part of our creation” (17:70). human dignity is fundamental in understanding the tradition’s key bioethical concepts such as: distributive justice, common good, right to life and right to health care. according to the mu'tazilite framework, one can use human dignity as a reliable basis which is emphasized by the scripture; therefore, it can shed light on debatable bioethical issues in the islamic world such as euthanasia in general, and pve in particular. in such a way, the plausibility of human dignity not only can be grasped through the reason, by its own, but also it is rooted in the god’s will which makes it more reliable and acceptable by muslim communities. having considered both the kantian and the shiite-mu'tazilite notions of human dignity, at this stage, let us utilize these approaches in order to see whether or not pve is justified. it can be said that in both kantian and shiite ethical perspectives, self-destruction is immoral, as it originates from disregarding human dignity. moreover, pve is an example of self-destruction as one willingly refuses to accept life-saving interven tions. therefore, generally, pve is immoral in both approaches. however, the absoluteness of immorality of pve, in both approaches is challengeable. ross tried to rehabilitate the kantian deontologistic ethics by introducing the notions of 'prima facie duty' and 'actual duty' in twentieth century. according to him, the way in which kant formu lates his categorical imperatives is counter http://www.ascensionhealth.org/ethics/public/key_principles/distributive_justice.asp http://www.ascensionhealth.org/ethics/public/key_principles/common_good.asp http://www.ascensionhealth.org/ethics/public/issues/right_life.asp http://www.ascensionhealth.org/ethics/public/issues/right_healthcare.asp j med ethics hist med 2009, 2:21 soroush dabbagh and kiarash aramesh page 4 of 4 (page number not for citation purposes) intuitive, as it is not compatible with our common sensual moral intuitions. in fact, in the rossian story, prima facie duties have ontological merits while actual duties have the epistemological one and are action-guiding. in ethical cases in which different prima facie duties come into conflict, we have to use our intuition in order to arrive at the more stringent prima facie duty which makes our actual duty (9). for instance, imagine cases in which we are confronted with two patients with cardiac arrest, both of them need life-saving treatments. however, because of the limited resources (only one ventilator is available); we are obliged to choose between them. in this case, a patient is an old man with cancer who has been in persistent vegetative state for a couple of years, and the other one is a young girl who is victim of an accident and otherwise healthy. at the first glance, it sounds plausible to choose the young girl and save her. in this case if the old man had signed an informed consent and requested not to be resusci tated after his cardiac arrest, we have committed pve and this act does not seem immoral, intuitive ly speaking. similarly, according to islamic and shiite jurisprudence, committing pve is not immoral either. most shiite authorities verdict that in moral dilemmas in which we are obliged to select between saving an established (mustaghar rah) and a non-established (gheyr-emustaghar rah) life, we should choose the former (10). an established life is the one which is not likely to end in the near future, but the non-established life is the one which is likely to end in the near future (e.g., cases of brain death). on the other hand, based on the kantian approach, which considers the permis sibility of pve as categorical; it is very difficult to make a decision in such case and probably the only solution will be relying on the blind chance. having considered the rossian approach to pve, it seems that the way in which shiite scholars deal with pve is more compatible with the rossian perspective rather than the kantian one, in general. in fact, according to shiite scholars the impermis sibility of pve is not categorical, as kant believes. rather, in the cases which we are confronted with conflict, committing pve could be moral (11). conclusion in conclusion, it can be said that, according to kantian ethical framework, committing pve is immoral. moreover, based on shiite thoughts, it can be said that committing pve is immoral, though it could be moral in some ethical contexts. in other words, the way in which shiite scholars deal with pve is more similar to rossian ethics rather than the kantian one. moreover, the discussed similarities between kantian and mutazilite-shiite ethics can be regarded as a promising ground for establishing a common global ethics. meanwhile, achieving common standards of good practice and compiling cross-cultural ethical codes is possible accordingly. j med ethics hist med 2009, 2:21 soroush dabbagh and kiarash aramesh page 5 of 4 (page number not for citation purposes) references 1. kamm fm. ending life. in: rhodes r, francis l, silvers a, eds. the blackwell guide to medical ethics. malden, ma: blackwell publishing; 2007, p. 142. 2. motahari m. adle elahi. tehran: sadra; 1981, p. 11-45. 3. aramesh k. human dignity in islamic bioethics. iran j allergy asthma immunol 2007; 6(suppl 5): 27-30. 4. fanayi a. din dar tarazouye akhlagh. tehran: serat; 2005, p. 23-47. 5. kerstein sj. kant's search for the supreme principle of morality .cambridge: cambridge university press; 2002, p. 139-60. 6. caygill h. a kant dictionary. oxford: wiley-blackwell; 1995, p. 171-5. 7. soroush a. types of religiosity. in: soroush a. mobasser n, jahanbakhsh f, eds. the expansion of prophetic experience: essays on historicity, contingency and plurality in religion. leiden&boston: brill academic publishers; 2009, p. 181-192. 8. motahari m. falsafeh e akhlagh. tehran: sadra; 1989, p. 53-5. 9. audi r. ethical reflectionism. monist 1993; 76: 295-315. 10. mohammadi a. ghatl az mavaane’e erth ast. http://www.ghavanin.ir/paperdetail.asp?id=294 (accessed on nov 2009) 11. dabbagh s. in defence of four principles approach in medical ethics. iran j public health 2008; 37(1): 31-8. journal of medical ethics and history of medicine evaluation of moral competency using standardized patient: presenting an experience fariba asghari 1* , bagher larijani 1,2 1.medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. 2.endocrinology and metabolism research institute, tehran university of medical sciences, tehran, iran. *corresponding author: fariba asghari address: no.23, medical ethics and history of medicine research center, 16 azar st., tehran, iran. tel: (+98) 21 66 41 96 61 e-mail: fasghari@tums.ac.ir received: 03 jan 2010 accepted: 08 sep 2010 published: 30 oct 2010 j med ethics hist med. 2010; 3:5. © 2010 fariba asghari and bagher larijani; licensee tehran univ. med. sci. abstract keywords: evaluation, medical ethics, osce, standardized patient. introduction one of the important challenges in medical ethics education is the evaluation of trainees. evaluation of students' competencies is one of the essential tools for assessing success of education programs in accomplishment of its objectives. on the other hand, evaluation is a major determinant of students' learning patterns. in other words what is not evaluated will not be considered important (1, 2). evaluation method should be compatible with educational objectives. some believe that ethical evaluation of medical students should emphasize on ethical knowledge and moral reasoning while some others think that in addition to these objec tives, compassion, respect and altruism are essential moral competences which need to be evaluated (3). it means that although moral reasoning is an important goal, this competency does not necessarily end to ethical and professional practice of students. the other challenge in moral evaluation is that how it is possible to evaluate students` attitude and values and ethical practice in a valid and in this study we discuss our experience of including an ethics objective structured clinical examination (osce) station in endocrinology board exam. one osce station on truth telling was developed and a standardized patient was trained for role playing in this station. based on a pilot study, the evaluation checklist got modified. then the finalized station added into the osce phase of endocrinology board exam. based on this experience, adding ethics station in board exams is practical and reasonable. since osce method could evaluate students' ethical decision making and communication skill it could be used in combination with other kinds of evaluation in assessing ethics competency of graduates. using this method could push the ethics learning approach toward more practical and skill based ones. j med ethics hist med 2010, 3:5 fariba asghari and bagher larijani page 2 of 4 (page number not for citation purposes) reliable way (4). in published literatures there are so many papers introducing and discussing different tools for evaluation of ethical attitude, reasoning and behavior (2, 5-7). defining issue test (dit), sociomoral reflection measure (srm), and moral judgment interview (mji) have been developed for evaluation of moral reasoning, not being enough specific they are used generally for research purpose though (8). in practice, for evaluation of students' medical ethics competency, methods such as multiple choice questions, short essay, portfolio, objective structured clinical examination (osce), faculty evaluation and 360 degree evaluation are being used (2, 7). although there is no consensus among ethicists on the best evaluation method, they all agree that different methods should be used (7). one method which is able to evaluate trainee's competencies in practice is osce. this method not only evaluates trainee’s ethics knowledge but also assesses their moral reasoning and ethical behavior. nowadays increas ing number of medical ethics osce stations are including in comprehensive exams in different educational phases in medical schools around the world (2, 9-11). in iran, there is a consensus about the necessi ty of evaluation of graduate's ethical competency among medical education leaders and they have mandated adding some medical ethics multiple choice questions (mcq) to pre-internship compre hensive exam, residency entrance exam, annual residency and board exam. since multiple choice question method alone is not enough for moral competency evaluation, we decided to assess practicality of evaluation of ethical competency by designing and conducting an osce station for medical ethics. success of this method could convince educational leaders to use other methods for evaluation of graduate's ethical competency. in this paper we present our experience of including one medical ethics station in seven endocrinology osce stations of endocrinology board exam. method we used bioethics osce experience of to ronto center for bioethics to design one station on truth telling. the scenario is about an inoperable pancreatic cancer patient whose wife asks physi cian not to tell the diagnosis to the patient. a standardized patient played the role of the patent’s wife in this station and talked to examine physi cians. we used a ten item checklist to rate physi cians' interaction in this station. we also used two global rating questions using likert scale to score their ethical decision making and communication skill. this station was pilot tested in a medical eth ics education workshop in may 2009 which the standardized patient was trained for. in pilot conduct of this station some ethics teachers and bioethics phd students had participated. one of workshop attendees participated as the examinee and other six participants rated his performance. all scores were very close to each other, indeed 5 out of six participants gave the same mark to the examinee and the reliability of station was 0.83. participants also evaluated the face and content validity of the checklist. based on their suggestion one item added to the checklist hence the station and its checklist got standardized. the finalized station included in the osce part of the endocrinology board exam in september 2009. nineteen physicians took this exam. time for each physician's interview with simulated patient in ethics station was 5 minutes. one rater (first author) was present in the station to fill checklists and rate examinees. results most participants had good to excellent com munication skill and only one participant did not communicate with the standardized patient and easily accepted her request (table 1). in their ethical decision making, %26 (5) of participants had poor performance and only 3 of them had good or acceptable ethical encounter. most participants asked for the patient's wife reason for her request (15 people) and almost all of them (18 people) mentioned that patient had right to know about his condition. the most prevalent mentioned justification for patient's right was the need to plan for the rest of life (12 people). two people told that patient might ask about his condition and one participant gave several different reasons for refusing her request such as she is not telling lie to patient because it is unprofessional, finally patient would find out they were hiding something form him, also if he heards about his condition he would lose his trust on physicians and would be affected by a worse emotional stress. nine participants refused to withhold the truth from patient, however no one acknowledged the patient's right not to know. all of them believed that they had to give information to the patient in any case. mean number of mentioned items by partici pants was 3.53 out of 11(1-7). there was a signifi cant correlation between participant's score of communication skill and score of their ethical decision making (r=0.48, p=0.03). although the mean score of board osce for those with good ethical performance was higher, this correlation was not significant (table 2). a positive correlation has been observed between participants' osce score and their communication skill score but it was not significant. mean ethical performance score of female participants (2, 17) was significantly higher than male ones (1.43 out j med ethics hist med 2010, 3:5 fariba asghari and bagher larijani page 3 of 4 (page number not for citation purposes) of 5) (p=0.01), however there was no significant difference between their communication skill. discussion small though, this experiment showed practi cability of conducting and including an osce ethics exam in evaluation of trainees. low score of participant's ethical performance was due to lack of training in their educational course and we could not expect them to show good ethical competency just by reading ethics text books. osce is a good method for integrated evalua tion of trainees’ knowledge and skills in facing with ethical dilemmas. this method of evaluation could improve teaching and learning methods. evaluation method is an important determinant for learner's learning behaviors (5). if we just use multiple choice questions for evaluation of ethics competency, students learning will be limited to knowledge while using methods that could evaluate their moral judgment and behavior will encourage them to learn practical ethics competencies. moreover standardized patient could be used as a teaching method. in teaching medical ethics besides reflection and discussion on ethical dilemmas, students need to practice their ethical skills and receive feedbacks on their practice (13). we should notice that osce method alone is not enough for precise evaluation of ethical practice. since the pattern of all ethics station could be recognized by students and they could get ready for showing good competency in those stations, being able to have ethical performance is not equal to having ethical practice (5). in other words, osce method is not able to evaluate students' ethical attitude. thus other evaluation methods such as 360 degree evaluation are needed to assess this dimension of educational objectives in medical ethics (2). furthermore osce method is very costly and having enough number of ethics station will pose logistical difficulties. in a study con ducted by singer et al, 4-6 ethics station had internal consistency reliability (cronbach's α) of 1.28 to 0.46. they estimated that at least 41 ethical stations are needed in an osce test for achieving acceptable internal consistency of 0.8 (12). although inter-rater reliability of our station in its pilot phase was good, because of small sample size in the pilot study, we should have evaluated its reliability in the main study. unfortu nately due to logistical problems we were not able to have two raters, so we did not evaluate inter rater reliability of the station. the other important pitfall of our study was that one station has not content validity for assessing ethical performance. in other words, we could not be sure of ethical competency of physi cians in encountering with different types of ethical problems in their professional life through watch ing their conduct in facing with just one ethical problem. conclusion this study showed that it is practical to de velop an ethics station in comprehensive medical exams in different phase of medical education course and this method could motivate medical students to learn ethical practice. despite all straight points of this evaluation method, it should be noticed that conducting one or two osce station in graduate comprehensive exam is not enough for evaluation of their ethical practice and other complementary evaluation methods such as continuous peer and faculty evaluation of students during their educational course are necessary. page 4 of 4 (page number not for citation purposes) j med ethics hist med 2010, 3:5 fariba asghari and bagher larijani table 1. frequency (percent) of ethical performance and communication skill score of endocrinology board examinee. poor fair good very good excellent attention to ethical issues 5 (26.3) 11 (57.9) 3 (15.8) 0 (0.0) 0 (0.0) communication skill 1 (5.3) 0 (0.0) 6 (3.16) 5 (26.3) 7 (36.8) table 2. mean score of board exam of participants with different level of ethical performance and communication skill. poor fair good very good excellent total pay attention to all ethical issues mean score of osce board exam 79.8 77.1 90.3 79.9 number 5 11 3 0 0 19 communication skill mean score of osce board exam 75 76 79.8 84 79.8 number 1 0 6 6 7 19 page 5 of 4 (page number not for citation purposes) j med ethics hist med 2010, 3:5 fariba asghari and bagher larijani references 1. calman kc, downie rs. practical problems in the teaching of ethics to medical students. j med ethics 1987; 13(3): 153–6. 2. campbell av, chin j, voo tc. how can we know that ethics education produces ethical doctors? med teach 2007; 29(5): 431-6. 3. miles sh, lane lw, bickel j, walker rm, cassel ck. medical ethics education: coming of age. acad med 1989; 64(12): 705-14. 4. boon k, turner j. ethical and professional conduct of medical students: review of current assessment measures and controversies. j med ethics 2004; 30(2): 221-6. 5. wong j, cheung e. ethics assessment in medical students. med teach 2003; 25(1): 5-8. 6. savulescu l, crisp r, fulford kw, hope t. evaluating ethics competence in medical education. j med ethics 1999; 25(5): 367-74. 7. mattick k, bligh j. teaching and assessing medical ethics: where are we now? j med ethics 2006; 32(3): 181-5. 8. eckles re, meslin em, gaffney m, helft pr. medical ethics education: where are we? where should we be going? a review. acad med 2005; 80(12): 1143-52. 9. singer pa, cohen r, robb a, rothman a. the ethics objective structured clinical examination. j gen intern med 1993; 8(1): 23-8. 10. beaulieu md, rivard m, hudon e, saucier d, remondin m, favreau r. using standardized patients to measure professional performance of physicians. int j qual health care 2003; 15(3): 251-9. 11. tchorz km, binder sb, white mt et al. osce training in ethics and palliative care: a pilot study during the surgical clerkship. j surg res 2008; 144: 184-5. 12. singer pa, robb ak. the ethics osce: standardized patient scenarios for teaching and evaluating bioethics, 1994. http://wings.buffalo.edu/bioethics/osce.html (accessed in 2010) 13. edinger w, robertson jd, skeel j, div m, schoonmarler j. using standardized patients to teach clinical ethics. medical educ online 1999; 4(4). http://www.med-ed-online.org (accessed in 2010) ____________________________________________________________________________________________________________________________________________ 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____________________________________________________________________________________________________________________________________________ 1 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e original article volume 13 number 3 may 2020 copyright © 2020 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. personal factors affecting medical professionalism: a qualitative study in iran *corresponding author zahra shahvari azad university complex of gachsaran, ferdousy blvd., gachsaran, iran. postal code : 7581863876 tel : (+98) 74 32 33 533 email : shahvarizahra@gmail.com received: 28 dec 2018 accepted: 20 april 2020 published: 5 may 2020 citation to this article: alipour f, shahvari z, asghari f, samadi s, amini h. personal factors affecting medical professionalism: a qualitative study in iran. j med ethics hist med. 2020; 13: 3. fateme alipour1, zahra shahvari2*, fariba asghari3, shahram samadi4, homayoun amini5 1.associate professor, eye research center, farabi eye hospital, tehran university of medical sciences, tehran, iran. 2.assistant professor, department of nursing and midwifery, islamic azad university of ghachsaran, ghachsaran, iran. 3.associate professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. 4.associate professor, department of anesthesia and intensive care, school of medicine, tehran university of medical sciences, tehran, iran. 5.professor, department of psychiatry, school of medicine, tehran university of medical sciences, tehran, iran. abstract professional behavior with patients and interactions with colleagues, the institution and professional bodies are influenced by many factors. the purpose of this manuscript is to clarify those personal factors affecting medical professionalism in clinical settings affiliated with tehran university of medical sciences. for this purpose, a qualitative study was carried out. one hundred and eighty-two participants were recruited through purposive sampling of clinical staff, physicians, and medical students in tehran. data were collected through 22 focus group discussions, and conventional content analysis was used to analyze the data. the results were reported in five categories to present the participants’ views. categories were extracted from 103 codes and consisted of 1) people's belief in professionalism, 2) personality traits, 3) problems in family, 4) mental or physical health status, and 5) communication skills. the results showed that despite the facilitator roles of some personal factors, others act as barriers to professional behaviors. in order to control their impact, it is crucial to pay attention to them at the time of student/staff selection. strengthening support systems in the organization is also essential for decreasing the effect of family problems or physical and mental health problems. keywords: medical professionalism; clinical setting; qualitative research; professional behavior; personal factors personal factors affecting medical professionalism: a qualitative study in iran 2 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 3 may 2020 introduction medical professionalism refers to attitudes, behaviors and relationships (1) that medical professionals should adhere to, in order to be trusted by the society. while trust is a key component of medical professionalism (2), there is some evidence that social trust in medical professionals is decreasing (2). adhering to the rules of professionalism could improve social trust and quality of care in clinical settings. commitment to professional behavior in clinical settings is a well-accepted principle categorized under patients' and colleagues' rights, and is considered the responsibility of clinical staff at any level. however, professional behavior toward patients and also interactions with colleagues, institutions and professional bodies are influenced by many factors (3). some of these factors act as barriers and challenge professional behavior. barriers refer to those conditions that make commitment to professional values difficult for medical staff (3). in facing barriers to professionalism, those who are not trained or lack sufficient experience may show lapses. attempting to remove these barriers leads an organization to create a professional climate (4). efforts to recognize and remove or lessen these barriers seem necessary, and so does increasing knowledge in medical professionals. some researchers recognized certain aspects of factors that affect professionalism, for instance time constraints, workload, and difficulties in interacting with challenging patients (5), and some identified further factors (6). among the factors affecting professionalism, personal factors have not received sufficient attention; despite their importance, their aspects have not all been evaluated and very few articles have attempted to assess them. however, personal factors have been noted as being significant in predicting professional learning activities (7). some research articles have pointed to personal factors indirectly, for example “physicians’ knowledge, attitude and behavior” (6) or "individual culture" (8). the role of personal factors in adhering to professional behavior has been discussed more directly in some articles, but these are either general (9) or based on review articles (10). researchers blame some personal factors such as personality traits and lack of communication skills for threatening fundamental professionalism elements such as empathy. they have categorized the personal factors that can potentially impact professional behavior in 3 groups: 1) personal well-being, including quality of life, balance between personal and professional life, burnout, depression and stress; 2) personality traits such as motivation, work ethics, integrity; and 3) interpersonal qualities and skills such as communication skills, compassion, cynicism and detachment (10). like any other capability, professionalism is a context-based concept (11) as are its related factors. it seems reasonable to perform qualitative research in order to alipour f., et al. 3 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 3 may 2020 identify the challenges to professionalism. we evaluated these challenges in the clinical settings affiliated with tehran university of medical sciences (tums), and since they were considerable and diverse, we had to report each category separately; one of these categories was personal factors. as managing patients in clinical settings is a team effort involving different levels of care providers, we decided to include all levels of clinical staff in our study, although the focus group sessions were held separately for each group (i.e., attending staff, nurses and trainees). in our view, personal factors are rooted in personal character and attitude and develop throughout life. they start from early childhood or are the result of difficulties in ongoing personal life, and lead people toward professional or unprofessional behaviors. the purpose of this manuscript is to clarify those personal factors affecting medical professionalism in clinical settings. methods this study was part of an extended qualitative research project on identifying barriers to maintaining professional behaviors in clinical environments using focus group discussions (fgd). ethical considerations the protocol of the study was approved by the ethics committee of tehran university of medical sciences. there were no requirements for participation in the research. accepting an invitation to attend the focus group sessions was considered as consent to participate in the study. the purpose of research was introduced at the beginning of each session and the participants were assured that the discussions would be kept confidential and only the overall results would be reported. however, they were free to withdraw at any time. the data were collected during 22 focus group discussions (fgds) with 182 faculty members, residents, interns, nurses, midwives, and other clinical staff. fourteen sessions were held with non-physician staff, 6 sessions with faculty members and residents, and 2 sessions with interns. numbers of sessions were determined based on the total number of each group (i.e., attending staff, nurses and trainees) in the university and hospitals, considering the mean accepted invitation for attending in the sessions. subjects were invited by faculty (faculty members), student agents (residents and interns), and the nursing bureau of the university (nurses), considering their age, sex, and work experience. response rate was 70% for faculty members, 90% for residents and interns, and 95% for nurses. inclusion criterion was education or occupation in one of the 13 hospitals affiliated with tums, and exclusion criterion was unwillingness to participate in the study. the participants were selected using selective sampling and according to the aims of the research. to ensure all themes were identified, attempts were made to include participants with maximum diversity in terms of age, work personal factors affecting medical professionalism: a qualitative study in iran 4 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 3 may 2020 experience, work location, grade and field of study. the sessions were conducted by 2 of the authors (shahvari z. and alipour a.) in all 13 hospitals affiliated with tums for maximizing rate of participation. the mean number of participants in each session was 12. fgds ranged in length from 90 to 120 minutes (mean = 105.71 minutes). data were collected between october 2015 and march 2016. in order to inform the participants about codes of ethics, they were provided with a list of codes of professional conduct based on tums codes (12) at the beginning of the sessions. participants were asked to review the items and express their comments regarding barriers to observance of each item or overall barriers to maintaining a high standard of professional behavior. after each session, the related audio files were transcribed, and the researchers gained an overall sense of each session through frequent readouts of the transcripts. as the next step, the transcripts were coded. data analysis and verification all fgds were audio recorded, transcribed verbatim, and checked for accuracy. the data were analyzed using conventional content analysis and version 10 of the maxqda software. data analysis was begun during the data collection phase, and after each fgd, the notes were written down. at the end of each session, two of the authors (shahvari z. and alipour a.) listened to all fgd recordings carefully. the important concepts were recognized and transcribed, and all the transcriptions were re-checked for accuracy. the coded document was discussed by the research team again and revisions were made based on unclear codes. for data categorization. codes were defined based on the information obtained from the first interviews and revised and completed through reading all the transcripts (13). categories emerged by inductive reasoning via careful inspection and continuous data comparison (14). to establish trustworthiness of the findings, we tried to win the trust of the participants by providing a safe environment. no relevant data were excluded or irrelevant data included during data analysis. in addition, the research team tried to increase the validity of the data through long-term engagement and data immersion. the transcripts and codes were verified in group sessions held by the research team. the researchers reanalyzed the corrected transcripts and modified discrepancies in code extraction. results we reached 103 codes around the personal factors affecting medical professionalism (table 1). alipour f., et al. 5 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 3 may 2020 table 1personal factors affecting professional behaviors codes sub-categories categories p e r so n a l fa c to r s different families and different morals what they have learned from family not believing in honesty in family at all • familial background clinical staff’s belief in professionalism unwillingness to take part in teamwork justification of unethical behavior in society misuse of others’ professional behaviors • society-based norms being cautious • special traits personality traits being introverted being influential lack of respect for older generation caring about own comfort irresponsibility different values losing the spirit of patience having a different definition of work ethic being self-centered • different millennium generation features facing problems in family life paying loans • common problem family problems outside the workplace the kids getting sick facing trouble in life • sudden events having rheumatologic problems being tempted to resign suffering from various ailments • poor physical health mental or physical health status being aggressive insulting a colleague • poor mental health interacting well with each visitor calming the atmosphere • good communication skills communication skills being sulky even with each other not knowing how to talk to patients • poor communication skills results are organized according to five categories that clarify those personal factors, affecting professional behavior in clinical settings: 1) clinical staff’s belief in professionalism, 2) personality traits, 3) problems in family, 4) mental or physical health status, and 5) communication skills. an overview of the results is presented in figure 1. figure 1personal factors affecting professional behaviors personal factors i. clinical staff’s belief in professionalism  familial background  society-based norms ii. personality traits  special traits  millennial generation traits iii. family problems outside the workplace iv. physical or mental health status v. communication skills personal factors affecting medical professionalism: a qualitative study in iran 6 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 3 may 2020 i. clinical staff’s belief in professionalism this subcategory refers to those causes of professional misconduct that are related to personal beliefs. beliefs could be categorized as rooted in “familial background” and/or “society-based norms”. familial background this category refers to the norms derived from beliefs that originate in the family. one of the residents said, “different families have different morals. people may have been raised in families with lower moral and ethical standards. not all people are born in moral families. some people do not believe in honesty at all… whenever a situation is not going well, they turn their back on their own immoral nature”. another resident said, “personal character should not be neglected. some people have good character and some do not, some people adhere to professional behavior even when they are under high pressure, and some just act professionally under normal situations. nothing can be done; this is based on their past and what they have learned from family or school.” society-based norms these refer to the norms rooted in the society, including the educational and work environments that medical professionals are part of before entering into clinical practice. our participants believed “unwillingness to take part in teamwork”, “justification of unethical behavior in society”, and “misuse of others’ professional behaviors” were some negative norms based in the society. also, “lack of moral attitude in the society” was considered as an important barrier to professionalism. in this regard one of the residents asked, "why should clinical staff behave ethically while other people in the society do not?” behaviors such as lack of adherence to honesty, failure to respect others, egoistic interest-seeking behaviors, and the spread of disrespect and distrust in the society were some of the negative social behaviors that the participants mentioned. in their opinion, medical staff is affected by these trends in the society. participants pointed out the distrust in interactions between clinical staff and patients, and physicians, patients and staff-managers. in their view, when teamwork is not appreciated in the society, people are not interested in it and will not make an effort to promote it. participants were also concerned about others’ misinterpretation of their professional behaviors. one of the nurses said, “if i respect the ward worker who is much older than me he won’t do his job perfectly….” ii. personality traits participants in this study believed that personality traits are among personal factors that push people toward or away from professional behavior. some participants believed that reserved or introverted people have difficulty in effective communication with patients. one of the nurses commented, “i have seen many knowledgeable, talented professors who are so immersed in the books that they do not even hear others greeting them! so they have the same behavior with patients and colleagues”. one resident said, “in the last flu outbreak, even when we stated that in our opinion as infectious disease subspecialists, there is no need for alipour f., et al. 7 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 3 may 2020 isolating the patients and observing them from a safe distance and wearing a surgical mask would suffice, many of the nurses and interns avoided approaching the affected patients.” the role of impressive traits as a positive factor was also emphasized. one of the interns said, “some people are different from others. they affect their environment. the environment is the same for all of us, but some people always think about patients as their very first priority. we don’t have the right to behave unprofessionally in less than optimal situations, and there are some people in this environment that control the circumstances and make them better.” in this regard, a difference was noted between the millennial generation and the older generation. many of the medical students and clinical staff belong to the millennial generation. they have different values and performance. losing the spirit of patience and tolerance, having a different definition of work ethic and work conscience, and being self-centered were mentioned as a major difference that may act as a barrier to professional behavior. one of the nurses said, “the new generation cares more about their own comfort than anything else. they like to earn the highest salary with the least effort… they do not like to bother themselves to help their colleague….” iii. family problems outside the workplace anyone may face problems in their family life that are unrelated to the work environment. these problems could affect people’s performance, including their interactions with others. one of the participants said, "sometimes a problem in the family causes an individual to be aggressive. we all have families; (for example) our child may become sick…. when someone has trouble in his or her life, she or he certainly cannot offer full service to others.” iv. physical or mental health status from our participants’ point of view, physical or mental health status will affect one’s professional behavior. one of the nurses said, “some employees have poor physical health that makes them unfit to work in the clinical setting, and some have poor mental health. there are people who are so aggressive; they insult a colleague over a small issue, while they seem to be so polite and advise others to be calm and polite! however, some have good mental health and don’t have any communication skill problems.” work in the hospitals may also exacerbate some physical and mental problems. one of the nurses said, “even a very resistant person cannot tolerate the situation for more than 10 years. after ten years you will end up suffering from various ailments. i myself have rheumatologic problems, sometimes i'm tempted to resign.” v. communication skills some participants believed that poor or rich communication skills are affected by effective interaction with patients. one nurse said, “some employees have good communication skills and interact well with each visitor, some are sulky even with each other.” the excuse of some participants for failure to communicate effectively with patients was high disparity at a socio-cultural level. personal factors affecting medical professionalism: a qualitative study in iran 8 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 3 may 2020 one nurse said, “in our workplace, the cultural and social level is low. one does not know how to talk to patients so they won’t be angry.” the participants believed that lack of communication skills also affects managers’ and staff’s interactions. one of the nurses said, “if i protest to my manager that my salary is low, he does not pay attention. he just wants us to work; he does not even sympathize with me because he cannot understand me.” discussion the results of this study confirm and extend previous findings (10, 15). clinical staff’s belief in professionalism in our participants’ view “belief in professionalism” is a significant factor for professional behavior. it is rooted in “familial background” and “society-based norms". in stressful settings, people’s moral beliefs will make them behave professionally, and those who do not believe in the necessity of observing their own professional behavior will follow the dominant atmosphere (4). “low conviction” (16), “negative attitudes toward criteria for medical ethics” and “no belief in compliance with ethical codes” were mentioned as barriers to professionalism commitments (17). thus, it seems reasonable to pay attention to professional attitude when choosing people for studying or working in clinical majors/environments. overcoming problems caused by the norms stemming from the society requires interinstitutional collaboration. one example identified in this study was teamwork problems. our participants believed this was rooted in society-based norms. although many reports emphasize the importance of teamwork in clinical settings (18, 19), and insist that professionalism truly is a team effort (4), teamwork in iran suffers from numerous weaknesses. as kalantari et al. suggested, “to improve teamwork and increase quality of behaviors, utilization of educational solutions can be effective” (20). however, managers need to pay more attention to the personnel’s ability to work as team members at the time of recruitment. rectification of all erroneous society-based norms through involvement of the concerned organizations (such as the ministry of education and other cultural bodies) is also recommended. in addition, the role of education should not be neglected, both at the level of academic curriculum and in continuing education. "justification for unethical behavior" is also a problem at the society level. many societies face a decline in moral values, and since clinical staff members come from the same community, they may also be affected. therefore, raising personnel's moral awareness by organizing regular educational events such as in-depth ethical/professional case discussions in hospitals may cause resistance to wrong social norms. "my colleagues take advantage of my professional behavior" was one issue mentioned by some participants, while others believed that it could not be generalized and was a kind of objection to workload or "justification for unethical behavior". since professionalism is an interactive behavior, this is a result of lack of awareness about professional commitment, or failure to clarify everyone's duties. in case of "justification", alipour f., et al. 9 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 3 may 2020 interventions that increase the clarification and close supervision of each ethical code have been shown to be effective (21). moreover, ethical salience decreases justifications by increasing self-awareness (22). personality traits from the perspective of our participants, cautious and introverted characters may negatively affect professional climate, especially in the field of effective communication, and conversely, people with a positive, impressive character will improve professional climate. some researchers also believe that certain personality traits are related to the attitude of people to work and work atmosphere (9). based on our findings, being cautious, introverted, or charismatic are among these traits. in one research, medical students who were extroverted and self-confident had better social performance (23). introverted and cautious people have difficulty in socializing and this may make behaviors such as empathy and communicating with patients or colleagues difficult. personal traits hardly ever change, so paying attention to them at the time of student selection and job allocation seems necessary. unfortunately, though, the only criterion for student selection in any clinical major is currently their achievement in an mcq exam. for those members of the staff that are already in a job position, consultation, proper task allocation and education may diminish these negative effects. in this study, participants talked about the millennial generation. challenges between different generations seem to be a worldwide problem. older generations have difficulty in understanding and respecting the millennial generation (24). the new generation of learners sees the world differently and may have a different perception of professionalism. this highlights the need for the teachers to clarify the expectations of students as they interact in classrooms and clinical settings (25). the millennial generation asks for work-life balance. it does not like ambiguity and demands clear, straightforward rules and interactions (26). each profession must clarify its behavioral standards to make sure the needs of those it serves are addressed (27). in order to improve professional behavior in this generation, institutions need clear instructions, guidelines and processes. family problems outside the workplace & physical or mental health status “family problems outside the workplace” and “physical or mental health status” were mentioned in this study as factors that affect professional behaviors. in our opinion, such factors may lead to emotional exhaustion, which has been reported as somehow related to participation in professional learning activities (7), and in this study to behaving in a professional way. professionalism may require accepting some degree of inevitable risks (e.g., dealing with patients who have contagious diseases or personality disorders. at the same time, work-life balance is important and should not be neglected (28). happiness is affected by different factors, particularly by satisfaction with mental health (29). some professional behaviors, for instance altruism, are directly linked with happiness and health (30). according to levinson, organizations must decrease mental concerns for health professionals in personal factors affecting medical professionalism: a qualitative study in iran 10 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 3 may 2020 practicable ways (4). existing support systems in an organization may decrease the psychological burden of personal problems on individuals. communication skills our participants mentioned occasions when disrespect from low social level patients led them to act unprofessionally. in some previous studies, “unusual expectations of patients” and “patients' inappropriate behaviors” were mentioned as barriers to professionalism (16, 17, 31). although challenging patients are considered a barrier to professional climate (5), those with effective communication skills can connect with everyone for treatment purposes, regardless of their social and cultural levels. since cultural beliefs add to the complexity of health promotion strategies in health care (32), it seems that some clinical staff consider professionalism rules reciprocal and do not think that everyone deserves to be treated professionally! insufficient training, unawareness of professionalism rules and weak communication skills could be the reasons for this discrimination. the need for support and/or additional communication skills training was also emphasized. however, cultural sensitivity includes knowledge of the preferred communication styles of different cultural groups (33). weakness in communication skills not only affects interaction with patients, but also causes difficulties in interaction with colleagues. inappropriate behavior among medical staff was mentioned in a study as one of the ethical issues in neonatal intensive care units (34). it should be remembered that inappropriate feedback and insufficient support from managers and colleagues will decrease job satisfaction and moral sensitivity (35 37). as sprangers et al. emphasized, “egos, lack of confidence, lack of organization, and structural hierarchies hinder relationships and communications” (38). one communication intervention study demonstrated that the style of speech between nurses and residents was mostly neutral, and positive and negative communications were less common (38). we believe that by providing communication skills training for staff, hospitals can support patient-centered care. likewise, by demonstrating respect and support for clinicians in daily interactions, hospital administrators can model the same behaviors (4). our results were somehow different from the available classifications (10).we emphasized “clinical staff’s belief in professionalism”, although in previous studies, professional attitudes were considered as a personal factor that could predict professional learning activities (7). furthermore, this study added “family problems outside the workplace” and “mental or physical health status” to the personal well-being subcategory, as well as “cautious, introverted and impressive character” in the personality traits subcategory of walt and shanafelt classification. however, more research is needed for detecting other personality features that may also affect the individual's professional behavior. the researchers were successful in winning the trust of the participants by providing a safe environment for expressing their experiences, and all participants were involved effectively. a large sample size from all levels of clinical care providers, and attending all 13 alipour f., et al. 11 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 3 may 2020 hospitals affiliated with tehran university of medical sciences were the strong points of this study. although researchers used the strategy of maximum variation, they realize that this study was a qualitative research and may not be generalizable to clinical settings with different cultural backgrounds. referring a qualitative study to a specific geographical region was one limitation of this study. moreover, the results were based on participants’ perspective and may be affected by their judgment or mood. conclusion different personal factors may affect professionalism in clinical settings. despite the facilitator roles of some personal factors, some others act as barriers for professionalism. there are some differences in personality traits between the old and the millennial generation. not all personalities are considered functional in any given major including medicine and its branches, and some of these factors like personality traits hardly ever change. in order to control their impacts, it is essential to pay attention to them at the time of student selection (for nursing, medical or any clinical majors). also, personality traits should be considered in job allocation at the time of hiring staff. training staff will control personal norms and beliefs and improve their communication skills, and strengthening support systems in the organization may decrease the psychological burden of personal problems on individuals. acknowledgements researchers are grateful to tums nursing office, faculty of medicine deputy of education, and managers of imam khomeini and shariaty hospitals who helped us to conduct this study. we would also like to thank all nurses, students, physicians and other people who participated in the focus group discussions. conflict of interests none declared. personal factors affecting medical professionalism: a qualitative study in iran 12 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 3 may 2020 references 1. london rcopo, editor doctors in society: medical professionalism in a changing world: technical supplement to a report of a working. uk: royal college of physicians of london; 2005. 2. cohen jj. professionalism in medical education, an american perspective: from evidence to accountability. medical education. 2006; 40(7): 607-17. 3. lesser cs, lucey cr, egener b, braddock ch, linas sl, levinson w. a behavioral and systems view of professionalism. jama. 2010; 304(24): 2732-7. 4. levinson w, ginsburg s, hafferty f, lucey cr. understanding 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romijn-luijten a. communication skills training in a nursing home: effects of a brief intervention on residents and nursing aides. clinical interventions in aging. 2015; 10: 311-9. ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ 1 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e © 2019 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. original article volume 12 number 11 september 2019 clinical teachers as positive and negative role models: an explanatory sequential mixed method design *corresponding author ali asghar hayat sina-sadra halls complex, neshat ave., shiraz, iran. tel: (+98) 0713 23 33 064 email: ali.hayat63@gmail.com received: 31 dec 2018 accepted: 7 july 2019 published: 4 sep 2019 citation to this article: bazrafkan l, hayat aa, tabei sz, amirsalari l. clinical teachers as positive and negative role models: an explanatory sequential mixed method design. j med ethics hist med. 2019; 12: 11. leila bazrafkan1, ali asghar hayat1*, seyed ziaaddin tabei2, leila amirsalari3 1.assistant professor, clinical education research center, shiraz university of medical sciences, shiraz, iran. 2.professor, department of medical ethics and philosophy in health care, school of medicine, shiraz university of medical sciences, shiraz, iran. 3.researcher, department of pathology, school of medicine, shiraz university of medical sciences, shiraz, iran. abstract today, role modeling is an essential component of medical education that facilitates the students' learning and affects their attitudes and behaviors. hence, this study aimed to examine the characteristics of positive and negative role models using a mixed method approach. in the quantitative part, data were collected using a questionnaire with 24 items. the research population included medical students who were in their clinical period between may 2017 and december 2018 at shiraz university of medical sciences (n = 750). a total of 282 questionnaires were completed by these students, and in the qualitative part, 26 semi-structured interviews were conducted with them. the most important components of role modeling for students included: individual characteristics, clinical skills and competence, teaching skills and professionalism, in that order. the qualitative analysis confirmed the results of the quantitative analysis. the findings showed that the characteristics of a negative role model can also be classified in four main components. the results demonstrated that 46.8% of the students identified one or more medical teachers as negative models. students paid attention to not only the positive characteristics of their teachers, but also their negative features, stating that they had been influenced by both. therefore, it can be concluded that clinical teachers should improve their performance as positive role models through reducing these negative effects and reinforcing positive characteristics. keywords: role model; clinical teacher; medical education; medical students https://www.ncbi.nlm.nih.gov/pubmed/?term=tabei%20sz%5bauthor%5d&cauthor=true&cauthor_uid=25512836 clinical teachers as positive and negative role models … 2 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 11 september 2019 introduction today, role modeling is an integral and essential component of medical education (1 5). role models facilitate medical students' learning and affect their attitudes, behaviors and ethics (2 4, 6 9). moreover, they form the students' values and professional identity and influence their behavior regarding provision of care services. in other words, students' professional identity develops by observing their teachers communicate and interact with patients, colleagues and others (2, 7, 10 13). in this regard, some researchers believe that training by way of modeling is one of the most effective methods to transfer experiences and improve students’ professional attitudes (6, 14). it helps medical students to develop high standards of professionalism and affects their career choices and satisfaction (2, 15). students learn through observing their teachers and emulating their behavior not only in clinical and formal settings, but also in other situations (4). therefore, teachers should understand that their interactions and behaviors could impact students (1, 2, 7, 16) both in a positive and negative manner (2, 7, 16). students directly observe their teachers’ positive and negative behaviors. in this regard, wright discovered that more than 50 percent of the faculty members were not perceived as positive role models by the residents (17). medical students often saw a discrepancy between what they had learnt in the classroom and what they observed in other settings (18). therefore, clinical teachers should always be conscious that all their interactions, personal views, behaviors and attitudes are observed and followed by students under the circumstances (18). previous studies on role modeling showed that personality traits, teaching skills and clinical competence are the key components for medical students in selecting role models (2, 4, 5, 19). in a study by wright and carrese (2), the results showed that certain features of role modeling pertained to several domains such as personal characteristics (interpersonal skills, positive attitude, commitment to excellence, growth, integrity and leadership), and teaching behaviors (establishing rapport with learners, development and promotion of specific teaching methods and philosophies, and commitment to improving learners). moreover, perceived barriers to an effective role model comprised being impatient, stubborn and reserved; going too far; and having difficulty remembering names and faces (2). the results of another study by wright et al. (1) showed that the most important factors in selecting role models were personality, clinical skills and competence, and the ability to teach, while research achievements and academic position were the least important. the study also showed that 90 percent of the students had selected a teacher as a role model while they were in medical school (1). several studies have been conducted on characteristics of role models, but most of them have been sporadically carried out in western countries using a quantitative or qualitative approach, and may not have covered all aspects of role models. in iran, there has been little research on role modeling (20); thus, given the significant bazrafkan, l., et al. 3 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 11 september 2019 effect of role models in all areas of clinical education and their efficacious impact on personality formation, identity and professional behavior of medical students, this study was an attempt to fill this gap using a mixed method design. methods this study was conducted using an explanatory sequential mixed method design, which includes a two-phase scheme. in the first phase, the researcher gathers quantitative data and analyzes the findings, and in the second, uses the results to design (or build onto) the qualitative part. the general purpose of this project was to collect qualitative data that would help explain in more detail the initial quantitative results and explore them in more depth (21). the quantitative phase of the study participants were medical students from shiraz university of medical sciences in their externship or internship periods in the years 2017 2018 (n = 750). they were selected from among the students in the hospital and dormitories using convenience sampling. in this section, we first developed a 27-item questionnaire by reviewing the literature and background related to role model components identified in previous studies (2, 5, 12, 22 24). content and face validity were used to examine the validity of the questionnaire, and three questions that did not meet the criteria were subsequently eliminated. second, kaiser-meyer-olkin (kmo) and bartlett’s test of sphericity indicated that the use of factor analysis and classification of questions were permissible (bartlett = 1602.95; p-value ≤ 0.01). the results of the kmo test (0.71) showed that research data were suitable for factor analysis. finally, the results obtained by factor analysis (principal components analysis) with varimax rotation confirmed that there were four factors in the items, which were then classified into four groups: individual characteristics, teaching skills, clinical skills and competence, and professionalism. internal consistency reliability was assessed through composite reliability (cr) and cronbach's alpha, and the values were over the recommended criterion of 0.7 for all constructs. to determine the convergent validity, factor loadings and average variance extracted (ave) were assessed. if all item loadings are greater than 0.7, they can be considered appropriate (25), and according to the findings, all the items indicated a loading higher than 0.7 on their corresponding construct with appropriate ave ranging from 0.51 to 0.68. therefore, reliability and validity of the research constructs were attained. the students were then asked to give their views about each item in a 5-point likert-scale questionnaire. in total, 282 questionnaires were completed and returned by the participants. the data were analyzed using spss version 16 and smart pls2, and descriptive statistics (mean and sd) and inferential statistics (one-way anova and independent t-test) were also applied. the qualitative phase of the study in the second stage, we used a qualitative clinical teachers as positive and negative role models … 4 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 11 september 2019 research approach with purposeful sampling to explore medical students’ perceptions and experiences of role modeling in their clinical teachers through semi-structured interviews. after explaining the aims of the study, we asked the participants to answer the following questions: “is there a teacher in shiraz university of medical sciences who has positive role model characteristics?”; “describe the characteristics of a teacher who is a positive role model.”; “is there a teacher in shiraz university of medical sciences who has negative role model characteristics? (anonymous)”; and “describe the characteristics of a teacher who is a negative role model (anonymous)”. we conducted a total of 26 interviews with medical students. it is important to state that data were saturated in the 22nd interview when no further new data were obtained, but we continued to the 26th interview. each interview lasted 25 to 40 minutes. all interviews were recorded and then typed. qualitative content analysis was used for data analysis after adjusting the notes obtained from the interviews. first, we read and reviewed all the texts line by line repeatedly to achieve immersion and obtain an overall understanding of the subject. then, we extracted the initial codes and continued the process. the extracted codes were reread frequently and sorted into subcategories based on their similarities. next, we compared the subcategories with one another and placed them in broader categories based on their similar characteristics. to ensure reliability and validity, we used four criteria: credibility, transferability, dependability and confirmability, introduced by guba and lincoln in the 1980s (26). in addition, to ensure qualitative rigor, we used member checks when coding as well as peer debriefing, and confirmed the results with the participants. for this study, we obtained permission from the research ethics committee of shiraz university of medical sciences (ir.sums.rec.1387. s3967). however, anonymity of the students was provided using id codes, written informed consent was obtained from each participant, and confidentiality of the identities of both students and teachers was considered. results the quantitative phase of the study the response rate in this study was 75.6%. after collecting the questionnaires and eliminating the low validity ones, 282 questionnaires were analyzed. descriptive analysis showed that the students’ mean age was 23  3.37, and 39.4% were students, 35.8% externs, and 24.8% interns. in terms of gender, 33.7% were male and 66.3% female. based on the obtained information, the most important component of role modeling for students was individual characteristics, followed by clinical skills and competence, teaching skills, and finally professionalism. from the male students' perspective, the most important component was clinical skills and competence and the least important one was professionalism. according to the female students, the most important component was individual characteristics and the least important was professionalism (table 1). bazrafkan, l., et al. 5 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 11 september 2019 table1the most important components of role modeling from medical students’ point of view rank student (n=111) mean & sd extern (n=101) mean & sd intern (n=70) mean & sd male (n=95) mean & sd female (n=187) mean & sd total (n=282) mean & sd r 1 individual characteristics (4.48± 0.053) individual characteristics (4.46± 0.51) clinical skills & competence (4.45± 1.22) clinical skills & competence (4.11± 0.65) individual characteristics (4.51± 0.50) individual characteristics (4.38± 0.58) r 2 teaching skills (4.25± 0.56) teaching skills (4.26± 0.52) individual characteristics (4.11± 0.68) individual characteristics (4.38± 0.62) teaching skills (4.28± 0.52) clinical skills & competence (4.22± 0.76 r 3 clinical skills & competence (4.16± 0.51) clinical skills & competence (4.14± 0.53 teaching skills (3.94± 0.66) teaching skills (3.96± 0.65) clinical skills & competence (4.19± 0.82 teaching skills (4.18± 0.59) r 4 professionalism (3.87± 0.68) professionalism (3.91± 0.62) professionalism (3.66± 0.57) professionalism (3.74± 0.72) professionalism (3.88± 0.60) professionalism (3.83± 0.64) sd= standard deviation the anova test showed a significant difference in all four components of role modeling based on the students’ educational level (p < 0.01). consequently, scheffe’s post hoc test was used to investigate the difference between the groups of students (based on educational level) in terms of role model components (table 2). table 2comparison of students’ views at different levels regarding role model components anova ss df ms f pvalue post hoc individual characteristics between groups 6.90 2 3.452 10.60 0.001 stu > ext within groups 90.85 279 0.326 stu > int* total 97.76 281 ext > int* teaching skills between groups 5.20 2 2.603 7.78 0.001 stu < ext within groups 93.22 279 0.334 stu > int* total 98.42 281 ext > int* clinical teachers as positive and negative role models … 6 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 11 september 2019 anova ss df ms f pvalue post hoc clinical skill & competence between groups 4.82 2 2.411 4.18 0.016 stu > ext within groups 160.87 279 0.576 stu < int* total 165.64 281 ext < int* professionalism between groups 2.927 2 1.464 3.55 0.030 stu < ext within groups 114.90 279 0.412 stu > int total 117.83 281 ext > int* *. the mean difference is significant at the 0.05 level stu: student; ext: extern; int: intern; ss=sum of squares; df= degree of freedom; ms= mean square finally, the independent t-test showed that there was a significant difference in the two components of clinical skills and competence, and professionalism between male and female students’ views (table 3). table 3comparison of male and female students’ views regarding role model components p-value t-test mean difference sd mean sex 0.001 -5.37 -0.40 0.65 4.11 male individual characteristics 0.50 4.51 female 0.001 -4.39 -0.31 0.65 3.96 male teaching skills 0.52 4.28 female 0.36 0.91 0.08 0.62 4.28 male clinical skills & competence 0.82 4.19 female 0.08 -1.73 -0.14 0.72 3.74 male professionalism 0.60 3.88 female sd= standard deviation the qualitative analysis in general, the results of the participants' responses and the coding process showed that the characteristics of teachers who were positive role models were grouped in 5 main categories and 43 subcategories (table 4). bazrafkan, l., et al. 7 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 11 september 2019 table 4the characteristics of teachers who can be positive role models based on medical students’ views themes subthemes professionalism respect for and empathy with patients and students, respect for the rights of coworkers, appropriate behaviors, commitment to professional development, and accepting criticism. clinical skills and competence performing detailed examinations, sound clinical judgment and reasoning, good decision-making abilities, competence in patient management, diagnostic skills, the ability to manage rounds, cooperation, the capacity to monitor all aspects of treatment, and effective communication. teaching skills excellent and interactive teaching, employing new teaching methods, providing proper feedback, encouraging student participation in education. updated knowledge and information professional mastery, high academic achievements, updated information, using the power of knowledge, conducting valuable research. individual traits confidence, intelligence, the power to convey knowledge, piety and modesty, tireless, caring, ready to help others, committed and patient, good manners, punctuality, authority, the ability to adjust to the team, conscientiousness, sociability, creativity, and honesty. 1) professionalism the findings suggested that the students considered teachers with higher levels of professionalism as positive role models. in this regard, a participant pointed out, “a professor may set the students an example of treating patients and students with respect”. another participant argued, “a professor should possess a professional character and observe good manners”. 2) individual characteristics our findings showed that the students considered personal characteristics among the most important features of positive role models. one participant stated, “a doctor should treat their audience gently and be kind to them”. another student said, “i believe a professor should be kind and gentle”. 3) teaching skills the qualitative study results showed that from the students’ point of view, teaching skills were among the components of positive role models. in this regard, a participant stated, “not only is a professor expected to exhibit professional behavior, but also to deliver quality teaching, interact with students and provide what they need”. another participant said, “once a professor shows up in class, you have the feeling that she/he is doing her/his best to educate the students to accept responsibility. she/he would want to teach all that she/he has learned”. 4) clinical skills and competence our findings showed that the students considered clinical competence as an important feature of positive role models. one of the students stated, “to me, a good clinical teachers as positive and negative role models … 8 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 11 september 2019 clinical professor is a good physician who has sound clinical judgment and reasoning”. 5) updated knowledge and information the results revealed that the students were specifically concerned with the lecturers’ knowledge and scientific competency. in this respect, one of the students said, “in my opinion, a lecturer should have sufficient knowledge and expertise as well as good conduct and manners”. considering the question” is there a teacher in shiraz university of medical sciences who has positive role model characteristics”, the obtained result showed that 79 percent of the students acknowledged one or more teachers as role models, while about 6 percent explicitly stated that there was no positive role model at their university, and finally about 15% did not answer the question (table 5). table 5students’ answers about positive role models at the university question 2 positive answers negative answers no answers is there a teacher at the shiraz university of medical sciences who has positive role model characteristics? 222 (79%) 17 (6%) 43 (15%) as to the question “describe the characteristics of a teacher who is a negative role model (anonymous)”, the results obtained from the coding process showed that, based on the students' views, characteristics of a teacher who is a negative role model could be grouped in 4 main categories and 28 subcategories (table 6). table 6characteristics of negative role models based on students' views themes subthemes lack of professional behaviors bad behavior toward students, failure to respect the dignity of others, bad behavior toward patients and their relatives, regarding students as competitors, criticizing other teachers, looking at patients according to their specialty and not from a human perspective, mocking students, and not caring about student rounds. poor clinical competence lack of awareness of patients, undue insistence on diagnosis, failure to identify priorities, poor diagnosis, and weak clinical judgment and reasoning. insufficient knowledge and information inadequate knowledge, ignorance about scientific developments, outdated information, and inadequate familiarity with foreign languages. negative personal traits materialism and excessive regard for money, money worship, narcissism, bad temper, being too strict and inflexible, hypocrisy, being impolite, lack of confidence, being too proud, creating stress, low energy, selfishness, and lack of discipline. bazrafkan, l., et al. 9 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 11 september 2019 the qualitative analysis showed that students had observed an absence of professional behaviors in some of their teachers. in this regard, a participant pointed out, “i’ve witnessed several cases where the professor treated the students disrespectfully in front of the patients”. another participant said, “i have seen professors who look at patients materialistically and not from a human perspective”. the results showed that students considered negative personal traits as a negative feature of role models. one participant stated, “some professors are unpredictable. you cannot tell whether they are in a good or bad mood. they are moody”. another student said, “some professors are arrogant and don’t look at the people they are talking to. they behave as if there is no one around”. another participant said, “some professors are used to insisting on their own views with no regard for others’ circumstances”. the participants considered insufficient knowledge and information as negative features of role models. one of them pointed out, “in some classes, you notice the professor hasn’t updated himself/herself and just repeats what he/she has been teaching in the past years”. the results showed that 46.8% of the students acknowledged one or more teachers as negative role models, whereas about 24.82% stated that there was no negative role model in the university, and about 28.36% did not respond to this question (table 7). table 7students’ answers about negative role models in the university question 4 positive answers negative answers no answers is there a teacher at the shiraz university of medical sciences who has negative role model characteristics? 132 (28.36%) 70 (24.82%) 80 (28.36%) discussion teachers play a vital role in medical education, and shape the students’ professional life and identity (14, 19, 27). in order to better understand and improve role modeling as an educational strategy, we need to have a clear view of the determining factors that cause a teacher to be seen as a role model. the results showed that students considered individual characteristics to be among the most important features in this regard. these results are in line with the findings of previous studies (1, 2, 12, 28, 29). for example, wright and carrese (2) showed that such features as interpersonal skills, positive views, commitment to promotion and development, and honesty could be effective in making a lecturer a role model. in general, it can be said that the individual characteristics of teachers can be clinical teachers as positive and negative role models … 10 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 11 september 2019 powerful predictors for role modeling, and students pay special attention to their teachers’ characteristic traits. from the students’ perspective, teachers with the following personality traits were more interesting than others and had more positive effects: confidence, intelligence, the power to convey knowledge, piety, modesty, good manners, punctuality and the ability to adjust to the team; these teachers were also caring, helpful, committed and patient, authoritative, conscientious, sociable, creative and honest. therefore, we can conclude that medical students are sensitive to their professors’ behaviors in all circumstances, and pay special attention to their conduct and characteristics. for that reason, professors should be aware of their behaviors and personality traits in educational environments, and constantly be careful about everything they say or do. in line with previous research, the students in this study considered their teachers’ clinical skills and competence among the most significant aspects of role models (1, 2, 5, 12, 22, 24, 2831). in this respect, a study by wright et al. (1) on the impact of role models on students showed that clinical competence is one of the significant factors in selection of role models. it is the essence of medical education to ensure the best practices and to care for patients. the results showed that students considered the value of optimal patient care in the selection of these components as important factors in role modeling. based on the students’ views, medical teachers made good role models if they had the following features: examined patient’s behavior thoroughly; had sound clinical judgment and reasoning, and excellent decision making abilities; had good patient management and diagnostic skills; could manage rounds efficiently; were cooperative; and had the capacity to supervise all aspects of treatment. the results also showed that teaching skills were regarded as the third important component of role models. this is in line with the findings of previous studies (1-3, 5, 22, 28, 31, 32), indicating that when professors improve their teaching skills, they will be more likely to be considered as positive role models. another finding of our study demonstrated that professionalism could act as a critical component of role modeling. the results suggest that teachers with higher levels of professionalism are considered as positive role models by students, which has also been highlighted in previous studies (10, 23, 33). some found that teachers’ professionalism can affect the students' selection of a teacher as a role model; hence, role modeling can be facilitated through interacting effectively, being compassionate toward others, behaving respectfully, practicing open and interactive communication, having a sense of humor, supporting the students fully and improving their self-esteem (23). in this regard, reuler and nardone (1994) concluded that self-criticism, responsibility, humility, and respect, sensitivity to patients and students are considered as characteristics of role models (34). the results of the qualitative analysis showed that the students’ views on the characteristics of positive role models could bazrafkan, l., et al. 11 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 11 september 2019 be classified into five main components including professionalism, clinical competence, teaching skills, updated knowledge and information, and individual characteristics. the qualitative results confirmed the quantitative results. in other words, the components and features of role models as extracted from the interviews were consistent with the results of the quantitative part of the study. the results also showed that 79% of the students reported at least one teacher at the university as a positive role model. in this regard, the results of wright and carrese’s study (2002) showed that 90% of the students identified a model or role model teacher during their studies at the school of medicine (2). students observe their teachers’ behavior directly, and therefore, clinical teachers can improve their performance through awareness of their impact as role models. they should always be conscious and understand that all their interactions, personal views, behaviors and attitudes are observed and followed by students in various situations. other results of the qualitative analysis showed that 46.8 percent of the students acknowledged one or more medical teachers as negative role models. based on the students’ views, characteristics of a teacher who is a negative role model can be classified into four main components including unprofessional behavior, poor clinical competence, insufficient knowledge and information, and negative personal traits. in this regard, some studies have shown that more than 50 percent of the university faculty members were not seen as positive role models by the residents (14, 29). in addition, some researchers have pointed out the influence of negative role modeling in clinical settings (35, 36). for example, in a study conducted by murakami et al. (2009), the result showed how the career choices and professional behaviors of students were adversely affected by negative role models (36). this issue occurs in the form of hidden curricula and in informal environments. similarly, white et al. (2009) showed how students’ values and behaviors were shaped through the perceived conflicts between formal and informal curricula in medical schools. they showed that during clinical clerkships, medical students experienced serious inconsistencies between what they had read and learned regarding patient-centered care in the first two years and what they observed in their role models in the third year (35). teachers have both positive and negative effects on the future professional behaviors of their students. there is a need for revision and consideration of all aspects of the learning environment, particularly the non-structured and hidden curricula, since these are the factors that determine students’ future professional behaviors. in other words, students are constantly observing and examining their professors' behaviors in all formal and informal environments, and are more affected by the latter. the results also showed that the students noted the professors’ negative roles in different circumstances. it is important to add that negative role models can have an equally strong influence on students' attitudes and professional behaviors, and students can clinical teachers as positive and negative role models … 12 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 11 september 2019 easily imitate these behaviors. considering the difficulty of controlling role models’ conduct, we should confirm the necessity of having a structured curriculum for teaching professional principles in medicine. hence, educational planners and policymakers, as well as professors, should pay special attention to the role of hidden curricula and its effect on the future professional behavior of students. finally, it is imperative that all clinical teachers be aware of their conduct and adopt proper techniques to reduce these negative effects. generally, although some studies have been conducted on role modeling, the present article is one of the few articles using mixed method design which yields a better understanding of role modeling. moreover, the other strength of this study is considering positive role models as well as negative ones mutually. this aspect of research will enrich the role modeling literature in the context of iran and will provide a new insight as to role modeling in medical education. conclusion this study revealed that the characteristics of medical teachers as role models could be classified in the following domains: individual characteristics, clinical skills and competence, teaching skills and professionalism, in that order. consequently, teachers' consciousness and self-awareness in education, personality, patient care and other behaviors are considered as the cornerstones of a good role model. consciousness and self-awareness are the two most important characteristics of any teacher dedicated to presenting exemplary (praiseworthy) behaviors both inside and outside the classroom. graduates’ future conduct will probably be dependent on these laudable behaviors in the classroom and outside. hence, it is expected of teachers to exhibit behaviors that reflect moral virtues in compliance with professional conduct. suggestions 1. encouraging and introducing positive role models and lecturers in the university to highlight appropriate conduct. 2. sharing the results of this research with teachers in order to increase their awareness and reflect on the characteristics of positive and negative role models, as teachers’ awareness is the first step in improving their performance as role models. 3. inviting positive role models to present and share their experiences with other teachers. 4. granting privileges to or facilitating the promotion of professors who are considered as positive role models in order to encourage positive behaviors and examples. 5. holding professional development programs for lecturers to improve their clinical skills, competence and teaching skills, as these are considered by students to be important features of role models. 6. holding self-reflection sessions for professors regarding their behaviors and individual characteristics such as piety and modesty, helpfulness, good manners, sociability and honesty. our results showed that these factors are crucial in effective role modeling. bazrafkan, l., et al. 13 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 11 september 2019 acknowledgements the authors wish to thank mr. h. argasi at the research consultation center (rcc) of shiraz university of medical sciences for his invaluable assistance in editing this manuscript. in addition, we would like to thank all the students who participated in this study and shared their valuable experiences. conflict of interests the authors declare that they have no conflicting interests. clinical teachers as positive and negative role models … 14 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m 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modelling—making the most of a powerful teaching strategy. bmj. 2008; 336(7646): 718-21. 30. côté l, leclère h. how clinical teachers perceive the doctor—patient relationship and themselves as role models. acad med. 2000; 75(11): 1117-24. 31. burgess a, goulston k, oates k. role modelling of clinical tutors: a focus group study among medical students. bmc med educ. 2015; 15:17. 32. jayasuriya-illesinghe v, nazeer i, athauda l, perera j. role models and teachers: medical student’s perception of teaching-learning methods in clinical settings, a qualitative study from sri lanka. bmc med educ. 2016; 16: 52. 33. jha v, mclean m, gibbs tj, sandars j. medical professionalism across cultures: a challenge for medicine and medical education. med teach. 2015; 37(1): 74-80. 34. reuler j, nardone d. role modeling in medical education. west j med. 1994; 160(4): 335-7. 35. white cb, kumagai ak, ross pt, fantone jc. a qualitative exploration of how the conflict between the formal and informal curriculum influences student values and behaviors. acad med. 2009; 84(5): 597-603. 36. murakami m, kawabata h, maezawa m. the perception of the hidden curriculum on medical education: an exploratory study. asia pac fam med. 2009; 8(1): 9. journal of medical ethics and history of medicine observance of ethical codes in selecting supervisor by postgraduate students zahra bayrami 1 , mohammad abdollahi 2* 1.ethics committee secretary, pharmaceutical sciences research center, tehran university of medical sciences, tehran, iran. 2.faculty of pharmacy, ethics committee manager, pharmaceutical science research center, tehran university of medical sciences, tehran, iran. *corresponding author: mohammad abdollahi address: pharmaceutical research center, tehran university of medical sciences, tehran, iran. postal box: 1417614411 e-mail: mohammad@tums.ac.ir received: 10 jan 2011 accepted: 07 feb 2011 published: 14 feb 2011 j med ethics hist med. 2011; 4:1. © 2011 zahra bayrami and mohammad abdollahi; licensee tehran univ. med. sci. abstract keywords: ethics, thesis, supervisor, doctorate students, research. introduction science, teaching, and learning in iranian cul ture have always been a prominent interestand under consideration of religious leaders, scholars and scientists who have provided the rules and instructions about teaching, learning and related ethical aspects in their writings and books. among them, abu al-nasr al-farabi (827 ce) in the books "tahssil al-saada" and "ara' ahl al-madina al fadila", mentions the purpose of education as improving human intellectual and moral virtues, and making her/him to be effective in prosperity of the society. avicenna (980 ce), who is one of the famous medical scientists of iran and the world and the books attributed to him is more than one hundred (1, 2), has discussed in 16 books that practice and teaching medical sciences is under direct influence of ethics (2). nasir al-din al-tusi (1201 ce) in "akhlaq e nasri" has provided opinions regarding the nowadays, with development of medical sciences, several ethical challenges have raised which make research more complicated. observance of student’s right in selecting interested research topic and the supervisor, in addition to its positive effect on the research process, will cause satisfaction and quality promotion in the educational system. to observe that issue, during a confidential survey of a number of postgraduate students in 2009, students were asked to confidentially describe any displeasure they might get during their study and research. the most important items included: imposing thesis by a supervisor without informing the student, compulsory assignment of students to a specific supervisor, little time allocated for students by the supervising team who may be selected without students interests, prolongation of the research time, and noncooperation in publishing the results. establishment of a proper way to transfer student’s displeasure or criticism to supervisors and establishing a continuous program for informing research teams including supervisors and students about ethical codes can positively affect the issue. http://en.wikipedia.org/wiki/avicenna j med ethics hist med 2011, 4:1 zahra bayrami and mohammad abdollahi page 2 of 4 (page number not for citation purposes) education, and in another book called "adab al mote'allemin" which has been attributed to him, studied the issue of education in details. this is the first independent book of an islamic scholar that exclusively discussed the subject of science in terms of characteristics of supervisors and students. also shahid e saani (1505 ce) in his famous book called "monia al-morid fi adab al-mofid va almostafid", introduced the characteristics and duties of the teacher and the learner comprehen sively. this book is the most complete and detailed book of a great shiite scholar in the subject of education. he has divided duties of the supervisor and student into three parts, including the relation ship between supervisors and students, special duties of supervisors, and special duties of students. today, some translations and rewritings of this book is available in persian (3, 4), and such resources can be used to explain the positions and rights of supervisors and students, providing detailed instructions and rules that are compatible with current teaching space in universities and training centers, and even to resolve deficiencies. in the past, it was common that seminary stu dents were used to select a teacher by themselves, and after a long duration of internal and external searching for this purpose, they had to follow his preferences and guidance directly as a mentor. in the history of culture, art and literature of islam and iran, carefulness in selecting the supervisor and then following his instructions and tips, along with politeness and humility for the grand position of the teacher, was guaranteeing the student luck to gain science and literature. so, since many of the student researches are performed as the thesis under supervision of supervisors, obviously creating a proper and continuous relationship between supervisor and student is necessary for achieving many higher goals of research activities during the period of study. the relationship between supervisor and student is not only a simple consultation and pre determined duty, but it is a voluntary, consistent, widespread, dynamic, interactive and truly support ing process between an experienced person with beginner and the final purpose is scientific, professional and personality development of the student. nowadays, with development of medical sciences, the related researches have become more complex in its various fields. therefore, considera tion of medical and research ethics and clear legislation in different cases, not only help re searchers, but also can identify their options and responsibilities as well as other team members, patients and subjects. since students, who are doing research and thesis under supervision of an academic member are main participants in many studies, obviously, their interests to research and the topic of the thesis has a direct influence on the speed and quality of research and moreover, has a great effect on student academic life. this issue is seen in the life of outstanding scientists and professors. therefore observance of students rights in selecting research topic and the supervisor, in addition to its influence on the research process will cause satisfaction and quality promotion of education in the teaching system. teacher with all his/her energy and ideas, make a relationship with student, and thus student will receive necessary guidance, support, and encouragement for advancement. therefore, in this study we aimed at exploring any closed complaint or displeasure among students in the matter of selecting research thesis and supervisor in a confidential manner and presenting some strategies for improving the situation. methods to realize the problems just in a very confi dential manner, a total of 30 postgraduate students in 2009 in the field of pharmacy or medicine at the campus of tehran university of medical sciences (tums), were asked to give their problems or complaints relevant to the issue of thesis and mainly the supervisor orally. duplicated or similar comments were classified as a single and general subject. the participants were guaranteed not to be disclosed for their names or specific issues. the points raised by students were examined by authors and solutions to these criticisms were proposed. results general issues that were stated by students were as follows: 1a person was imposed on the supervisors or advisors team that has not been selected by the student. 2a person has been added to supervisors or advisors team that did not have effective role in the implementation of thesis. 3the topic and main idea of the supervisor and student was transferred to another person because of various excuses. 4the number of supervisors and advisors was six while each student only needed one or maxi mum two and the rest had no role. 5some students complained of disrespecting to them by some department members or even advisors. 6there were conflicts between department members that resulted in harms for students 7the students were afraid to complain. 8some faculty members did not permit the student to get access to some laboratory instru ments. j med ethics hist med 2011, 4:1 zahra bayrami and mohammad abdollahi page 3 of 4 (page number not for citation purposes) 9some faculty members did not devote enough time to answer questions of students and solve their problems. 10despite of the existence of research funding, student had to pay for speeding up the process of the thesis. 11the student was not listed as the first author despite his/her main action. the above items raised by students were ex amined by authors and solutions to these criticisms were proposed as follows: 1informing faculty members of students’ com ments and criticisms that were never stated directly by students. 2establishing a continuous program to streng then knowledge and ethical attitude of faculty members (human willingness to learn and improve until end of life). 3providing hints for those who do not consider ethical codes in their relationships with students and are known as immoral. 4notifying ethical codes to both teachers and students. 5full respecting to students and well behaving with them. 6having good morals and professional ethics. 7having knowledge about ethics and behavior of youth and considering the level of scientific, welfare, and culture of students. 8being flexible to criticisms and revising bad behaviors. 9being positive, motivate students and not frustrate them 10continuously and confidentially reviewing teacher’s functions with observance of all ethical codes and maintaining their honor and dignity. 11no discriminating among students and no wasting their useful time 12using the most updated methods, tools and psychological principles in teaching. 13observance of principles, standards, work rules and disciplines. discussion although these issues often are considered and respected by faculty members, but considering the possible issues that cited by the students is effective in promoting current status. of course, students also have some vices that are complained by teachers and needs attention but they were beyond the subject of this paper. every teacher and faculty member is a men tor, and thus it is necessary for them to promote altruism and discussions in addition to scientific knowledge. in other words, supervisors should be powerful innovators in the direction of their scientific activities. most successful people believe that their successes owe to their teachers and supervisors, and conversely. impressibility of the students clearly shows the importance of the role of the supervisors in reforming the society. thus, fundamental transforms in any society depend on transformation of its educational system. mean while, teachers and supervisors are the main axis of development and evolution as constructors of scientific thoughts, the propagators of social values and deliverer of these values to the students, because the human resources is the first principle in training. even some considered teachers as educators of human and society, comparing their functions to prophets. in research ethics some items including ob servance of patients’ rights, data fabrication, data falsification, the other types of plagiarism, and authors rights are considered essential. so far, students rights in taking and passing the thesis has not been seriously considered and it seems neces sary for university professors and mentors to respect students rights in the process of getting up to defend the thesis which has not been observed in the regulations yet. in a planned structure, supervisor and student can establish a strong link, so this relationship would be useful for each of them. in forming this relationship, supervisor is considered as the main mentor and has four roles. first, the teacher as a supervisor may offer help, shows the way and provides appropriate feedback. second, the teacher as a facilitator gives the student the opportunity to gain new experiences and skills and learns using them. third, the teacher as a counselor helps students to define their goals and achieve them. and fourth, the teacher as an interface creates effective networks among colleagues, profession als, students, teachers and other deals. in such circumstances, the student can achieve his/her goals in the future. the goal of this relationship is that student reaches a level of autonomy to be able to perform his activities without help of the supervisor, and the most powerful connections are formed when placed under protection by both sides in relation with an appropriate environment, and they receive benefit and appropriate feedback from this relationship. conclusion observance the students’ rights in taking and passing the thesis as an ethical issue should be taken into account to prevent any undisclosed displeasure among students. it is essential to note that expressing the criticisms is only a start point for discussing and realizing the problem, not for approving the problem. authors of this paper believe that the majority of the academic communi ty adhere to the professional ethics, but observance of ethical codes in this area would increase efficiency of universities. j med ethics hist med 2011, 4:1 zahra bayrami and mohammad abdollahi page 4 of 4 (page number not for citation purposes) acknowledgment this article was presented as an invited lec ture at the first annual iranian medical ethics congress in october 2010 hold in tehran universi ty of medical sciences. references 1. larijani b, zahedi f, malek-afzali h. medical ethics in the islamic republic of iran. east mediterr health j 2005; 11(56): 1061-72. 2. tschudin v. ethics in nursing: the caring relationship. london: elsevier; 2003. 3. hodjati smb. teaching and learning practices in islam. tehran: daftar-e nashr-e farhang-e eslami; 2007. [in persian] 4. shariatmadari hr. regulations to be a scientist. qum: dar al-islam; 2010. [in persian] ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ 1 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e © 2019 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. original article volume 12 number 8 august 2019 the relationship between moral distress in nurses and ethical climate in selected hospitals of the iranian social security organization *corresponding author mohsen shahriari nursing & midwifery care research center, school of nursing and midwifery, isfahan university of medical sciences, hezar jerib ave., isfahan, iran. postal code: 8174673461 tel: (+98) 31 37927500 email: shahriari@nm.mui.ac.ir received: 19 may 2018 accepted: 6 july 2019 published: 4 aug 2019 citation to this article: bayat m, shahriari m, keshvari m. the relationship between moral distress in nurses and ethical climate in selected hospitals of the iranian social security organization. j med ethics hist med. 2019; 12: 8. mina bayat1, mohsen shahriari2*, mahrokh keshvari3 1.msc student, school of nursing and midwifery, isfahan university of medical sciences, isfahan, iran. 2.associate professor, nursing & midwifery care research centre, school of nursing and midwifery, isfahan university of medical sciences, isfahan, iran. 3.assistant professor, nursing & midwifery care research centre, school of nursing and midwifery, isfahan university of medical sciences, isfahan, iran. abstract the present study was conducted to determine the relation between nurses’ moral distress and the ethical climate in selected hospitals of the iranian social security organization (isso). this descriptive-analytical correlational study was conducted in 6 hospitals under the coverage of the iranian social security organization in 2016. three hundred nurses were selected by convenience sampling method. data were gathered using corley’s standard moral distress and olson’s hospital ethical climate scales. data were analyzed using spss software version 19. the mean score of the nurses’ moral distress was 1.94 ± 0.66, which is considered moderate. the mean score of ethical climate was 88.97, indicating desirable ethical climate in these hospitals. the frequency score of moral distress had a unilateral reverse correlation with the total score of ethical climate as well as its dimensions, including colleagues, patients, hospitals and physicians. the score of the intensity of nurses’ moral distress also had a unilateral reverse correlation with the total score of ethical climate and the scores of the hospital and physicians dimensions. these results emphasized the importance of creating a positive ethical climate to decrease moral distress as well as the need for professional interventions to increase support in moral issues. keywords: moral distress; nurses; ethical climate; hospital the relationship between moral distress in nurses and ethical climate … 2 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 8 august 2019 introduction generally, providers of health-related services encounter various moral issues and problems on a regular basis (1). changes in the healthcare system lead to an increased need for ethics laws, policies and therapeutic instructions, and highlight the accountability of the healthcare personnel. also, occupational pressures and raised levels of social expectations increase health-care providers’ level of moral distress (2). on the other hand, developments in technology and medicinal interventions in patient care, especially when the results are uncertain, would escalate moral conflicts (3). these moral problems could lead to stress in caregivers and consequently cause physical, emotional, mental and social moral distress (1). as important members of the health team, nurses play an essential role in providing competent, responsive and moral care. however, nursing care is mostly provided in a context filled with moral conflicts and challenges (4). moral distress is frequently discussed in relation to occupational satisfaction, occupational burnout and interactions in nursing relationships (5). in addition, various personal and structural factors could be effective in causing moral distress (6). moral distress is a disturbing mental imbalance caused by recognition of a morally correct action that cannot be performed due to organizational barriers such as lack of time, supervisors’ unwillingness, physicians’ inhibiting power structure, organizational policies and legal considerations (7). moral distress is a common phenomenon in nursing practice that can cause conflicts when encountering patients and providing quality care. on the one hand, moral distress may disrupt the process of achieving care system objectives and consequently have an adverse effect on the health pattern of the society (8); on the other, it can create mental and physical problems for nurses, which may influence their occupational satisfaction and their willingness to remain in the profession, and eventually the quality of care (9). nurses have reported moral distress as a result of changes in human resources and the health system as well as increased social demands (2). moral distress affects not only nurses’ professional life by disturbing their focus and creating feelings of inefficiency, but also their personal life by causing mood disorders and irritability (5). study results have shown that increased levels of moral distress could cause medical errors, harm, burnout, excessive fatigue and reluctance to help patients (10). furthermore, extreme disappointment and occupational dissatisfaction might lead to collateral violence and in general, an insecure work environment (11). in most studies, the emphasis has been on determining the relation between nurses’ personal characteristics and moral distress, and less attention has been paid to the organizational environment and interorganizational relationships (12). ethical climate indicates a common understanding of the organizational activities associated with moral decisions and interorganizational issues such as power, trust bayat m., et al. 3 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 8 august 2019 and human relationships (13). fry et al. showed that the lower the level of the hospital ethical climate is, the higher the severity of perceived moral distress and its complications will be (14). also, borhani et al. revealed a reverse relationship between perceived moral distress in nurses and their perception of the ethical climate (8). hart showed that a negative ethical climate is related to nurses’ decision to leave their job or the nursing profession (15). corley et al. reported that 25% of the studied nurses had left their positions due to moral distress. aiken et al. also found that 40% of the nurses were not satisfied with their work environment and 1 out of 3 nurses aged under 30 planned on leaving their jobs within the next year (16). also about half of the nurses (44%) reported a decline in the quality of the care they provided. it seems that in order to determine the causes of moral distress, occupational satisfaction and nurses’ willingness to change their place of duty, the ethical climate needs to be improved (17). there is evidence about the higher occurrence of moral distress in certain occupational situations (1). rice et al. reported that nurses working in oncology and organ transplant wards experience moral distress more than other nurses (18). another study reported that health community nurses and nurses working in mental hospitals experience lower levels of moral distress (19). anke et al. showed that in providing end-of-life care, due to lack of internal independence, sometimes nurses are not able to work based on their values, which might lead to moral distress (5). also, there is evidence about the effect of colleagues’ support (4), supervision (20) and ethical climate on moral distress, all of which are influenced by the perceptions of the nursing staff, organizational viewpoints and management of moral issues (6). most of the studies in this field have been conducted on the quiddity, prevalence and personal determinants of moral distress. few studies have been conducted on occupational factors involved in occurrence or nonoccurrence of moral distress (21) and the effect of the workplace on the occurrence of moral distress (22). therefore, it is necessary to evaluate these factors comprehensively and provide effective solutions to prevent moral distress among nurses (23). according to surveys, all related research in iran has been conducted in hospitals affiliated with medical universities and the issue has not been investigated in hospitals under the coverage of the iranian social security organization (isso). the iranian social security organization (isso) is a public insurance institution whose main mission is to cover wage and salary workers (compulsory) and selfemployed individuals (optional). the population covered by this organization is about 12 million insured people and more than 2 million pensioners, and reaches 37 million including family members who receive health care. by law, the isso is a public nongovernmental establishment that is not reliant on government resources, and the major part of its funding comes from the premium provided through participation of the relationship between moral distress in nurses and ethical climate … 4 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 8 august 2019 the insured and the employer. for this reason, its assets pertain to segments covered in successive generations and cannot be merged with any governmental or nongovernmental organization or institution. the core of this organization is the tripartite participation of employers, insured persons and the government in various fields of policyand decision-making as well as financing. hospitals covered by the isso do not operate under the supervision of medical universities and therefore do not have a strong academic and educational background. since a large portion of health services in iran is provided by this organization and many nurses are hired there after graduation, research in this field, which has so far been outdated, seems to be necessary. moreover, the results of such studies can contribute to a better understanding of this huge part of the community health system. additionally, since the researcher is employed as a nurse in one of the isso hospitals, she is familiar with the study environment and relevant authorities, which has facilitated the research process and helped to better reflect the actual experiences of the participants. for these reasons, the present study was conducted to determine the relationship between moral distress in nurses and the ethical climate in selected hospitals of the isso in two cities. method the present study was a descriptiveanalytical correlational study conducted in 6 hospitals under the coverage of the isso (4 in tehran and 2 in isfahan) during 2016. the sample size for this study was calculated to be 255 participants, and after considering a 20% sample loss, the number was increased to 300. the share of each hospital was determined based on the number of the nurses working there. at first the sampling method was quota, and then samples were selected using convenience sampling from the wards of the selected hospitals. the inclusion criteria were having at least a bachelor’s degree in nursing and having a minimum one-year work experience at the hospital. we had to obtain permission from the ethics committee of the isfahan university of medical sciences (no. 395230) and make arrangements with the treatment management of the isso in the study environment. after explaining the goals of the study and presenting the proposal, we received approval to enter the selected hospitals. to attract the participation of nurses, a meeting was held with the presence of hospital management and nursing managers to explain the process and methods of the study, and participants were assured that the results of the study would be presented to hospital authorities, optionally. after preparing a list of the nurses in each ward, the number of participants from each ward was determined based on the quota to each hospital, and the questionnaires were distributed among the nurses through convenience sampling. to provide ethical considerations, the participants’ written consent was obtained at the beginning of the queries to make certain of their agreement to participate in the bayat m., et al. 5 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 8 august 2019 research. as the next step, the goals and nature of the study were explained to the participants and they were assured of confidentiality of their information and the voluntary nature of participation. subsequently, questionnaires were distributed among the nurses in three working shifts based on the allocated quota for each ward. to answer the questions of the participants, the researcher remained at each ward during an entire working shift. the questionnaires were distributed among the participants at the beginning of each working shift when there was enough time to talk, and the manner of answering the questions was explained to them. the participants were asked to complete the questionnaire before their next working shift at the latest, and then place it in the envelope that was given to them and hand it to their head nurse. due to the sensitivity of the issue and in order to ensure data collection precision, the researcher personally did the entire work for all the 300 participants, and was present in the research environment both in tehran and isfahan. a three-part questionnaire was used for gathering the data. the first part was about demographic characteristics including age, gender, marital status, educational level and profession-related information such as type of employment, working ward and hospital, work experience and the number of overtime hours. the second part included olson’s ethical climate scale, designed and psychometrically evaluated by olson in 1995 to measure hospital ethical climate. olson determined the validity of the questionnaire using content validity index (cvi) at 87% and its reliability at 91% using cronbach’s alpha (olson 1995). this scale was translated and used in a study by hariri et al. in 2011 (24), and its content validity index and reliability were measured using internal consistency and test-retest methods (content validity was 0.89). in the present study, the translated tool from hariri’s study was used. this scale has 26 items scored from almost never (1) to almost always (5) using a 5-point scale. thus the score of each questionnaire ranges between 26 and 130, with higher scores indicating more positive ethical climates. this questionnaire contains 5 factors that evaluate nurses’ perceptions about their colleagues (questions 1, 10, 18 and 23), patients (questions 2, 6, 11 and 19), managers (questions 3, 7, 12, 15, 20 and 24), hospital (questions 4, 8, 13, 16, 21 and 25), and physicians (questions 5, 9, 14, 17, 22 and 26). the third part aimed to measure moral distress and was first designed by corley in 1995. this scale has 24 items, each presenting a stressful situation and asking the respondents to score the moral distress they would experience in each case. corley’s scale shows the frequency and severity of moral distress in nurses based on a 5-point likert scale from 0 to 4. to determine the severity of distress, options varying from “it causes no distress for me” (score of 0) to “it causes great distress for me” (score of 4) were used. to determine the frequency of perceived distress, options varying from “i have never experienced moral distress” (score of 0) to “i have experienced a lot of moral distress” (score of 4) were used. the lowest score (0) indicated the relationship between moral distress in nurses and ethical climate … 6 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 8 august 2019 the minimum perceived distress at the intended situation and the highest score (96) indicated the maximum perceived distress at the intended situation. the total score of the questionnaire would be categorized as low (0 to 24), moderate (24.1 to 48), high (48.1 to 72) and very high (72.1 to 96). also, at the end of the questionnaire, there was a three-choice question to evaluate nurses’ intention to leave the nursing practice. in this study, the translated tool from borhani’s study was used. the validity of this scale was measured to be 100% by borhani et al. (2014) (8), using content validity index (cvi). the reliability of the tool was approved using test-retest and cronbach’s alpha. data were analyzed using spss software version 19 and descriptive statistics including mean, percentage, standard deviation, tolerance and inferential statistics to determine the relation and correlation between qualitative and quantitative variables including pearson’s correlation coefficient, spearman’s correlation coefficient, and one-way variance analysis. results three hundred questionnaires were completed by the nurses and then analyzed. according to the results, the mean age of the participants was 37 years, 73.3% were female, 78.7% were married, and 84% had a bachelor’s degree. in terms of employment, 58% had ordinary organizational positions, 76% were officially employed, and 88.3% did not work in other hospitals. also, 86% had a work experience of 15 to 19 years and the mean of their overtime hours per month was 77.4, while 76% had to work extra obligatory hours. most of the participants (56%) were working rotational shifts, 7.51% had passed ethics courses, and 61 percent were chosen based on their interest in nursing (table 1). according to the results, the mean score of perceived moral distress in nurses was 1.94 ± 0.66, which indicated moderate moral distress. among the items related to the frequency of occurrence of moral distress, the item of “giving nursing care to a patient under ventilation with no hope for living” had the highest (2.1 ± 9.34), and the item of “when patient’s death is inevitable, i speak to the family about organ donation” had the lowest frequency of moral distress (1 ± 1.16). among the items related to the severity of moral distress, the item of “due to the large number of patients, i cannot provide high quality care to all of them” had the highest (with a mean of 2.1 ± 84.26), and the item of “i accept the physician’s request not to talk to a near-death patient about death” had the lowest (with a mean of 1.1 ± 82.37) severity of moral distress among nurses. the mean score of ethical climate was 88.97, which indicated good ethical climate in the selected hospitals. among the items related to the ethical climate questionnaire, the item of “i have an appropriate working relationship with my colleagues” had the highest score (with a mean of 4), and the item of “in this hospital, nurses are supported and respected” had the lowest score (with a mean of 2.65). bayat m., et al. 7 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 8 august 2019 table 1mean score of moral distress of nurses and their perception of ethical climate in terms of individual characteristics statistical test severity of moral distress frequency of moral distress frequency individual characteristics p-value mean p-value mean independent t-test 0.92 sex 50.3 0.002 41.1 220 woman 50.1 47.8 80 man independent t-test 0.33 marital status 50.6 0.07 43.6 236 married 47.8 39.3 64 single one-way analysisvariance 0.34 employment status 51.1 0.72 43.3 228 official 46.7 41.6 55 pseudo-official 50.8 41.3 17 contractual anova 0.027 ward 2.14 0.001 1.81 167 intensive 2.04 1.75 68 surgical 2.44 2.27 20 internal 1.67 1.31 23 pediatric 1.99 1.74 22 other independent t-test 0.95 passing ethics courses 2.09 0.004 1.89 155 yes 2.09 1.66 145 no independent t-test 0.46 city 50.8 0.63 42.6 205 tehran 49 43.6 95 isfahan the results of the present study showed no significant difference between nurses in isfahan and tehran regarding the frequency and severity of moral distress. also, the total mean score of the frequency of moral distress was 1.0 ± 78.68, and the total mean score of the severity of moral distress was 2.09 ± 0.81. while the mean score of the frequency of moral distress was significantly higher among male nurses, the mean score of the severity of moral distress was not significantly different between male and female nurses. also, no significant difference was observed between single and married nurses regarding the mean scores of frequency and severity of moral distress (table 1). there was no significant relationship between the means of frequency and severity of moral distress in nurses and their hospital the relationship between moral distress in nurses and ethical climate … 8 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 8 august 2019 of duty (p = 0.07), organizational position (p = 0.89), employment status (p = 0.44) and the type of overtime hours (p = 0.46). also, nurses who had passed ethics courses had encountered morally distressful situations more often, but regarding the severity of moral distress, no significant difference was observed between nurses who had passed ethics courses and those who had not. the results of the present study showed that the mean scores of frequency and severity of moral distress in nurses had a significant relation with their working department. in this regard, nurses working in the internal wards reported higher frequency and severity of moral distress (mean = 2.27) compared to nurses working in other wards. also, pediatric nurses reported the lowest moral distress (mean = 1.31). the results showed no significant relationship between the mean scores of frequency and severity of moral distress in nurses and their age, overtime hours, or work experience. likewise, no relationship was found between the mean of the severity of moral distress and the nurses’ educational level and work experience. however, there was a direct relationship between the mean score of the frequency of moral distress and the nurses’ educational level, that is, with their educational level rising from bachelor’s to master’s degree and ph.d., their perception of moral distress was improved (table 2). table 2pearson’s correlation coefficients between the severity and frequency of moral distress in nurses, and age, overtime, education level and work experience severity of moral distress frequency of moral distress score p r p r 0.75 0.018 0.99 0.001 age 0.90 0.007 0.63 0.027 overtime 0.87 0.009 < 0.001 0.218 level of education 0.75 0.018 0.78 0.016 work experience according to the results, the mean score of ethical climate in the isso hospitals of isfahan and tehran was 88.97, which is at a good level based on the applied rating scale. as for the total mean score of ethical climate and its domains, there was no significant difference between the nurses of isfahan and tehran (p > 0.05). also, in both cities, nurses had the most desirable viewpoint in the managers’ domain and the least desirable viewpoint in the patients’ domain (table 3). bayat m., et al. 9 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 8 august 2019 table 3mean of total score of ethical climate and its domains by city of service score isfahan tehran independent t-test mean standard deviation mean standard deviation t p total score of ethical climate 88.7 14.9 89.1 16.3 0.19 0.85 ethical climate/colleagues 15.4 2.6 15.3 2.6 0.30 0.77 ethical climate/patients 13.7 2.7 13.9 2.4 0.68 0.50 ethical climate/managers 21.3 5.2 22.2 5.5 1.24 0.21 ethical climate/hospital 19.7 3.8 19.1 4.2 1.08 0.28 ethical climate/physicians 18.6 4.3 18.6 5.2 0.03 0.98 the score of the frequency of moral distress in nurses had a reverse relationship with the total score of ethical climate, and the domains of colleagues, patients, hospital and physicians. however, no significant relationship was observed between the score of the frequency of moral distress and the score of ethical climate in the domain of managers. also, the score of the severity of moral distress had a reverse relationship with the total score of ethical climate, and the domains of physicians and hospital (table 4). table 4 pearson’s correlation coefficients between severity and frequency of moral distress in nurses, and the total score of ethical climate score frequency of moral distress severity of moral distress r p value r p value total score of ethical climate 0.194 0.001 0.170 0.003 ethical climate/colleagues 0.187 0.001 0.069 0.23 ethical climate/patients 0.181 0.002 0.053 0.36 ethical climate/managers 0.090 0.12 0.092 0.11 ethical climate/hospital 0.139 0.02 0.153 0.008 ethical climate/physicians 0.224 < 0.001 0.259 < 0.001 discussion according to the results of the present study, the mean scores of frequency and severity of moral distress in nurses indicated moderate moral distress among participants from the selected isso hospitals. also, the scores of moral distress in the nurses of isfahan and tehran were both at a moderate level, and the relationship between moral distress in nurses and ethical climate … 10 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 8 august 2019 no significant difference was observed between the nurses of these two cities. the results showed that the severity and frequency of moral distress in nurses had a significant unilateral reverse relationship with the hospital ethical climate. this means that the more positive and favorable the ethical climate of a hospital is, the lower the severity and frequency of moral distress will be. overall, the mean score of ethical climate in the selected hospitals of the isso in isfahan and tehran was at a good level. different studies have reported different results regarding moral distress among nurses. fernandez-parsons et al. reported low moral distress among emergency nurses (25), while de veer et al. found that nurses experience high levels of moral distress (5). a study by abbaszadeh et al. reported a moderate level of moral distress and showed a significant relationship between the severity of moral distress and its recurrence (23). sile´n et al. demonstrated that although the severity of moral distress increased in situations where secure and appropriate care was not provided for the patient, the frequency and severity of nurses’ moral distress were still at a low level. in general, they reported that the frequency of moral distress was less than its severity. they also showed that a more positive perception of the ethical climate would decrease the frequency of morally distressful situations (12). these differences in the results might be due to the different scales that were used in various studies on moral distress. also, the items of the moral distress questionnaire may not sufficiently cover the moral concerns of the participating nurses, and even for those who have recognized their own distress, the items might cause too much discomfort, distress and disruption to answer realistically (6). in studies that have reported higher levels of moral distress compared to the present study, there could be other personal and organizational factors causing moral distress to escalate among nurses; these factors may include the disproportion between the number of nursing personnel and the number of empty beds at the hospital, or the presence of unskilled physicians and managers. also in studies that reported lower perceived moral distress, these factors might have a certain quality that could consequently decrease the level of perceived moral distress among nurses (6). in a study by pinhero and de souse in 2016 on operating room nurses with at least one year of work experience at the central hospital of portugal, it was revealed that work environment and occupational satisfaction were at a desirable level and to improve and enhance this environment, the cooperation of the managerial team was necessary (26). another study by humphries and woods in new zealand showed that participants’ perceptions of the hospital ethical climate had been formed under the influence of interrelated factors (27). these factors included staffing levels, patient throughput (turnover) and the dynamics between the nursing staff and others within the workplace (27). also in a 2007 study by ulrich et al. conducted on 300 nurses across bayat m., et al. 11 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 8 august 2019 four different states of the united states, most of the participants evaluated the ethical climate of their workplace positive and higher than neutral with a mean score of 93 (2). a 2016 study by bartholdson et al. showed the nurses to have a weak perception of the ethical climate (28). this was due to interprofessional interactions, for instance the physicians’ attention to the opinions of nurses and assistant nurses, treatment-related decisions and respect for others’ opinions, especially at times of disagreement between different specialists on the best approach for the patient. after reviewing 32 articles, schluter et al. revealed that weak ethical climate would escalate issues such as moral distress, insufficient or futile care, and unsuccessful or insufficient support for others, and might create false hope for the patients and their families (4). according to the results, a significant relationship exists between the nursing service hospital and the ethical climate scores in the managers and hospital domains, but not the other domains. this indicates the effectiveness of the impact of management in the creation and development of a suitable and safe environment for the activities of the staff, which ultimately contributes to preventing or reducing moral distress among nurses and the adverse effects of these disturbances in the health care system. the nurses who participated in this study expressed the most favorable opinion in the domain of managers, and the most unfavorable viewpoints in that of patients. in a study by fazljoo et al. in 2014, the most favorable opinion pertained to managers and the most unfavorable viewpoint was related to physicians (29). since nursing directors are chosen from among members of the nursing community and most of them have long-term clinical backgrounds, it seems reasonable that they should have a good understanding of the ethical atmosphere in this field. on the other hand, the hospitals affiliated with the isso are very crowded clinical centers in iran, and providing health care for a large number of insured persons in this organization is very difficult and time consuming. nurses are the most accessible responders to patients and are therefore required to address their needs and health expectations, which leads to inconveniences and problems in providing proper service and ultimately creates an undesirable view in this domain. of course, health care organizations seem to be able to control the distresses by providing the nursing staff with ethical support and empowering them to offer quality care. it should also be noted that, managers and peers must also be willing to advocate for each other, should ethically difficult situations arise (4). in the moral distress questionnaire, the highest frequency pertained to item 5 (continue to participate in care for a hopelessly ill person who is being sustained on a ventilator, when no one will make a decision to withdraw support) with an average of 2.90. conversely, item 2 (when the patient’s death is inevitable, i talk to the family about organ donation) had the lowest the relationship between moral distress in nurses and ethical climate … 12 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 8 august 2019 frequency with an average of 1.01. these findings are fully consistent with the results of other studies (10, 23, 30). in general, review of the literature did not greatly change the results. the findings of different studies on nurses working in various clinical environments indicated that desirable ethical climate would decrease moral distress. a study by pauly et al. in columbia also showed that there was a significant relationship between nurses’ perceived moral distress and the hospital ethical climate, that is, improved ethical climate would decrease the perceived moral distress by nurses (6). fry et al. also found that the more undesirable the hospital ethical climate was, the higher would the intensity of the perceived ethical distress and its complications in nurses be (14). similarly, fazljoo et al. showed a direct negative relationship between severity of perceived moral distress in nurses and ethical climate (29). based on the results of the present study, the mean scores of frequency and severity of moral distress was significantly lower among nurses who had selected nursing practice based on their own interest compared to those who had done so without interest. borhani et al. also showed that the frequency and severity of moral distress were higher among nurses who had selected nursing practice without passion (8). according to their results, the mean scores of frequency and severity of moral distress were significantly lower among nurses who had never considered quitting their position or their profession compared to other nurses. these findings were in line with the results of other studies (2, 25, 31). a review study by schluter et al. in 2008 demonstrated that moral distress and unfavorable ethical climate were causing a growing shortage of nursing personnel and an increase in nurses’ intention to transfer (4), and there is evidence indicating the effect of weak ethical climate on quitting the nursing practice. it seems that selecting nursing practice with passion could decrease nurses’ encounters with morally distressful situations due to better adjustment to the existing conditions (7). although many researchers have stated that weak ethical climate and moral distress would cause nurses to leave the profession, the phenomenon has unfortunately not been accurately measured and reported. in fact, nurses’ decision to quit their profession due to moral distress and their perception of their workplace is still undetermined (4). if nursing practice is recognized as an ethical profession and nurses believe that they are performing an ethical act, the need for determining the effect of organizational barriers to performing the right action will be felt (32). in the present study, all of the dimensions of ethical climate (colleagues, patients, hospital and physicians) had a significant relationship with moral distress, except for the dimension of managers. also, the score of severity of moral distress had a significant reverse relationship with the total score of ethical climate and the dimensions of hospital and physicians. these results indicate that a series of factors are effective in nurses’ perception of ethical climate, and that a complex relationship exists between bayat m., et al. 13 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 8 august 2019 experiencing moral distress and the dimensions of ethical climate (6). in the present study, the frequency and severity of moral distress varied in different wards. thus, nurses working in the internal ward reported the highest level of moral distress compared to other nurses. the reason for this difference might be the fact that nurses of the internal ward would spend more time with their patients in comparison to nurses of other wards. patients may be hospitalized in the internal ward for a long period of time, which can cause challenges to providing care. also, the highest mean of severity of moral distress belonged to the item of “due to the large number of patients, i cannot provide high quality care”. this indicates the occurrence of moral distress in situations where nurses are forced to provide care for a large number of patients in a short amount of time. a study by de veer et al. in 2013 showed that nurses who face a shortage of time in providing care for their patients experience more moral distress, and the perceived pressure resulting from lack of time probably causes further concerns about the quality of the care they provide (5). participants in the present study had the most desirable viewpoint in the managers’ dimension and the least desirable viewpoint in the patients’ dimension. since nursing managers are part of the nursing community and mostly have a lot of experience working in clinics, it seems only natural that they should have a more desirable perception of the ethical climate in this dimension. on the other hand, the isso hospitals are some of the most crowded medical centers and providing service and care for such a large number of patients is exhausting if not intolerable. nurses are required to fulfill all of the patients’ medical needs and expectations, and since they are the most available staff members, they are bound to encounter problems and experience dissatisfaction, and eventually develop undesirable viewpoints in this dimension. organizations providing health services could control the dissatisfaction by providing guaranteed moral support for the nursing staff and empowering them to have control over the provision of quality care. managers and other colleagues should also try to support each other in morally difficult situations (4). the present study was conducted in the isso hospitals of isfahan and tehran. in iran, the variables affecting the relationship between nurses’ moral distress and ethical climate have been examined by only one study conducted in hospitals covered by medical universities of yazd. in the large cities of iran, especially in tehran, no similar study has been performed on the subject. the current study was done in the isso hospitals, which are rather different from university hospitals for reasons explained in the introduction section above. therefore, to improve the generalizability of the results, it is recommended that future studies be conducted with larger sample size and participation in other large city hospitals. conclusion this study was an effort in the field of moral distress and ethical climate in the nursing the relationship between moral distress in nurses and ethical climate … 14 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 8 august 2019 community of the isso hospitals, and indicated that moral distress is closely related to hospital ethical climate. it is clear that determining strategies for decreasing the intensity and frequency of moral distress is an importance issue in these settings. current study results showed the importance of creating a positive ethical climate to decrease moral distress in nurses and their tendency to leave their position or even the profession. this would lead to presentation of professional interventions for managing moral stress, increasing support for moral problems, creating appropriate communication within the organization and eventually decreasing moral distress in nurses. acknowledgements the authors would like to thank the school of nursing & midwifery of isfahan university of medical sciences for supporting this study financially. we would also like to thank all the persons who made this study possible. conflict of interests the authors have no conflict of interests to declare. bayat m., et al. 15 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 8 august 2019 references 1. corley mc, minick p, elswick rk, jacobs m. nursing moral distress and ethical work environment. nursing ethics. 2005; 12(4): 381-90. 2. ulrich c, o’donnell p, taylor c, farrar a, danis m, grady ch. ethical climate, ethics stress, and the job satisfaction of nurse and social workers in the united states. soc sci med. 2007; 65(8): 1708-19. 3. halcomb e, davidson p, salamonson y, ollerton r, griffiths r. nurses in australian general practice: implications for chronic disease management. j clin nurs. 2008; 17(5a): 6–15. 4. schluter j, winch s, holzhauser k, henderson a. nurses’ moral sensitivity and hospital ethical climate: a literature review. nurs ethics. 2008; 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____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ 1 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e original article volume 13 number 13 september 2020 copyright © 2020 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. investigation of moral intelligence’s predictive components in students of shahid beheshti university of medical sciences (sbmu) *corresponding author maryam mohammadi department of public health, school of health, shahid beheshti university of medical sciences, yaman st., velenjak, chamran highway, tehran, iran. postal code : 198353-5511 tel : (+98) 21 22 43 20 41 email: mohammadim@sbmu.ac.ir received: 23 sep 2019 accepted: 7 sep 2020 published: 20 sep 2020 citation to this article: mohammadi m, mohammadi s, mehri a, bagheri mazraeh f. investigation of moral intelligence’s predictive components in students of shahid beheshti university of medical sciences (sbmu). j med ethics hist med. 2020; 13: 13. maryam mohammadi1*, shabnam mohammadi2, ali mehri3, fatemeh bagheri mazraeh4 1.assistant professor, health education and health promotion, department of public health, school of public health, shahid beheshti university of medical sciences, tehran, iran. 2.assistant professor, neurogenic inflammation research center, mashhad university of medical sciences, mashhad, iran. 3.assistant professor, department of health education, school of health, sabzevar university of medical sciences, sabzevar, iran. 4.researcher, student of public health, school of public health, shahid beheshti university of medical sciences, tehran, iran. abstract this study aimed to investigate dominant predictor components of moral intelligence (mi) based on the lennick and kiel's model in students of shahid beheshti university of medical sciences (sbmu). in this descriptive-analytical study, 322 students of sbmu were chosen through cluster sampling. to collect data, a 40item questionnaire, whose validity and reliability was confirmed in previous studies, based on the lennick and kiel's model was used. the collected data were analyzed by spss 21 software using appropriate descriptive and analytical statistics. of 322 participants, 180 and 142 were female and male, respectively. the mean age of the participants was 22.30±2.69 years. the study’s regression analysis revealed that the most and the least direct effects were related to the forgiveness (r2=0.320) and compassion (r2=0.284) components, respectively. among the inspected components, the responsibility component with an overall effect of r2=0.655 was shown to be the strongest predictor component of mi. universities play a significant role in students’ moral development and enhancement. the present study’s findings suggest that developing strategic plans and interventions can enhance mi level (e.g., incentive systems for individuals maintaining high moral responsibility). since today’s students will be tomorrow’s medical and healthcare professionals, upgrading of mi level in students studying in various divisions of medical sciences enhances their moral responsibility through setting out strong ethics principles to follow and the quality of care that they will provide to patients, thereby improving health. keywords: moral intelligence; students; medical sciences; lennick and kiel’s model. mailto:mohammadim@sbmu.ac.ir investigation of moral intelligence's predictive components in students of … 2 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 13 september 2020 introduction moral intelligence (mi) can be referred to as human’s capacity to distinguish right from wrong and to apply moral principles to humans’ intentions, goals, beliefs, values, and actions. as a newlyintroduced concept, mi has been less researched compared to other types of intelligence (e.g., social, emotional, and cognitive). recently, mi has received more attention in researches conducted in psychology and management fields (1). mi provides a framework for humans to act in accordance with moral principles; such framework can provide potentials to advance our understanding of human behavior, and thereby can act as a predictor of human behavior (2). behaviors and actions of humans are influenced by their mindset of ethical principles and values (3). considering the link between mi and human behaviors, humans exhibit and creates a system of principles and rules to direct them in distinguishing right from wrong (4). people with high mi levels usually evaluate compatibility of their functionality with ethical principles, leading to enhancement of their commitment and responsibility as well as to improvement of individual and group efficiency (3). according to lennick and kiel (5), mi involves four principles of integrity, responsibility, compassion, and forgiveness. the principle of integrity is acting on and standing for what we know as right principles, values, and beliefs, thereby creating harmony between words and actions. the principle of responsibility emphasizes on acting consciously, being accountable for our mistakes and failures, accepting responsibility for consequences of our actions as well as being committed to help and serve others. the principle of compassion focuses on respecting to, paying attention to as well as actively and persistently caring for others. the principle of forgiveness advocates flexibility regarding human mistakes and failures considering that human is error-prone and fallible and contains imperfections (5). mi, as a compass for our actions, leads our other intelligence types (e.g., social, emotional, and cognitive) toward conducting worthwhile actions (6). individuals with high mi level do the right actions consistent with their values and beliefs, thereby linking their actions with ethics (3). mi is not inherent and is learned through nurturing, teaching, training, and modeling (i.e., ethics-observing social environment is essential in moral development). higher education institutions such as universities and colleges are among the most important social environments. in addition to transferring advanced-level knowledge and competencies to students, universities promote social, ethical and cultural values, enhance individual and social skills as well as stimulate personality, emotional, behavioral, intellectual, and moral development (7). development of moral characteristics (e.g., empathy, self-control, respect, kindness, conscientious action, patience, fairness) in students and their moral growth is important (5) because today’s students will be tomorrow’s professionals of the country. development of mi and moral characteristics among medical sciences’ students, who will work in healthcare and clinical centers in future, will improve the quality of care provided to patients, thereby improving health. medical students with high mi level can minimize potential risks through careful consideration of their mohammadi m., et al. 3 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 13 september 2020 actions’ consequences in the workplace. since they act according to ethical principles, they perform well both at individual level and in teamwork (5). considering the importance of mi level, this study aimed to investigate predictor components of mi in sbmu students based on the lennick, kiel and jordan model (5). method this descriptive-analytical study was performed on sbmu students after receiving the code of ethics (ir.sbmu.phns.rec 1397.0999) from the university. initially, faculties of sbmu were considered as clusters. then, final samples were selected from each faculty based on the number of students qualified for this study (sbmu students who completed at least one semester at the time of this research) using available sampling method. to observe research ethics obligations, consent of participants was initially received, and their information were kept confidential. the standard questionnaire of lennick and kiel (2011) was used to collect data (5). the questionnaire consists of 40 questions for four components: integrity (10 questions), responsibility (10 questions), forgiveness (10 questions), and compassion (10 questions). the method used to score this questionnaire was on a five-point likert (always, often, sometimes, rarely, never). score range of each participant, ranging from 40 to 200, divided by two to have our target final scores, ranging from 20 and 100. respectively, score ranges of 90-100, 80-89 ,70-79, 60-69 and 68-0 are indicators of excellent, good, above average, average and poor levels. martin and austin. initially established validity and reliability of the questionnaire (8). araste et al. translated the questionnaire from english to persian, localized it, and established its validity and reliability; cronbach's alpha reliability was confirmed by araste et al. and it was shown to be 0.897 (9). the collected data were analyzed using descriptive and analytical statistics by spss 21 software. results from 322 sbmu students participated in the study, 180 were female (55.9%) and 142 were male (44.1%), respectively. the mean age of participants was 22.30±2.69 years, and their age ranged from 18 to 34. respectively, students of medical faculty and rehabilitation faculty with overall mi scores of 73.98±6.97 and 70.40±7.45 had the highest mean and the lowest mean. the mean was 72.48±7.28 and 71.28±7.49 for female and male participants’ mi scores, respectively. statistical tests showed no significant difference between mi scores of female and male genders (p=0.14). in addition, no significant correlation was found between variables of age and field of study regarding mi score (p<0.05). the results showed that the mean of mi components’ score was 72.05±7.31, where the highest mean and lowest mean were attributed to the forgiveness and compassion components with scores of 18.49±2.13 and 16.97±2.40, respectively (table 1). investigation of moral intelligence's predictive components in students of … 4 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 13 september 2020 table 1mean and standard deviation of mi’s different components based on lennick and kiel’s models components possible range mean standard deviation integrity 10-25 18.22 2/31 responsibility 10-25 18.36 2/17 forgiveness 10-25 18.49 2/13 compassion 10-25 16.97 2/40 total mean 40-100 72.05 7/31 to inspect the most important predictor components of mi in participants, researchers firstly investigated the variables having a significant correlation with mi (p≤0.05) based on pearson correlation test as depicted in table 2, and then examined them through regression analysis. table 2correlation coefficient matrix of elements components mi integrity responsibility forgiveness compassion mi 1 integrity **0.812 1 responsibility **0.858 *0.641 1 forgiveness **0.878 **0.637 *0.720 1 compassions **0.810 *0.555 **0.569 **0.658 1 **: significance at 0.01 results of regression analysis showed that all components directly affect mi (table 3). the direct and indirect effects among components showed that the most and the least direct effects were related to the forgiveness (r2=0.320) and compassion (r2=0.284) components, respectively. responsibility component with an overall effect of 0.655 was the strongest predictor component of mi in lennick and kiel’s model (table 3, chart 1). table 3direct, indirect, and overall effects of lennick and kiel’s predictor components on mi independent variables direct effect indirect effect overall effect dependent variable integrity 0.295 (0.171 × 0.161×0.320) + (0.171 × 0.720 × 0.458×0.320)+(0.171×0.294)+(0.171×0.720 ×0.284) 0.407 moral intelligence responsibility 0.294 (0.720 × 0.284) + (0.720 × 0.458×0.320) + (0.320 × 0.161) 0.655 forgiveness 0.320 0.320 compassion 0.284 (0.458 × 0.320 ) 0.430 mohammadi m., et al. 5 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 13 september 2020 chart 1correlations among the lennick and kiel’ predictor components with mi discussion this study’s results showed that the mean of students’ mi total score was 72.05; the integrity, responsibility, forgiveness, and compassion components had scores of 18.22, 18.36, 18.49, and 16.97, respectively. rucinski and bauch showed that the mi level was different in two genders (10); however, wimalasiri reported that gender had no effect on mi (11). in this study, no significant difference was observed between the two genders’ mean of mi score, and no significant correlation was found between variables of the age and field of study. to assess mi, raisi et al. conducted a research in qom university of medical sciences on 210 midwifery-nursing students, using standard lennick and kiel’s questionnaire and 5-point likert scale; the overall mean of students’ mi score was 73.2, indicating that students’ mi level was good (12) psychological, social, and hereditary factors can also affect the mi level, and hence these factors may be the cause of differences observed in correlations among demographic characteristics and mi in previous studies. jahaniyan et al. at kharazmi university conducted a research on 220 post-graduate students in educational sciences using 40item lennick and kiel questionnaire. in this study, students' mi was above average. statistical analysis results were indicative of a positive and significant correlation between age and mi. in addition, significant differences were observed in mi levels of students majoring in different disciplines (13); biochemistry and anesthesiology investigation of moral intelligence's predictive components in students of … 6 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 13 september 2020 disciplines had the highest and the lowest overall mi scores, respectively. significant differences in mi scores of diverse disciplines indicated the effect of educational curricula as well as the effect of the program and educational environment on student’s mi development. therefore, the effect of curricula on mi and the influence of mi on professional performance show the role of education on students’ moral and professional development as well as emphasize on the need for efforts to make maximum use of these aspects of education. bayattork et al. conducted a cross-sectional study on 214 medical and nursing students using the 40-item lennick and kiel questionnaire. the mean of mi scores in medical and nursing students were 74.07 and 76.44, respectively. their results were indicative of statistically significant difference between the mi scores’ mean for medical students and nursing students, respectively. in addition, a significant difference was observed between the mi scores of freshmen and senior students. compared to other mi components, the score of integrity was significantly higher in medical students; and, mi of the students was good (14). bakhtiari and soleimani at urmia university conducted a study on mi level of two categories of 20 academic cheating students and 20 non-academic cheating students. the results showed no significant difference between the two groups regarding compassion component; however, for other three components, the scores were lower in academic cheating students (15). zerrati et al. in 2014 conducted a research on 359 students of tehran, baqiyatallah, shahed and shahid beheshti universities using lennick and kiel’s 40-item questionnaire. the results showed that students’ mi was average and below average. a significant correlation was observed among mi level, marital status, and education level factor. the highest and lowest mean score were related to integrity (60.76) and forgiveness (15.15) components, respectively (16). in our study, however, the responsibility component had the highest score because participants believed that they were accountable for their choices’ consequences and actions. according to lennick and kiel, humans are responsible for improving each other's lives because all element of the whole world are interdependent (9). in lennick and kiel’s view, compassion is more about collective interest than individual interest (5). thus, in this study, the lowest score on compassion component indicate that the students tend to prioritize personal benefit to collective benefit. ghaffari et al. conducted a study on medical students of azad and public universities in 2014. their results showed a positive and direct correlation between students’ academic performance and variables of social intelligence, compassion, responsibility, forgiveness, and integrity (17). the limitations of this study are as follows: first, cross-sectional studies cannot show the causality, and changes in behaviors resulting from changes in mi level occur over time. second, as a limitation of self-reporting tools, controlling of all the research mohammadi m., et al. 7 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 13 september 2020 variables (e.g., accuracy of answer and bias) and answering to the questions (i.e., completing the questionnaire) cannot be simultaneous. conclusion a satisfactory level of moral intelligence in students majoring in different disciplines of medical sciences can strengthen the stimulating and effective role of universities in students’ moral development. since today’s students of medical sciences field will be tomorrow’s medical and health care professionals, upgrading of moral intelligence level in these students enhances their moral responsibility through setting out strong ethical principles to follow and the quality of care that they will provide to patients, thereby improving health. acknowledgments the authors are grateful to the research committee of shahid beheshti university of medical sciences for their support, and the students who participated in this study. conflict of interests the authors declare no conflicts of interest in relation to this article. investigation of moral intelligence's predictive components in students of … 8 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 13 september 2020 references 1. mohammadi s, nakhaei n, borhani f, roshanzadeh m. moral intelligence in nursing: a cross-sectional study in east of iran. iranian journal of medical ethics and history of medicine. 2013; 6(5): 57-66. 2. eskandari n, golaghaie f, aghabarary m, et al. explaining the relationship between moral intelligence and professional self-concept with the competency of nursing students in providing spiritual care to promote nursing education. j educ health promot. 2019; 8: 230. 3. flite ca, harman lb. code of ethics: principles for ethical leadership. perspect health inf manag. 2013; 10(winter): 1d. 4. turner n, barling j, epitropaki o, butcher v, milner c. transformational leadership and moral reasoning. j appl psychol. 2002; 87(2): 304-11. 5. lennick d, kiel f. moral intelligence: enhancing business performance and leadership success. usa: wharton school publishing; 2005. 6. bahrami ma, asami m, fatehpanah a, dehghani tafti a, ahmadi 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australia. journal of managerial psychology. 2001;16 (8): 61434. 12. raisi m, ahmari tehran h, bakouei s, jafarbegloo e, momenuan s, abedini z. evaluation of moral intelligence in nursing and midwifery students of qom university of medical sciences. j educ ethics nurs. 2016; 5(3) :9-16. 13. jahanian r, saiearasi r, tayyeba m. examining moral intelligence and its aspects and variables in university students (case of study: khwarizmi university students). journal of behavioral sciences. 2013; 5(15): 55-72. 14. bayattork r, alikhah a, alitaneh f, mostafavian z, farajpour a. moral intelligence and its relative demographic factors in medical and nursing students studying at islamic azad university of mashhad. iranian journal of medical ethics and history of medicine. 2018; 11(1): 353-64. 15. bakhtiari n, soleimani e. the comparison of moral intelligence and its components in academic cheating and non-academic cheating students at urmia university. culture in the islamic university. 2017; 7(2(23)): 205-26. 16. zerrati sh, reje n, ahmadivash tm, davati a. a study of ethical intelligence of medical students. medical ethics. 2014; 8(27): 71-91. 17. ghaffari m, hajlo n, bayami s. the relationship between social and moral intelligence with academic performance of medical students in maragheh and bonab, iran in 2015. journal of nursing education. 2015; 4(3) :48-55 journal of medical ethics and history of medicine original article physicians’ attitude toward their ethical responsibility regarding air pollution: a qualitative research saeedeh saeeditehrani1, alireza parsapour2, saharnaz nedjat3, maliheh kadivar4, bagher larijani5* 1phd candidate in medical ethics, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. 2assistant professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. 3professor, department of epidemiology and biostatistics, tehran university of medical sciences, tehran, iran. 4professor, department of pediatrics, division of neonatology, children’s medical center, tehran university of medical sciences, tehran, iran. 5professor, endocrinology and metabolism research center, endocrinology and metabolism clinical sciences institute, tehran university of medical sciences, tehran, iran; medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. corresponding author: bagher larijani address: no.23, 16 azar ave, keshavarz blvd, tehran, iran. email: larijanib@tums.ac.ir tel/ fax: + 98 21 66 41 96 61 received: 9 dec 2016 accepted: 30 jul 2017 published: 2 sep 2017 j med ethics hist med, 2017, 10:7 © 2017 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract air pollution is among the environmental problems that adversely affect people’s health. there is a close relationship between medicine and environment, and as a consequence, there are ethical considerations surrounding the problem of air pollution. the present research aimed to determine physicians’ attitude toward their ethical responsibility regarding air pollution, and their role in reducing it. this was a qualitative research using content analysis, conducted in tehran university of medical sciences. the focus group included 21 physicians with specialties and subspecialties in pediatrics, infectious diseases, pulmonology, gynecology, and midwifery selected through predetermined sampling along with 13 personal in-depth interviews. a number of questions were asked regarding physicians’ ethical responsibility to decrease environmental crises, particularly air pollution. as a result, 4 themes and 20 subthemes were extracted by assessing the focus group and interviews. these four general themes included the role of a physician as 1) an ordinary person, 2) a special citizen and a role model, 3) a professional person with special personal and social commitments, and 4) an administrator of the healthcare system. in the present research, physicians acquired a special attitude toward air pollution. the research population mentioned physicians’ impact as role models for the society, as well as their educational, supervisory, informative, promotional, and administrative roles among their most important obligations regarding air pollution. it is recommended to conduct further studies on physicians’ knowledge, attitude and practice regarding their responsibility toward environmental issues in order to investigate this important matter further. keywords: air pollution, physician, professional commitment, ethical responsibility, environment. j med ethics hist med 10: 7, september, 2017 jmehm.tums.ac.ir saeedeh saeeditehrani et al. page 2 of 11 introduction air pollution is considered a real problem both nationally and internationally (1). scientific findings indicate several adverse effects of air pollution on human health (2 4). the most prevalent side effects of air pollution appertain to the respiratory system (5 6). there is also a significant relationship between air pollution and premature birth, infant death and lung capacity reduction (7 10). the adverse effects are not limited to the respiratory system; for example, excess lead exposure due to air pollution can cause nervous system complications in children (11), induce an increase in blood pressure among adults (12), and have a negative impact on the cardiovascular system (13). air pollution has adverse effects on the reproductive system, pregnancy, fetuses, and infants (14-16). genetic studies demonstrate the harmful effects of air pollution (17, 18), and there are evidences that it may also result in infertility in men (19). certain symptoms may be direct indicators of exposure to air pollution, such as nausea, chest pain, dyspnea, itchy throat, eye irritation, headache, palpitation, sputum, coughs, , and excessive fatigue (20). moreover, several studies have demonstrated that air pollution raises the rate of hospitalization significantly (21 23) and others have pointed to an increased number of emergency visits when pollution prevails (24). it is evident that all the costs and side effects ensuing from air pollution appertain to the healthcare system. thus, the healthcare system and health service providers should have a special ethical sensitivity to environmental problems due to their responsibility to protect people’s physical and mental health; hence, their ethical liability toward the environment is more noticeable, which naturally creates certain roles for them. based on the aforementioned points, physicians’ sensitivity, awareness and attitude with respect to their ethical responsibility play a major part. studies also demonstrate the influence of physicians’ attitude toward air pollution on changing the public view of the subject (25 28). moreover, due to their status in the society, physicians’ conduct can provide a proper model to contribute to a change of public attitude toward environmental problems, which are basically created by man. air pollution is an example of an environmental problem resulting from activities such as transportation, energy production (transformation), and other energy-related industrial activities, which are the major producers of pollutants (29). thus, changing the behavior and attitude of the people in a society will be a significant contribution to the reduction of air pollution. physicians’ role in this issue may be different depending on their approach to the subject. few studies have been conducted on physicians’ moral responsibility regarding air pollution and its status in physicians’ personal and professional priorities, or the attitude of this significant social class toward their role in reducing environmental crises. consequently, it is of utmost importance to investigate the above-mentioned issues in order to provide the opportunity for interventions (for instance through altering or consolidating physicians’ influential attitude), and create the grounds for conducting further studies to discover the obstacles and deterrents. therefore, this study endeavors to elicit the ideas of physicians and experts as professionals who are notably involved in the issue, and solicit their opinions on their own ethical role and responsibility regarding the reduction of air pollution. method this study was conducted between march 2014 and february 2016 in tehran university of medical sciences. it investigated physicians’ attitude toward their role in reducing air pollution and presented the personal and public solutions offered by this social group. in order to discover the profound and diverse aspects of the issue, it seemed necessary to apply a qualitative methodology, and therefore the methodology used in this research was “content analysis” (30, 31). the data collection method consisted of semistructured interviews and focus group interviews. first, a group discussion took place with the presence of 21 physicians, including 7 pediatricians, 2 neonatologists, 2 fellowship specialists in high risk pregnancy and perinatology, 3 medical ethics experts, and 6 asthma specialists and allergists. the session started with the statement of the problem by the researcher followed by a real medical case; then, several questions were asked and the subject matters were discussed. after implementing and evaluating the session, in-depth interviews were conducted in order to complete the data, as the researcher inferred that more comprehensive results could be achieved by spending more time and conducting personal interviews. subjects were selected by purposeful sampling with maximum variation and grouped based on gender, age, specialty and rate of clinical experience. these four indicators were chosen because they were easy to identify and evaluate, and not only affected the objective of the study, but also had sufficient variation among the participants. after the interviews began, more subjects were added through theoretical sampling. since the authors aimed at studying different opinions, the samples were selected out of four groups: pediatricians, pulmonologists, medical ethics experts, and internists. thus, based on the reference review mentioned in the introduction, those specialists who were more involved in air pollution and the resulting side effects and costs were selected as samples. prior j med ethics hist med 10: 7, september, 2017 jmehm.tums.ac.ir saeedeh saeeditehrani et al. page 3 of 11 to the interview, a text containing the guideline to questions and a summary of research objectives were sent to the participants via email. all interviews were recorded with participants’ consent and permission from the ethics committee of tehran university of medical sciences (no. 1686-1395). each interview began with 5 open questions. the questions were designed in a general and unbiased way in order to encourage the participants mentioning any item they considered valuable in this field (table 1); then the follow-up question were asked based on the information provided by the participants to clarify the construct. questions for further interviews were prepared based on extracted classifications. sampling continued until saturation, i.e. when the researcher felt certain that no new data could be added anymore, and continued up to 13 samples (3 internists, 2 pulmonologists, 1 dermatologist, 4 pediatricians, and 3 medical ethics experts). the last two interviews contained similar information, and the researcher was satisfied with adequacy of interviews. table 1general questions concepts of questions the relationship between health and environment physicians’ role in air pollution and the related side effects, and the obstacles to the realization of their role in air pollution reduction the role of policymakers and administrators in reducing air pollution to analyze the data, the present research used “the corbin & strauss constant comparative method” consisting of three stages of open coding, axial coding, and selective coding (32, 33). during the open coding stage, the texts were first implemented and then reviewed and reread multiple times. researchers examined the data and extracted the major points and constructs, then gave a special code to each sentence. lincoln and guba’s evaluative criteria method was applied to validate the data (34) and the validity of all eight criteria of this qualitative research was confirmed. the researcher’s long-term involvement in the research atmosphere and constant observations were considered. the researcher spent fourteen months collecting evidence from various resources, while external research was controlled by a third party arbitration, that is, the medical ethics expert who was not involved in the research. triangulation and negative case analysis were performed by the researcher, and the discussions were presented using thick description. as a final stage, member check was applied to increase validation. results participants and procedure twenty-one physicians (55% male and 45% female) participated in focus groups and 13 in interviews. their average age was 40, and they had an average of 18 years (±10) of clinical experience. the focus group sessions lasted 100 minutes, and the average duration of the interviews was 30 45 minutes. researchers coded each transcript independently, which resulted in extraction of 887 codes from the focus groups, and 105 codes from the interviews. a thematic analysis was performed after each interview and focus group session. interpretation of the coded texts enabled classification of the codes and establishment of the relationships between the various codes or categories. the codes were compared and discussed until agreement was reached. after classification, various categories were identified on the basis of descriptive hypotheses, and 4 themes and 20 subthemes were extracted overall. table 2: evaluation of physicians’ role in mitigating air pollution and environmental problems codes subthemes themes physicians are ordinary citizens, and are effective and influential in their role as members of the society. since air pollution and the environment are public concerns, physicians ought to observe these issues as other individuals, for instance use their personal cars less frequently, use public transportation, avoid smoking, contribute to tree planting, observe regulations such as vehicle inspection, and so on. observing environmental issues as ordinary citizens physicians’ role as ordinary citizens physicians have a distinctive position as special citizens and role models. physicians are role models in the society and can influence the perspective of the general public. therefore, they have greater individual and social obligations, and are more influential in culture making. people believe in physicians. physicians must have an appropriate conduct toward the environment physicians’ role as special citizens and role models j med ethics hist med 10: 7, september, 2017 jmehm.tums.ac.ir saeedeh saeeditehrani et al. page 4 of 11 as individuals, physicians have two roles: a) improving behavior b) teaching. if physicians are concerned with the environment, they can make contributions through activities such as making posters conveying environmental messages, separating dry and wet waste in the clinic, and avoiding improper methods of garbage disposal. such acts have a promoting and educational effect on patients. physicians’ professional conduct is especially significant; if physicians separate their wastes or have a healthy conduct, they can influence their patients’ and others’ outlook. this is also a form of education for patients and a way of culture building for the society, since such physicians not only behave properly and professionally, but also educate the society. as an example, physicians’ use of public transportation has a tremendous educational effect on other members of the society. they can teach others directly they can teach others implicitly (by providing role models) physicians are influential because they can publish healthrelated articles. for example, articles showing accurate statistics about the dangers of air pollution in various organizations. they can also attract the attention of policy makers and managers to this important issue. reliable, scientific and updated articles, statistics and reports can attract the attention of associations and scientific centers now more than ever. physicians and other health care providers must understand the need for research in this field reliable scientific articles with real statistics can cause the public to look into the issue. this raises awareness both in the scientific community and across the whole society. it can also have a significant impact on the general outlook and even direct it. provision of monthly and annual detailed statistics to the ministry of health and other related organizations can be very effective in making changes in the present state of affairs. there are few scientific papers and detailed statistics on air pollution and its harms to the environment. it is important that physicians be concerned about this issue. monitoring environmental problems and responding to them is essential. it is important that physicians be concerned about the environment, especially air pollution. factories that are built around large cities all contribute to pollution. such problems arise when people care only about economic interests and plan without first conducting the necessary environmental studies. likewise, employment and development are important, but all should be in line with the environment. writing papers on air pollution and its adverse effects on human health presenting real statistics and reports for informing the healthcare system, the society, and the public conducting relevant research projects about air pollution and its harmful effects on health informing and raising awareness in three levels: public associations, policymaking, and the society monitoring air pollution in a more systematic way, for instance on a monthly or daily basis showing sensitivity to prevalent environmental crises; in general, professional physicians should have a comprehensive insight and show sensitivity to environmental crises observing some points by physicians and the healthcare community (in the clinic, hospital, or laboratory) which decrease air physicians’ role as professionals with special ethical liabilities and sensitivities, both personal and social j med ethics hist med 10: 7, september, 2017 jmehm.tums.ac.ir saeedeh saeeditehrani et al. page 5 of 11 deforestation, irresponsible urban development, car manufacture, production of non-standard cars and fuels, and destruction of the environment are very important issues, and the medical community should also show sensitivity towards them. physicians and health care providers should start from themselves. every physician should evaluate issues in their workplace and address problems that can be resolved by themselves or the hospital. gynecologists stated that the incubator machine produces a type of gas harmful to children, and the older the incubator, the higher the produced gas rate will be, an item mostly neglected by physicians. moreover, physicians have some frequent unnecessary visitors, an issue that can be taken care of by telemedicine, or phone and internet communication. repetitive unnecessary visits to physicians can be reduced through tele-medicine via phone or the internet. green hospitals and developing organizational guides for the staff to promote environmental behavior in the workplace is very effective. prevention is also another responsibility of physicians, and solving environmental problems is related to this issue. treating patients is a major duty, but the harms and damages that air pollution induces on health should also be prevented. drinking milk, for instance, can prevent the adverse effects due to the calcium in milk, or vitamin c intake is useful because of its antioxidant feature. providing information on such subjects by physicians is very important for patients and the society alike. physicians can offer solutions for vulnerable groups to help them become less affected by air pollution, for instance by introducing a type of nutrition beneficial to children, or providing masks to pregnant women. as another vulnerable group, women should not to be exposed to air pollution, and must be encouraged to drink milk to protect them from the adverse effects. likewise, the elderly should stay at home or avoid exercising in polluted air. pollution. all physicians should evaluate the circumstances in their clinic or hospital in order to reduce air pollution in their professional domain social commitments based on the attention of health organizations to the importance of the subject, and designing the necessary models for environment-protecting clinics, laboratories, or hospitals professional commitment to treatment and follow-up of the patients professional commitment to paying special attention to the health of vulnerable groups in this regard, physicians and hospitals must take serious actions. green hospitals can contribute to environmental protection. having green hospitals and developing organizational guide the staff to have effective environmental behavior in the hospital. this strategy is very effective. physicians should address the psychological and social aspects of the issue, which often necessitates consultation with colleagues and talking with patients and their relatives. it is also important to reach an agreement and get help from others if necessary and obtain the participation of all stakeholders. creating codes and directives on green hospitals, laboratories and faculties consulting with experts and patients and attracting the beneficiaries’ participation physicians’ role as administrators of the healthcare system, and their environmental responsibilities j med ethics hist med 10: 7, september, 2017 jmehm.tums.ac.ir saeedeh saeeditehrani et al. page 6 of 11 education is very important for medical students, patients and other people, and physicians and health care managers can contribute. culturalization begins with universities and academic environments. therefore, professors and university presidents can educate the students in environmental issues. the faculty and the department must support air pollution research and ask physicians to present related articles and reports. follow-ups by the authorities help and create an urge for physicians and experts in the field. healthcare providers and health policy makers are responsible for making the health industry green. they should implement clean and green policies in hospitals, health centers, laboratories, and university departments. for example, green hospitals have specific codes. in general, health system actions on the policy-making level must be environmentally friendly. health authorities should constantly think and function in environmental terms. physicians should review research plans that may potentially harm the environment. physicians may submit reasonable requests to related centers, such as public transportation or environment organizations, and urge activities to reduce air pollution. they may even go as far as observing environmental problems and showing proper and timely reaction to environmental degradation (factory building, deforestation, drying the lakes and rivers). furthermore, they can acquire a comprehensive insight and study the effects and outcomes of environmental degradation. teaching environment protecting behavior by university authorities supporting environment-related research (on air pollution): if healthcare authorities support research projects, physicians and experts will pay heed to such activities more carefully a serious request from experts and physicians to present reports and scientific papers in the field reviewing all research plans in terms of environmental threats (specialty committees) healthcare system administrators should expect answers and explanations regarding environmental crises from authorities first theme: physicians’ role as ordinary citizens: one subtheme was extracted in this regard, which was observing environmental points as ordinary citizens. more explanations have been provided in table 2. second theme: physicians’ role as special citizens and role models: there are three main subthemes in this item: a) a physician must have an appropriate conduct toward the environment; b) he/she can directly teach others; c) he/she can implicitly teach others (table 2). third theme: physicians’ role as professionals with special ethical liabilities and sensitivities, both personal and social: a) physicians should write relevant papers regarding air pollution and its adverse effects on human health. this issue was considered particularly valuable and was pointed out in most interviews. b) physicians can present real statistics and reports. this is very useful for informing the healthcare system, society, and public, as the statistics given by this social class will be scientifically accurate, and appropriate solutions can be based on them. c) conducting relevant research projects on air pollution and its harmful effects on health will be extremely helpful. d) informing should take place on three levels: public associations, policy-making, and the society. physicians have certain social commitments and should be sensitive to affairs that jeopardize the public health. informing can be useful at all levels, either at the social or policy-making level. in addition to statistics and papers mentioned earlier, informing can be done in the form of interviews and technical meetings with the media, social networks, and so on. e) monitoring air pollution in a more systematic way, for instance on a monthly or daily basis, is especially important. those who are engaged in environmental activities, particularly physicians, are expected to monitor j med ethics hist med 10: 7, september, 2017 jmehm.tums.ac.ir saeedeh saeeditehrani et al. page 7 of 11 environmental issues more systematically since they are much more involved in air pollution costs and harms thanks to the facilities and possibilities available for them. f) physicians need to be sensitive to prevalent environmental crises; in general, professional physicians should have a comprehensive insight into such issues, because the majority of environmental crises have a direct or indirect impact on human health. g) in clinics, hospitals and laboratories, physicians and members of the healthcare community must observe certain details regarding environmental protection. more specifically, physicians should evaluate measures to be taken in the clinic or hospital in order to reduce air pollution in their professional domain (table 2). h) physicians have social environmental commitments based on the attention of health organizations to the importance of the subject, and they can help design the necessary models for environment-protecting clinics, laboratories, or hospitals (table 2). i) physicians have the professional commitment to treat and follow up their patients (table 2). j) another professional commitment of physicians concerns the provision of special care to the health of vulnerable groups (table 2). fourth theme: physicians’ role as administrators of the healthcare system, and their environmental responsibilities: a) physicians are required to create codes and directives on green hospitals, laboratories and faculties. there is great need for such establishments, and writing organizational guides on the staff’s conduct in relation to environmental protection is also useful. b) physicians can consult experts and patients and attract the beneficiaries’ participation in environmental affairs. they may consider the mental and social aspects and problems and consult their colleagues, patients and their families to reach an agreement and resolve the issues; furthermore, they can ask other people for help if necessary, and try to attract the beneficiaries’ help. c) university authorities should also teach and promote environment protecting behavior. instructing patients, medical students and other members of the society is very important, and physicians and healthcare system administrators can participate in the process. culturalization initiates from universities and academic institutions; therefore, professors and heads of universities can educate their students on environment-related issues and principles. d) if healthcare system authorities support environment-related research projects (in this case on air pollution), physicians and experts will pay heed to such activities more often. participants’ examples are presented in table 2. e) there is serious request from experts and physicians to present reports and scientific papers on the field. f) specialty committees should review all research plans in terms of potential threats to the environment. for instance, ethical committees should consider the constructive points in research projects that contribute to protect the environment. g) healthcare system administrators should expect answers and explanations regarding environmental crises from government authorities. moreover, they may request environment-related action from all centers involved. participants’ examples are presented in table 2. discussion as health service providers, physicians face diseases and complications that result from environmental crises such as air pollution every day. as citizens in general and as professionals in particular, they are expected to assume responsibility for environmental crises. the present research was conducted to examine how they can participate in the process of reducing air pollution. this study showed that physicians believe they can be effective in this field on four levels: level 1: in their role as ordinary citizens, physicians resemble other citizens in that they are clearly expected to perform their duty to protect the environment. other studies have mentioned this role as well, for instance, lorenzoni et al. stated that those employed in the healthcare system are ethically responsible for the environment as individuals, both in their personal and social life (35). islamic ethics also frequently recommends the protection and reconstruction of the environment. influential islamic doctrine emphasizes that the nature belongs to god, so human beings are always present in the divine land, even if they are not aware of it. according to islamic teachings, environmental crises are the outcome of people’s negligence in their responsibilities toward the nature, and their wrong belief that the environment is separate from the divine land. thus, islamic thoughts always urge citizens to protect and preserve the environment (36 38). level 2: a physician is also a special citizen and a role model whose conduct is emulated and followed by the society. a physician’s conduct can be educational for the patients and others, both directly and indirectly. level 3: the next level mentioned in this research was a physician’s role as a professional with special personal and social commitments. this role is of utmost importance, as who also defined the responsibility of the healthcare system and hospitals beyond mere treatment and prevention of diseases in j med ethics hist med 10: 7, september, 2017 jmehm.tums.ac.ir saeedeh saeeditehrani et al. page 8 of 11 2009, stating that hospitals should align their policies with environmental and climate changes due to the effect of such factors on public health (39). the physicians in the present research also mentioned supplementary endeavors that show significant professional commitment to the subject. instances included writing papers, presenting reports, and informing the public, all of which may take place on three levels: in scientific centers, policy-making, and the society. global studies also indicate that health service providers should be ethically sensitive to environmental problems because of their immediate and direct impact on human health. for instance, climate change and the related issues have a serious effect on people’s well-being, so the healthcare system is professionally expected to consider them (40). the common point between the present research and other studies was the importance of healthcare providers’ direct and indirect role in environmental problems that affect not only the general health but also the environment (41). the next point achieved in the research was showing sensitivity to these problems and taking a comprehensive view on the matter. this topic has been discussed and agreed on in some studies, albeit in a different light; for example, a qualitative study conducted in 2015 on 18 nurses demonstrated that the nurses’ view of their duties and responsibilities is mostly confined to their job-related tasks. they turned out to prioritize hygienic issues such as infections, and did not have a comprehensive insight on climate change or environmental problems, or at least did not prioritize them even when aware of their importance (42). meanwhile, a 2005 study conducted in paris insisted on the necessity of healthcare providers’ comprehensive concern for environment, since environmental issues can play a major part in every individual’s health in general (43). a 2015 study in the uk showed that those in the medical profession display their individual and organizational training and leadership roles in issues such as release of penicillin, tobacco control and enforcement of vehicle safety belt laws. relying on such instances, the present study refers to physicians’ important role in resolving social problems and urges a similar role in environmental issues (44). thus, a medical treatment team with heightened sensitivity to the environment may not only direct their professional conduct toward environmental protection, but also will look at environmental problems in a professional light and present their views on public health to policymakers. in fact, therapists are one of the best groups to observe and study environmental problems and provide policymakers with appropriate data. level 4: physicians also have the role of caretakers of the health and education system. this role can be categorized into two groups: reforming educational policies and directing them toward the attitudes resulting in proper conduct, and appropriate policymaking to protect the environment as much as possible. this study reviewed a new concept of environmental responsibility within the framework of physicians’ social responsibility, presenting it as physicians’ role in environmental issues. these roles are summarized as follows: the first role teaching environmental ethics to students by university authorities was a pivotal point mentioned in this case. as centers of education and culturalization, faculties are highly important. informing the students will contribute greatly to changing their attitude and behavior, and consequently those of the society. a 2011 study on senior medical students of medicine examined their attitude toward climate change and demonstrated that their opinions were changeable and resulted from the general attitude of the healthcare system toward environmental problems (45). thus, the attitude and conduct of authorities will significantly affect the students’ behavior. the second role three domains can be mentioned in this respect: presenting proper executive policies, supporting research projects, and review and supervision. one of the subjects discussed here was regulation of codes and directives for green hospitals, laboratories and faculties. this is extremely useful and fundamental, as many renowned medical faculties all over the world have regulated related ethical codes and directives (46, 47). committees and unions throughout the world have discussed this important issue in their ethical codes. for instance, the international council of nurses published nurses’ ethical codes in 2012, taking into consideration the environmental issues and observations (48). unfortunately, there are no such ethical codes in iran, and aside from the ethical code of research on animals (49) and medical research codes (only in one paragraph) (50), there is no clause among the thirteen written codes which specifically address environmental issues. another item related to this role is the support of research projects. the subthemes mentioned in the last topic as physicians’ professional duties depend on the support of healthcare system administrators in order to be realized. thus, writing papers, presenting statistics, preparing scientific and valid reports, and conducting relevant research on the subject require the support of healthcare system authorities. moreover, in order to establish green hospitals and make proper use of telemedicine, the essential substructures should be provided by healthcare system administrators, and research ethical committees should be bound to study and assess the rate of pollution from an ethical viewpoint. supervising this vital item is one of the duties of the heads of faculties. j med ethics hist med 10: 7, september, 2017 jmehm.tums.ac.ir saeedeh saeeditehrani et al. page 9 of 11 the third role healthcare system administrators should ask the authorities for explanations regarding environmental crises, because although problems such as air pollution are environmental in nature, the healthcare system will be responsible for the resulting harms and damages. therefore, ethical sensitivity and concern about such problems are essential for healthcare system authorities. to summarize, environmental issues should be taken into consideration in the light of medical ethics to determine the ethical duties of the medical society. limitations of the study since the topic was rather new, some of the experts did not have an adequate mental background in the subject and were therefore unable to cooperate in their full potential. in order to remove this obstacle, we provided them with the question guide (42). furthermore, in spite of the attempt to reach data saturation in the studied specialties, some of them may not have been prioritized in the interviews; however, almost all of the relevant specialties were considered according to the literature review. conclusion ideas on medical professionalism at all three levels (interpersonal, intrapersonal and public) and physician’s social responsibilities are frequently overlapping. both require the physician to be accountable to the communities and the society in which they serve. therefore, the physician should be increasingly prepared to respond to the growing environmental challenges and their social consequences. the present research shed a light on some aspects of this mutual relationship, suggesting that policymakers consider these aspects when establishing laws, supervisory mechanisms, and educational and research policies to create a positive attitude and control physicians’ conduct regarding environmental issues. since there is not much positive attitude in the field of environment, one of the priorities of the healthcare system can be to establish an appropriate attitude through different means, for instance by way of education. acknowledgment this study was extracted from the researcher’s ph.d. dissertation supported by tehran university of medical sciences. j med ethics hist med 10: 7, september, 2017 jmehm.tums.ac.ir saeedeh saeeditehrani et al. page 10 of 11 references 1. künzli n, tager i. the semi-individual study in air pollution epidemiology: a valid design as compared to ecologic studies. environ health perspect. 1997; 105(10): 1078–83. 2. roemer w, hoek g, 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vezeau t. hospitals going green: a holistic view of the issue and the critical role of the nurse leader. holist nurs pract. 2009; 23(2):101-11. 48. anonymous. code of ethics. www.icn.ch/about-icn/code-of-ethics-for-nurses (accessed on 2017). 49. anonymous. ethical guidelines. http://mehr.tums.ac.ir/showcode.aspx?codeid=9&lang=fa (accessed on 2017). 50. anonymous. ethical guidelines. http://mehr.tums.ac.ir/showcode.aspx?codeid=130&lang=fa (accessed on 2017). journal of medical ethics and history of medicine original article obstacles and problems of ethical leadership from the perspective of nursing leaders: a qualitative content analysis maasoumeh barkhordari-sharifabad 1 , tahereh ashktorab 2 *, foroozan atashzadeh-shoorideh 3 1 phd student in nursing, school of nursing and midwifery, shahid beheshti university of medical sciences, tehran, iran; department of nursing, school of medical sciences, yazd branch islamic azad university, yazd, iran. 2 professor, department of medical-surgical nursing, school of nursing and midwifery, shahid beheshti university of medical sciences, tehran, iran. 3 assistant professor, department of nursing management, school of nursing and midwifery, shahid behshti university of medical sciences, tehran, iran. corresponding author: tahereh ashktorab address: vali-asr avenue, cross of vali-asr and neiaiesh highway, opposite to rajaee heart hospital, tehran, iran. postal code: 1996835119. email: t.ashktorab@sbmu.ac.ir tel/fax: +98 2188655366 received: 25 jul 2016 accepted: 5 feb 2017 published: 21 feb 2017 j med ethics hist med, 2017, 10:1 © 2017 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract in the nursing profession, leadership plays a significant role in creating motivation and thus enabling nurses to provide high quality care. ethics is an essential component of leadership qualifications and the ethical leader can help create an ethical atmosphere, offer ethical guidance, and ensure the occupational satisfaction of personnel through prioritizing moralities. however, some issues prevent the implementation of this type of leadership by nursing leaders. the aim of this study was to identify and describe some problems and obstacles in ethical leadership faced by nursing leaders, and to help them achieve more accurate information and broader perspective in this field. the present study was conducted using a qualitative approach and content analysis. a total of 14 nursing managers and educators were selected purposefully, and deep and semi-structured interviews were conducted with them. content analysis was performed using an inductive approach. three main categories were obtained after data analysis: ethical, cultural and managerial problems. “ethical problems” pertain to doubt in ethical actions, ethical conflicts and ethical distress; “cultural problems” include organizational and social culture; and “managerial problems” are connected to organizational and staff-related issues. nursing leaders put forth various aspects of the problems associated with ethical leadership in the clinical setting. this style of leadership could be promoted by developing suitable programs and providing clear-cut strategies for removing the current obstacles and correcting the organizational structure. this can lead to ethical improvement in nursing leaders and subsequently the nurses. keywords: ethical leadership, nursing, content analysis, qualitative research j med ethics hist med 10: 1, february, 2017 jmehm.tums.ac.ir maasoumeh barkhordari-sharifabad et al. page 2 of 11 introduction today, health care organizations are subject to rapid and fundamental changes aimed at enhancing the quality of service, patient satisfaction and productivity (1). parallel with these changes, nurses face cases such as heavy workload, increased patient awareness, various problems related to staff skills, lack of resources, low occupational and life quality, and workplace violence (2). however, there is the expectation that nurses should treat patients in an ethical manner and put ethics first in their professional performance. across the world, nurses are guided to use professional codes that emphasize their obligation to respect, protect and defend the fundamental rights of the people involved in nursing and health care (3). one of the most powerful methods to promote ethics in health care and the nursing practice is to role model ethical performance on the managerial level (4). nurses in formal leadership positions should promote ethics (5), which means they should implement ethical leadership (6), an approach that has attracted much attention in recent years. this style of leadership involves the development of appropriate normal behavior through personal actions and interpersonal interactions, and also promotion of such behaviors in subordinates through bilateral exchanges and strengthening of decisionmaking (7). ethical leaders must strive to model and support ethical performance (4) and at the same time be sensitive to moral issues and enhance nurse's performance by fostering respect for human dignity; thus, they can play an important role in promoting patient safety (8), increase the capacity to discuss and act upon ethics in daily activities (9), and support the ethical competence of nurses (10). some studies in this field have indicated that ethical leadership leads to reduced work leave and increased job satisfaction in nurses through decreasing moral distress and creating an ethical milieu (11). furthermore, this style of leadership boosts confidence in the leader, organizational commitment, and psychological empowerment among the personnel (12). moreover, it exerts considerable effects on the staff’s creativity and their energetic feeling (13). disappointment and lack of confidence, commitment and motivation are among the side effects of leaders’ unethical behavior that influence both patients and organizational efficacy negatively (14). some studies have demonstrated that the leaders’ supportive behavior and confidence in management are essential for stabilizing nursing values. these behaviors include empowering nurses to express their concerns and worries, and providing recommendations for improving their work environment and nursing care (15 17). the islamic republic of iran is located in the middle east and enjoys one of the oldest civilizations of the world. it is a developing country with specific ethical values and a population of more than seventy million people. islam is the formal religion in this country (18), and a combination of iranian and islamic cultures form its identity. the religious discipline and cultural beliefs of the iranian people have entered the health care system and ethical issues are prominent in the patient care protocols (19, 20). the nursing manpower in iran is estimated to exceed 150,000, forming a considerable portion of the health care staff. the iranian health system, like any other developing country, suffers from limited manpower and financial resources inconsistent with health care requirements (20). similar to their peers in many other countries, iranian nurses are dissatisfied with their jobs due to work pressure and shortage of time and resources that prevent them from proper fulfillment of their duties (21). furthermore, they have been shown to suffer from inappropriate work environment, lack of support, discrimination, conflict, limited opportunities for development, dissatisfaction with work conditions due to heavy workload and unusual work hours, lack of power, and undesirable social status (22). government policies have resolved nurses’ concerns to some extent, including workload and nurse-patient professional issues; however, there is still the need for a solution to increase the quality of care and improve patient safety (20, 23). it seems that these problems are imposed by lack of leadership skills in nursing managers. studies have revealed that task-oriented behaviors are the dominant style of health care leaders and educational systems in iran (24). leadership plays a role in creating a culture of care (25), and leadership ethics and confidence in nursing leaders are important components of a healthy work environment culture (6, 17, 26, 27); therefore, this study aimed to identify the barriers that impede the application of ethical leadership in health care settings in iran. thus, the authors decided to conduct a qualitative research in this field from the perspective of formal nursing leaders in order to get more detailed information on the nature of the problems and obstacles in ethical nursing leadership. method the present study used conventional qualitative content analysis and purposive sampling to investigate the problems and obstacles of ethical leadership in nursing. conventional content analysis is usually the preferred method in studies that focus on elucidating a phenomenon. this design is suitable when there are limited numbers of existing theories or sporadic literature on the phenomenon under study. in this case, the researchers avoided the application of presupposed categories and managed to distill the categories from the data. hence, the categories are manifested through deduction (28). j med ethics hist med 10: 1, february, 2017 jmehm.tums.ac.ir maasoumeh barkhordari-sharifabad et al. page 3 of 11 seeing that in the qualitative approach, the phenomena must be investigated in their natural context, the hospitals and nursing schools of tehran, iran, were selected as the research setting. among the formal nursing leaders, those with at least 2 years of managerial work experience who wished to participate in the study were chosen. selection criteria for the educators included experience in teaching ethics, leadership status, and publication of books and articles in the field of leadership and ethics. these individuals possessed deep information and experience related to the subject under study (they were key informants) and could provide the researcher with much information. as decisionmakers in the health care system, clinical leaders and university authorities cannot be separated from each other, and the emergence of ideas on ethics requires the participation of both; therefore, nursing educators were also involved in this research. moreover, the participating educators had some experience in clinical settings and leadership, and a number of them were occupied in the capacity of formal leaders at the time. this study tried to cover a sample with great variety in age, gender, management level, department, and work experience. to find the more experienced participants with a richer reservoir of data, the initial sample was used, which included nursing educators with a 22-year management experience at various levels of nursing as well as teaching ethics. a total of 14 individual interviews were conducted. data saturation was achieved after 11 interviews, but an additional three were carried out to reach certainty. as confirmed by research participants, the interviews were held in a quiet room in their workplace at hospitals and colleges. all interviews were conducted by the first author, a female phd candidate in nursing, and a nursing instructor. she has received the customary training for phd students to prepare for doctoral dissertations, and has also completed a content analysis workshop. after obtaining the approval and written informed consent from the participants, deep and semistructured interviews were conducted to collect the data. the interviewer began with general questions and proceeded to ask, “where is the position of ethics in your leadership?” then, based on the goals of the study, the more detailed questions followed, for instance: “have you ever been in a situation where you did not do what was ethical despite being aware of it? please explain.” and “what happened that led you to behave like that?” in order to obtain more data and clarify certain issues, some probing questions were also asked, such as: “can you give us an example? what did you mean by that? can you explain further?” individual interviews lasted for 35 to 90 minutes and the participants were then asked to discuss any remaining issues that came to mind. the interviews continued till data saturation was achieved so that no new code of data could be retrieved. in this study, the common points were identified, coded and categorized by using latent content analysis. in this method, the researcher searches for specific concepts and the meaning of all the data within the context, and will then design the structural model that can relate the meaningful classes with similar themes (29). all interviews were recorded on tape and the transcripts were typed, reviewed and coded at the end of each interview. to observe the principle of confidentiality, participants’ names were not revealed. instead, each of them was given a specific number and their important particulars such as age, type of degree, and managerial experience were recorded. data were analyzed simultaneously and continuously by collecting information. semantic units were extracted in the form of initial codes or open codes from the interviews. the codes were reread several times and placed in subcategories on the basis of similarity and proportion of the participant expressing the same topic. next, the subcategories were compared with each other and those with similar characteristics were combined to create wider categories, which were presented once more. some of the measures taken to enhance data accuracy included prolonged involvement with the topic, confirmation of findings by the participants, and observer reviews. to ensure dependability of the data, in addition to the members of the research team, two experts out of the research team were asked to evaluate the interviews, codings and categories. as regards the conformability of the data, all research steps, including data collection and analysis, observer reviews and the research process were documented on a regular basis. to enhance transferability, the entire process of the research and all the work done in the course of the study were prepared in clear and accurate written form to enable others to track and study population characteristics. this study was approved by the human research ethics committee of shahid beheshti university of medical sciences in tehran, iran. in the course of the study, permission was obtained from the authorities of hospitals, departments and colleges. the interviewer began by introducing herself and explaining the purpose of the research to the participants, who were then asked to complete the demographic questionnaire and informed consent. moreover, permission to record the interviews and take notes was obtained from the participants, and confidentiality and subjects’ freedom to participate in or withdraw from the research was observed. the participants were also assured that their names will not be revealed under any circumstances. interview tapes are kept anonymously in a safe place and can be accessed only through codes assigned by the researcher. j med ethics hist med 10: 1, february, 2017 jmehm.tums.ac.ir maasoumeh barkhordari-sharifabad et al. page 4 of 11 results there were 14 participants with a mean age of 46 years and an average management experience of 12 years. in terms of managerial level, 3 were supervisors (all matrons), 6 were head nurses, and 5 were nursing educators (table 1). analysis of the handwritten notes on participants’ experiences of the problems associated with ethical leadership in nursing resulted in the formation of 73 original codes, which were reduced to 21 after merging similar codes. eventually, three main categories and 7 subcategories emerged that are presented in table 2. major groups included ethical problems, cultural problems and managerial problems. table 1: characteristics of the study participants characteristics number gender male 6 female 8 education level bachelor’s degree 6 master’s degree 3 doctoral degree 5 position head nurse 6 supervisor 3 nursing educator 5 table 2: generated categories, subcategories and examples of codes an example of the code subcategories categories negative outcome of introducing a role model to staff uncertainty about how to deal with staff doubt in ethical act ethical problems conflict between the needs and expectations of nurses conflict in meeting the similar needs of employees conflict between leaders’ values and the values of the organization ethical conflict discomfort following the implementation of procedures in accordance with organizational policies and rules dissatisfaction caused by being forced to perform certain tasks due to shortage of staff ethical distress absence of a culture of democracy in the organization lack of the proper culture in introducing the role model organizational culture cultural problems negative public perception of the nursing community negative feelings of patients’ families with regard to the night shift attitude of the majority of the population to nurses as physician assistants social culture lack of power and authority in recruitment physician-oriented system low regard for the nursing profession lack of facilities characteristics of the clinical environment issues related to organization managerial problems staff's abuse and bullying undesirable behavior such as speaking ill of each other understanding of justice among personnel issues related to staff from the perspective of the nursing leaders in this study, there are three major types of problems and obstacles in ethical leadership: ethical, cultural and managerial problems. ethical problems ethical problems were among the categories abstracted from the data. in nursing leadership, these types of problems are sophisticated and pervasive due to their far-reaching implications and varied solutions on the one hand, and uncertain events and personal impressions on the other. the reason is that acts performed by nurse leaders affect staff, patients and other people. if these acts affect others inconsistently, or harm them in an uncontrolled manner, ethical problems arise. this category j med ethics hist med 10: 1, february, 2017 jmehm.tums.ac.ir maasoumeh barkhordari-sharifabad et al. page 5 of 11 consists of three subcategories of doubt in the ethical act, ethical conflict, and ethical distress. a) doubt in the ethical act: quite often the consequences associated with ethical choices are not clear, and this will make leaders doubt their ethical performance. participant number 2 who has a phd in nursing and 8.5 years of management and leadership experiences at various levels puts it this way: [i introduced an ethical example to others in a meeting, but my ethical act was associated with an adverse result, which made a group of people upset. i thought i was introducing a model, but others thought that i was accusing them of not acting ethically. now, i do not know if it was ethical or not, if it is ethical, so why didn’t what we read about in books work?] (participant no.2) some participants stated that doubt in the ethical act is a challenge in nursing leadership. for example, participant number 11, a 45-year-old nurse with 9 years of experiences in different wards says: [i try to behave in the correct way and pay attention to these issues, for example, i try to be friendly with the personnel and respect them, but i see they have different perceptions. they take advantage of my kindness…. sometimes i think maybe i am not doing it right and i should be like the others and treat them in a way so they won't dare to disobey me.] (participant no. 11) b) ethical conflict: differences in ethical values in practice will lead to ethical conflicts. participants admitted that sometimes they are involved in situations where the needs and expectations of nurses are in conflict with each other. participant number 6, a 38-year-old nurse with a 6-year experience in head nursing and supervisory says in this regard: [i have a novice among my personnel. well, ethically i should team her up with a more experienced employee, but in such cases, the more experienced ones will complain because this will increase their workload. they may request to work with another person in the same shift. see, you are involved in a situation where you don’t really know what to do, so what does ethics say here?] (participant no. 6) another aspect of the conflict is that both employees have similar desires, and therefore the nurse leader experiences negative feelings as to whose needs to meet under the circumstances. participant number 14, a master of nursing with 20 years of management experiences at various levels (head nurse, supervisor and matron) says: [when planning shifts, you can't always be fair; for example, on many occasions, two employees needed a day off on the same date, and it was very important for both of them to take that particular day off. on the other hand, it was impossible for me to let both of them have a day off because i was short on staff, so i had to choose one.] (participant no. 14) participants stated that sometimes there is a conflict between their values and beliefs and those of the organization. as nursing directors, they are expected to act in accordance with organizational values and justify them for the personnel, even though they might have different opinions. participant number 9, a 44-year-old nursing phd with 5 years of management experiences states: [it is interesting that sometimes high-level executives or security managers tell us to be tactful, and by that they mean we should tell a lie, pretend to be more skillful than we actually are, and ignore many things. i'm not like that.] (participant no. 9) participants believed that ethical leadership is harder and more complex in the clinical setting than other work environments such as nursing education due to a high rate of ethical conflict: [in my opinion, there is a great deal of ethical conflict about leadership and management issues in hospitals…. you don’t know who’s right, the patient or the ward nurse, because nurses work really hard on various shifts and are under a tremendous amount of pressure. on the other hand, you see that patients are also right and want to receive the best service possible.] (participant no. 2) c) ethical distress: participants stated that when they are faced with obstacles that force them to act against their ethical beliefs, they feel discomfort, dissatisfaction and frustration. they acknowledged that they are often involved in situations where they know the right way to do things, but organizational policies and rules and lack of support from superiors make it impossible for them to perform their duties appropriately and this causes them distress and discomfort. [sometimes i'm asked to do something that is not within the rules, but is right by logic, reason and humanity. i know that if i do that, the consequences will come back to me and i’ll be held accountable later. these things make me sad and angry.] (participant no. 2) another condition that causes ethical distress in nursing leadership is lack of adequate and skilled manpower in wards. in this regard, participant number 5, a nursing expert with a 20-year experience of head nursing in different wards says: [the ward nurse calls me and says her child is sick and asks me to give her a day off or change her shift. i don’t want to say no to her, but i am short on staff, so i oblige her to come. the situation makes me very sad, but i do not have any other choice.] (participant no. 5) similarly, participant number 9, who is a 44-year-old phd with 5 years of management experience, states: [i am forced to put someone that i don’t trust in charge. i just do this so that somebody fills the post, because i do not have any efficient workforce. it is clear that i am very dissatisfied with this situation, but there is nothing i can do.] (participant no. 9) cultural problems in data analysis, cultural problems were abstracted as the second category. like any other institution, j med ethics hist med 10: 1, february, 2017 jmehm.tums.ac.ir maasoumeh barkhordari-sharifabad et al. page 6 of 11 hospitals and health care centers have their own beliefs and norms that determine the way of thinking, behavior and performance of employees within the organization. the beliefs and opinions of organization members reflect those of the society in which they grew up. the nursing leaders in this study noted cases that can be classified as cultural problems, including two subcategories of social culture and organizational culture. a) social culture: culture is a model of values, beliefs and attitudes of people in every society, and the culture of any organization, including health care centers, is therefore no exception. lack of respect for the nursing profession and the negative public image associated with it were among the cases that the participants pointed out. this negative attitude has an impact on the self-confidence and motivation of nurses, including nursing leaders. leaders with low levels of self-confidence and motivation cannot play their leading and supportive role as may be expected. in this regard, participant number 9 states: [when i passed the nursing entrance exam, i did not get much positive feedback. my family got upset that i was going to nursing school, and, well, that's all it takes to diminish one’s self-confidence. it is much better now, but the impact still remains.] (participant no. 9) the iranian society is a family-centered one, and this creates a negative attitude towards women working late hours and night shifts. some participants mentioned this as an obstacle to their ethical practice. for example, participant number 13 says in this regard: [the night shift is a problem for some female personnel, as their families simply don't understand that nursing means working nights and circulating shifts. very often you see families call and say, “don’t assign x for the night shift.] (participant no. 13) b) organizational culture: organizational culture is a control agent that shapes the attitudes and behavior of employees, and the participants pointed out the problems in this area as one of the cases. for example, participant number 3, a 52-year-old nursing phd with 7 years of experience in management states: [one problem is that there is no culture of democracy in our organizations, that is, when you believe that you should lead a group in a democratic way, you will get hurt.] (participant no. 3) another participant says: [people are encouraged to introduce a model in ethical leadership. well, i did, and it caused annoyance, which means that doing so will bother people and is not conceived as a norm for employees.] (participant no. 2) managerial problems another issue in the field is connected to managerial problems. these problems revolve mainly around axes such as inappropriate procedures, guidelines and evaluations as well as the poor performance of the nursing staff. this category consists of two subcategories: issues related to the organization and issues related to staff. a) issues related to the organization: lack of authority in recruitment, low regard for nursing, shortage of manpower and resources, and certain clinical characteristics were mentioned by the participants in this respect. of the above-mentioned factors, they considered the first as one of the most challenging. for example, participant number 13, 44 years old, with 15 years of management experience states: [the problem with our job is that the employment criteria are the same for all the staff; the payment is also the same… yet, the work done by different individuals varies from individual to individual. the head nurse does not have the authority for proper employment and payments; this is an obstacle to the administration of justice.] (participant 13). participants had also experienced a lack of respect for nurses. they said that sometimes decisions are made for the nursing department without considering their opinions. nurses are simply asked to implement those decisions, and do not even receive explanations and clarifications on the process. for example, participant number 8 says: [apart from the fact that sometimes they make decisions about us without asking for our opinions, they do it without even telling us how to implement those decisions, let alone expect us to act ethically.] (participant no. 8) one source of power for leaders is their authority, which is based on reward and punishment. in order to use these power sources fairly, it is essential to evaluate staff performance, the most important purpose of which should be the improved quality of patient care and safety. but nursing leaders believe that the common evaluation method of staff performance is not fair: [we deal with humans in our workplace, so a fair evaluation of personnel is hard. for example, they provide a patient with education, their care quality is different from each other, and it is difficult to evaluate how much harm is brought about due to the errors they make.] (participant no. 13) characteristics of health care organizations and in particular clinical environments, which are a component of the nursing profession, have created challenges for ethical leadership: [given the circumstances of the clinical environment, it is so hard to establish democracy and justice. there are guidelines, instructions and policies in the clinical environment that might be in conflict with the spirit of democracy.] (participant no. 3) b) issues related to staff: ethical or unethical behavior and performance of the nursing staff can trigger positive or negative consequences at the j med ethics hist med 10: 1, february, 2017 jmehm.tums.ac.ir maasoumeh barkhordari-sharifabad et al. page 7 of 11 organizational level; thus, non-observance of some ethical standards is a source of concern for efficient leaders. one of the things referred to by the participants in this study was abuse and bullying on the part of nurses. participant number 10, a specialist nurse with 18 years of management experience states: [there are some people who complain no matter how you plan their shifts. you give them good shifts that they like, but when they see that others got good shifts too, it’s like they feel jealous…. sometimes they disrupt your ward’s atmosphere, for example by irritating someone, and then it is no use trying to be just.] (participant no. 10) adherence to ethical values on the personal level is the individual dimension of ethics, and a lack thereof will cause greed, selfishness, speaking ill of others, and so on. such behaviors will lead to an escalation of conflict in the organization. participant number 9, a 44-year-old phd with 5 years of management experience says: [when i was manager, i noticed that people can perform a lot of unethical acts and sometimes they do whatever they can to cause harm to one another.] (participant no. 9) participants believed that members of the staff are different from each other, even if placed in similar circumstances. one challenge faced by nurse leaders was lack of acceptance of individual differences among the staff, and a sense of injustice. in this regard, participant number 7, 47 years old, with 9 years of management experience at various levels states: [there are too many individual differences among personnel. well, one considers these in planning shifts and such, but to make them understand these differences is another story. for example, none accepts that one person’s quality of work differs from that of others. they may think that i pay more attention to x and have someone’s back more than others.] (participant no. 7) discussion the findings of the present study were similar to those of other studies on this topic. three main categories were identified, indicating the participants’ perceptions and experiences of ethical leadership barriers and problems in the sociocultural context of the iranian health care setting. it should be mentioned that all formal nursing leaders in this study showed a kind of positive feeling and interest with respect to this leadership style. this was to be expected as members of the nursing workforce are committed to ethical practice in their profession (6). ethical problems were among the abstracted categories in this research. nursing leaders experienced doubt in the ethical act, ethical conflicts and distress in the clinical setting. other studies with similar findings have also mentioned these issues (30 33). the results of this study demonstrated that the unexpected outcomes of ethical behavior could cause nursing leaders to hesitate about performing ethical acts. one issue that is raised in emergence of ethical complaints is that not all criteria used to justify ethical beliefs are fair, as they are affected by the ethical beliefs of a culture or a person (34). in one study, scott states that identification of a right performance is a challenge to organizational resources. she believes that consideration of others’ views, detection of unintended consequences and engaging in continuing education is useful for tackling this challenge (30). today, ethical conflicts and controversies are inevitable in health care organizations round the globe, and this may lead to ethical distress (35). the study participants had experienced this conflict between the nurses’ expectations and needs, their own values and beliefs and those of the organization, and the needs of patients and the personnel. other studies have shown that in the changing health care environment, ethical leaders encounter three different values, i.e., individual (power, value and respect), professional (patient-centered care) and organizational values (competition, risk-taking and position) (31). lack of balance between care and management duties may lead to ethical conflict in leaders (32). nursing managers experience conflicts between individual and organizational ethics, especially when they cannot provide quality care due to organizational constraints (33). the results of this study showed that obstacles such as organizational policies and rules, lack of support from superiors, and lack of sufficient and qualified manpower will weaken leaders’ capability to perform ethical acts and create ethical distress. these findings are similar to those of the study by gaudine and beaton. their findings revealed that disagreement with organizational policies over employee discipline, centralized decisions, and lack of ethical resources available to nurses are among the sources of ethical distress in ethical leaders (36). shirey and fisher believe that ethical distress arises from role complexity and increased stress, and is a source of psychological stress associated with conflicts experienced by nursing managers (37). however, due to the descriptive and general nature of problems, sources of ethical distress were not specifically investigated in this study. leadership and management are affected by cultural, social, and economical factors. cultural problems were one of the categories extracted from the participants’ statements. the role of culture in human behavior is one of the most important concepts discussed in behavioral sciences. in the present study, participants considered cultural and professional identity as one of the factors contributing to the promotion of the profession and professional attitude. positive or negative cultural j med ethics hist med 10: 1, february, 2017 jmehm.tums.ac.ir maasoumeh barkhordari-sharifabad et al. page 8 of 11 factors can be seen in any society. for example, negative attitudes towards nurses expressed by the participants can be effective on their self-confidence, authority, professional socialization process and professional identity. these findings are approved by other studies as well (21, 38 45). the sociocultural context can greatly affect the leadership course and efficacy factors, as well as the approval of leadership features in a specific social culture (46 48). the assessment and interpretation of leaders’ behavior and characteristics are related to various sociocultural backgrounds. the participants experienced improper organizational culture such as an absence of model acceptance, which affected their ethical leadership. the cultural values of an organization are usually a reflection of the society and the environment in which it belongs. some other studies have suggested that the organizational culture is correlated with individual and leadership efficacies. the constructive aspects of organizational culture encourage individuals to find a way for selfcorrection and acquiring job satisfaction (49). similar to this study, aitamaa et al. referred to organizational and cultural factors such as lack of respect for, and the general negative attitude towards the nursing profession in health care organizations, stating that this culture has a negative impact on nurses’ work motivation (39). moreover, research on leadership points out that an understanding of the organizational culture cultivates the efficacy of leadership (50), and that ethical leadership plays the mediating role in the relationship between the organizational culture and personnel consequences such as satisfaction, extra effort, effectiveness (51). data analysis confirmed that managerial problems are obstacles for ethical leadership. issues related to the organization such as lack of power and authority in recruitment, low regard for the nursing staff, shortage of manpower and resources, and specific clinical features were among the cases referred to by the participants. this is not consistent with the findings by fradd, who emphasizes the important role of nursing mangers in organizational decisionmaking in the scope of nursing (52). of course, other studies have highlighted the limited power and influence of nursing managers and nurses and lack of their participation in organizational decision-making and inequality of professions in organizations (21, 39, 42). in this study, participants referred to behaviors on the part of the personnel that disrupted the environment and had an impact on the quality of care, thus challenging ethical leadership. for instance, mistreatment, bullying and behavioral disorders such as defamation were among the cases referred to by the participants. behaviors such as bullying are quite common in the nursing profession, as has been reported in many studies (53 57). in a study by gilbert et al., 86.2 % of nursing managers witnessed bullying by the nurses and 52% of them were victims of bullying (56). aitamaa et al. also investigated issues common among the staff, for instance lack of cooperation, help and trust, groundless criticism, and noncommitment to group decisions (39). latent behaviors such as insulting or humiliating others and backbiting are among destructive overt behaviors (58, 59). the participants mentioned the difference in attitudes towards the same subject as one cause of these behaviors. this is consistent with the findings by aitamaa et al. for example, in planning personnel shifts and holidays, some see justice as assignment of various shifts in equal numbers, while others believe in planning shifts by taking into account the wants and life conditions of personnel (39). conclusion this study showed that despite the emphasis on ethical leadership in existing research, there are some barriers and problems in the implementation of this style of leadership. these obstacles have various aspects in ethical, cultural, and managerial domains. identification of these factors can promote the ethical dimension of leadership. health care policy makers may utilize the findings of this study to formulate programs and clear-cut strategies to remove these barriers and improve organizational structure and thus promote this style of leadership. moreover, development of organizational ethical codes for guiding the performance of nursing leaders in confrontation with these problems may be helpful. ethical leadership is feasible through correction of social and organizational cultures, and securing the public confidence in nursing from organizational and extra-organizational aspects. in conclusion, nursing leaders are required to consider the individual and occupational features and characteristics of personnel when approaching these problems. discussions about the nursing profession and nursing leaders’ conditions can improve the standards in this regard. the leaders themselves play a key role in such discussions and should make their actions clearer and more specific. the findings of this study may help with the development of an instrument for investigating the barriers and problems of ethical leadership in nursing. further studies are required on ethics in management and research, specifically in the case of each of the obstacles, causes of ethical problems, and their frequency and severity as well as their differences in various levels of management. yleneserp , erele is very limited information about the values, resources and mechanisms to resolve ethical problems, and that could be the basis for future research. j med ethics hist med 10: 1, february, 2017 jmehm.tums.ac.ir maasoumeh barkhordari-sharifabad et al. page 9 of 11 acknowledgement authors would like to express their deepest gratitude to the deputy of shahid beheshti university of medical sciences who provided financial support for this project, as well as the participants, and all our colleagues who helped us in conducting this research. this study was approved by the human research committee of shahid beheshti 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l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e © 2019 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. original article volume 12 number 4 april 2019 ethical considerations in the biomedical research: analysis of national biomedical research ethics guidelines in iran *corresponding author maryam nakhoda department of information science & knowledge studies, faculty of management, jalal al-ahmad st, tehran, iran. postal code: 14155-6311 tel: (+98) 21 88 00 02 45 email: mnakhoda@ut.ac.ir ehsan shamsi gooshki no.23, 16 azar st., medical ethics and history of medicine research center, tehran, iran. postal code: 1417633114 tel: (+98) 21 66 95 38 33 email: ehsanshamsi713@gmail.com received: 21 july 2018 accepted: 13 mar 2019 published: 17 apr 2019 citation to this article: mardani ah, nakhoda m, noruzi a, shamsi gooshki e. ethical considerations in the biomedical research: analysis of national biomedical research ethics guidelines in iran. j med ethics hist med. 2019; 12: 4. amirhossein mardani1, maryam nakhoda2*, alireza noruzi3, ehsan shamsi gooshki4* 1.phd student in information science & knowledge study, department of information science & knowledge studies, faculty of management, university of tehran, tehran, iran. 2.assistant professor, department of information science & knowledge studies, faculty of management, university of tehran, tehran, iran. 3.associate professor, department of information science & knowledge studies, faculty of management, university of tehran, tehran, iran. 4.assistant professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran; department of medical ethics, school of medicine, tehran university of medical sciences, tehran, iran. abstract the national guidelines for biomedical research ethics are approved by the “national committee for ethics in biomedical research” at the iranian ministry of health and medical education as the regulatory body for biomedical research in the country. the focus of these guidelines should be on the ethical issues related to different stages of the research process, which would lead to increased research integrity and better supervision of research activities. the present study analyzed the contents of these national guidelines to clarify the ethical considerations connected to the five stages of a research process including 1) proposing, 2) approval, 3) operation, 4) documentation and 5) publishing. the findings showed that the assessed guidelines laid more emphasis on the ethical considerations related to the research operation stage rather than the proposal stage. in other words, activities such as identification of the research problem, formulation of hypotheses and questions, financial evaluation, data analysis and data interpretation did not receive adequate attention in these guidelines. most of the guidelines presented subject categories such as the rights of participants and supervisory considerations in the “research operation stage”, ethical considerations in the “evaluation and approval procedure stage”, and editorial responsibilities in the “research review and publication stage”. in general, despite noticeable content for guiding researchers for ethical conduction of research the national guidelines are not adequately developed to cover comprehensive and sufficient ethical considerations regarding all the activities of research. keywords: research ethics; research process; ethical considerations; research ethics guideline ethical consideration in the biomedical research … 2 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 4 april 2019 introduction ethical codes stipulated in research ethics standards include responsibilities and considerations that are set to prevent violation of research integrity during the research process. these ethical considerations must be extended to all research activities from research design to publication (1), because every stage of the research process is prone to irresponsible behaviors and research misconducts, which can cause deviations in research activities (2, 3). despite the development of standards for research ethics, however, researchers encounter additional challenges that are not specifically addressed in the standards; such inadequacies may jeopardize research integrity and increase the risk of misconducts in all stages of the research process (4). thus, one of the most important functions of research systems is to develop ethical standards for all research activities from research design to publication (5). due to the significance of following these standards throughout research stages, most developed countries exercise systematic supervision over all stages of the research process (6). the iranian ministry of health and medical education (mohme) has approved national guidelines for biomedical research ethics as a comprehensive framework of ethical considerations to improve research quality. these guidelines focus on the necessity and importance of observing research ethics standards not only in publication, but in all research stages (7). the ultimate goal of research ethics standards, including guidelines and instructions, is to develop and modify a comprehensive framework for ethical responsibilities and considerations in research (7). therefore, assessing the content of officially approved guidelines for research ethics allows us to understand the present state of the considerations already issued by mohme as the main authority. a number of studies have been conducted to investigate the research ethics in iran and have proposed ethical considerations for different stages of the research process (1, 5), but they have not addressed the ethical considerations related to activities in biomedical research. the present study, however, tried to investigate the research ethics guidelines approved by mohme to assess implementation of the ethical considerations in various stages of the research process. in other words, it aimed to determine which activities of the research process have received more attention in the guidelines, and what ethical considerations pertain to each stage of research. in order to perform a solid and accurate analysis of the ethical considerations related to research stages in the guidelines for research ethics, it is essential that we acquire a deep understanding of the research process in the biomedical research environment in iran. previously (8), we described the process of biomedical research in five stages and fifteen steps (figure 1), and the present study adopted this framework to investigate ethical considerations in research. mardani ah., et al. 3 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 4 april 2019 figure 1stages and steps of biomedical research process (8) methods for a textual investigation of research ethics standards, a qualitative content analysis was used to examine the text of the codes and general and specialized guidelines approved by mohme. additionally, the concept of a multi-stage research process was used to formulate the ethical considerations in research (5). stages of the research process in figure 1 were considered as predefined categories for recording information. because of these predefined categories, we employed directed content analysis, which is more systematic than other methods of content analysis (9). the units of analysis included concepts of the ethical considerations stipulated in the ethical codes of the guidelines, where information such as ethical considerations is categorized based on the stages of the research process. ethical considerations included behaviors that one must or must not engage in and are clearly pointed out in the codes of ethical conducts (10), for instance, the obligation of researchers to fully inform research participants about the benefits and risks of their study. accordingly, we tried to extract the concepts and considerations implicitly mentioned in the ethical codes and match these concepts with the stages of the research process. open and axial coding were used to extract and collect data. in open coding, the information stipulated in the ethical codes was segmented into independent concepts. the results of open coding are shown in table 2. the extracted concepts of the ethical considerations are categorized in the steps of the research process as depicted in table 2. for axial coding, the results of open coding were reorganized and subdivided into subcategories. the results of axial coding are shown in table 3, where the stages of the ethical consideration in the biomedical research … 4 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 4 april 2019 research process are presented as the main categories, and issues such as financial contracts or the rights of research participants as the subcategories. finally, two medical ethics experts who were familiar with research ethics guidelines and the coding process were asked to evaluate the validity of the data collection and analysis. results in this study, thirteen documents, all in farsi and available through the website of the “national committee for ethics in biomedical research of iran” were reviewed for content analysis during 2017 (table 1). table 1approved biomedical research ethics guidelines and instructions by mohme available links year guidelines number http://ethics.research.ac.ir/docs/pu blication_guideline.pdf?cbt=2 2009 national publications ethics guidelines 1 http://ethics.research.ac.ir/docs/ge neral.doc 2013 general ethics guidelines for medical research including human subjects 2 http://ethics.research.ac.ir/docs/m ulti_central.pdf 2014 instructions for performing multicentral research 3 http://ethics.research.ac.ir/docs/dat a_access9.doc 2014 instructions for using health information and data 4 http://ethics.research.ac.ir/docs/bi oequivalence6.pdf 2014 guidelines for approval process of clinical trial protocols for new drug registration by the iranian food and drug organization (fdo) 5 http://ethics.research.ac.ir/docs/piresponsibility-7.pdf 2014 guidelines for administration of clinical trials in association with pharmaceutical and medical equipment companies and other private firms 6 http://ethics.research.ac.ir/docs/res earch_misconduct_guideline.pdf 2009 instructions on investigation of research misconduct 7 http://ethics.research.ac.ir/docs/eth ics.pdf 2013 instructions for formulation, categorization and description of responsibilities of ethics committees in biomedical research 8 http://ethics.research.ac.ir/docs/ste m_cell.doc 2016 the specific ethics guidelines for stem cell research 9 mardani ah., et al. 5 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 4 april 2019 available links year guidelines number http://ethics.research.ac.ir/docs/tis sue_and_organ.doc 2015 the specific ethics guidelines for research on human organs and tissues 10 http://ethics.research.ac.ir/docs/vu lnerables.doc 2013 the specific ethics guidelines for research on vulnerable groups 11 http://ethics.research.ac.ir/docs/cli nical_trial.doc 2013 the specific ethics guidelines for performing clinical trials 12 http://ethics.research.ac.ir/docs/pat ient_funded_clinical_trials-11.pdf 2013 national instructions for patientfunded clinical trials 13 overall, 161 ethical considerations were identified and categorized based on their concepts and subjects in the five stages of the research process. clearly, there is a larger number of ethical codes in the text of the research ethics guidelines. however, the ethical considerations were identified and categorized according to the subjects mentioned in one or more ethical codes. ultimately, duplicate and similar codes were merged. 1. research proposal analysis of the standards indicated that the concepts related to the step ‘identification of the research problem’ had only been mentioned in two ethical codes: 1) “others’ ideas may not be used without observing the intellectual property rights” in the instructions on investigation of research misconduct; and 2) “the main purpose of every research is to promote human health while respecting human rights and dignity” in the general ethics guidelines for medical research including human subjects. the ‘hypotheses and questions formulation’ step had not been addressed in the standards. furthermore, researchers need to examine ethical considerations related to the research method and design in the step of ‘planning the method of investigation’; however, the ethical codes related to this step generally focused on the rights of participants (informed consent, confidentiality of personal information, and follow-up), facilitation of research supervision (location and setting) and registering the proposals. moreover, researchers need to take into account certain financial issues at the time of planning the study. aside from financial priorities that should be considered in research centers and university committees, the ethical codes only involved refraining from accepting unfair conditions by financial sponsors regarding publication of results, and declaring conflict of interests in financial contracts (table 2). ethical consideration in the biomedical research … 6 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 4 april 2019 table 2ethical considerations related to “research proposal” research step related considerations stipulated in the ethical codes guideline(s) research problem observing intellectual property rights when using research ideas proposed by others in proposals 1,2,3,7,9,12 promoting human health while respecting human dignity and rights as the main aim of research 1,2,3,7,9,12 planning research design observing publication ethics standards, ethical codes and research regulations in preparing research proposals 1,2,3,7,9,12 conducting research based on a pre-defined proposal 1,2,3,7,9,12 preparing protocols for clinical trials 1,2,3,7,9,12 preparing informed consent forms 1,2,3,7,9,12 predicting and introducing a clearly defined protocol to ensure confidentiality and security of information 1,2,3,7,9,12 determining and predicting follow-up with human subjects after study completion 1,2,3,7,9,12 determining the exact location of the research site in the research proposal 1,2,3,7,9,12 registering the proposals for clinical trials on the irct 1,2,3,7,9,12 following official criteria and ethical codes while signing a contract with financial sponsors 1,2,3,7,9,12 declining the financial sponsor's condition to remove or not publish undesirable findings in the contract between the researcher(s) and the financial sponsor 1,2,3,7,9,12 declining the financial sponsor’s condition to not declare conflict of interests in the research report in the contract between the researcher(s) and the financial sponsor 1,2,3,7,9,12 2. evaluation and approval of the research unlike the previous stage, the main actors in this stage are the committees responsible for scientific evaluation of proposals based on peer review process, financial evaluation, and finally ethical evaluation. research ethics committees conduct an evaluation of research proposals prior to issuing an ethics approval. therefore, the confidentiality of personal information is taken into account when dealing with research misconduct, conflict of interests among committee members, privacy and confidentiality of participants, and cooperation of other researchers for accountability. as a general rule, issues related to ‘research financial evaluation’ are addressed by the committee for scientific evaluation to determine priorities in attracting financial support. the studied documents did not consider such matters. although these financial issues and criteria were included in the assessed mardani ah., et al. 7 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 4 april 2019 standards, concepts such as disclosure of financial resources by researchers and attention to criteria of financial contracts as well as requirements of financial sponsors were mentioned in ‘ethics evaluation’. in addition, the codes related to ‘scientific evaluation’ were very rare and limited to research methodology and conflict of interests among members of scientific associations. (table 3). table 3ethical considerations related to “evaluation and approval of the research” research step related considerations stipulated in the ethical codes guideline(s) scientific evaluation evaluating and approving the scientific aspects and methodology of research proposals 1,2,3,5,6,7,8,9,11,12,13 disclosing conflict of interests of members of the scientific committee in relationship to the researchers and financial sponsors 1,2,3,5,6,7,8,9,11,12,13 ethical evaluation submitting proposals to the ethics committee to achieve a certificate 1,2,3,5,6,7,8,9,11,12,13 evaluation and approval of the research proposal by the research ethics committee 1,2,3,5,6,7,8,9,11,12,13 evaluation and approval of clinical protocols by the research ethics committee 1,2,3,5,6,7,8,9,11,12,13 appointment of a qualified supervisor by the research ethics committee 1,2,3,5,6,7,8,9,11,12,13 ensuring the research ethics committee will enforce and implement information protection and confidentiality 1,2,3,5,6,7,8,9,11,12,13 evaluation of the potential profit-loss ratio for human subjects by the research ethics committee 1,2,3,5,6,7,8,9,11,12,13 observance of confidentiality of complaint proceedings through the end by the research ethics committee when dealing with research misconduct and deviations 1,2,3,5,6,7,8,9,11,12,13 providing research data and evidence to the research ethics committee by researchers 1,2,3,5,6,7,8,9,11,12,13 informing the research ethics committee of changes in protocol and proposal by researchers 1,2,3,5,6,7,8,9,11,12,13 declaring conflict of interests between members of the research ethics committee, and researchers and financial sponsors 1,2,3,5,6,7,8,9,11,12,13 obligation of the research ethics committee to address limitations in publishing research results 1,2,3,5,6,7,8,9,11,12,13 ethical consideration in the biomedical research … 8 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 4 april 2019 research step related considerations stipulated in the ethical codes guideline(s) in the contract between researchers and financial sponsors establishing the scientific and technical competencies of researchers to design and conduct research 1,2,3,5,6,7,8,9,11,12,13 adaptation of research methods to social, cultural and religious values of human subjects and the society 1,2,3,5,6,7,8,9,11,12,13 disclosure of financial sponsors’ identity by researcher 1,2,3,5,6,7,8,9,11,12,13 declaring conflict of interests among the researchers in a research team 1,2,3,5,6,7,8,9,11,12,13 3. research operation the codes related to ‘data collection’ focused on accessibility and confidentiality of the information collected from participants, informed consent, protection of study subjects, and supervision of the study. text of the standards for other stages including ‘data analyses and ‘data interpretation’ did not contain any specific details (table 4). table 4ethical considerations related to “research operation” research step related considerations stipulated in the ethical codes guideline(s) data collection clarification and facilitation of access to health data 1,2,3,4,6,7,8,9,10,11,12 not requesting a share of research (such as author’s rights) solely due to ownership and provision of health data 1,2,3,4,6,7,8,9,10,11,12 sharing health data 1,2,3,4,6,7,8,9,10,11,12 appropriate registration, application and storage of health data 1,2,3,4,6,7,8,9,10,11,12 maintaining privacy in providing health information to researchers by health institutions or health databases 1,2,3,4,6,7,8,9,10,11,12 respecting the privacy and preserving the confidentiality of human subjects’ information 1,2,3,4,6,7,8,9,10,11,12 providing human subjects with any information that may affect their decision to take part in research 1,2,3,4,6,7,8,9,10,11,12 informing human subjects of changes in the research process as well as new findings related to the advantages and risks of interventions in research 1,2,3,4,6,7,8,9,10,11,12 mardani ah., et al. 9 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 4 april 2019 research step related considerations stipulated in the ethical codes guideline(s) obtaining in-time and clear informed consent from human subjects 1,2,3,4,6,7,8,9,10,11,12 obtaining informed consent from human subjects for publishing their data 1,2,3,4,6,7,8,9,10,11,12 providing human subjects with the freedom to accept or refuse participation in the research 1,2,3,4,6,7,8,9,10,11,12 providing human subjects with the necessary motivation or reward to take part in the research 1,2,3,4,6,7,8,9,10,11,12 ensuring the health and security of human subjects during and after research 1,2,3,4,6,7,8,9,10,11,12 preserving the human dignity, respect, and physical and mental integrity of research participants 1,2,3,4,6,7,8,9,10,11,12 paying attention to the personal, cultural and religious differences of research participants 1,2,3,4,6,7,8,9,10,11,12 avoiding prejudice toward a special group of people 1,2,3,4,6,7,8,9,10,11,12 taking care of vulnerable groups 1,2,3,4,6,7,8,9,10,11,12 conducting research in a place with precise control facilities 1,2,3,4,6,7,8,9,10,11,12 informing the research ethics committee of changes in research proposal and protocol 1,2,3,4,6,7,8,9,10,11,12 supervision and monitoring of the research by the research ethics committee 1,2,3,4,6,7,8,9,10,11,12 providing the research ethics committee with periodical reports of the research progress 1,2,3,4,6,7,8,9,10,11,12 adherence of the researcher to contents of the research proposal 1,2,3,4,6,7,8,9,10,11,12 4. reporting and documenting the research this stage involves issues such as referencing, copyrights, data falsification and fabrication, and precise and real-time reporting of the results to all beneficiaries in the form of ethical codes related to the ‘reporting style’. it also comprises consideration of authors’ rights and criteria, authors’ accountability for accuracy and ethics conformity of research content, disclosure of organizational dependencies, and conflict of interests among authors for the step of ‘preparing a copy of the research’. codes related to ‘submission to journals’ deal with deviations such as publication of overlapping materials and duplicate publication (table 5). ethical consideration in the biomedical research … 10 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 4 april 2019 table 5ethical considerations related to “reporting and documenting the research” research step related considerations stipulated in the ethical codes guideline(s) writing the research report avoiding reference to oneself or others for the sole purpose of increasing the number of irrelevant references 1,2,7,8,9,10,12 asking the permission of intellectual property owners to use tables, questionnaires and texts 1,2,7,8,9,10,12 mentioning the reference when citing a text or its translated counterpart, conclusion, summary or ideas 1,2,7,8,9,10,12 making citations in agreement with the intentions of the original authors 1,2,7,8,9,10,12 avoiding verbatim or partial plagiarism from articles or proposals by other authors 1,2,7,8,9,10,12 avoiding data fabrication and falsification in research 1,2,7,8,9,10,12 preserving the confidentiality and privacy of individuals and their information when publishing research results 1,2,7,8,9,10,12 publishing and making research results available in an accurate, timely and appropriate manner for other stakeholders 1,2,7,8,9,10,12 disclosure of negative and positive results as well as the side effects of the research 1,2,7,8,9,10,12 avoiding authors from limiting the publication of research results due to issues such as sensitivity of the study participants, negative social consequences, or financial sponsors requests 1,2,7,8,9,10,12 preparing the manuscript avoiding author’s name fabrication (i.e., removing qualified names and adding unqualified names) 1,2,7,8,9,10,12 observing the author’s rights based on the four authoring conditions 1,2,7,8,9,10,12 observing the order of the authors’ names based on their level of participation and by collective agreement 1,2,7,8,9,10,12 informing all contributors and adjusting the final manuscript to include their names in the authors’ list 1,2,7,8,9,10,12 selecting the contributor with the largest share in the presentation of the research idea as the first author 1,2,7,8,9,10,12 accountability of all authors regarding accuracy of the manuscript 1,2,7,8,9,10,12 assuming responsibility in terms of the general and specialized research ethics guidelines in research reports 1,2,7,8,9,10,12 mardani ah., et al. 11 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 4 april 2019 research step related considerations stipulated in the ethical codes guideline(s) authors’ assurance of the capability of all persons involved in the research 1,2,7,8,9,10,12 avoiding services such as those that type hand-written texts and submit manuscripts to journals 1,2,7,8,9,10,12 disclosing the organizational affiliation of authors 1,2,7,8,9,10,12 mentioning authors’ affiliation when submitting the manuscript to a journal 1,2,7,8,9,10,12 disclosing the financial resources of the research 1,2,7,8,9,10,12 declaring any potential conflict of interests among manuscript authors 1,2,7,8,9,10,12 declaring any conflict of interests arising from the contract between the researchers and financial sponsors 1,2,7,8,9,10,12 submitting the manuscript considering the authors’ freedom to select scientific journals for the publication of their articles 1,2,7,8,9,10,12 informing the journal to cancel publication before approval of the manuscript 1,2,7,8,9,10,12 avoiding duplicate submission and publication of overlapping manuscripts in different journals 1,2,7,8,9,10,12 informing editors of journals about reprint of a paper published in another languages 1,2,7,8,9,10,12 5. research review and publication activities related to this stage are concerned with responsibilities of journals. technical and scientific competencies, confidentiality and privacy of the reviewing process, conflict of interests among reviewers and editors, as well as investigation and reporting of research misconduct are all the focus of ‘peer review’. the ‘acceptance for publication’ step deals with issues such as independency of the journal, confidentiality of the identities of study participants, and the possibility of publishing undesirable results. the codes related to the ‘publication of research’ step revolve around issues such as the possibility of criticizing recently published articles and publishing undesirable results (table 6). ethical consideration in the biomedical research … 12 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 4 april 2019 table 6ethical considerations related to “research review and publication”1 research step related considerations stipulated in the ethical codes peer review selecting individuals with the necessary scientific and technical ability to review manuscripts informing the journal editor of a lack of the scientific and technical qualifications necessary for reviewing manuscripts providing reviewers with the required information and guidelines declaring any conflict of interests in the reviewing of manuscripts introducing the sponsors of the journal declaring conflict of interests in the reviewing of manuscripts by the editorial board members preserving the confidentiality of the manuscript by the reviewer respecting privacy and confidentiality at all stages of the manuscript review by the editor avoiding usage of reviewed manuscripts for other purposes asking the editor’s permission to consult others about reviewed manuscripts preventing potential communication between manuscript authors and reviewers respect for the intellectual independence of manuscript authors by the reviewer reviewing the manuscripts on the preset date announced by the editor fair and impartial review and prioritization of the manuscripts considering only scientific and technical qualities ensuring the receipt of the research ethics code and registration of the clinical trial related to the article notifying the editor of any failure to observe the provisions of the guidelines and ethical codes in the manuscript investigating possible occurrences of research misconduct and deception in the received manuscripts and meting out appropriate treatment reporting occurrence of research misconduct while maintaining maximum confidentiality to the research ethics committee, or the director/head of the authors’ place of work, or the education department if the authors fail to provide a convincing explanation addressing complaints about the submission process or other stages in the procedures required by the journal mardani ah., et al. 13 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 4 april 2019 research step related considerations stipulated in the ethical codes acceptance for publication respecting the editor’s independence in accepting or rejecting manuscripts ensuring confidentiality of the information of individuals and patients following publication of the article referring issues and decision-making about publishing the identity of participants in the study to the research ethics committee not forcing the authors to cite studies published in the previous volumes of the journal asking the corresponding author to determine the contribution of all authors involved in a study providing the conditions for publication of studies that use the right methodologies and produce undesirable results publication of research editor and editorial board member’ participation as author only in 20% of the articles of the journal providing readers with the opportunity to criticize published papers preventing placement of advertisements aimed at attracting readers by providing non-scientific and false information 1.all ethical codes are related to guideline no. 1 in addition to classifying the considerations according to stages of the research process, an attempt was made to categorize these considerations deductively to obtain a better description of guidelines and instructions for each stage. as can be seen in table 7 to 11, 14 categories were established for ethical considerations of each stage (table 7-11). table 7categories of the ethical considerations related to “research proposal” category related considerations stipulated in the ethical codes research design considerations observing intellectual property rights when using research ideas proposed by others in proposals observing publication ethics standards, ethical codes, and research regulations in preparing research proposals promoting human health while respecting human dignity and rights as the main aim of research conducting research based on a pre-defined proposal preparing protocols for clinical trials preparing informed consent forms predicting and introducing a clearly defined protocol to ensure confidentiality and security of information determining and predicting follow-up on human subjects after study completion ethical consideration in the biomedical research … 14 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 4 april 2019 category related considerations stipulated in the ethical codes determining the exact location of the research site in the research proposal registering the proposals for clinical trials on the irct research financial contracts following official criteria and ethical codes while signing a contract with financial sponsors declining the financial sponsor's condition to remove or not publish undesirable findings in the contract between the researcher(s) and the financial sponsor declining the financial sponsor’s condition to not declare conflict of interests in the research report in the contract between the researcher(s) and the financial sponsor table 8categories of the ethical considerations related to “evaluation and approval of the research” category related considerations stipulated in the ethical codes ethical considerations submitting proposals to the ethics committee to achieve a certificate evaluation and approval of the research proposal by the research ethics committee evaluation and approval of clinical protocols by the research ethics committee appointment of a qualified supervisor by the research ethics committee evaluation of the potential profit-loss ratio for human subjects by the research ethics committee evaluation of respecting the privacy and preserving the confidentiality of human subjects' information by the research ethics committee obligation of the research ethics committee to address limitations in publishing research results in the contract between researchers and financial sponsors establishing the scientific and technical competencies of researchers to design and conduct research adaptation of research methods to social, cultural and religious values of human subjects and the society scientific criteria evaluating and approving the scientific aspects and methodology of research proposals disclosing conflict of interests of members of the scientific committee in relationship to the researchers and financial sponsors conflict of interests for research evaluation declaring conflict of interests between members of the research ethics committee, and researchers and financial sponsors disclosure of financial sponsors’ identity by researchers declaring conflict of interests among the researchers in a research team mardani ah., et al. 15 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 4 april 2019 table 9categories of the ethical considerations related to “research operation” category related considerations stipulated in the ethical codes accessibility of health information clarification and facilitation of access to health data appropriate registration, application and storage of health data maintaining privacy in providing health information to researchers by health institutions or health databases not requesting a share of research (such as author’s rights) solely due to ownership and provision of health data sharing health data rights of research participants providing human subjects of any information that may affect their decision to take part in research informing human subjects of changes in the research process as well as new findings related to the advantages and risks of interventions in research obtaining in-time and clear informed consent from human subjects ensuring the health and security of human subjects during and after research preserving the human dignity, respect, and physical and mental integrity of research participants respecting the privacy and preserving the confidentiality of subjects’ information providing the subjects with the freedom to accept or refuse participation in the research providing the subjects with the necessary motivation or reward to take part in the research paying attention to the personal, cultural and religious differences of research participants avoiding prejudice toward a special group of people taking care of vulnerable groups supervisory considerations supervision and monitoring of the research by the research ethics committee informing the research ethics committee of changes in research proposal and protocol ensuring the research ethics committee will enforce and implement information protection and confidentiality ethical consideration in the biomedical research … 16 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 4 april 2019 category related considerations stipulated in the ethical codes providing the research ethics committee with periodical reports of the research progress conducting research in a place with precise control facilities adherence of the researcher to contents of the research proposal observance of confidentiality of complaint proceedings through the end by the research ethics committee when dealing with research misconduct and deviations providing research data and evidence to the research ethics committee by researchers informing the research ethics committee of changes in research protocol by researchers table 10categories of the ethical considerations related to “reporting and documenting the research” category related considerations stipulated in the ethical codes author’s task avoiding author’s name fabrication (i.e., removing qualified names and adding unqualified names) accountability of all authors regarding accuracy of the manuscript assuming responsibility in terms of the general and specialized research ethics guidelines in research reports authors’ assurance of the capability of all persons involved in the research informing all contributors and adjusting the final manuscript to include their names in the authors’ list avoiding services such as those that type hand-written texts and submit manuscripts to journals avoiding reference to oneself or others for the sole purpose of increasing the number of irrelevant references informing the journal to cancel publication before approval of the manuscript considering the authors’ freedom to select scientific journals for the publication of their articles intellectual property rights of stakeholders observing the author’s rights based on the four authoring conditions observing the order of the authors' names based on their level of participation and by collective agreement selecting the individual with the largest share in the presentation of the research idea as the first author mentioning authors’ affiliation when submitting the manuscript to a journal mentioning the reference when citing a text or its translated counterpart, conclusion, summary or ideas mardani ah., et al. 17 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 4 april 2019 category related considerations stipulated in the ethical codes asking the permission of intellectual property owners to use tables, questionnaires and texts making citations in agreement with the intention of the original authors avoiding verbatim or partial plagiarism from articles or proposals by other authors avoiding duplicate submission and publication of overlapping manuscripts in different journals informing editors of journals about reprint of a paper published in another languages obtaining informed consent from human subjects for publishing their data preserving the confidentiality and privacy of individuals and their information when publishing research results clarity of research results publishing and making research results available in an accurate, timely and appropriate manner for other stakeholders disclosure of negative and positive results as well as the side effects of the research avoiding authors from limiting publication of research results due to issues such as sensitivity of the study participants, negative social consequences, or financial sponsors requests avoiding data fabrication and falsification in research conflict of interests for authors declaring any potential conflict of interests among manuscript authors declaring any conflict of interests arising from the contract between the researchers and financial sponsors disclosing the organizational affiliation of authors disclosing the financial resources of the research table 11categories of the ethical considerations related to “research review and publication” category related considerations stipulated in the ethical codes editorial responsibilities respecting privacy and confidentiality at all stages of the manuscript review by the editor ensuring confidentiality of the information of individuals and patients following publication of the article ensuring the receipt of the research ethics code and registration of the clinical trial related to the article respecting editor independency in accepting or rejecting manuscripts declaring conflict of interests in the reviewing of manuscripts by the editorial board members ethical consideration in the biomedical research … 18 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 4 april 2019 category related considerations stipulated in the ethical codes introducing the sponsors of the journal selecting individuals with the necessary scientific and technical ability to review manuscripts providing reviewers with the required information and guidelines preventing potential communication between manuscript authors and reviewers fair and impartial review and prioritization of the manuscripts considering only scientific and technical qualities asking the corresponding author to determine the contribution of all the authors involved in a study providing the conditions for publication of studies that use the right methodologies and produce undesirable results not forcing the authors to cite studies published in the previous volumes of the journal providing readers with the opportunity to criticize published papers addressing complaints about the submission process or other stages in the procedures required by the journal editor and editorial board member’ participation as author only in 20% of the articles of journal preventing placement of advertisements aimed at attracting readers by providing non-scientific and false information investigating possible occurrences of research misconduct and deception in the received manuscripts and meting out appropriate treatment reporting the occurrence of research misconduct while maintaining maximum confidentiality to the research ethics committee, or the director/head of the authors’ place of work, or the education department if the authors fail to provide a convincing explanation referring issues and decision-making about publishing the identity of participants in the articles to the research ethics committee reviewer responsibilities having the scientific and technical qualifications necessary for reviewing manuscripts informing the journal editor of a lack of the scientific and technical qualifications necessary for reviewing manuscripts declaring any conflict of interests in the reviewing of manuscripts preserving the confidentiality of the manuscript by the reviewer avoiding usage of reviewed manuscripts for other purposes asking the editor’s permission to consult others about reviewed manuscripts mardani ah., et al. 19 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 4 april 2019 category related considerations stipulated in the ethical codes respect for the intellectual independence of manuscript authors by the reviewer reviewing the manuscripts on the preset date announced by the editor notifying the editor of any failure to observe the provisions of the guidelines and ethical codes in the manuscript the following categories were, respectively, significantly prominent in the guidelines and instructions: 1) ‘rights of research participants’ (33 items from 161 ethical considerations: 20.49%) related to the stage of ‘research operation’; 2) ‘ethical considerations’ (22 items: 13.66%) related to the stage of ‘evaluation and approval of the research; 3) ‘editorial responsibilities’ (20 items: 12.42%) related to the stage of ‘research review and publication’; and 4) ‘supervisory considerations’ (18 items: 11.18%) related to the stage of ‘research operation’. moreover, issues related to financial contracts, scientific criteria for evaluation and approval of research, accessibility of health information for researchers and clarity of research results were emphasized in guidelines and instructions (figure 2). figure 2distribution of the ethical considerations categories in the research process 10 3 22 4 6 5 33 18 7 13 5 7 20 8 research proposal evaluation and approval of the research research operation reporting and documenting the research research review and publication research design considerations financial contracts ethical considerations scientific criteria conflict of interest for research evaluation accessibility of health information rights of research participants supervisory considerations author’s task intellectual property rights of stakeholders clarity of research results conflict of interest for authors editorial responsibilities reviewer responsibilities ethical consideration in the biomedical research … 20 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 4 april 2019 with 56 considerations related to the ‘research operation’ stage, it is the most highlighted stage in terms of attention to ethical considerations in the guidelines and instructions for various stages of the research process. on the contrary, ‘research proposal’ is the least prominent stage with just 13 considerations pertaining to it. moreover, in the stage of ‘reporting and documenting the research’, editors of research ethics guidelines and instructions focus on different issues in different categories. discussion the guidelines for biomedical research ethics offered by mohme as the main authority may serve as a means to prevent research deviations and enhance supervision over research activities. however, our findings showed that the existing ethical considerations are not adequately developed to cover different activities in various stages of the research process. these guidelines do not provide comprehensive and sufficient insight about the ethical responsibilities and considerations related to all activities of the research process. research ethics guidelines have mainly focused on the stages of research operation, reporting and publication. one reason for this could be the dominant approach of corresponding authorities to the approval and supervision of the research activities related to these stages. furthermore, prevention and control of research misconducts are not supervised continuously during the research process (11). as the stage of ‘research review and publication’ is more vulnerable to misconduct, it has received a lot of attention in the form of supervisory measures. evident manifestations of research misconduct have received the most supervision by research ethics committees in universities and have been especially emphasized in research ethics standards. they are mainly comprised of deviations in the reporting and publication stages including plagiarism, data fabrication, data falsification, re-publication and overlapping of research results. nevertheless, research misconduct constitutes an expansive range of irresponsible behaviors and is not just limited to the reporting and publication stages (12, 13). thus, it seems that in dealing with various representations of misconduct in the research process, it would be better to benefit from a more practical solution in view of the ethical considerations in research ethics guidelines. the study results showed that the majority of these guidelines pay great attention to the rights of research participants including informed consent, ensuring the health and security of human subjects, preserving human dignity, subjects’ physical and mental integrity, maintaining confidentiality of the subjects’ information, and taking care of vulnerable groups. research standards emphasize free and informed consent as well as a net balance of benefits over harms for all participants (14). consistent with present findings, a study on the guidelines, regulations, and ethical codes of arab mardani ah., et al. 21 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 4 april 2019 countries in the middle east by alahmad et al. indicated that scientific validity and obligations for informed consent, confidentiality, and the balance of benefits and risks are mentioned in most of the documents (15). in the examined research ethics standards, ethical considerations about pre-research activities such as research motives, research problems, and planning research design were less emphasized. there were very limited ethical codes related to research problems, which could be due to intangibility of some activities, and the low potential of certain issues for supervision and monitoring at this stage. thus, research should be conducted based on the needs of health-care providers, and this is an ethical obligation for researchers also highlighted in research ethics guidelines and instructions. notwithstanding, this matter has been neglected in research ethical codes. in other words, the relationship between research, the researcher and community research needs are overlooked. lack of research in the field of health and medical sciences based on national and local needs and insufficient application of national research results are among the most notable problems that affect the effectiveness and efficiency of research in this domain (16). therefore, it seems that ethical codes could serve as an indirect and useful intervention in the process of conducting research based on local needs. indeed, in addition to a lack of need-based research, the proclivity of faculty promotion regulations and other research protocols toward quantitative measures may solely motivate researchers toward research results publication and earning quantitative privileges (17, 18). another important issue that requires more attention is related to financial contracts. some cases of research misconduct have been reported following the demand and pressure of financial sponsors for publishing desirable results. this is because the conditions and shares of parties (researchers and financial sponsors) are not clarified in contracts, and research ethics committees do not examine the contracts meticulously enough (19, 20). it is necessary to define and clarify the conditions and shares of financial sponsors in research ethical codes. another important point in research guidelines is the accessibility of data and information for researchers. limitations in existing research ethics guidelines have subjected researchers to situations where owners of data or equipment make unjust and unconventional demands in return for access to information. therefore, it is essential that officials and administrators develop independent guidelines and instructions to clarify the conditions and requirements for sharing health data and accessibility of data for research stakeholders. lack of ethical codes in the ‘review of research proposal’ stage is another issue that should be taken into account. the challenging issue that still remains unresolved is whether or not research ethics committees should attend the sessions for scientific evaluation of proposals. the scientific criteria mentioned in ethical codes are limited to methodology of research proposals and conflict of interests among ethical consideration in the biomedical research … 22 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 4 april 2019 research committees. it is necessary that the scientific review be conducted strictly because much of the deviations in the following stages including inappropriate criteria for inclusion and exclusion of participants or lower statistical power occur because of incorrect projection of the research process. the necessity for involvement of methodology and statistics experts in research ethics committees also attests the importance of scientific standards in research evaluation and approval. generally speaking, scientific and ethical evaluations cannot be separated, and the research ethics committee naturally needs to consider these two simultaneously. according to the declaration of helsinky, medical research on human beings should follow approved and scientific principles and be based on comprehensive knowledge of scientific texts, related resources, laboratory experimentations and animal trials if necessary (21). furthermore, failure to address issues of research methodology is evident in some activities in the ‘research operation’ stage. there was no ethical code for data analysis and data interpretation in the guidelines. in the end, it should be added that activities including quality control of research data or careful handling of statistical premises that entail serious ethical considerations may lead to research misconduct )22). conclusion the contents of research ethics guidelines affect their interpretation and application, and therefore modifying and improving them can enhance their usage, prevent research misconducts and improve supervision of the research process. although national research ethics guidelines stress the necessity of research integrity, a current evaluation of the guidelines approved by mohme indicated that ethical considerations are not adequately developed to cover different activities involved in various stages of the research process. in order to implement a systematic supervision approach throughout the research process, it is necessary that responsible authorities revise and modify the existing research ethics guidelines. thus, research ethics committees will consider these responsibilities and considerations in their supervisory function, and other stakeholders will be informed about the ethical considerations related to them. required ethical considerations are extensive and should be observed throughout the research process, and the need for a comprehensive framework to organize these considerations is clear. since studies on research integrity in the field of biomedical research have failed to describe it, the present study attempted to make its contribution by investigating the ethical considerations involved in the research process. the results of this study provide a better understanding of the basic function of the iranian biomedical research system in the development of ethical standards for research. so far, studies on biomedical research ethics in iran have been exclusively limited to investigations into researchers’ observation of research ethics standards and considerations in their publications. therefore, it seems that future studies must identify all research ethics considerations mardani ah., et al. 23 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 4 april 2019 and the responsibilities involved in the research process. furthermore, stakeholders could discover the pertinent inadequacies that can be overcome and modified in research ethics guidelines. acknowledgments none declared. conflict of interests the authors declare that they have no conflict of interests. ethical consideration in the biomedical research … 24 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 4 april 2019 references 1. afshari b, eshaghian z, bakhtiyar nasrabadi ha. an analysis of ethical principles in the process of conducting researches in the field of educational sciences. [faslanemeh akhlagh].1394; 11(40): 67-94. [in persian] 2. ana j, koehlmoos t, smith r, yan ll. research misconduct in low-and middle-income countries. plos medicine. 2013; 10(3): e1001315. 3. fierz k, gennaro s, dierickx k, achterberg t, morin kh, de geest s. scientific misconduct: also an issue in nursing science?. j nurs scholarsh. 2014; 46(4): 271-80. 4. anonymous. ethical considerations. [cited on december 2018]; available from: https://cirt.gcu.edu/research/developmentresources/tutorials/ethics 5. lashkarbolouki m. a framework for codification of values and ethical codes of scientific and technological researches. international journal of ethics and society. 2009; 1: 105114. [in persian] 6. resnik db, rasmussen lm, kissling ge. an international study of research misconduct policies. account res. 2015; 22(5): 249-266. 7. anonymous. guidelines for responsible conduct of research. [cited on december 2018]; available from: http://www.provost.pitt.edu/documents/guidelines%20for%20ethical%20practi ces%20in%20research-finalrevised2-march%202011.pdf 8. mardani ah. designing a model to identify factors associated with research misconduct in medical research in iran [dissertation]. tehran (iran): university of tehran; 2018. [in persian] 9. hickey g, kippin c. a multistage approach to the coding of data form opened questions. nurse res. 1996; 4(1): 81-91. 10. anonymous. code of ethical conduct and statement of commitment. [cited on december 2018]; available from: https://www.naeyc.org/sites/default/files/globallyshared/downloads/pdfs/resources/positionstatements/ethics%20position%20statement2011_09202013update.pdf 11. bahmanabadi s, kalateh jafarabadi t, shabani varaki b. the degree of observation of ethical standards in research: a case study of phd theses of faculty of humanities of ferdowsi university, mashad, 2007-2012. strategy for culture. 2014; 7(25): 129-52. 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[in persian] 19. tijidnk jk. publish and perish: research on research and researchers. tijdschr psychiatr. 2017; 59(7): 406-13. 20. fanelli d. do pressures to publish increase scientists’ bias? an empirical support from us states data. plos one. 2010; 5(4): e10271. 21. anonymous. international ethical guidelines for biomedical research involving human subjects. [cited on december 2018]; available from: http://www1.paho.org/hq/dmdocuments/2011/cioms%20guidelines.pdf 22. munafò mr, nosek ba, bishop dvm, et al. a manifesto for reproducible science. nature human behavior. 2017; 1(0021): doi: 10.1038/s41562-016-0021. ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ 1 © 2019 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. review article volume 12 number 7 june 2019 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e examining the ethical challenges in managing elder abuse: a systematic review *corresponding author elham navab school of nursing and midwifery, tohid sq., nosrat st, tehran, iran. postal code: 141973317 tel: (+98) 21 66 91 43 68 email: e-navab@sina.tums.ac.ir received: 7 aug 2018 accepted: 3 june 2019 published: 15 june 2019 citation to this article: saghafi a, bahramnezhad f, poormollamirza a, dadgari a, navab e. examining the ethical challenges in managing elder abuse: a systematic review j med ethics hist med. 2019; 12: 7. afsaneh saghafi1, fatemeh bahramnezhad2, afsaneh poormollamirza3, ali dadgari4, elham navab5* 1.m.s, school of nursing and midwifery, tehran university of medical sciences, tehran, iran. 2.assistant professor, department of critical care nursing, school of nursing and midwifery, tehran university of medical sciences, tehran, iran. 3.m.s, school of nursing and midwifery, tehran university of medical sciences, tehran, iran. 4.assistant professor, center for health related social and behavioral sciences research, shahroud university of medical sciences, shahroud, iran. 5.associate professor, school of nursing and midwifery, tehran university of medical sciences, tehran, iran. abstract elder abuse is an increasingly intangible phenomenon that has created numerous ethical issues for care teams and caregivers. although different studies have concentrated on various ethical issues regarding abuse, no study has arrived at a comprehensive conclusion. therefore, the present study aimed to determine the existing ethical challenges in this context. for this purpose, two researchers familiar with systematic search approach examined national and international journals on pubmed, excerpta medica database (embase), scientific information database (sid) and similar databases between january and february 2017. they were able to find 116 articles that met the inclusion and exclusion criteria, and finally selected 15 articles based on the predesigned questions. the findings were classified in five subtitles as follow: 1) the common definition of elder abuse, 2) a comprehensive legislation on elder abuse, 3) comprehensive ethical principles about elder abuse, 4) ethical considerations regarding patients without competency, and 5) reporting and sharing information about elder abuse. the study results revealed no common definition and no legislation about elder abuse, and also showed that health care providers’ observance of ethical principles depends on the ethical and legal conditions of the community. nowadays, elder abuse is a serious problem in many countries. cultural and religious differences are the reasons for lack of a common definition and legislations, which comprises the biggest obstacle to protecting the rights of elderly people. it is clear that ethical principles should be respected as far as a person has competency. furthermore, localization of clinical guidelines related to this issue leads to proper functioning of health care providers, especially nurses as the first line of treatment. keywords: elder abuse; elder maltreatment; ethics examining the ethical challenges in managing elder abuse … 2 volume 12 number 7 june 2019 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e introduction abuse is among the most common challenging issues in both developed and developing countries around the world (1, 2). presently, elder abuse is the most covert form of mistreatment that involves issues such as health, justice, ethics, and human rights (3). this phenomenon has been taken into consideration by world health organization (who) since 2002 (4). different definitions have been provided for abuse over time (5). elder abuse may refer to an act or absence of a proper act that will cause harm or suffering to an older person, and it happens in a relationship that normally requires trust, and may be performed only once or several times (1,2,6). while little information is available about elder abuse especially in developing nations, it is predicted to be on the rise in countries that experience the phenomenon of population aging. according to who estimations, one out of every six elderly people experiences abuse, and only 1 out of 24 abuse cases is reported (1). since awareness of abuse is influenced by knowledge, expertise and preparedness of caregivers (3, 7), the care team and nurses as the first line of treatment are responsible to identify and report mistreatments and support vulnerable populations such as the elderly (8, 9). elder abuse is an example of human rights and freedom violation (5) that leads to a serious loss of human dignity, independence and respect (6), and influences ethical principles such as autonomy, competency, beneficence, and nonmaleficence (10). intervention in case of abuse is accompanied by ambiguity and ethical challenges, because lack of professional principles leads to personal, legal and ethical concerns (11). however, it is difficult for nurses and other members of the care team to perform a successful intervention for an elderly who is willing to stay in the abusive situation (12). also, this phenomenon causes challenges for nurses and other care team members when legal commitments are not consistent with ethical principles (11). questions and challenges in this context include: are there any comprehensive ethical principles and regulations? is it illegal to share the information and secrets of patients with the care team in order to reach a diagnosis or choose the appropriate intervention? which ethical principle is violated in elder abuse? when is respect for autonomy not consistent with ethical principles? in what cases are beneficence and non-maleficence in conflict with the other ethical principles? in cases where the patient suffers from a cognitive disorder, what are the ethical considerations that need to be taken into consideration by the nurse? should reporting elder abuse be a legal requirement? what ethical challenges will nurses face when the elderly are not willing to share information with the authorities? abuse by a family member or intimate partner is complex, because the elderly may be struggling against social, cultural and religious aspects of life to live with abusive people (12). according to college of nurses of ontario (cno), ethical conflicts and challenges emerge when two or several ethical values relevant to a particular saghafi a., et al. 3 volume 12 number 7 june 2019 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e situation necessitate conflicting measures (13). elder abuse causes physical harm, depression, increased referral to hospitals, frequent hospitalizations, and increased mortality (1,2,14,15). it also creates problems such as job burnout and ethical distress for nurses and care team members (16), who should have a thorough and accurate understanding of the ethical concepts and challenges involved in elder abuse and decide on the best intervention (17). in view of the importance of this issue, this study aimed to examine the ethical challenges pertaining to elder abuse according to evidence-based ethical principles. method the present study was a systematic review to determine the ethical challenges involved in elder abuse and was conducted in 2017 by collecting related documents, articles, and sources. data sources and search method to find articles, national and international journals from databases such as pubmed, embase, proquest central, web of science, sid, magazine iranian (magiran) and psychology information (psycinfo) were examined. for this purpose, journals were searched using persian and english keywords according to mesh. important keywords included “elderly”, “aged”, “abuse”, “neglect”, “mistreatment”, “ethics”, “ethos”, “moral”, and “autonomy”. in order to increase sensitivity, general persian and english keywords such as “violence” and “senior” were also used in the search process. article selection criteria according to the inclusion and exclusion criteria, different articles available in the context of descriptive studies were examined. since the nature of this issue is descriptive, articles with more evidence were selected. the search was performed by two researchers familiar with systematic search approach between january and february 2017 according to the keywords and databases, and the details were documented. in this regard, 116 articles were found as seen in figure 1. figure 1article examination flowchart examining the ethical challenges in managing elder abuse … 4 volume 12 number 7 june 2019 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e forty-nine articles were identified by endnote to be duplicates and were therefore excluded from the study. according to the inclusion criteria, articles published after 2000 and those cases that had not been published were included in the initial examination. the abstracts were then studied by the two researchers in order to exclude unrelated articles, obtain the full texts for the ones that were related, and extract data for two of the articles whose full texts were not available. finally, 15 articles were entered in the study to answer the following questions: has a common definition been offered for elder abuse so far? is there a comprehensive ethical set of regulations about elder abuse? what ethical principle is violated in elder abuse? when is the autonomy of elder people in conflict with ethical principles? in order to minimize error, the required information was extracted according to the checklist (table 1) by the two researchers and the results were matched. checklist variables included title, author, year, journal, place and objective, definition of elder abuse, method, concepts, ethical issues, and clinical points. after collecting the data based on the checklist, data quality was assessed by two experts. in order to prevent bogus, names of journals and authors were eliminated and the data were given to two experts. the publication years of 15 articles were between 2000 and 2012, 9 articles had been authored in the united states, 1 in canada, 3 in the uk, 1 in france, and 1 was a koreanamerican article. articles were descriptive, cross-sectional, and case study. no persian article was found by searching these keywords. results along with the proposed questions, the findings of the present study were classified in five subtitles as follow: 1. the common definition of elder abuse question: has a common definition been offered for elder abuse so far? the researchers did not find any specific definition for the term. a study conducted in 2012 stated that concepts related to elder abuse are abstract and there is no widely accepted definition for it. this lack of definition poses challenging questions. us laws recognize cases such as physical abuse, neglect and financial abuse, but the definitions are not the same in various states and to all researchers and doctors (5). another american study declares that all 50 states in the unites states have laws concerning abuse, but the definitions for elder abuse and those who are covered by these laws are different (18). in this regard, another study stated that in most us laws, physical, sexual, financial, and psychological/emotional abuse pertain to elder abuse, as does self-neglect, which is in concordance with the older adult welfare law (oawl) definition of abuse (19). adult protective services (aps) has identified three misconducts in connection with vulnerable elderly people: abuse, financial exploitation, and neglect. abuse is defined as intentional harm to people. financial exploitation is an illegal process of using vulnerable elderly people to obtain assets without their conscious consent. neglect is the inability of an elderly person saghafi a., et al. 5 volume 12 number 7 june 2019 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e for self-care (self-neglect) or failure of a caregiver to provide appropriate care (20). other studies have pointed to the definition provided by who that states “elder abuse consists of committing an inappropriate action in a trustful relationship that causes harm to an elderly person”, and four studies did not address the definition of abuse (21, 22, 23, 24). 2. a comprehensive legislation on elder abuse question: is there a comprehensive legislation about elder abuse? most us states combine elderly support laws and disabled adult laws. the laws are different in terms of classifications of abuse, but in general, elder abuse can be classified in five categories: physical abuse, psychological/emotional abuse, financial exploitation, neglect/self-neglect, and sexual abuse. across the us, elder abuse protection (eap) laws share three common functions: 1) collecting the suspected abuse reports, statistical data management, and patients’ needs evaluation; 2) efforts to decrease or eliminate abuse risk for elderly people by providing instructions and interventions through referral to social services; 3) connection with courts and organizations that are responsible to execute the law in special cases (23, 25, 26). the results of bergeron and gray’s study in 2003 revealed three major differences between the laws in different states of the us. first, in some states, it is mandatory to report suspected elder abuse. the second difference is the definition of “elderly” provided by law. in order to limit interventions in the private lives of citizens, some states have restricted their laws to vulnerable elderly people. the third difference is related to the authorization given to eap staff in some states to conduct studies on abuse and make interventions in cases where abuse has been proved. for example, some states ask the eap staff to receive permission from the victim in all research steps unless the victim lacks competency, while other states do not (23). the national association of social workers (nasw) and the canadian association of social workers (casw) have specified values and principles as guidelines for the professional behavior of social services experts. these principles emphasize prioritization of the best interests of patients and protection of those who lack competency for decision-making. they also require that confidentiality of information be taken into consideration, which may be in conflict with abuse reporting responsibilities (11). also in january 2004, oawl established stable laws to offer protection services for elderly people such as 24-hour emergency phone lines to report abuse, standards to issue certificates for protective facilities, and professional standards to care for elderly people (19). 3. comprehensive ethical principles about elder abuse question: are there any comprehensive ethical principles about elder abuse? a study conducted in the unites states pointed out that when disclosing information, psychologists should use american psychological association (apa) examining the ethical challenges in managing elder abuse … 6 volume 12 number 7 june 2019 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e codes (5, 27). in this regard, another study proposed that psychologists consider ethical commitments in addition to the legal aspects of abuse reporting. reporting suspected cases according to apa ethical codes should be in line with beneficence, non-maleficence, and respect for human rights and dignity. code 4/02 is related to privacy limitation and code 4/05 pertains to disclosure of information regarding elder abuse. if the elderly suffers from cognitive disorders, psychologists should try to maintain the confidentiality of their information and contact legal authorities. according to code 4/02, they are allowed to disclose information in suspected abuse cases even without the patient’s consent. according to code 4/05, psychologists are allowed to share the private information of patients with the latter’s families or with other experts to protect patients against harm (18). in a 2009 study by doe et al., similarities and differences between the protection systems of korea and the united states were investigated. the two countries are similar in that they both have national laws to prohibit elder abuse, and legal definitions include abuse and neglect. in addition, laws necessitate mandatory reporting by experts. as for the differences, in the united states, federal laws are executed by different federal systems that implement both the methods of reporting abuse and referral. emergency cases enter triage from the very beginning and a protection plan is designed for abuse cases and other forms of mistreatment. laws prosecute the guilty person and punishments are specified for failure to report. however, in korea, the law is enforced by a centralized system that only implements the reporting of abuse. emergency cases are triaged within 12 hours and care plan only exists for abuse cases. these laws allow the patient to file a civil complaint about abuse, but they do not specify any punishment for failure to report (19). question: what ethical principle is violated in elder abuse? findings showed that the principle of respect (dignity and autonomy) is almost violated in psychological abuse, and the principle of non-maleficence in cases of neglect and physical or financial abuse (28). in most cases, autonomy may be violated because self-neglect, beneficence and nonmaleficence may come before it, and as for self-neglect, caregivers can delay the required interventions as far as possible (10). autonomy autonomy includes independent decisionmaking without any limitation, and respect for independence is a professional commitment (29). according to the american nurses association (ana) autonomy not only means respect for patients’ decision-making, but also for the decision-making method (30), and patients have the right to participate in making decisions related to themselves (31). another study stated that social workers are responsible for creating a balance between patients’ rights and the principle of autonomy, which aims to protect vulnerable populations. nevertheless, in nasw, it is pointed out that social workers should have authority over patients’ right to autonomy saghafi a., et al. 7 volume 12 number 7 june 2019 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e when potential and actual actions of patients cause serious, predictable and unpredictable risks for themselves and others (11, 32). also, another was consistent with the abovementioned points and stated that autonomy to maintain independence is acceptable only as far as it is reasonably and ethically possible (10). negative autonomy emerges when the elderly prevents services and the caregivers accept this behavior, which is indeed a kind of neglect. prevention is acceptable if the person has the capability for decisionmaking and his or her mental capacity is approved (33). beneficence and non-maleficence beneficence and non-maleficence are both based on ethical commitment toward others, and while the former focuses on the wellbeing of others, the function of the latter is to avoid harming them (29). together, the two aspects provide more comprehensive principles to devise measures against elder abuse. for example, if a nurse considers a threat or damage serious and is convinced that measures are necessary to prevent harm, he or she will report the abuse to aps. therefore, the nurse may use the principle of beneficence to promote health and ensure the best interests of the patient (10). justice in the 15 papers that were examined in this study, the principle of justice had not been mentioned. 4. ethical considerations regarding patients without competency question: in cases where the patient lacks competency, what ethical considerations should be taken into account by the nurse or the care team? a study entitled “capacity for decisionmaking in alzheimer's disease: selfhood, positioning and semiotic people” showed that capacity and competency are often used interchangeably. capacity has dimensions such as decision-making, self-care, selfprotection, and execution. according to experts, competency can fluctuate. in dementia, there is memory impairment, but personality, values and long-term memory stay intact. dementia patients can be extremely vulnerable under undesirable conditions and their right of decisionmaking for different aspects of their life is unfairly influenced (34). dementia diagnosis is not the only criterion for lack of competency (35, 36). for competent elderly people who expose themselves or others to harm, the caregiver may decide to work in support of beneficence, trying to achieve the best longterm results for the patient. it is noteworthy that one should consider interdisciplinary interventions, ethical principles, and cultural and gender differences when trying to determine decision-making capacity by means of valid and reliable measurements. dick suggests that nurses should note the cultural beliefs and patterns of adaptation of family members who neglect an elderly person’s personal and environmental health requirements rather than consider it a pathological finding (37). nevertheless, according to most studies, when the elderly is incapable of decision-making due to examining the ethical challenges in managing elder abuse … 8 volume 12 number 7 june 2019 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e cognitive impairment, the task can be left to another person. this person should support the patient and be aware of his/her needs. most regional councils for elderly issues provide care services in which a group of competent people function as decisionmakers for elderly people (5). in cases where decisions are related to the patient’s capacity, consultation with a group of interdisciplinary experts is necessary and the decisions should eventually be in favor of the elderly people (10). 5. reporting and sharing information about elder abuse question: is it illegal to report abuse and share the information of elderly people? respect for confidentiality and trust is one of the most important ethical principles that has to be taken into consideration by caregivers. however, the results of one study indicate that in cases where a serious harm is caused, the care team can disclose information without obtaining consent (11). these findings were confirmed by another study, which presented statements with similar wording. for example, in the united states, if a therapist is suspicious about abuse, he/she should report it to authorities such as aps despite his/her concerns over the patient’s privacy (26). also, according to code 4/05, psychologists are allowed to disclose patients’ private information to protect them against harm (17). however, they should try to engage the patient in the reporting process and only report relevant data to observe the privacy of the patient as far as possible (26). table 1characteristics of the reviewed articles on the ethical challenges in caring for elder abuse objective type of study country year resource updating moral considerations regarding elder abuse in psychological domain providing recommendations to improve problem solving related to elder abuse descriptive the united states 2012 scheiderer em(5) forms of elder abuse in nursing homes reasons for elder abuse in nursing homes which ethical principles are violated in nursing homes? descriptive the united states 2011 bužgová r (28) discussion about important ethical perspectives on self-neglect among elderly people descriptive the united states 2011 mauk kl(10) examining abused people according to ethical codes and guidelines to enable psychologists to solve the problems of these people helping to resolve challenges to reporting these cases and specifying certain standards for reporting. descriptive the united states 2011 zeranski (18) saghafi a., et al. 9 volume 12 number 7 june 2019 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e solving the complications arising from elder abuse concentrating on informing social services experts about challenges resulting from ambiguity in laws and guidelines descriptive canada 2010 donovanet (11) examining the gap between the existing laws about elder abuse, and implementing them examining protection of elderly people against elder abuse descriptive england 2010 ash(21) examining the existing texts about elder abuse suggesting preventive measurement to decrease the incidence of abuse descriptive england 2010 formanet (26) examining the relationship between cultural values such as individualism and identification of the ethical issues and consequences of policymaking; discussing about similarities and differences in the reporting system descriptive koreanamerican 2009 doe (19) examining women’s understanding of different economic and social conditions regarding elder abuse and the ethical problems in support systems descriptive the united states 2009 dakin (38) determining who the people experiencing abuse are, how they are identified, and which professionals are trying to resolve these conditions? descriptivecrosssectional france 2006 françois (39) describing an ethical decision-making model according to an empowerment framework for care service providers descriptive the united states 2006 koenig (22) proposing the perspective of psychologists on elder abuse, and the psychological and ethical issues regarding this subject descriptive the united states 2006 beaulieu (33) stating the reasons for abuse according to the statements of social workers in england descriptive england 2004 wilson (24) discussing ethical concerns about reporting or failure to report abuse providing recommendations to help service providers in the decisionmaking process descriptive case study the united states 2003 bergeron (23) establishment of a standard ethical model to deal with elder abuse descriptive the united states 2000 johnson (40) examining the ethical challenges in managing elder abuse … 10 volume 12 number 7 june 2019 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e discussion concepts related to elder abuse are complex and abstract, and therefore no common definition has been offered for this phenomenon (5). in most cases, the word abuse is replaced by maltreatment and mistreatment (41). one reason for lack of a common definition is related to cultural and religious differences among societies. accordingly, people from different races have their own definition of abuse and its types based on their regional priorities (41, 42). care team members need a clear definition to identify and prevent elder abuse (43). when a suitable definition does not exist for the phenomenon, accurate statistics cannot be obtained, which makes it impossible to identify and report abuse; consequently, the prevalence of this phenomenon will remain obscure. therefore, measures related to elder abuse should be specific to each region where authorities function as the main foundations. another duty of governments includes establishment of regulations and ethical principles related to elder abuse. since comprehensive ethical and legal regulations have not been developed and there are many ambiguities and conflicts, abuse cases are not reported due to the inability of the care team to interpret the ethical and legal codes (5). based on the existing evidence, elder abuse is a general issue in italy where different policies and laws exist for the phenomenon and lack of a national and comprehensive strategy is tangible. while certain laws are in place for child protection, there are no specific regulations for elderly people. lack of legislation is the biggest obstacle to protecting the rights of elderly people in many countries. constitutions normally emphasize rights, freedom, dignity and equality for all people, with the main emphasis on the latter. elderly people may not be able to defend their rights. therefore when they become dependent, they may be vulnerable to abuse and misconduct (44). the first federal law on elder abuse was codified as “the elder justice act” in march 2010 including the following main articles: (a) formation of the elder justice council to suggest recommendations related to federal, regional and private agencies involved in elder abuse; (b) formation of a council to plan strategic programs on elder justice; (c) budget provision; (d) founding and supporting legal centers; (e) provision of budget for long-term treatment programs; (f) financial assistance to improve long-term treatment programs for staff; and (g) budget provision for national institutes (45, 46). moreover, laws related to aps aim to control elder abuse in home environments or institutes. depending on the type of law, in each country there is a reporting system for elder abuse and social services provisions to support victims and change the conditions. nevertheless, the aforementioned laws are mostly related to abuse of adults with disabilities and vulnerabilities rather than elder abuse (47). therefore, the availability of ethical principles and laws helps the care team deal with abuse. ethical principles are laid down by experts to protect the profession, and saghafi a., et al. 11 volume 12 number 7 june 2019 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e social workers will be directed to implement the pertinent activities by standard establishment. this helps professionals defend themselves against ethics supervisory boards as well (47). sometimes professionals deal with elderly people who experience conditions not directly specified by ethical standards, and this creates challenges (48). in such cases, members of the care team face controversial ethical and legal conditions in action. ethical principles concentrate on rights and commitments against ethical challenges and specify what care team members should do in order to observe these principles. however, they may refrain from performing an ethical task for fear of the consequences, and may not implement any type of intervention in cases of abuse because they are concerned about violation of the patients’ rights (11). ethical principles are taught theoretically and when complications arise, care team members have a tendency to neglect ethical teachings, believing that theoretical teaching is one of the factors that complicate elder abuse (24). it is necessary for those who deal with elderly people to be aware of the professional, legal and ethical issues of elder abuse. in order to stay committed to caregiving values, the care team should have an effective performance and provide safety for elderly people and at the same time respect their dignity. important ethical principles that are violated in abuse are autonomy, beneficence, nonmaleficence, and justice. this phenomenon not only involves elderly people, but also other vulnerable classes of the society such as women, children, people with disabilities, and people who suffer from mental disorders. abuse creates challenges for the care team and puts them in dilemma. the question that now arises is: should the rights and freedom of an elderly person who has been abused be violated out of concern for his or her safety? in truth, the dual commitment of staff and other caregivers may violate the patient’s right to autonomy. one study showed that professionals who are responsible for protecting patients should keep in mind that when an elderly person decides to reject services (autonomy) and continue to live in threatening conditions, logical thinking under critical circumstances will be a necessity (11). in a 2003 study by healy the responses to a self-assessment by social services staff to ethical dilemmas concerning the decision-making capacity of elderly patients suffering from cognitive impairment are reported. in the section pertaining to house safety conditions, participants stated that they were faced with conflict when they had to force the person to go somewhere safe or respect his/her decision to continue in the existing conditions. in such cases, social workers face a decision-making challenge: to refrain from intervention and respect the person’s autonomy, or try to prevent harm to the person and introduce the culprit to the judiciary system (49). however, discussion about ethical principles is complex, because they are based on the culture in each society. autonomy should be respected as far as the person has examining the ethical challenges in managing elder abuse … 12 volume 12 number 7 june 2019 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e competency and poses no risk for people and the community. the principles of beneficence and non-maleficence are no exception. when a patient’s decision jeopardizes individual and social interests, the two principles of beneficence and autonomy are in conflict, because respect for one principle violates the other. in these cases, the care team should select the best functional option according to regional interests, consultations and guidelines. another controversial issue relating to abuse is the principle of confidentiality. confidentiality is one of the important principles ruling the relationship between patients and the care team, and one justification for it is respect for patient’s autonomy. the principle of autonomy emphasizes the patient’s right over all stages of life. therefore, one’s personal information belongs to oneself and no one should be aware of it without permission. if confidentiality is violated, the patient’s autonomy will be violated too. however, reporting abuse is another challenging issue. discussion about elder abuse reporting is not limited to the social context, but it necessitates awareness about medication, law execution, and social services. all professionals who have relationships with elderly patients regarding treatment and law execution should assume the ethical responsibility to protect them against harm. rodriguez et al. conducted interviews in 2006 with primary health-care providers. they concluded that in los angles, physicians experience a conflicting relationship between life quality and obligatory reporting laws. most respondents believed that the effects of abuse result in both improvement and harm for the patient, and experts’ tendency to promote patients’ life quality may decrease due to frequent reports (50). the ethical principles of the american counseling association (aca) emphasize the mandatory nature of consultation with other experts when counselors are not sure whether the case meets the reporting criteria or not. it should be mentioned that professionals should not only report suspected abuse, but they should be familiar with laws and regulations related to reporting, so that if a problem occurs, they can report it effectively (23). opponents of mandatory reporting argue that this type of reporting violates autonomy where the privacy of people is compromised (38). evidence shows that social workers in korea choose not to execute mandatory reporting because they feel that by modifying the conditions that cause abuse, family members can participate in providing care for the elderly at home. social workers believe that providing care at home, improving the relationship between the elderly and their families and intermediation role provide a better cultural option for the elderly (19). there are concerns about receiving services from all ethnic groups. studies on services showed that elderly people from various racial groups prefer to receive assistance from family members and friends to solve all types of problems except health and financial problems (23, 51). however, the mandatory reporting law saghafi a., et al. 13 volume 12 number 7 june 2019 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e should observe the dignity and privacy of people. now, the question is, what is the objective of the care team in reporting suspected abuse cases? the objective should not be to obtain or complete the statistics of abuse cases, but the principles of beneficence and nonmaleficence should be prioritized. the reporting system is unique in every country and follows the ethical principles and laws of that country. mandatory reporting is valued when there are protective systems and laws to help the elderly and rescue them from trouble. in countries where these laws do not exist, however, mandatory reporting does not promote a person’s quality of life, and even increases the gap between that person and his/her family members who have committed abuse. since a support system is non-existent in these countries, the elderly has to continue to live with the abusive family member(s), who may do more harm to the elderly, and even cause their death, because no education, reward or punishment system is in place. as for the competency of the elderly, the obvious point is that despite the availability of instruments such as the mini-mental state examination (mmse) that examines cognitive capacity, researchers should fully examine the cultural concerns associated with environmental and lifestyle patterns (52). finally, for decision-making the care team can benefit from the communication ethics approach, which is a participatory method comprising several stages: (a) the defense stage to clarify conditions and issues; (b) consultation; and (c) negotiation that leads to agreement (40). iranian ethical challenges the definition of elder abuse varies in different societies. according to an iranian study by heravi et al. conducted in 2013, elder abuse may be defined as an act or absence of a proper action by family members or relatives, which may happen once or several times, and can cause harm or distress to an older person (53). comprehensive ethical and legal regulations have so far not been developed in iran. according to investigations by a researcher in iran, no specific law exists about reporting and handling elder abuse. the secretariat national council of the elderly in iran, established in 2004, is the only organization that is active in various fields related to the elderly, but it seems that no significant activity has been performed regarding elder abuse. also, social emergency has been active in iran since 2007 to prevent harms and also provide services in connection with elder abuse, but they have not mentioned any specific ethical principles for managing elder abuse, its identification and referral. it is clear that availability of ethical principles and laws can help the care team deal with abuse. in chapter three of the constitution of the islamic republic of iran, the importance of autonomy and human dignity has been addressed. according to the constitution, respect for human dignity is a principle accepted by the islamic republic of iran, obliging the government to provide care services to everyone (54). accordingly, care examining the ethical challenges in managing elder abuse … 14 volume 12 number 7 june 2019 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e services should be based on respect for rights and dignity of patients. accordingly, the patient should choose and decide freely. respect should be provided for the patient while receiving care services based on respect for patients’ privacy and confidentiality of information. in this regard, a study by davis et al. showed that the possibility of decision-making is vital for elderly people, and lack of autonomy leads to depression (51). based on our iranian-islamic beliefs, confidentiality means trust, and it has to be protected. sharing personal information with others indicates betrayal. also, according to article 648 of the islamic penal code, disclosure of patients’ secrets is illegal except when personal or public interest is at risk (55). in iran, there is no particular penal code for elderly people, but according to article 596 of the islamic penal code on financial abuse, the abuser will be sentenced to 16 months to 2 years of imprisonment and payment of a fine. if the abuser is the guardian of the victim, in addition to the fine, the abuser will be sentenced to 3 to 7 years of imprisonment (56). thus, according to the above-mentioned points, elder abuse is a phenomenon that needs more attention from the government. conclusion abuse is a serious problem among elderly people. although the care team is responsible for the support and promotion of the independence of elderly people, ethical challenges are the result of unsatisfactory performance of the care team and people who endanger themselves or the others. in decision-making about measures related to elder abuse, ethical principles such as autonomy, beneficence, non-maleficence and competency should be taken into consideration. the care team should protect the autonomy of elderly people and consider their health and welfare. however, they should not impose their beliefs regarding living environments or social decisionmaking on the elderly. as far as possible, the relationship between elderly people and family caregivers should be promoted. at the same time, protecting elderly people will not be possible unless the society can help them maintain their independence outside of the family system. this will allow the elderly to enjoy a positive relationship with members of their family who are also their caregivers. the achievement of these goals necessitates long-term coordination between services and institutes. some measures that can be effective in this context include: devising appropriate instructions for the care team, particularly nurses who deal with abuse issues; communication and consultation with other service providers while observing privacy and autonomy; commitment to follow instructions; observing ethical considerations regarding abuse; and conducting empirical studies. nurses as the first line of treatment and other care team members have an important role in this respect. compilation or localization of clinical guidelines for the care team not only influences their perspectives into saghafi a., et al. 15 volume 12 number 7 june 2019 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e ethical issues, but also helps them perform properly and select the best functional option. finally, clinical guidelines support the behavior and performance of the care team and serve as a criterion to assess the caregiving quality. acknowledgements this article is part of a dissertation for a master's degree approved by tehran university of medical sciences, faculty of nursing and midwifery under the code of ethics 9411580003. the researcher declares her appreciation to the officials of the nursing and midwifery faculty of tehran university of medical sciences. conflict of interests authors declare no conflict of interest. examining the ethical challenges in managing elder abuse 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elder abuse: between a rock and a hard place. ann fam med. 2006; 4(5): 403-9. 51. gelfand de, kutzik aj, eds. ethnicity and aging: theory, research, and policy. usa: springer publishing company; 1979. 52. xu g, meyer js, thornby j, chowdhury m, quach m. screening for mild cognitive impairment (mci) utilizing combined mini‐mental‐cognitive capacity examinations for identifying dementia prodromes. int j geriatr psychiatry. 2002; 17(11): 1027-33. 53. heravi-karimooi m, rejeh n, foroughan m, ebadi a. designing and determining psychometric properties of the elder neglect checklist. iranian journal of ageing. 2013; 8(3): 25-34. 54. ramazani rk. constitution of the islamic republic of iran. middle east journal. 1980; 34(2): 181-204. 55. meghdadi mm, delavari mh. the civil liability due to revealing medical secrets in iran's law and common law. medical law journal. 2014; 8(30): 99-145. 56. akbari ma, ramezani a. the status of delinquent infants and children in iran criminal law. survey of malaysian law. 2017; 14(2): 104-13. journal of medical ethics and history of medicine an innovative method of self-education through a bioethics group: the ziauddin experience, karachi, pakistan nausheen saeed assistant professor, department of surgery, ziauddin hospital, karachi, pakistan. *corresponding author: nausheen saeed address: ziauddin hospital, karachi, pakistan. e-mail: minhalzay@yahoo.com received: 31 may 2009 accepted: 30 aug 2009 published: 14 sep 2009 j med ethics hist med. 2009; 2:17. © 2009 nausheen saeed; licensee tehran univ. med. sci. introduction world advancement in biotechnology has emerged as a challenge to humanity as well as physicians working in the community. with changing traditions and values, it is the need of the day to identify the ethical implications of our profession in order to deal with clinical dilemmas with a better understanding (1). the importance of bioethics teaching was overlooked till late 1990s in pakistan and for the first time this subject gained recognition by pakistan medical and dental council (pmdc) in 2002 ( 2). as a result of this, all public and private medical colleges are bound to incorporate ethics as a subject in their curriculum. however, the young doctors who begin their career in university hospitals were not exposed to bioethics education; they feel the need of a formal training because they encounter problems in facing ethical dilemmas emerging from their clinical practice (3). in addition, they have to participate in undergraduate bioethics teaching. in order to meet these demands physicians have started showing their enthusiasm to educate themselves. the centre of biomedical ethics and culture (cbec) introduced a one year postgraduate diploma (pgd) program in 2006. it is the only postgraduate-awarding degree program in biomedi cal ethics in pakistan. the focus of cbec is to educate mid-career health care professionals particularly belonging to university hospitals throughout pakistan (4). one of the mandatory requirements of this diploma course is to take up a project with an objective of disseminating bioethics education in different spheres of medical field. ziauddin university started organizing bioeth ics-related activities in its campus about seven years back. it is among one of the few private medical universities of the country which is forward looking and open to accept the challenges of new medical world. this institution recognized the need of teaching ethics even before its inclusion in pmdc code and started formal lectures for faculty by a consultant who had background in ethics. ziauddin hospital comprises of three campuses based in karachi. keamari campus is a 110 bedded, low cost, tertiary care hospital which caters to a large population of keamari (it is the main coastal town of karachi situated in the central and western parts of the city) (5). the hospital includes special ties like general medicine and allied, general surgery and allied, obstetrics and gynecology, eye, ear, nose and throat (ent), pediatrics etc. the clinical teaching of the medical students has been divided into three campuses and this campus provides a great opportunity for third and fourth year students to gain knowledge and skills (6). the group coordinator has been working in the campus as an assistant professor in the department of general surgery and is actively involved in under-and post-graduate teaching. the majority faculty at this campus felt the requirement of initiating bioethics related activities. the need for starting bioethics education was raised because of a particular case of a woman j med ethics hist med 2009, 2:17 nausheen saeed page 2 of 3 (page number not for citation purposes) having down’s pregnancy. the ethical issues related to this pregnancy were discussed in a weekly multidisciplinary meeting in which the author was invited as she had background know ledge of bioethics. this specific activity set a stage to develop a bioethics group that could address such issues. the author could sense the need for a forum and it was the opportune time to start a bioethics group as a project. methodology a session was planned in order to sensitize the faculty members about bioethics in june 2008. as a result of this meeting, nine consultants from different specialties showed their interest in the subject. therefore, it was decided to establish a bioethics group in the campus and its goals were defined. the primary objective of the group is self education and capacity building of the faculty. the first meeting was called in august 2008 after taking approval from the administrative body. in its first meeting, a catchy acronym was agreed upon and hence begz (bioethics group of ziauddin) came into being. the terms of references including membership criteria, schedule of the meetings, keeping minutes were decided. group coordinator (author) was responsible for arranging the meetings on monthly basis, and circulating the information of the meeting a week prior through email. initially only physicians showed enthusiasm in joining the group although the forum was open to residents and nursing staff also. the interest in the group was disseminated through word of mouth and, as a result, three postgraduate residents and three nurses joined the group. with the passage of time, the number has grown from eleven to seventeen; the members belong to diverse special ties like surgery, dermatology, psychiatry, medi cine, obstetrics & gynecology, ophthalmology and ent. until now the discussions have been on a wide range of issues such as informed consent, patient doctor relationship, abortion , pharma physician relationship, ethical dilemmas, religious and gender discrimination and environmental ethics. the format of the meeting is kept very flexible and simple which helps in maintaing the interest of the members. multiple instructional modalities that have been used so far include movie clips, photographs, real life scenarios, poetry and literature in urdu (national language) and role play. out of these teaching tools, the role play has been an attention grabbing experience for the majority as this exercise is interesting and at the same time thought-provoking (7). it helps in improving the level of understanding and changing attitudes. it is one of the most effective teaching modality which is often overlooked in bioethics education, though it has been used for a long time in other fields. after completing six months of this activity a pretested self administered questionnaire was distributed and members were asked to give their opinions and suggestions regarding the improve ment of begz. results there were fourteen members who filled up this proforma and shared their experiences. it was found that ten out of fourteen agreed that the capability of identifying ethical issues in their clinical practice has been enhanced. while eight out of fourteen were of the opinion that they could identify the ethical issues in their day to day life also. eight out of twelve felt a change in their interaction with their patients, while four did not notice any change in their behavior. on inquiring about the most relevant topics discussed, the majority [9] agreed for discrimina tion and pharma-physician interaction. the most often suggested topics for the upcoming sessions are research ethics, clinical ethics and beginning of life issues. impression it is encouraging to note that begz has made some headway (8). the number of members has increased from eleven to seventeen in just nine months. it is also important to note the diverse representation of the members. begz comprises of not only physicians, but also postgraduate students and nurses. the inclusion of nurses may be a rarity if not the exception. the introduction of nurses in the bioethics group into the realm of biomedical ethics gives a sense of great accomplishment. bioethics groups by themselves are few and far between in pakistan. begz activity started with some skepticism and apprehension among some faculty members but many of those fears have been allayed. this group activity appears to be sustaina ble because of the continued interest of its partici pants and innovative format of teaching. these preliminary experiences are being shared for the purpose of a better understanding of this distinctive way of learning. the effectiveness of this mode of education regarding awareness of bioethical issues and the perception/attitude of members will be reflected again after some time for further improvement. acknowledgement i would like to thank dr tabinda ashfaq and dr moinuddin siddiqui for their support and assistance in writing this commentary. j med ethics hist med 2009, 2:17 nausheen saeed page 3 of 3 (page number not for citation purposes) references 1. van mccrary s. the role of bioethics in medical education: a crucial profession under threat. http://www.actionbioscience.org/biotech/mccrary.html#primer (accessed on oct 2008) 2. anonymous. the pakistan medical and dental council code of ethics for medical and dental ers. http://www.pmdc.org.pk/ethics.html (accessed on 10 oct 2008). 3. egan ea. ethics training in graduate medical education. am j bioeth 2002; 2(4): 26-8. 4.anonymous. postgraduates diploma in biomedical ethics, (pgd). http://www.siut.org/bioethics/pgdcourse.html (accessed on 10 oct 2008) 5. anonymous. keamari town. http://www.nationmaster.com/encyclopedia/keamari_town (accessed on 1 dec 2008) 6. anonymous. dr ziauddin hospital keamari campus. http://www.zu.edu.pk/history-university.htm (accessed on 1 dec 2008) 7.anonymous. bioethics education project. managing discussion role play. http://www.beep.ac.uk/content/487.0.html (accessed 15 may 2009) 8. saeed n. a bioethics group of ziauddin hospital keamari campus (begz) [dissertation]. cbec (siut). pakistan; 2008. 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____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ 1 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e © 2019 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. original article volume 12 number 1 january 2019 *corresponding author forouzan akrami department of bioethics, medical ethics and law research center, shahid beheshti university of medical sciences, 1st floor, n0. 8, shams alley, tavanir station, vali-asr square, tehran, iran. tel: (+98) 21 88 78 10 36 fax: (+98) 21 88 77 75 39 email: froozan_akrami@yahoo.com received: 02 sep 2018 accepted: 03 nov 2018 published: 22 jan 2019 citation to this article: asghari a, pourfathollah a, abbasi m, mohammadi t, akrami f. adoption of iran’s code of ethics for blood donation and transfusion as a public health policy. j med ethics hist med. 2019; 12: 1. abolfazl asghari1, aliakbar pourfathollah2, mahmoud abbasi3, tooran mohammadi1, forouzan akrami4* 1. researcher, blood transfusion research center, high institute for research and education in transfusion medicine, tehran, iran. 2. professor, department of immunology, school of medicine, tarbiat modares university, tehran, iran. 3. associate professor, medical ethics and law research center, shahid beheshti university of medical sciences, tehran, iran. 4. researcher, department of bioethics, medical ethics and law research center, shahid beheshti university of medical sciences, tehran, iran. abstract blood is a public resource of human origin and its transfusion process is essential to individual and public health. this study aimed to develop a national code of ethics for blood donation and transfusion (bdt). this was a qualitative research with a multi methods approach in which a combination of methods including situational analysis, focus group discussion and expert panels were used. after situational analysis and orientation, the code of ethics for bdt was developed based on the findings of a content analysis within the framework of the four principles of biomedical ethics. the results were categorized into two sections: situational analysis and underpinnings measures, and the clauses of the code. the iranian blood transfusion organization has carried out three essential supportive measures over the past decades: approval of insurance coverage of blood recipients against communicable diseases; inclusion of 14 blood services in the book of “relative value units of health services”; and formation of the national ethics committee of transfusion medicine. after recognition and orientation, the national code of ethics for bdt was adopted and imparted to blood donation centers. the code consists of two sections: “blood transfusion centers: donors and donation” in 19 clauses, and “hospitals: patients” in 8 clauses. the national code of ethics for bdt establishes moral norms in order to protect the rights of blood donors and recipients. it could also serve as a basis for addressing the related ethical challenges and right decision-making in the area of bdt. keywords: ethics/morals; blood transfusion; donation; public health adoption of iran’s code of ethics for blood donation and transfusion as a public health policy adoption of iran's code of ethics for blood donation … 2 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 1 january 2019 introduction due to the functional necessity of establishing social relations based on common ethical values, most professions have implicitly accepted to observe a series of ethical guidelines as the code of professional ethics, which is recognized by members of that profession. in recent years, guidelines have been formulated in the form of codes of ethics for medicine, nursing and research (1). the code of ethics refers to a collection of moral norms developed in a specific profession based on a common value system. the purpose of establishing these codes is the identification and prioritization of ethical values in order to guide the right action and address the ethical challenges within the profession. the criteria can be used to assess professional competence and accountability to some extent. the hippocratic oath is one of the first pledges that medical graduates take and are expected to observe. according to this oath, physicians should apply their utmost effort and specialty to prevent harm to patients and promote medical preservation, and refrain from unfair treatment of individuals, assistance with euthanasia and abortion, and involvement in any act of abuse, especially sexual abuse (2). professional moralities include ethical codes and standards for a special profession or setting, and are one form of a particular morality (1). thus, each country establishes a code of ethics in medical areas in accordance with the human rights charter, international codes, and its own politicomoral philosophy. there is no unique model for appropriate responses against conscientious refusal that would apply to all beneficiaries and all cases; however, it has been recently emphasized that a code of ethics should contain ethical “musts” and “must nots” as well as the moral virtues in each professional area (1). given the fact that these codes are written by experts in the profession, surveying beneficiaries and public opinions seems necessary to preserve the rights and needs of patients and the public. blood is a public resource of human origin, and its donation and transfusion process is essential to protection and improvement of public health (3). the special nature of blood and its components distinguishes them from other medicines and therapies, and therefore the world medical organization (who) has categorized them as essential medicines (4). in 1975, who adopted statement number 28.72 on “utilization and supply of human blood and blood products”, demanding that commercial activities in the private sector in the area of plasmapheresis take note of the prevailing health threats and ethical consequences, and emphasizing the necessity of establishing regulations to protect the health of donors. this statement asked member governments to develop blood transfusion (bt) on a voluntary and non-remunerated basis before discussing the issue of the code of ethics for blood donation asghari a., et al. 3 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 1 january 2019 and transfusion (bdt). there were serious concerns about concentrating exclusively on the production and provision of more blood and blood components and disregarding the threats to the health of donors and the quality and safety of donated blood. consequently, who and the international society of blood transfusion (isbt) worked together to develop the code of ethics for bt to address these concerns and regulate the relationship between blood transfusion centers, blood donation volunteers and patients based on the mutual rights and obligations specified by isbt. the above-mentioned code was adopted by the general assembly in 1980 (5) and updated in 2000 with an emphasis on the importance of voluntary non-remunerated blood donation, and was later amended by who and red cross associations on september 5, 2006 (6). in the years 2005 and 2010, who adopted two statements on the observation of the rights of blood donors and recipients: 1) blood safety: proposal to establish world blood donor day (no: 58.13), and 2) availability, safety and quality of blood products (no: 63.12) (7). accordingly, the january 2017 report shows that the organization has established a framework in terms of ethical rules as well as structural and procedural requirements for humanoriginated medical products with the aim to write a comprehensive and integrated document, which was published after a widespread survey (8). as a basis for the health of donated blood, quality assurance cannot bring the risks to zero (9, 10); however, due to the inherent risks of bt, the code of ethics for bt can be considered as a guarantee for donation and health of the donated blood in functional terms. the iranian blood transfusion organization (ibto) was established in may 1974 with the main goal of providing safe blood and blood components. the safety and adequacy of blood supply depends on well-managed blood donation and distribution by the steward organization. the key strategy to provision of adequate and safe blood supply is recruitment and retention of voluntary and non-remunerated blood donors (11). although blood donation in an iranianislamic context is considered as a charitable and ethical act, it is necessary to raise awareness among community members and encourage them to continuously donate blood. a 2009 study of the knowledge, attitudes and practices of the iranian population on the subject of blood donation showed that 55% of the donors had donated blood more than once. the most common motivation for blood donation was altruism, and the most important obstacle was the difficulty of access to donation centers (12). on the other hand, the commitment of the steward organization to support the right to health care requires enhanced community participation and the trust of blood donors. by developing and enacting the code of ethics, the ibto can increase the supply of safe blood through reassuring the public, adoption of iran's code of ethics for blood donation … 4 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 1 january 2019 resolving their concerns and doubts, and establishing good services. thus, considering the politico-moral foundations of the country’s health care system, including the right to health care and the obligation of the state to provide it, and observation of distributive justice with a focus on vulnerable and disadvantaged groups (13), the present study aimed to develop the national code of ethics for bdt. method in this qualitative study, the multi-method approach was used, which is a combination of methods that produce data of the same type (14). this approach brings about integrity of the findings and increases the credibility of the research (14, 15). in the present study, the data obtained at different stages of the study were mainly of qualitative type. establishment of the code of ethics for bdt in iran began in december 2015 in response to the proposal of the director of the ibto to the legal department of the organization. in the first stage, analysis of the current situation was performed through an investigation of relevant publications using mesh subheadings of “blood” [mesh terms] and “ethics” [mesh terms] in pubmed database; non-mesh subheadings of “ethics” and “blood donation and transfusion” via google scholar search engine; and the ibto website for national documents. at the next stage, a focus group discussion was held to receive opinions about the themes to be considered in the drafting of the code as well as the main ethical issues in bdt. the focus group consisted of 14 expert specialists in the fields of medical ethics (2 persons), medical law (2 persons), medicine (2 persons), pharmacy (2 persons) and organizational management (6 persons). these people were selected purposefully by the supreme council of ibto. after explaining the purpose of the study and obtaining verbal consent of the participants, formal invitation letters were sent to them. the group discussion was conducted and recorded by the first researcher and lasted 1 hour. the collected data were analyzed using deductive content analysis under the two main categories of blood transfusion centers: donors and donation, and hospitals: patients considering the international code of ethics for bt and the findings of the group discussion, the national code of ethics for bdt was drafted and codified within the framework of principlism. the primary draft was discussed and completed in two expert panels with the contribution of 12 member persons of the supreme council of ibto, including experts in the fields of blood transfusion medicine (3 persons), medical ethics (2 persons), medical law (1 person), immunology (1 person), hematology (1 person), pharmacy (1 person), pathology (1 person), community medicine (1 person), and food and drug administration (1 person). the second draft was then sent as an official letter to 10 managers of the asghari a., et al. 5 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 1 january 2019 provincial bureau of blood transfusion, 3 specialists of blood transfusion medicine, and 3 specialists of medical ethics who were not employed in the ibto for external review. simultaneously, the comments of 6 community members who were familiar with blood transfusion concepts were also collected. after receiving the comments and applying them, the third draft was submitted to the department of quality assurance and control as well as the deputy of technics and new technologies of the ibto in order to receive their approval. the last draft was then propounded and finalized in the meeting of the ethics council on transfusion medicine in february 2017, and was adopted and communicated to blood transfusion centers throughout the country. a number of the clauses in this code refer to the performance of hospitals regarding the transfusion of blood and its components, and the way in which patients use such services. therefore, in october 2017, the national code of ethics was discussed and approved with minor revisions in a meeting with representatives of the main stakeholder organizations including the ministry of health and medical education, medical council, and council of ethics of the iranian academy of medical sciences. selection of the participants in discussion sessions was based on the objectives of the study. all research steps were in accordance with the national code of ethics in biomedical research. verbal consent was obtained from the participants to attend discussion sessions, and official invitation letters were sent to them before each session. results the results are categorized in two sections: the current situation and underpinning measures, and the code of ethics for bdt. a) the current situation and underpinning measures ibto is a non-profit organization affiliated to the ministry of health and medical education and operated by the supreme council, which is composed of five expert members selected by the minister of health as the decision maker and managing director as the pillar of implementation. according to article 4 of the statute of the ibto, adopted in 1984, the supply, provision and distribution of blood should be entirely free of charge. in the case of blood products and derivatives that require specialized and costly processes, according to article 7, clause (c) of the statute, the cost of the added processes can be received based on the tariff approved by the supreme council of ibto. according to the organization’s statute, blood transfusion services such as the recall and recruitment of volunteers for donating blood and cellular and plasma products, the selection of donors from among these volunteers, blood sampling and screening, and preparation and distribution of the blood and blood components to the hospitals is exclusively the responsibility of ibto. in this regard, the prescription and transfusion adoption of iran's code of ethics for blood donation … 6 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 1 january 2019 of blood and blood components is beyond the responsibility of the organization and falls within the expertise of responsible physicians. however, article 7, clause (d) of the organization’s statute is merely implemented in hospitals through the supervision of the ibto according to the “code of activity of the blood bank and blood consuming sectors” as one of the requirements for ensuring the health of the blood cycle. all hospitals have a structure called the bt section, which operates as blood bank and blood transfusion center and management. the bt department and the physician in charge collaborate to manage the blood transfusion cycle, since the need is announced for the blood and blood components until they are administered and the patient’s state is preserved. one document that is observed in the records of the ibto is the “ethics charter”, in which the seventh clause and its following four sub-clauses refer to the ethical principles of blood donation. this clause comprises issues such as voluntary donation, obtaining the written consent of volunteers, preserving donors’ health, the necessity of donors’ awareness of their ethical responsibility toward recipients of blood and the possible risks of transmitting infections, and the confidentiality of donor information. the ibto has adopted the following measures in the past decade, which can be considered as supportive actions for donors and recipients of blood transfusion services: first, based on the proposal of the ibto and the approval of the islamic consultative assembly of iran in 2007, recipients of blood transfusion services were covered by insurance companies against the possible complications of blood consumption. in the following years, the ibto provided insurance for not only recipients, but also blood donors against such probable events. second, fourteen cases of blood transfusion services were mentioned in the second edition of the book titled “relative value units of health services” since 2015 through approval of the supreme council of health insurance and approval of the cabinet of ministers, and these services are currently covered by social security. third, the “ethics committee of blood transfusion medicine” was established with the aim of determining the policies and strategies related to the ethics of bdt and decision making about the ethical challenges in this area, as well as developing and supporting education and research activities in terms of the ethical considerations in bdt. finally, formulation of a code of ethics for bdt was included in the ibto agenda. b) code of ethics for blood donation and transfusion using deductive content analysis, the following themes emerged under two main categories: 1) blood transfusion centers: donors and donation in this category 8 themes were extracted: voluntary non-remunerated blood donation; respect for the rights of donation volunteers; asghari a., et al. 7 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 1 january 2019 continuity of donation and assurance of the safety of blood supply; requirements for maintaining safety of the blood transfusion cycle from donation to injection; commitments and obligations of blood transfusion centers; privacy and confidentiality; exemptions; and education and research. 2) hospitals: patients the following 4 themes emerged in this category: protecting the rights of blood recipients; responsibilities and obligations of blood transfusion centers; observing clinical standards; and managing blood consumption. the code of ethics for bdt was formulated and adopted based on the obtained subthemes and in the framework of the four principles of beneficence, non-maleficence, respect for autonomy and justice. the code included an introduction and the main body, which consisted of two parts: “blood transfusion centers: donors and donation” in 19 clauses, and “hospitals: patients” in 8 clauses (appendix). blood transfusion centers: donors and donation the first clause of section 1 emphasizes voluntary, non-remunerated blood donation, done only for the purpose of helping one another and with altruism as motivation. thus, volunteers donate their blood freely without expecting any type of reimbursement such as cash or cash alternatives. on this basis, even the granting of a work leave is recognized as a form of wage, unless it is necessary for the referral and conduct of the donation process. however, entertaining donors or reimbursement of transportation costs is acceptable when necessary. clauses 2, 3 and 4 concern the informed consent of donors and related issues. clause 5 emphasizes donors’ awareness of the consequences and risks of donating blood and their ethical responsibility toward the recipients of donated blood. according to clause 6, donors must answer the questions that are asked of them honestly and accurately. clause 7 points out that blood transfusion centers are obliged to inform donors about cases of exemption from blood donation as well as the reasons, and if the volunteer is exempted, the center should declare the cause, type and duration of the exemption. clause 8 emphasizes that care and recommendations after blood donation should be clearly explained to volunteers/ donors, and this should be confirmed by them. clause 9 clarifies that donors can cancel the blood donation process at any stage. clauses 10 and 11 emphasize the necessity of respecting the privacy of volunteers/donors and the confidentiality of their information, and states that they should be aware of these considerations. clause 12 emphasizes that blood donors and recipients should not be aware of one another’s identity, barring exceptional cases. clauses 13 and 14 point out the necessity of observing the national bt standards and adoption of iran's code of ethics for blood donation … 8 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 1 january 2019 state that all bt processes should be carried out under supervision of a qualified physician. clauses 15 and 19, respectively, refer to non-discrimination on the grounds of gender, race and socio-economic status, and fair access for all patients. clause 16 states that blood donors and recipients should be aware of any complications, and clauses 17 and 18 emphasize that the organization should avoid profitable incentives and develop executive processes to prevent the loss of this public resource and protect individual and public health. hospitals: patients in this section, in addition to the emphasis on patients’ best interests, clause 1 highlights the right of patients to be aware of the risks and benefits of transfusion and alternative therapies. moreover, clause 2 states that transfusion of blood and blood components should only be conducted with the informed consent of the patients, their parents or legal representatives. based on clause 3, the patient can cancel the process of receiving blood at any stage of the treatment. to make this decision, the patient should be aware of the potential consequences, and the decision should not affect the behavior and function of the hospitals and their staff. in clause 4, based on the charter of safety of blood and its components, all relevant processes in the treatment centers must be in accordance with national bt standards. according to clause 5, the only basis for the administration of blood transfusion is the clinical condition of the patient, and in cases where the patient needs only a particular part of blood (for instance plasma or cell derivatives), prescribing the whole blood is not allowed. clause 6 states that prescribing blood or blood components should not be based on financial incentives or benefits. clause 7 specifies that adoption of measures such as the use of blood substitutes, autologous transfusion, limited use of blood transfusion, and optimal blood management are the professional obligations of medical practitioners. finally, according to clause 8, the administration and transfusion of blood and/or blood components should be carried out under the supervision of qualified physicians. discussion the main goal of the ibto is to provide universal access to sufficient and safe blood and blood products and ensure their appropriate clinical consumption. the situation analysis indicates the necessity to establish the national ethics committee of transfusion medicine and develop the main infrastructures, including regulations on the provision of safe and sufficient blood supply, by the supreme council of ibto over the past decade (16). leadership and governance is one of the main domains that has been emphasized and assessed by the who-eastern mediterranean region. the assessment report of blood transfusion services showed that among 18 respondent countries, 14 have a national policy, 13 have strategic plans, 12 have advisory asghari a., et al. 9 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 1 january 2019 committees, and only 9 countries have a legislative mechanism (17). based on the “framework for action for blood safety and availability 2016 2025” (17), the second phase of the present study was performed to develop and implement a legislative system for supervising the blood donation and transfusion services. accordingly, the national code of ethics for bdt was formulated and codified based on scientific standards and the four principles of biomedical ethics and its derivatives, including: consideration of the benefits and burdens of patients and donors; respect for autonomy and the rights of donors and patients; emphasis on respect for privacy and confidentiality of information; and equity in two sections: “blood transfusion centers: donors and donations” and “hospitals: patients”. due to the nature of blood and blood donation as a public resource, the first section of the national code was mostly formulated based on the principles of public health ethics (18, 19). the second section, however, was mainly focused on the principles of clinical ethics due to its patientcentered nature (20). for this reason, in the second section of the national code, all the terms of the international code have been addressed and the obligations of health professionals according to clinical and paraclinical guidelines have been emphasized. the code of ethics of isbt has also been divided into two sections: “blood transfusion centers: donors and donations” in 11 clauses, and “hospitals: patients” in 7 clauses. the pillars of this code are the following ethical elements (21): the principle of voluntary non-remunerated blood donation without material incentives as the basis for blood transfusion services, and universal access to blood as a public resource. a review of the 2017 version of the international code indicates that the revision has been based on human dignity and the four principles of biomedical ethics, which is similar to the national code developed in this study. the difference in the number of clauses in the first section is due to the emphasis on instances of informed consent and the ethical responsibility of volunteers for public health in the national code. access to blood mainly relies upon voluntary and non-remunerated contribution of a human donor (22). thus, the first clause of section 1 emphasizes voluntary and nonremunerated blood donation with the motive of altruism. a survey conducted in shiraz blood transfusion center on motivations for blood donation showed altruistic causes to be the main motive at 65.3%, while other common motivations included controlling individual health status, earning money, treating illnesses and curiosity in that order (23). according to the regional strategic framework for blood safety and availability (2016 2025), the volunteers/donors and their actions must be respected, and all necessary measures should be taken to protect their health and safety, and to ensure that blood products are equitably and adoption of iran's code of ethics for blood donation … 10 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 1 january 2019 appropriately distributed (17). therefore, given the importance of protecting donors as the main source of blood supply in continuous voluntary non-remunerated blood donation, the next clauses mainly focuse on respecting the rights of the volunteers/donors. one of the 10 basic functions of public health is mobilizing the community to contribute to solving health problems (24). a sense of social responsibility will lead to participation in public health activities to achieve public good. according to weed and mckeown et al. responsibility is a profound concept that is linked to commitment to someone or something. therefore, being responsible entails commitment to a positive action, or the attempt to achieve a high value such as social or public good (25). in public health, social responsibility has been considered as a moral norm, which, in addition to promoting participation, helps to protect and promote public health (26). in this area, people are responsible for what will happen if preventive measures are not applied, which is referred to as consequentialist responsibility (27). with regard to blood donation for check-up purposes, especially by donors with highrisk behaviors, clauses 5 and 6 emphasize the moral agency of the donors and confidential self-exclusion strategy to ensure the health of both donors and recipients (28). in terms of accountability (17), the focus of these clauses is on the proper governance and management of the blood transfusion cycle. as previously mentioned above, the second section of the code is mainly patientcentered; clauses 1, 2 and 3 of this section pertain to respecting the rights of recipients and patients, while the succeeding clauses are about observing professional standards and patient blood management. promotion of the clinical use of blood and blood products (17) and patient blood management are priority interventions to optimize the care and improve patient safety and clinical outcomes (29, 30). in the next phase of the study, the revision of the code will be considered 3 years after adoption. for this purpose, the new national evidences and recommendations of the main stakeholders will be investigated with more focus on the moral norms in public health policy and the stewardship role of the ibto. conclusion the developed national code of ethics for bdt adopts moral norms for protecting the rights of blood donors and patients alike. it uses human rights literature and the values of the iranian health care system and transnational documents within the framework of citizenship laws. these norms, along with cultural beliefs and values, develop a common ethical framework in the relationships among volunteers/donors, blood transfusion centers, health centers and hospitals, medical doctors and other health professionals, and the patients; at the same time, they provide a basis for addressing asghari a., et al. 11 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 1 january 2019 ethical challenges and making the right decisions in the area of bdt. since these moral norms have been formulated based on respect for the rights of volunteers and donors, they can encourage volunteers to continue donation and can be effective in supplying adequate and safe blood supplies. the internalization of these moral norms as well as their observation as an organizational behavior by medical professionals and blood donors can ensure the implementation of the code. acknowledgments financial support was provided by ibto and the research deputy of sbmu. authors appreciate the academic board and experts who contributed to this national study. conflict of interests the authors declare that they have no conflict of interests. adoption of iran's code of ethics for blood donation … 12 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 1 january 2019 references 1. beauchamp t, childress j. principles of biomedical ethics, 7ed. uk: oxford university press; 2013. 2. veatch rm. cross-cultural perspectives in medical ethics, 2nd. usa: jones and bartlett; 2000. 3. busby h. biobanks, bioethics and concepts of donated blood in the uk. sociol health illn. 2006; 28(6): 850-65. 4. anonymous. world health organization: 19th who model list of essential medicines (april 2015). [cited on january 2019]; available from: http://www.who.int/medicines/publications/essentialmedicines/eml2015_8-may-15.pdf. 5. andre a. montreal 1980: a code of ethics for blood transfusion. vox sang. 1981; 40(4): 303-5. 6. flanagan p. the isbt code of ethics and the altruistic donor. isbt science series. 2012; 7(1): 303-6. 7. anonymous. world health organization: universal access to safe blood transfusion. [cited on januray 2019]; available from: http://www.who.int/iris/handle/10665/69747 8. anonymous. world health organization: universal access to safe blood transfusion. [cited on januray 2019]; available from: http://apps.who.int/iris/bitstream/handle/10665/254047/who-his-sds-2017.1eng.pdf?sequence=1&isallowed=y 9. goodnough lt. blood management: transfusion medicine comes of age. lancet .2013; 381(9880): 1791-2. 10. kramer k, verweij m, zaaijer h. are there ethical differences between stopping and not starting blood safety measures? vox sang .2017; 112(5): 417-24. 11. mahmoudian shoshtari m, pourfathelah a. an overview analysis of blood donation in the islamic republic of iran. arch iran med . 2006; 9(3):200-3. 12. mousavi f, tavabi aa, golestan b, et al. knowledge, attitude and practice towards blood donation in iranian population. transfus med. 2011; 21(5): 308-17. 13. akrami f, abbasi m, karimi a, shahrivari a, majdzadeh r, zali a. analyzing the politicomoral foundations of the iran’s health system based on theories of justice. j med ethics hist med. 2017; 10: 4. 14. hall rf. mixed methods: in search of a paradigm. [cited on january 2019]; available from: https://www.researchgate.net/publication/259045135_mixed_methods_in_search_of_a_p aradigm 15. bowen ga. document analysis as a qualitative research method. qualitative research journal. 2009; 9(2): 27-40. 16. abbasi m, pourfathollah a, asghari a. legal analysis of the ethical code of blood donation and transfusion. bioethics journal. 2015; 5(16):143-82. [in persain] 17. anonymous. world health organization: strategic framework for blood safety and availability 2016–2025. [cited on januray 2019]; available from: https://apps.who.int/iris/bitstream/handle/10665/254837/emropub_2017_en_19608.pd f?sequence=1&isallowed=y 18. sachdev s, mittal k, patidar g, et al. risk factors for transfusion transmissible infections elicited on post donation counselling in blood donors: need to strengthen pre-donation counselling. indian j hematol blood transfus. 2015; 31(3): 378-84. https://www.researchgate.net/publication/259045135_mixed_methods_in_search_of_a_paradigm https://www.researchgate.net/publication/259045135_mixed_methods_in_search_of_a_paradigm https://apps.who.int/iris/bitstream/handle/10665/254837/emropub_2017_en_19608.pdf?sequence=1&isallowed=y https://apps.who.int/iris/bitstream/handle/10665/254837/emropub_2017_en_19608.pdf?sequence=1&isallowed=y asghari a., et al. 13 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 1 january 2019 19. akrami f, zali a, abbasi m, et al. an ethical framework for evaluation of public health plans: a systematic process for legitimate and fair decision-making. public health. 2018; 164: 30-8. 20. akrami f, abbasi m. exploring the prominence of ethical principles and moral norms in the areas of clinical practice and public health. ann med health sci res. 2018; 8: 11-15. 21. beal r. the international society of blood transfusion and a code of ethics for blood donation and transfusion (2000). vox sang. 2002; 82(3):165. 22. petrini c. between altruism and commercialisation: some ethical aspects of blood donation. ann ist super sanita. 2013; 49(4): 412-6. 23. kasraian l., torab jahromi s.a. a motivation survey of blood donation in shiraz blood transfusion center. sci j iran blood transfus organ. 2006; 2(6):259-67. [in persain] 24. anonymous. 10 essential public health services. [cited on januray 2019]; available from: https://www.apha.org/about-apha/centers-and-programs/quality-improvementinitiatives/10-essential-public-health-services 25. mckeown r.e, weed d.l, kahn j.p, stoto m.a. american college of epidemiology ethics guidelines: foundations and dissemination. science and engineering ethics. 2003; 9(2) : 207-14 26. mckeown r, weed d. ethics in epidemiology and public health ii. applied terms. j epidemiol community health. 2002; 56(10): 739-41. 27. abbasi m, majdzadeh r, zali a, karimi a, akrami f. the evolution of public health ethics frameworks: systematic review of moral values and norms in public health policy. med health care philos. 2018; 21(3):387-402. 28. turoldo f. responsibility as an ethical framework for public health interventions. am j public health. 2009; 99(7): 1197-202. 29. anonymous. world health organization: who global forum for blood safety: patient blood management.[cited on january 2018]; available from: https://www.who.int/bloodsafety/events/gfbs_01_pbm/en/ 30. shander a, isbister j, gombotz h. patient blood management: the global view. transfusion. 2016; 56(suppl. 1): s94-102. adoption of iran's code of ethics for blood donation … 14 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 1 january 2019 appendix iran’s code of ethics for blood donation and transfusion purpose the purpose of the code is to establish ethical and professional principles that should be observed in all activities in the field of blood donation and transfusion according to the iranian blood transfusion organization (ibto). introduction the code of ethics for blood transfusion and donation puts forward a set of moral norms to protect the rights of blood donors and patients. these norms, along with cultural beliefs and values, establish a common moral system for blood donors, blood transfusion centers, medical centers, medical practitioners and patients, while establishing a basis for addressing ethical challenges and making related decisions and solutions. the main foundations for developing the code included: observing scientific and ethical principles, considering donors’ and patients’ interests as well as harms that they may suffer, emphasizing the privacy and confidentiality of donors’ information, respecting the dignity and rights of patients and donors, and obtaining informed consent. definitions “blood donation” is the voluntarily donation of blood, which is collected either for direct transfusion or preparation of a medicinal product for human use. “blood transfusion center” refers to an entity that is responsible for any aspect of the recruitment of donors, collection and screening of blood, and also blood processing, storage, and distribution, when intended for transfusion. “screening” refers to a laboratory process that determines the safety of donated blood by performing tests to detect certain infectious agents transmitted through the bloodstream. “qualified physician” is a person who holds a valid medical professional license and has passed related training courses and received a certificate. “autologous transfusion” is a condition in which donated blood is used exclusively for self-administration by the donor. “restrictive transfusion strategy” is blood transfusion that is performed only if the patient has a hemoglobin level of less than 7 g/dl and is considered in stable condition. “patient blood management” is an evidence-based, patient-centered and multidisciplinary approach that is adopted to manage anemia, minimize iatrogenic blood loss, and harness tolerance of anemia in an effort to improve patient outcome. blood transfusion centers: donors and donation 1. blood donation must be voluntary and non-remunerated under all circumstances and performed solely for the purpose of altruism. volunteers donate their blood without any compensation, whether cash or cash alternatives. thus, even a work time off, other than for the purpose of conducting the donation process, is recognized as a form of wage. however, refreshments and reimbursement of direct travel costs are not contrary to voluntary, non-remunerated donation. 2. blood donation must be voluntary and done with the donors’ informed consent. donors have the right to be clearly informed about the conditions for donating blood, the stages, and any actions and expenditures related to blood and blood components, and their consent should also be obtained to use the blood and blood components. asghari a., et al. 15 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 1 january 2019 3. donors have the right to be fully informed about the blood donation conditions and processes. 4. donors have the right to be informed about the potential risks of blood donation. in all cases, the priority is to protect the health and safety of the donor. 5. donors should be aware of the hazards and consequences of donating infected blood, and of their moral responsibility toward potential recipients. 6. donors should answer the questions honestly and clearly. 7. blood transfusion centers must inform donors about cases of exemption from blood donation and the reasons. in the event of a voluntary exemption from donation or detection of infections during the screening process, the centers should inform donors about the type, cause and duration of exemption. 8. post-donation care should be clearly communicated and it must be established that the donor has fully understood it. 9. donors can cancel the blood donation at any stage. 10. the privacy of donors must be respected during the medical interview and the screening process. 11. the information of donors must not be disclosed, and they must be ensured about the confidentiality of their information and medical records. 12. blood donors and recipients should not be aware of one another’s identity, barring exceptional cases. blood transfusion centers and hospitals must take all the necessary measures in this respect. 13. all the processes related to blood donation must be performed in accordance with the standards of the national blood transfusion organization, and under the supervision of a qualified physician. 14. the only criterion for accepting or exempting donors is the standards of the national blood transfusion organization. physical examinations and interviews must be conducted under the supervision of a qualified physician. 15. any discrimination based on gender, religion, ethnicity or nationality is prohibited. blood donation centers and their staff should not make discriminatory requests from donors and recipients. 16. blood donors and recipients must be informed about any possible complications. 17. establishing blood transfusion centers and providing blood services must not be done for commercial motives and profitable purposes. 18. all measures from donation up to blood transfusion should be implemented in such a way as to prevent the loss of blood and blood components. 19. all patients must have access to blood and blood components when necessary. hospitals: patients 1. patients have the right to be clearly informed about the risks and benefits of blood transfusion as well as alternative therapeutic procedures by the physician. 2. the transfusion of blood and its components must only be performed after obtaining the written informed consent of the patient or her/his legal representative; if this is not possible, the decision for transfusion of blood and blood components should be based on the “best interests of the patient”. 3. the patient has the right to refrain from receiving blood or blood components at any stage of the treatment. in this case, he/she should be notified of the possible consequences of the decision, and the final decision should be documented and approved by him/her. however, such a decision should not adversely affect the behavior of physicians and medical practitioners in providing the best alternative adoption of iran's code of ethics for blood donation … 16 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 1 january 2019 treatment and reducing the consequences of the patient’s decision. 4. to ensure the safety of the blood and blood components, all relevant processes must be done in accordance with the standards of the national blood transfusion organization. 5. the blood transfusion must be done only based on the patient’s clinical condition; therefore, in cases where the patient only needs a specific component of the blood (plasma or cell derivatives), administration of the whole blood is not permitted. 6. the administration of blood or blood components must not be due to financial incentives. 7. adoption of measures such as the use of blood substitutes, autologous transfusion, restrictive transfusion strategy and patient blood management fall within the domain of professional ethics, and must be supervised by responsible physicians. 8. the prescription and administration of blood and blood components must be done by a qualified physician.  blood transfusion centers, hospitals, and other related centers are required to comply with this code of ethics and take it into account when compiling or revising their guidelines.  the ethics committee of the supreme council of ibto is responsible for the supervision and revision of the code. journal of medical ethics and history of medicine a simple apparatus for measuring the blood urea, manufactured by dr. luigj benusi in 1943 in albania flamur tartari 1 , stiliano buzo 2 , gentian vyshka 3* 1.service of urology, uhc mother theresa, rr. dibrës 371 tirana, albania. 2.department of biochemistry, faculty of medicine, rr. dibrës 371, tirana, albania. 3.section of human physiology, faculty of medicine, rr. dibrës 371, tirana, albania. *corresponding author: gentian vyshka address: section of human physiology, faculty of medicine, rr. dibrës 371, tirana, albania. tel: (+355) 67 29 07 082 e-mail: gvyshka@yahoo.com received: 31 oct 2009 accepted: 18 nov 2009 published: 22 nov 2009 j med ethics hist med. 2009; 2:19. © 2009 flamur tartari, stiliano buzo and gentian vyshka; licensee tehran univ. med. sci. abstract keywords: blood urea nitrogen, ambard law, hypobromite, kowarsky method. introduction it is well known that determination of nitro gen level and other organic liquids in blood is particularly important. the respective methods and the apparatuses are various, and, as per the ex pected results, they are more or less precise. in the everyday clinical practice, it may be sufficient even if being a very simple and quick method. the simplicity of the apparatus we’re describ ing in this article is very particular. due to the historical conditions of the second world war (sww), it was impossible for albania to import technologies; dr. luigj benusi, at that time, invented a simple way to measure blood urea, coining a very simple apparatus, made from ordinary materials and means that could easily be found in every clinical or biochemical laboratory of the time. there are several methods proposed and ap plied for measuring blood urea. almost all of them rely upon the application of the hypobromite reagent for ammonia and urea, as introduced by knopf. the reagent has been prepared by dissolv ing bromine in strong alkali solution (1). theoreti cally the methods conform to the law of ambard, based upon his extraordinary work regarding urea concentration and output. according to ambard’s the apparatus invented by dr. luigj benusi in 1943, in tirana, was a practical application of the kowarsky technique and ambard laws, helping in determining blood urea levels and very important to a variety of diseases, mainly kidney disorders. the apparatus was invented and prepared from very simple laboratory materials, such as glasses, test tubes, corks and volumetric cylinders. technologically, it was based upon the determination of blood urea through hypobromite, and, among the advantages of the apparatus of benusi, were its extreme simplicity, the smaller amount of blood needed for producing results (2 milliliters), as well as an easiest way to clean up and to manage the apparatus from a practical point of everyday use. mailto:gvyshka@yahoo.com j med ethics hist med 2009, 2:19 flamur tartari, stiliano buzo and gentian vyshka page 2 of 4 (page number not for citation purposes) work, the speed of carbamide (synonymous to urea) secretion is proportional to the square of the carbamide-concentration in the blood; and reverse ly proportional to the square root of the carbamide concentration in the urine (2 4). the situation of medical services in albania, after the second world war, was very problematic. the lack of devices was felt almost in every field. the apparatus described herein, invented by dr. benusi, helped a lot in the practical and everyday determination of blood urea nitrogen. the analyses were up to that moment, based upon the kowarsky technique, but the simplicity of benusi apparatus was striking, and the applicability in the everyday practice was decisive in the introduction of this simple invention. the methods differ mainly on the amount of blood necessary for performing the analysis. there were also other methodologies, such as the urease method of marshall (5) and the calorimetric method of folin and denis (6). benusi apparatus uses the same procedure as applied with kowarsky or ambard apparatus and methodology, only the quantity of filter is decreased in 2 milliliter. apart from that, results were obtained in a very brief period of time; the maintenance of benusi appara tus was much more simple, and therefore, its everyday use was of great benefit to the albanian laboratory services of the time. the history of the apparatus dr. luigj benusi was specialized in clinical biochemistry and microbiology; in 1945, he was promoted as founder and chief of the state bacteri ological laboratory in albania. he was the first one to apply the typhus and paratyphoid vaccine in albania. figure 1 is a snapshot from his work in the above-mentioned laboratory. due to the severe conditions of the post second world war in albanian hospitals, the work of dr. benusi and his colleagues served as an incentive for reviving the medical system. the small apparatus invented in 1943 at the state bacteriological laboratory in tirana was composed of (numbers corresponding to the figure 2): 1. a glass approximately 6-7 cm long and 3-4 cm wide. 2. a small test-tube 3 cm long, with a diameter approx. 1.5 cm. the tube was prepared cutting an ordinary bacteriological test-tube. 3. a cork of soft rubber, with 1 or 2 holes. 4. a tap obtained from a burette, to be used if the cork has 2 holes. 5. a long glass tube 4 cm in length, with a diameter approx. 7-9 mm, to be adapted to one of the cork’s holes. a part of the tube remains in the upper part of the cork. 6. a tube of ordinary caoutchouc 30-35 cm long, a part of which will be adapted to the glass tube; the other end to the small pipe mentioned below. 7. a small pipe of 2 or 5 mm. 8. a volumetric bottle or a cylinder, with a narrow neck so that the small pipe will enter hermetically inside the cylinder. the cylinder will be filled with water mixed with an appro priate amount of sulfuric acid, to impede the contamination. methodology and results of the apparatus the glass no. 1 (figure 2) is poured with the filtrate (serum or probing solution), thereafter, 2 ml of sodium hydroxide (naoh) is poured to obtain the whole solution and to assure the acting of naoh as alkalifying and absorber of carbon dioxide (co2). the small test-tube (no. 2, figure 2) is filled with hypobromite and carefully poured into glass no. 1. the glass no. 1 communicates through the pipe with the volumetric cylinder; previously, the examiner ascertains that the level of water in the pipe corresponds to the beginning of the gradation. the two systems (glass no.1 and volumetric cylinder no. 8) at the time of the reaction should have no communication with the outer milieu. complying with this condition, the glass no. 1 is inclined 140to diffuse the hypobromite inside the glass, making, in the meantime, about 25 quick agitations. due to the reaction taking place, the level of the pipe due to gas production will decrease. the quantity of the gas in the pipe lifting it up, and decreasing the water level inside of it, is equal to that in the volumetric bottle, and therefore is measurable. the quantity of gas will indicate, through special formulas, the quantity of nitrogen contained inside the specimen of the glass no. 1 (serum or probing solution). the system was based on the same procedure for determination of blood urea nitrogen (7, 8) as other similar apparatuses, like the kowarsky apparatus (9), or the ambard method [ambard's or ivon's hypobromite method apparatus for estimat ing blood urea] (1-3). the necessary reagents were a 3-chlor-acetic acid solution; naoh solution 20%; hypobromide sodium solution 3-5%; carbamide solution 1%. prior to be applied in the clinical practice, the apparatus was tested using carbamide solution, serum and various urine specimens. the obtained results were compared with those obtained using kowarsky apparatus. the first test was made through the determination of the quantity of nitrogen produced by standard carbamide solution of up to 1 ml. other tests were made also using urine specimens of different individuals, diluted j med ethics hist med 2009, 2:19 flamur tartari, stiliano buzo and gentian vyshka page 3 of 4 (page number not for citation purposes) with distillated water. another test was performed using 5 serum specimens from diseased and healthy individuals. carbamide solution is used as a standard equalizing solution, in order to eliminate the use of small particular tables for the correction of nitrogen values according to the environmental temperature and the atmospheric pressure. each day before starting work, a preliminary test with carbamide was made, serving as a standardizing curve. in all cases, the results obtained with benusi apparatus were very similar to those obtained with the kowarsky one; this was verified through blood specimens, as well as through urine specimens. conclusion very serious attempts have been made since decades to determine blood urea nitrogen, as well as blood and urine chemistry (10). the results of reactions obtained from the two apparatuses (benusi’s and kowarsky’s) are quite proportional, therefore, mutually inter-exchangeable. the most valuable feature of benusi appara tus is its practicability:  it can be arranged through simple means that are overall available,  the reaction develops in a few seconds, whe reas kowarsky method needs 10 minutes,  the apparatus can be easily and quickly cleaned; the cleaning process of the correspond ing kowarsky apparatus is time-consuming. we think that this apparatus, used for two decades in our hospitals and out-patient settings, has undergone the proof of time, and may substi tute other analogue apparatuses for measuring blood urea nitrogen, based upon the hypobromite methodology. figure 1: dr. luigj benusi during his pioneer work in the state laboratory of tirana, 1945. courtesy of tartari f., albanian society of urology j med ethics hist med 2009, 2:19 flamur tartari, stiliano buzo and gentian vyshka page 4 of 4 (page number not for citation purposes) figure 2: the composition of the apparatus numbers correspond to the above explanation. when the small pipe (no. 7 in the figure 2) is put inside the bottle, the water level must correspond to the beginning of the gradation of the small pipe. j med ethics hist med 2009, 2:19 flamur tartari, stiliano buzo and gentian vyshka page 5 of 4 (page number not for citation purposes) references 1. knopf w. methode zur bestimmung des stickstoffs in ammoniak und harnstoffverbindungen. z anal chem 1870; 9: 225-31. 2. ambard l. lois numériques de la sécretion de l'urée. j physiol pathol gén1910; 12: 209-19. 3. ambard l. rapports entre le taux de l’urée. comptes rendus de la société de biologie, paris 1910; 2: 411-13. 4. ambard l. rapports de la quantité et du taux de l'urée dans l'urine la concentration de l'urée du sang étant constante. comptes rendus de la société de biologie, paris 1910; 2: 506-8. 5. marshall ek, jr. a new method for the determination of urea in blood. j biol chem 1913; 15: 487-94. 6. folin o, denis w. new methods for the determination of total non-protein nitrogen, urea and ammonia in blood. j biol chem 1912; 11: 527-36. 7. steinbrink jr cf, rockaway nj. : us3986834 (1976). 8. anonymous. australian medical association. : mhm03383 (1910). 9. kowarsky a. eine methode zur bestimmung des zuckergehaltes in kleinen blutmengen (fingerblutentnahme). deutsch med wochenschr 1913; 34(39): 1635-36. 10. gradwohl rbh. blood and urine chemistry. st. louis: c.v. mosby co; 1920. journal of medical ethics and history of medicine reform in medical ethics curriculum: a step by step approach based on available resources fariba asghari 1 , azim mirzazadeh 2* , aniseh samadi 3 , aliakbar nejati safa 4 , ali jafarian 5 , ali vasheghani farahani 6 , seyed hasan emami razavi 7 1.assistant professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. 2.assistant professor, imam khomeini hospital complex, tehran university of medical sciences, tehran, iran. 3.researcher, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. 4.associate professor, department of psychiatry, roozbeh psychiatric hospital, tehran university of medical sciences, tehran, iran. 5.associate professor, department of general surgery, imam khomeini hospital complex, school of medicine, tehran, university of medical sciences, tehran, iran. 6.assistant professor, department of cardiology, sina hospital, tehran university of medical sciences, tehran, iran. 7.professor, department of general surgery, imam khomeini hospital complex, school of medicine, tehran university of medical sciences, tehran, iran. *corresponding author: azim mirzazadeh address: department of medicine, imam khomeini hospital complex, tehran university of medical sciences, tehran, iran. postal box: 14185-481 tel: (+98) 21 66 93 99 22 e-mail: mirzazad@tums.ac.ir received: 11 nov 2010 accepted: 07 aug 2011 published: 14 aug 2011 j med ethics hist med. 2011; 4:8. http://journals.tums.ac.ir/abs/19013 © 2011 fariba asghari et al.; licensee tehran univ. med. sci. abstract keywords: curriculum, medical ethics, undergraduate medical education. in this project, we aimed to revise the medical ethics curriculum at the school of medicine, tehran university of medical sciences, in order to promote the level of students’ ethical awareness and enable them to make ethical decisions. ideal and long term educational objectives were set to determine directions for future reforms and to provide a baseline for future evaluation of the project. however, based on limited available recourses, the first stage of the reform was planned and implemented with a 3 years scope. in revising the curriculum, which was done according to the harden's ten questions, we focused on moral attitude and ethical reasoning skill in addition to academic knowledge base by using methods such as case discussions, portfolio, and clinical ethics rounds. the revised curriculum was implemented during the first semester of the 2006-2007 academic year for the first time. the student feedback indicated that the new curriculum was successful in increasing the students’ awareness of ethical issues and enabled them to understand and accept their professional obligations. revising the curriculum and its evaluation should be considered as an ongoing process. the present project was a successful experience that motivated faculty members to pursue the next steps of improving the curriculum on medical ethics and proved to be convincing for the authorities and policy makers to support it. http://journals.tums.ac.ir/abs/19013 http://journals.tums.ac.ir/abs/19013 j med ethics hist med 2011, 4:8 fariba asghari et al. introduction respecting professional obligations and mak ing decisions in accordance to medical ethics are essential skills that must be built in physicians during their training as medical students (1). any attempt aiming at improving medical ethics syllabus can play an important role in fostering those skills. tehran university of medical sciences (tums), being the oldest and the largest medical university in iran, plays a key role in medical education in the islamic republic of iran. the proposal of the revision of medical ethics curricu lum in iran was put forward for the first time during the national strategic ethics program in 2002 (2). to address this issue, medical ethics and history of medicine research center of tums in cooperation with the medical education develop ment office of the tums, school of medicine planed to reform medical ethics education in 2004. this paper is intended to report the process and evaluation of the implementation of this reform. prior to this reform, the department of foren sic medicine was in charge of medical ethics education for medical students at tums. teaching was delivered by the means of formal lectures as a 2-credit course in the fifth year of medical school. except for a list of headings and subheadings for each session, there was no officially endorsed curriculum for this course, and students’ evaluation was solely based on a multiple-choice question examination. a survey was conducted among the final year medical students of the school of medicine of tums to clarify their evaluation of ethics education in terms of its being successful in assisting them to deal with ethically challenging issues in clinical practice (a list of 23 ethical issues), and their opinions of the necessity of a change in the syllabus. the mean score given for the necessity of the course was 8.04 out of 10, while the mean score for the efficacy of the current ethics education in terms of enabling them to make accurate and sound decisions in the ethically difficult situations was 3.76 out of 10 (3). it is noteworthy that even the director of the ethics course believed it necessary to revise the content of the course and its delivery methods. based on this background, a team inclusive of faculty members of different departments of the school of medicine designed and implemented a reform project in 2005 in order to improve the quality of the medical ethics course. description initially, all former medical ethics lecturers and interested faculty members of different departments of the university were invited to participate in an introductory meeting. in this meeting which was held in winter 2005, the goals of revising ethics course and its suggested method ology were explained. fifteen out of the 17 attendees, who will hereafter be referred to as the members of the planning committee, declared their support and expressed their interest in participating in the project. all members of the planning committee were invited to a training workshop (held in spring 2006) in which the proposed approach to revise the course based on harden’s 10 questions was clearly explained. the domains that were expected to be covered in the new ethics course were discussed and a general agreement was reached. it was decided that the curriculum should include medical ethics, medical law, and professionalism. also, the vision was discussed during the workshop, and although it was decided to set ultimate goals, the curriculum was initially developed with a 3-years scope based on the facilities that the university may offer for the implementation of the program. meanwhile, minor revisions were decided to be made at the end of each semester, and major revisions at the end of each period of 3 academic years, so that the ultimate goals could be achieved. the 10 harden's questions method was used to revise the medical ethics curriculum (4). to prepare a draft of the new curriculum, the 6 member committee, referred to as the central committee was formed in may 2006. the central committee prepared the draft of the course curriculum stage by stage during their regular weekly meetings and presented it to the planning committee for evaluation, potential modifications, and approval. this phase of the project took about four months. curriculum elements needs assessment in this step, a review of literature on iranian’s satisfaction of health care delivery related services (5-9), physicians’ professional challenges in iran (10), prevalence of ethical conflicts (11), medical ethics curricula of medical schools in iran and other countries (12-15), and the evaluation of ethics education (16-18) was organized and carried out. moreover, 5 professors of medicine with a great reputation in following the principles of medical ethics in their clinical practice were interviewed. based on this needs assessment, it was concluded that it was of paramount importance to improve moral attitude, sensitize students to medical ethics issues, and develop ethical reasoning skills. page 2 of 10 (page number not for citation purposes) j med ethics hist med 2011, 4:8 fariba asghari et al. page 3 of 10 (page number not for citation purposes) objectives based on the results of needs assessment studies, the goals and objectives of the course were identified as summarized in table 1. these goals were set to provide the vision of the course, and no limit was considered for them during the first stage of the reform (the reform was planned within a 3-years scope). they were intended to serve as a baseline to evaluate the efficiency of the course and lead the future reforms. content and its organizational framework based on the needs assessment findings, 23 topics were proposed and discussed. these topics were then evaluated and scored by the central committee, and, 15 topics with highest scores were selected as the content of the medical ethics curriculum. a number of subtopics were assigned to each topic (table 2) so that to better represent the course contents. each topic was assigned to one of the mem bers of the planning committee to determine session contents and specific objectives. the members made suggestions based on literature review, general and intermediate objectives, and the available resources in the first step of the reform. the objectives of each session were reviewed by 2 peers. educational strategies considering the available resources, it was decided that medical ethics course should be directed towards a problem-based and student 1 during the clinical rotations and discuss them from an ethical point of view.  ethics rounds: on the last session of the course, students were divided into small groups based on the cases they had recorded in their portfolios. these cases were then presented and ethically analyzed in the presence of a tutor who then provided her/him feedback on the presented cases and discussed them with other students. assessment of the students this was performed through formative and summative approaches. in formative assessment, students were evaluated based on one of the cases they presented in ethics round session. in summa tive assessment, grading was based on the attend ance and active participation in group discussions (30% of the total grade), correct completion of their portfolio (20%), and their grade on the final written exam including case analyses and short answer questions (50%). educator evaluation this was done formatively using the follow ing methods: 1. evaluation forms which were filled out by students at every session and were returned to the educator. 2. observation of each session by a peer who was supposed to report to the faculty members through the course director. course evaluation this was done every semester through the fol lowing two methods: 1. course evaluation forms which were filled out centered strategy from spices 0f strategies. the by the students. following teaching methods were used for design ing and implementing these strategies:  case discussion in small groups: our medical curriculum is a traditional one based on universi ty lectures. teaching through discussion in small groups of students in an organized manner was introduced in our curriculum for the first time and was considered a new experience for the school. naturally, this raised concerns about the feasibil ity of the method and students’ attitudes toward it. students were divided into small groups and required to discuss educational cases in the presence of a tutor, report the group activity in class, and then the professor summarized the discussions and presented the session material.  educational portfolio: each student was required to record three cases she/he has encountered 1 s student-centred rather than teacher-centred p problem-based rather than information-gathering i integrated rather than discipline-based c community-based rather than hospital-based e electives rather than standard programme s systematic rather than apprenticeship-based 2. focus group discussions which required students to discuss the strengths and weakness es of the course. results of the evaluation were presented to the planning committee and used in the amend ments of future courses. communication of the new curriculum the study guide, containing information about goals and objectives of each session, teaching-learning and evaluation methods, and course regulations (developed in september 2006) was distributed among students. these documents were revised every semester. the course time table was available on the website along with all sessions’ presentation slides, required readings for each session, and the news. program management the members of the ethics course planning committee set up a virtual department consisting of the chair of department, a course director in charge of conducting and evaluating the course, and its j med ethics hist med 2011, 4:8 fariba asghari et al. page 4 of 10 (page number not for citation purposes) educators. these members hold regular monthly meetings and discussed and analyzed problems as well as potential changes in the course program in future. evaluation the revised curriculum was first implemented in the first semester of the 2006-2007 academic years. in order to evaluate the quality of the first run of the new curriculum, a study was carried out to assess the students’ abilities in terms of ethical reasoning and their knowledge and skills in ethical analysis at the beginning and the end of the course; and, it also compared students’ abilities who were trained in the new and the old curriculum, the results is published separately (19). here the result of students' survey of the curriculum success is presented. method and material the new curriculum was evaluated using a questionnaire by the means of which students’ opinions were asked regarding the new program, the educational methods, and its success in achieving its goals. in this questionnaire, some open-ended questions were used to encourage students to express their opinion of the strengths and weaknesses of the program and to offer their suggestions for its improvement. the question naires were distributed during ethics rounds (the final session of the course) and completed forms were collected on the same session. results a total of 113 completed questionnaires were returned (response rate = 82.5%). the students' views are summarized in table 3. in evaluating the process of the course, 74.0%, 74.3%, and 78.5% of students agreed or strongly agreed that the program had practical contents, the amount of information was enough and the program was well introduced at the beginning of the semester, respectively. according to students’ opinions, the program was mostly successful in terms of sensitizing them to ethical issues (more than 87.6% agreed), followed by giving them a better understanding and acceptance of their professional obligations, and humane and moral aspects of medical ethics (71.7%). however, it was mentioned that it fell short of significantly improving their ability to analyze medical ethical issues (51.3%). as regards evaluating the educational meth ods, 80.8% and 78.8% of students believed that small group discussions and ethics rounds were good or excellent in terms of quality, the amount of transferred information, and its role in motivating them. although our students had never experienced training in small groups, they not only accepted it quite well, but also rated it as a very advantageous method. among the 40 written comments about the strengths, the most commonly mentioned ones were small group discussions followed by using interactive methods and being applicable to a clinical setting. one student stated “this course increases students’ senses of ethical judgment and reasoning, and broadens their horizon”. another student expressed that "the strength of the course was the faculty members who were committed to medical ethics themselves, and no one recalled seeing any unethical behavior by them; this would make the material more acceptable.". in response to weaknesses, 43 comments were made, amongst which, the most important one was lack of an integrated reference for the course. another student mentioned not using a roll call, and reported that some students were against the negative effect of absenteeism in group work on their final grade. among the suggestions, one said “ethics ed ucation should be integrated into the whole medical education period, if possible”. another student suggested that feedbacks should be provided on all cases recorded in students’ portfo lios. it was also suggested that a great emphasis should be put on ethics education in clinical wards as part of clinical rounds. another method used for evaluating the pro gram was holding a focus group discussion with 9 students, 2 weeks after announcing the final exam results. students were selected from both genders based on their grades on final exam, their interest in ethics course, and different entry years. since the course evaluation questionnaire had been collected before the final exam and contained no items about the methods of assessment, a considerable propor tion of the focus group discussion was spent on evaluating the students' assessment methods. the unanimous findings of the meeting indicated that there was insufficient time to complete the exami nation. students demanded to receive feedbacks on what they had written on their final exam, or at least be given the correct answers after the exam. the students believed that discussions in group works were very helpful, and they suggested that tutors should have a better command of the subject so that they can lead the discussions more effec tively. discussion since a significant part of the course objec tives were attitudinal, it was very difficult to convey them and there was no tool to accurately assess the achievements. the results of course evaluation however, indicated a significant improvement in the quality of the teaching meth ods. in fact, the program proved to be attractive to the students and successful in raising their aware j med ethics hist med 2011, 4:8 fariba asghari et al. page 5 of 10 (page number not for citation purposes) ness of ethical issues in their daily practice. however, we failed to fully achieve some of the course objectives. since the assessment of achiev ing the objective of adhering to professional obligation was only based on students’ answers, we could not envisage how well they would really practice it in future. in order to translate ethical sensitization into the ability of ethical reasoning and practice based on professional commitments, it seems imperative to review and amend the curriculum repeatedly. the present program was planned with a 3-year scope. evidently, the present course as a 2-credit block one can fail to effectively provide students with a solid base for their considering principles of medical ethics in clinical practice. it is often argued that the current clinical edu cational environment in iran is incapable of promoting medical professionalism and moral values in students. it is argued that there exist several impediments in various clinical educational environments that make it inadequate for develop ing moral values and this in turn may even cause erosion and desensitization (18, 20). sophistication of medical decisions, heavy workload, difficult lessons, lack of time for relaxation and meditation, witnessing unethical behavior done by their superiors, insufficient support to confront stress, inability to discuss particular situations (e.g. when they had a dilemma, or unintentionally had to do something against their professional obligations) with others, seeing patients as mere educational subjects rather than a human individual who should be respected, and also scolding patients as a way to vent workplace frustrations are all examples of those deficiencies. obviously, we cannot expect a short course with a few credit points and limited time (over approximately 34 hours) on medical ethics to entail the desired attitude and the ability of ethical reasoning in medical students (21). indeed, a supportive system committed to the promotion of appropriate professional behavior in all settings of the university and learning atmosphere is the key factor to facilitate and strengthen this culture (22, 23). one of the most effective reforms suggested is the longitudinal integration of medical ethics and professionalism education in all phases of under graduate medical education (16). students' expo sure to ethical aspects of clinical care during ward rounds, role models in clinical settings and their reflection on ethical dilemmas in such environ ments seems to be of much more importance in comparison with attending large group lectures during a semester (22, 24). in other words, holding clinical ethics rounds at different wards appear to be more effective in making students’ learning more discernible and practical (22), and in helping them to maintain their ethical sensitivity in all difficult clinical circumstances (21). however, achieving this goal requires certain preparations, and this major reform seems currently elusive at our universities. in this study a number of different challeng es were confronted with, and a variety of obstacles emerged. one of the most important challenges was shortage of full time faculty members who wish to commit themselves exclusively to teaching medical ethics and improving the course teaching methods. all faculty members and project manag ers involved in this project, had simultaneously several different responsibilities, they participated in teaching medical ethics as a secondary responsi bility. this can jeopardize the consistency of the reform and hinder future improvement of the quality of this course. another issue which should be considered as challenge is the lack of motivation among members of the faculty to get involved in the ethical aspects of medicine. we cannot expect the faculty mem bers to pay attention to ethical issues in clinical practice and teach them to their students when their respect for these matters is not monitored and has no effect in their promotion. one of the limitations of this project was the lack of trained tutors to facilitate and lead discus sions and debates in the small groups. considering the successful results of group work in motivating students, to achieve a better outcome through this course, it seems quite necessary to train such tutors adequately so that they can better contribute to the overall improvement of the knowledge and skills of the students. our experience showed that revising the course of medical ethics, even with limited resources, can result in significant improvements in the quality of the program. however, reforming the program should be an ongoing process and the curriculum should be continually reviewed, revised, and adjusted to better achieve the course educational goals & objectives. to guarantee the success, the directors of medical schools should support the reform activities to motivate the faculty members and set proper conditions for the process. the favorable results of the presented project proved to be promising for designing and imple menting further steps of reform and convincing the directors of medical school of the need for their more supportive role. acknowledgements this study was conducted according to the project agreement number 132/3718 dated july 9, 2006, and financially supported by tehran univer sity of medical sciences. the authors wish to thank drs mahbubeh haj abdolbaqi, farhad shahi, hamid emadi, ali kazemian, fakhroddin taqadosinejad, alireza parsapour, kiarash aramesh, ali kazemi saeed, ahmad kaviani, and j med ethics hist med 2011, 4:8 fariba asghari et al. page 6 of 10 (page number not for citation purposes) seyed morteza karimian who assisted us in the design and implementation of the new ethics course as the members of the planning committee. also, we would like to thank drs nazila nikravan, maryam jessri, fatemeh shidfar, samaneh ansari, saeedeh sadeqi, and somayeh mahroozadeh who helped us in holding small group discussions as tutors. none of the authors had any conflict of interest. j med ethics hist med 2011, 4:8 fariba asghari et al. page 7 of 10 (page number not for citation purposes) table 1. the goals & objectives of tums ethics curriculum goals: students should be able to identify common ethical issues when providing health care, and make appropriate decisions. for this purpose, ethics education should: 1. enable students to understand and accept their professional obligations. 2. enable students to understand the humane and ethical aspects of the medical profession. 3. increase students’ awareness of ethical issues around them. 4. provide the required knowledge and skills background in students for ethical reasoning while considering legal issues. 5. enable students to make use of this knowledge and skills in ethical decision making. intermediate objectives: cognitive objectives. concern the transfer of knowledge in the following fields:  the principles of medical ethics and ethical theories  professional obligations  medical ethics issues (autonomy and informed consent, capacity and surrogate decision making, physician patient relationship, confidentiality and truth telling, research ethics, end of life, resource allocation, medical errors, ethics in medical education, maternal-fetal conflict, conflict of interest, and professional relation with members of the health care team) skill-wise objectives. concern ethical practice and the ability to make ethical decisions, which should include the following: 1. communicating with patients, their family members and other members of the medical com munity concerning medical ethics issues. 2. encouraging patients and their family members to participate in medical decision making and effective interaction concerning medical ethics issues. 3. self evaluation and increased observation of professional obligations. 4. presenting and accepting constructive criticism. 5. required skills to fulfill professional obligations and ethical decisions despite limitations at workplaces attitudinal objectives include the following: 1. ethical awareness in medical practice 2. respect, compassion, honesty, trustworthiness, and being responsive to patients’ and communi ty’s needs where patients’ interests come first. 3. being responsible and accountable before the patients, society, law, and the medical profession, and commitment to excellency. 4. commitment to justice and fairness in providing services. 5. respecting the role of the other members of the health care team. 6. respecting patients as human beings, and respecting differences in culture, religion, age, gender, and patients’ disabilities. 7. open to criticism, and self evaluation. 8. commitment to the health of one’s self and the other members of the medical community. page 8 of 10 (page number not for citation purposes) j med ethics hist med 2011, 4:8 fariba asghari et al. table 2. tums medical ethics syllabus professionalism  concept of profession and professionalism  medical oats  altruism  responsibility  duty  integrity & honesty  excellence  challenges to professionalism ethical theories  meta ethics  ethical theories:  deontology  utilitarianism theories  virtue ethics  islamic philosophy of ethics  jurisprudence and medicine principles of medical ethics and ethical tools  autonomy  beneficence  nonmaleficence  justice  approach to ethical issues  matrices in ethical decision making  physician–patient relationship  the importance of a proper ethical and clinical relationship with the patient  respect for patient beliefs, religion, and gender  financial doctor-patient relationship  compassion  respect for patient’s privacy autonomy and informed consent  the right to autonomy and its importance (including the right to refuse medical treat ment)  criteria for valid informed consent  amount and components of giving infor mation  participation in decision making  exceptions for informed consent  criticism on informed consent determining capacity and substitutes for decision making  definition of decision making capacity physician relation with members of the health care team  principles of professional relationship with peers (doctors and other members of the health care team)  approach to breach of professional behavior by peers  approach to peer error  consultation and its role in decision making medical liability and medical error  definition of medical error  necessity of disclosing medical error to patient  how to disclose errors  medical liability  medical negligence  how to deal with medical negligence ethics in medical education  patient consent  practicing on comatose and newly dead patients  maintaining quality services to patients while training students  the role of students in confronting errors by the medical community conflict of interest  definition of conflict of interest  self-referral  vendor relationships  conflict of interest in research  conflict of interest in educational centers  management of conflict of interest resource allocation  medical resources  concept of justice  levels of resource allocation  avoiding discrimination in giving services  approach to requests of inappropriate treatment  distribution of resources in disasters and war ethics in research  informed consent page 9 of 10 (page number not for citation purposes) j med ethics hist med 2011, 4:8 fariba asghari et al. table 2. tums medical ethics syllabus  methods of determining capacity  selecting a substitute  informed consent in cases of unstable capacity  principles of decision making on the behalf of incompetent people confidentiality and truth telling  necessity of confidentiality  terms for breaching confidentiality  necessity of truthfulness  breaking bad news  responsibility of telling the truth in the medical team  ethical issues in treating with placebo  confidentiality  risk / benefit evaluation  justice  research in vulnerable groups maternal-fetal conflict  different approaches to fetal right to life  conflict of maternal independence with fetal life or wellbeing  conflict of maternal health with fetal heath  rule and regulations on abortion in the islamic republic of iran ethical issues in end of life  decision making for terminal ill patient  ethical aspect of a non-resuscitation order  euthanasia  indications of withdrawing life support  brain death page 10 of 10 (page number not for citation purposes) j med ethics hist med 2011, 4:8 fariba asghari et al. table 3. students’ evaluation (%) after the first run of the revised curriculum process strongly agree agree neutral disagree strongly disagree the course introduction gave students was informative 21.4 57.1 14.3 6.3 0.9 sufficient information was transferred to the students. 15.0 59.3 18.6 6.2 0.9 course contents were practical for interns 23.1 50.9 13.9 11.1 0.9 interactive educational methods were used appropriately 15.2 48.2 18.8 17.0 0 course contents were scheduled appropriately 14.3 44.6 18.8 21.4 0.9 students evaluation methods were acceptable 6.7 30.5 43.8 15.2 3.8 management performance in terms of access to resources and information was acceptable 8.9 36.6 33.9 18.8 1.8 amount and contents of assignments were appropriate 18.6 50.4 18.6 10.6 1.8 j med ethics hist med 2011, 4:8 fariba asghari et al. page 10 of 10 (page number not for citation purposes) table 3. students’ evaluation (%) after the first run of the revised curriculum outcome strongly agree agree neutral disagree strongly disagree the course enabled students to realize and accept their professional obligations 12.4 59.3 15.0 13.3 0 the course enabled students to understand the human and moral aspects of their profession 11.5 54.9 20.4 12.4 0.9 the course increased students attention to ethical issues around them 34.5 53.1 9.7 2.7 0 the course provided adequate primary skills and knowledge for appropriate ethical decision making while considering legal matters 8.8 46.0 26.5 16.8 1.8 the course enabled students to use the acquired knowledge and skills in ethical decision making 7.1 44.2 27.4 16.8 4.4 teaching methods strongl y agree agree neutral disagree strongly disagree small discussion groups 30.3 50.5 14.7 2.8 1.8 lectures 6.4 40.4 42.2 9.2 1.8 case presentation on final ethics rounds 31.7 47.1 17.3 3.8 0 use of interactive methods 22.9 45.0 24.8 6.4 0.9 portfolio 12.1 39.3 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tabinda hasan department of anatomy, faculty of medicine, jazan university, saudi arabia. *corresponding author: tabinda hasan address: department of anatomy, faculty of medicine, jazan university, saudi arabia. e-mail: drtabindahasan@gmail.com received: 23 nov 2010 accepted: 14 mar 2011 published: 06 apr 2011 j med ethics hist med. 2011; 4:4. © 2011 tabinda hasan; licensee tehran univ. med. sci. abstract keywords: cadaver, dissection, education, ethics. introduction ever since the advent of medicine, life sciences have been running parallel to therapeutic sciences in forming the concepts of human life and the treatment of diseases which threaten it. the basic requisites for understanding man's diseases come only after understanding man's body. since times immemorial, the cadaver has been the fundamental and oldest source for providing gross morphologic details of human anatomy to medical learners. what is dissection? dissection (also called anatomization) is usually the process of disassembling and observing the human body to determine its internal structure and as an aid to discern the functions and relation ships of its components. dissection is often performed as a part of determining a cause of death in autopsy and is an intrinsic part of forensic medicine. discussion the issue of human dissection; an everlasting moral debate: the dissection of humans has always been an object of controversy among the stake holders of the religious and civilized society (1). there are many who consider dissection to be the ultimate insult to the dead and the most extreme breech of privacy of a person. some philosophers label dissection as a "blasphemous" violation of humani ty itself and the "last act of torment" ever possible. still, cadaver dissection has continued in the medical curriculum because of the obvious benefits of delivering first hand, unabridged and original morphological information of the human body .the diverging schools of thought have not deterred the practical and clinically oriented medical / surgical institutions in continuing their cadaver oriented studies. dissection is being jeopardized in the modern medical education. it has unrelentingly faced the lashes of time and has been the scapegoat for numerous convenient curricula reforms and subjective biases. the cadaver is unparallel in establishing core knowledge among the medical community and it needs to be appreciated in a new light in the "cyber anatomy" realm of today. this article elucidates the medical and ethical validity of continuing human body dissection in medicine which outweighs all the prejudices associated with it. j med ethics hist med 2011, 4:4 tabinda hasan page 2 of 4 (page number not for citation purposes) history of dissection in the past, anatomization of the body of con victed persons was sometimes ordered as part of the punishment. the bodies were taken to the local slaughterhouse, dismembered and their remains were denied a burial as a symbol of insult. the earliest science oriented systematic hu man dissections were carried out by the greeks in the early part of the third century bc. in the 13 th century christian europe, dissection and autopsy of humans was regularly carried out with reasonable socio-cultural and religious acceptance. throughout history, the dissection of human cadavers for medical education has experienced various cycles of legalization and proscription in different countries. but no universal prohibition of dissection or autopsy was exercised during the middle ages. then in modern history, many scandals clouded the dissection labs. the ways to obtain a body from "front doors" were full of legal hurdles and prompting many institutions to consort to unethical means, because the only bodies legally available were those of executed criminals which were scant to meet the rising educational demands. in the 19 th century there were increased incidents of grave robberies in the united states. the most notorious incident occurred in 1788 in new york, where a doctor waved to a child with the hand the mother's corpse that had been robbed of its grave (1). in response to this event, a law was passed in new york in 1789 that prohibited the robbing of tombs .then there was the william burke and william hare scandal of 1829 who were found guilty of killing the guests at their boarding house and selling their bodies for dissection. burke was hung, dissected, and exhibited as an apt punishment for his deeds (2). these incidents led to formulation of new laws that legalized dissection of all un claimed or voluntarily donated bodies. the present situation unfortunately, the current laws dealing with commercialization of human bodies are not immune to loopholes, tedious procedures and stringent biases. this has stimulated unethical practices for obtaining cadavers on one hand and the "studentcadaver ratio" being put in serious jeopardy on the other hand in the modern acade mia. the barriers to continuing human dissection are not only socio-religious. there are logistic and organizational barriers also; including the time constraints of modern medical curricula, lack of dissection trained personnel, scarcity of sufficient dead bodies available for dissection, student overloads, costly maintenance of dissection labs, health risks of prolonged formalin exposure and dead body contact; along with the ethical issues of human body exploitation as well. the introduction of computers as an alterna tive teaching tool has brought some relief to the stifled, overburdened education system of the 21 st century medicine. the computers have emerged as "quick relief" potions in the times of cumbersome, didactic, superfluous gross anatomy. unlike a cadaver, they are free from formalin smell, risk of dead body related infections and don’t require the specialized training of dissection. computers are time and cost friendly, aesthetical and easily manipulated, to obtain diverse view points. they provide colorful reversible and repeatable digital information and hense; they have procured many patrons in the medical education community (3). presently, the medical education community has polarized into two belief systems; the ‘pro dissection traditionalists’ who consider dissection as an integral part of anatomy education and the ‘anti-dissection modernists’ who regard dissection as obsolete and dispensable (4). the deeper issue that needs to be considered the enormous advances of computer based learning cannot be undermined. however, despite all their technology, the computers can never simulate the "real" in terms of establishing struc tural concepts (5). they cannot achieve the variations, pathology and biodynamics of man's body, and, with all their advancements, will still remain an artificial synthetic medium. hence, they can not instill core anatomy knowledge among the" upcoming health personnel" in much the same way as a cadaver can. the student who is deprived of cadaver based learning will only see the appearance or location of a body structure but he /she will never be able to feel the texture, friability, tough ness or elasticity of that structure. such learning will be superficial, protocol oriented learning and hence, can not be regarded as a deep approach to learning (4). the replacement of active dissection time by digital labs might produce a generation of confused, ill informed physicians and surgeons who have been spoon-fed on "intangible, abridged concepts" and who are unfamiliar with the com plete reality of human body and life. this gamble on technology may be too risky in terms of patient's safety and well being which will lie solely in the hands of these future caretakers of health. hence, the modern technological amenities should be reassessed in terms of their "functional, cognitive utility" rather than their "convenience". the cadaver has survived the most important test of pedagogical fitness"the test of times". dissection is unparallel as an educational tool for instilling gross anatomy concepts. there are long term cognitive benefits to the students of an active learning process involved in cutting through j med ethics hist med 2011, 4:4 tabinda hasan page 3 of 4 (page number not for citation purposes) various layers to expose morphologic details in a step wise manner. it provides an ideal training ground for future biomedical applications, clinical endeavors and invasive procedures .the psycho visual-tactile multi-sensory stimuli that are part of a dissection ritual leave an indelible mark on the minds of learners and aids recall (4). this hypothe sis has been statistically proved by improved exam scores of cadaver dissection groups as compared to intervention groups using other learning alterna tives (5). the computers provide intricate multidimen sional spatial configurations while the cadavers instill psychomotor dexterity, lexical enhancement and bioethical values. they reflect two different approaches to learning and combined; they can work wonders in the medical system (5, 6) and produce doctors who can work more effectively towards an ideal fulfillment of the hippocrates oath. human dissection: an ethical perspective the right to a decent burial is the most basic right of any human being. the cadaver remains deprived of this right for the benefit of our medical students and future care takers of health. a cadaver helps to preserve life science even in death .this is a symbol of generosity at its zenith and it deserves our extreme gratitude and reverence. the immense courage needed to give away the body of a loved one for dissection must be acknowledged and respected by all. even though withholding the cremation of the dead is viewed by many moral skeptics as inhu man, unsocial and against religion; and there are complex ethico-legal issues of autonomy as well; still we must remember that beneath this violation of normal human rituals, underlies a much deeper benefit to humanity. the intimate study of the dead is the only way to effectively train our future physicians and surgeons in the intricacies of human body. the bioethical values and reflective learning stimulated by the study of the dead help medical students to deal with issues concerning life, death and dying at a relatively early stage in their medical career which will ultimately train them towards being better doctors. dissection enhances communica tion, team work, leadership, experiential learning and group dynamics. most importantly, it enables the student to confidently face the picture of death that is so important in treating life. this experience cannot come through any other source of simula tion and there is no short cut way around it. cadaver dissection imparts to the medical learner that much needed strength of character that he/she will need during future clinical or hospital emer gency settings. a student trained on the cadaver will not become baffled or nervous at the sight of impending death or life threatening trauma and this perseverance and steadfastness will determine and define his /her role as a doctor and health care giver in future. along a wider picture, the thorough knowledge of the human body gained through dissection will prevent accidental damages to the related structures during invasive and non invasive procedures and impart better clinical skills to medical personnel. the recent obsessive interest of general public with the anatomic details of human body is evident by the huge popularity of anatomy art shows and body exhibitions in the so called "body worlds"(7). but the very concept of such obscene displays is questionable. such displays are only there for the sole purpose of callously attracting money by making a bawdy exhibit of the privacy of another human being like us. they lack the noble intention of imparting any medical knowledge to the future caretakers of health (very unlike dissections). such shows are an insult to the dead. they don’t lie in the same league as cadaver dissections where the first lesson learnt by medical undergraduates is that of reverence to the human body which is their temple of learning and applicable knowledge. conclusion when we deal with the dead, the margin be tween ethical and unethical is hair lined and fragile. it is very important to define the boundary between meaningful, judicious use, commercial exploitation and ravenous abuse. the purpose should be noble and ethically justified if we are to use; as a mere tool; another person who once had a full life legend behind him. our motives should be clear, produc tive and humane if we are to deal with cadavers. the pivotal role of the cadaver in the assimi lation of core biomedical knowledge among medical learners cannot be disregarded and hence, it must remain a central tool in medical education. the barriers to dissection are mainly logistic and psychological; an issue that can be solved through proper strategic organizational planning and an improved access to scientifically oriented informa tion in order to rule out emotional biases. also, the current cadaver crisis faced by many medical institutions can be resolved through increased awareness and proactive community involvement. cadaver donation, if done in an ethically, morally and legally justified manner, can help to preserve our cadaver heritage as the essence of medical anatomy studies and clinical therapeu tics. it will reinstate the fast declining "cadaver student ratio" which is paramount in the making of future doctors and surgeons. page 4 of 4 (page number not for citation purposes) j med ethics hist med 2011, 4:4 tabinda hasan references 1. hildebrandt s. capital punishment and anatomy: history and ethics of an ongoing association. clin anat 2008; 21(1): 5-14. 2. tward ad, patterson ha. msjama. from grave robbing to gifting: cadaver supply in the united states. jama 2002; 287: 1183. 3. marker dr, bansal ak, juluru k, magid d. developing a radiology-based teaching approach for gross anatomy in the digital era. acad radiol 2010;17(8): 1057-65. 4. granger na. dissection laboratory is vital to medical gross anatomy education. anat rec b new anat 2004; 281: 6–8. 5. biasutto sn, caussa li, criado del rio le. teaching anatomy: cadavers vs. computers? ann anat 2006; 188: 187-90. 6. rizzolo lj, rando wc, o'brien mk, haims ah, abrahams jj, stewart wb. design, implementation, and evaluation of an innovative anatomy course. anat sci educ 2010; 3(3): 109-20. 7. jones dg. speaking for the dead: cadavers in biology and medicine. ashgate; 2000. ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ 1 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e © 2019 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. commentary volume 12 number 13 october 2019 application of narrative in medical ethics *corresponding author saeideh daryazadeh department of medical education, medical education development research center (edc), isfahan university of medical sciences, hezar jarib st., isfahan, iran. postal code: 73461-81746 tel: (+98) 31 36 68 87 89 email: daryazadehs@gmail.com received: 14 july 2019 accepted: 12 oct 2019 published: 21 oct 2019 citation to this article: daryazadeh s. application of narrative in medical ethics. j med ethics hist med. 2019; 12: 13. saeideh daryazadeh ph.d. candidate of medical education, department of medical education, medical education development research center (edc), isfahan university of medical sciences, isfahan, iran. introduction the narrative approach in medicine the use of narratives as narrative discourse is a tool used to express the experiences of individuals (1). in medical sciences, the use of the narrative approach has been emphasized by rita charon (2). researchers who have used a narrative approach in medical education claim that practicing narrative writing can improve health care provision (3 6). in the health care system, narration is the usage of literature on patients' stories to facilitate clinical decision-making for physicians. lately, the narrative has applied a healing potential as “narrative care”, a method that uses story to improve health care. this approach focuses on patients' stories (7). the narrative plays a very effective role in making difficult ethical decisions, and therefore it is important to keep considerations and consequences in mind (8). with the growing use of narratives in medicine, its application as an educational tool in ethics has also increased (9). narrative analysis is a way of examining ethical problems and the use of a narrative approach to ethical issues and values prevents ethical challenges (2). fictional and factual narratives can be a prominent help to comprehension in medical ethics. literary criticism can be used to analyze ethical texts, and this process enhances our understanding of different perspectives on ethical challenges (2). the issues of rights, errors, emotions, beliefs, and behaviors are related to ethical narratives (1). application of narrative in medical ethics 2 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 13 october 2019 narrative ethics narrative ethics represents the postmodern critique of reason and emphasizes personal affective and creative interpretation. it originated in the domains of philosophy and theology. narrative ethics is a component of effective ethics and deals with particular circumstances, supplying extreme consideration to the background that highlights the outcomes and concerns stated by a dilemma. discursive representation is a narrative centering on a circumstance, and one that needs to be comprehended in a multidisciplinary way. these representations are stated in the form of narration, which offers an ethical approach (8). narrative ethics is a term that contains a wide range of concepts presented as approaches; thus, narration can be a source of ethical theories or a method for studying ethics and can be a replacement for traditional methods. hence, it is necessary to pay attention to the principles of narrative ethics. firstly, ethical situations are unique and cannot be generalized to other issues, like rules. secondly, narrative situations are decided based on the patient's status and his illness story (9). usually, caregivers and doctors publish a case report. in reporting a patient's case, compliance with standards and principles is normally done, but the expression of the patient’s psychological features is neglected. while the narrative in the patient's file may seem to provide irrelevant information, it can also describe the patient's status to others. therefore, the narrator presumes that in this way the ethical points will be better known (8). narrative ethics is a current ethical view that has emerged lately and fosters effective interaction between patients and physicians; however, attention should be given to its application in the physician-patient communication (8). narrative as a teaching method a review of several studies shows that medical students learn the most from clinical-role models, and the role of a clinical teacher as a model in the training of professional ethics is rather prominent (10, 11). however, there is a challenge that makes this impact undesirable. since students are exposed to both favorable and unfavorable role model behaviors, they may be affected adversely under the circumstances. also, the use of reflection and integration of humanities in medicine are other ways of teaching ethics to medical students (10, 12 14). conducting discussions in small groups and role-playing or interacting with a patient as a teacher also plays an effective role in teaching medical ethics (10, 15). the above-mentioned methods, some of which are still not widely used, can be effective in medical education, but it is necessary to pay attention to cultural issues as an important point in education. hence there is a need for a medical education system based on humanities (10, 16, 17). over the past few decades, narratives have been used as a method for teaching medical professional ethics. they provide ethical guidance through case examples, and as narratives of witness, address the review of daryazadeh s. 3 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 13 october 2019 professional ethical principles in medical practice (2, 18). in medical ethics, narratives are used in the following three forms: 1. examples of cases that have broad application in western medical ethics: since the advent of humanities in medicine in the 1970s, a link was formed between literature and medicine, and literature was employed to teach medical ethics. literary narratives were used to analyze the ethical challenges in short stories in a designated framework. hence, "stories as cases" are the principal method for teaching the principles of medical ethics (2). 2. moral guidance in all aspects of the lives of individuals: from the perspective of coles, complex literary texts such as novels are moral guides to making life better. stories are not only used to solve moral challenges, but also to provide moral reflection on all of life's affairs, and as such, they are effective in medical ethics (2, 19). 3. the “witness narratives” that are used to examine medical and ethical performance: analyses of ethical issues concerning patients or their relatives are important in terms of medical ethics. “witness narratives” are related to issues such as independence, respect for patients’ rights, informed consent, and medical errors. physicians and health care professionals share their experiences of such ethical issues and discuss the challenges. therefore, the interpretation of "witness narratives" plays an important role in solving ethical problems (2, 20). in summary, narratives can present ethical lessons, or create awareness and empathy through the expression of ethical issues and experiences. also, narratives can help us by providing relevant information on "ethical decision-making". on the other hand, narratives can be a way of understanding the moral reasoning that is created through contemplation and exploration of individuals’ narratives (7). acknowledgements none. conflict of interests the author declares no conflict of interests. application of narrative in medical ethics 4 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 13 october 2019 references 1. hurwitz b. the narrative turns in medical ethics. the lancet. 2003; 361: 1309. 2. jones ah. narrative in medical ethics. bmj. 1999; 318(7178): 253-6. 3. appelbaum kl. commentary: the art of forensic report writing. j am acad psychiatry law. 2010; 38(1): 43-5. 4. charon r. narrative medicine: honoring the stories of illness. uk: oxford university press; 2008. 5. pennebaker jw. telling stories: the health benefits of narrative. lit med. 2000;19(1): 318. 6. rees g. mortal exposure: on the goodness of writing medical ethics. perspect biol med. 2008; 51(2):163-75. 7. baldwin c. narrative ethics for narrative care. j aging stud. 2015; 34: 183-9. 8. lossignol d. narrative ethics in the field of oncology. curr opin oncol. 2014; 26(4):385-8. 9. mccarthy j. principlism or narrative ethics: must we choose between them? med humanit. 2003; 29(2): 65-71. 10. shapiro j. walking a mile in their patients' shoes: empathy and othering in medical students' education. philos ethics humanit med. 2008; 3: 10. 11. kenny np, mann kv, macleod h. role modeling in physicians' professional formation: reconsidering an essential but untapped educational strategy. acad med. 2003; 78(12): 1203-10. 12. levine rb, kern de, wright sm. the impact of prompted narrative writing during internship on reflective practice: a qualitative study. adv health sci educ theory pract. 2008;13(5): 723-33. 13. branch wt. use of critical incident reports in medical education. j gen intern med. 2005; 20(11): 1063-7. 14. macnaughton j. the humanities in medical education: context, outcomes and structures. med humanit. 2000; 26(1): 23-30. 15. kwilosz dm. patient as teacher. death studies. 2005; 29(8): 737-44. 16. christianson ce, mcbride rb, vari rc, olson l, wilson hd. from traditional to patientcentered learning: curriculum change as an intervention for changing institutional culture and promoting professionalism in undergraduate medical education. acad med. 2007; 82(11): 1079-88. 17. smith kl, saavedra r, raeke jl, o’donell aa. the journey to creating a campus-wide culture of professionalism. acad med. 2007; 82(11): 1015-21. 18. kelly am, mullan pb. teaching and assessing professionalism in radiology: resources and scholarly opportunities to contribute to required expectations. acad radiol. 2018; 25(5): 599-609. 19. coles r. medical ethics and living a life. n engl j med. 1979; 301: 444-6. 20. tovey p. narrative and knowledge development in medical ethics. j med ethics. 1998; 24(3): 176-81. ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ 1 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e letter to editor volume 13 number 7 august 2020 copyright © 2020 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. a brief historical overview of the anatomy of fascia in medieval persian medicine *corresponding author majid dadmehr no. 847, behesht st. vahdat islami st. faculty of persian medicine, tehran, iran. postal code : 1114733311 tel : (+98) 21 55 63 96 67 email : dadmehr.m@iums.ac.ir received: 1 sep 2019 accepted: 2 aug 2020 published: 25 aug 2020 citation to this article: bahrami m, shokri s, mastery farahani r, dadmehr m. a brief historical overview of the anatomy of fascia in medieval persian medicine. j med ethics hist med. 2020; 13: 7. mohsen bahrami1, saeed shokri2, reza mastery farahani3, majid dadmehr4 * 1.researcher, tehran, iran. 2.associate professor, department of anatomical sciences, school of medicine, zanjan university of medical sciences, zanjan, iran. 3.associate professor, department of biology and anatomical sciences, school of medicine, shahid beheshti university of medical sciences, tehran, iran. 4.assistant professor, school of persian medicine, iran university of medical sciences, tehran, iran; research institute for islamic and complementary medicine, iran university of medical sciences, tehran, iran. the study of fascia has a long history and has been considered by physicians of ancient civilizations. a review of historical medical manuscripts demonstrates a rich history of anatomy in ancient and medieval times, for instance in medieval persia (13). as one of the firstborn schools of medicine, persian medicine (pm) has a long history and was the principal medical source during the islamic golden age (from the 8th to the 13th century ad) in the medieval period (4,5). medieval persian practitioners were aware of other available medical traditions like those of ancient greece, egypt, india and china, and mostly applied the theories of hippocrates and galen as well. moreover, they added numerous valuable scientific theories to medieval medicine according to their observations and experiments (5). the textbooks of some pm scholars, for instance avicenna’s canon of medicine, were used by scientists and physicians in europe until the seventeenth century ad (4). there were a number of influential persian physicians who had years of experience in human dissection such as rhazes (865 925 ad), haly abbas (930 994 ad), avicenna (980 1037 ad) and jorjani (1042 1137 ad). they had a significant role in the development of anatomy applied in patient care (4,5). pm scientists were familiar with the anatomy and interrelationships of fascia, and widely used this anatomical term. a brief historical overview of the anatomy of fascia in medieval … 2 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 7 august 2020 according to pm manuscripts, fascia is classified as a seminal organ (relating to semen or manavi), which has been included in the category of nervous tissue with different functions. fascia is associated with tissue nourishment, protection from the invasion of harmful agents and transmission of innate heat, spirits and energies among organs; moreover, it is believed that fascia makes a significant contribution to the underlying mechanisms and also the treatment methods of some diseases (1 3). according to pm textbooks, fascia is classified as a simple organ originating from parental semen. anatomically, body organs are categorized into two main groups: simple and compound. organs that are created from a single material are called simple (e.g. bones, fascia and vessels), while compound organs are made up of a combination of simple organs (e.g. hand and eye) (2,3). simple organs are classified into two main subgroups: 1organs that are formed from blood, that is, sanguine organs, such as lahm or flesh (flesh, muscles and glandular tissue) and shahm or adipose tissue (fat tissue). 2organs that are formed from semen, that is, seminal organs, such as bones (bones, cartilage and joints), vessels (arteries, veins and lymphatic vessels) and nerves (nerves, ligaments, tendons and fascia); therefore, according to the perspective of pm scientists, fascia is classified as the main component of nervous tissue (2, 3). in the canon of medicine, avicenna has defined fascia as nerve-like, transparent, thin, rigid and woven wide fibers that surround body organs and cover their external surface (3). haly abbas elucidated that fascia is a thin and rigid object that encloses the organs, and there is no tissue thinner than it. he believed that after the bone, fascia is the most rigid tissue in the body, covering and maintaining the related organs and protecting them from the invasion of harmful agents; therefore, fascia is rigid so it will not be easily affected by harmful agents, and it is thin so it will not occupy a large space in the human body (2). pm scientists have used several terms such as bitanah (lining), ghilaf (sheath), ma’aliq (ligament) and ghisha (membrane or fascia) to introduce superficial, deep and visceral fasciae (1 3). the natures of these fasciae are not different from each other histologically; however, superficial fascia is general, but deep and visceral fascia is specialized. it has also been mentioned that the components and composition of the fasciae and their functions are different in various tissues (2,3). haly abbas believed that body parts such as muscles have a single layer membrane, while internal organs (the viscera) are covered in a double layer of fascia: the parietal layer envelopes the walls and the visceral layer covers those organs (2). according to pm textbooks, fascia can be divided into four general groups based on their locations in the human body: 1fascia of the brain and spinal cord two fasciae called omm ol-jafiyya (dura mater) and omm or-raqiqa (pia mater) surround the brain entirely. dura mater is joined to the fissures of skull bones and pia mater penetrates and is distributed all over the brain tissue. pia mater along with the fascia around the brain vessels create a structure like mashimah (chorion), while a third fascia spreads from the skull bones to the lower end of the vertebral column (2, 3). 2fascia of the chest rhazes and avicenna pointed out that a thin spidery fascia located on the inner surface of the ribs (chest wall) covers the ribs and the internal bahrami m., et al. 3 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 7 august 2020 organs of the chest (endothoracic fascia). two fasciae originate from this fascia and split the chest into two parts, joining the sternum from one side and covering the heart, lungs, blood vessels and nerves, and on the other side, they join the vertebrae on top of the esophagus (1, 3). 3fascia of the abdomen according to avicenna, the abdomen has two fasciae: maraqq, or the external layer or parietal peritoneum, and baritun, or the visceral peritoneum. maraqq is the fascia surrounding the digestive tract and is located under the skin and abdominal muscles. baritun is a thin, fragile and spidery fascia lining the abdominopelvic organs (stomach, liver, spleen, kidneys, bladder, uterus, testicles, omentum, vessels, nerves and so on) (3). 4fascia surrounding the fetus haly abbas explained that this fascia consists of three layers, each of which has a specific function as follows (2): the outermost layer surrounding the fetus is mashimah (chorion), which is responsible for nourishment of the fetus the second one called seqa is located inside the chorion the third layer named sela is located inside the seqa pm scientists like haly abbas and avicenna have mentioned several functions for fascia, some of which include enclosure and coverage of body organs, communication and mediation among organs, creating a mechanical barrier, splitting up an organ and preserving innate heat and spirits (2, 3). furthermore, haly abbas pointed out other functions for the pia mater including: connecting brain vessels so that they are fixed and are not loose covering the brain and protecting it from damage feeding the cerebral veins and conveying the innate heat to the arteries (2) based on the information provided by avicenna, the peritoneum has some other functions: enclosing the viscera under the diaphragm preserving the abdominal muscles from falling over the viscera and bladder contributing to peristalsis (with the help of abdominal muscles) joining together all the viscera under the diaphragm (each of them has a separate fascia with its own properties) (3) medieval persian scholars were aware of the widespread presence of fascia in all body tissues. fascia plays an important role in underlying mechanisms and corresponding therapies of a number of diseases in different organs (1-3). according to the canon of medicine, there is a relationship between brain and abdomen through fasciae and nerve sheaths (3). therefore, in patients who experience certain gastrointestinal manifestations, a higher prevalence of brain diseases such as epilepsy, headache and melancholia may occur (3). moreover, topical application of medicinal oils and abdominal massage are recommended for treatment of flatulence, lienteric diarrhea, constipation and bladder prolapse (3). in some gastric diseases, use of abdominal massage and applying oils through the anterior abdominal wall have been recommended (2, 3). these techniques have been mostly recommended in sick and elderly people who experience gastric disorders and constipation due to the weakness of abdominal wall muscles, fasciae and ligaments, as it is believed that these a brief historical overview of the anatomy of fascia in medieval … 4 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 7 august 2020 fasciae contribute to peristalsis with the help of abdominal muscles (2,3). avicenna has also mentioned a variety of headaches such as those related to the neck, kidneys, liver and spleen disorders, adding that the fascia network contributes to their pathophysiology (3). in some diseases, massage and manual therapy are used on the vertebral column to erode some of the confined cerebral wastes through the fascia surrounding the spinal cord (3). avicenna has dissected the covering layers of the parietal and visceral peritoneum and has explained the connection between peritoneum and testicular covering sheath through the inguinal hole. in addition, he has discussed the types of hernias in this area and their respective treatment methods (3). according to the principles of pm, the clinical effects of some treatment methods such as massage therapy, cupping therapy and anointing with oils are justified through the concept of fascia. in conclusion, pm scientists were conscious of the widespread presence, as well as the supportive and protective role of fascia throughout the entire human body (1-3). according to pm manuscripts, fascia is a seminal organ and in the category of nervous tissue with different functions that contributes to tissue nourishment and transmission of innate heat, spirits and energies among organs (2, 3). existing embryological evidence shows that the fascia network originates from the mesoderm, although some authors believe that this connective tissue is also found in the neural crests (ectoderm), especially in the cranial and cervical area (6). pm scientists believed that fascia has a communicating and mediating role among body organs and plays a significant role in the treatment of a number of diseases. they used dry cupping, massaging and anointing oil on the abdominal wall as a treatment method for certain diseases (2,3). there is a bidirectional interaction among fasciae and every muscle, organ, blood vessel and nerve (7). some evidence proposes that the fascia network has a key role in manual therapy and acupuncture (7,8). it seems that fascia can offer a pathophysiological basis for clarifying the clinical effects of these treatments, since it can be considered as a connection between the surface and the viscera on the depth of the body. this can provide the possibility of treating visceral diseases through the body surface. the fascia reacts to stimulation, and therapeutic efficacy is therefore clearly linked to accurate fascial localizations (7). acknowledgments the authors wish to thank bahare dadmehr for assistance with the manuscript editing. this research was supported by a grant from iran university of medical sciences, tehran, iran. conflict of interests the authors declare that there is no conflict of interests. bahrami m., et al. 5 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 7 august 2020 references 1. rhazes mz. [al-mansuri fi al-tibb]. [cited 2020 august]; available from: http://dorar.uqu.edu.sa//uquui/handle/20.500.12248/106800 2. haly abbas. [kāmil al-sināa al tibbiya]. [cited 2020 august]; available from: https://ia801004.us.archive.org/23/items/ktp2019-bgh1902/ktp2019-bgh1902.pdf 3. ibn-e-sina aah. [al-qānūn fī al-tibb]. [cited 2020 august]; available from: https://archive.org/details/avicennascanonofmedicine/mode/2up. 4. shoja mm, tubbs rs. the history of anatomy in persia. j anat. 2007; 210(4):359-78. 5. gorji a, khaleghi ghadiri m. history of headache in medieval persian medicine. lancet neurol. 2002; 1(8):510-5. 6. bordoni b, zanier e. clinical and symptomatological reflections: the fascial system. j multidiscip healthc. 2014; 7: 401-11. 7. finando s, finando d. fascia and the mechanism of acupuncture. j bodyw mov ther. 2011; 15(2):168-76. 8. simmonds n, miller p, gemmell h. a theoretical framework for the role of fascia in manual therapy. j bodyw mov ther. 2012; 16(1): 83-93. ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ 1 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 19 december 2020 review article copyright © 2020 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. neonatal end-of-life decisions and ethical perspectives madjid soltani gerdfaramarzi1, shabnam bazmi2* 1.phd candidate of medical ethics, medical ethics department, school of traditional medicine, shahid beheshti university of medical sciences, tehran, iran. 2.associate professor, medical ethics department, school of traditional medicine, shahid beheshti university of medical sciences, tehran, iran. abstract end-of-life decisions are usually required when a neonate is at high risk of disability or death, and such decisions involve many legal and ethical challenges. this article reviewed the processes of ethical decision-making for severely ill or terminal neonates, considering controversial issues including the followings: (i) identifying primary decision makers, (ii) the role of law and guidelines, and (iii) changes in treatment controversy, law and regulations over twenty years in several european countries such as switzerland, germany, italy, united kingdom, france, the netherlands, sweden, and spain. this review study conducted on accessible articles from pubmed, google scholar, web of science and scopus databases. based on two studies in 2016 and 1996, neonatologists reported that withholding intensive care, withdrawing mechanical ventilation or life-saving drugs, and involvement of parents in decision-makings have become more acceptable as time passes, indicative of trend change. trend of physicians on how end the life of neonates, at risk of death, varies in different countries, and cultural factors, parents’ involvement in decisions and gestational age are factors considered in end-of-life decision-making. future investigations continuously need to identify upcoming ethical aspects of proper decisionmaking. keywords: ethics; neonatal intensive care; end-of-life; decision-making; law. *corresponding author shabnam bazmi no. 8, school of traditional medicine, shams alley, across from shaid abbaspour st., vali asr ave., tehran, iran. tel: (+98) 21 88 78 10 36 email: sh.bazmi@sbmu.ac.ir received: 4 jan 2020 accepted: 30 sep 2020 published: 5 dec 2020 citation to this article: soltani gerdfaramarzi m, bazmi s. neonatal end-of-life decisions and ethical perspectives. j med ethics hist med. 2020; 13: 19. volume 13 number 19 december 2020 neonatal end-of-life decision and ethical perspective 2 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e introduction over the last twenty years, perinatal technology advances, have raised survival rate of the fragile and premature neonates. however, intensive care remains ineffective for a small number of such neonates that prolongs the death process and results in upsetting them and their families. despite many advances in diagnosis and treatment of congenital diseases, perinatal death is still widespread in european countries. most of such deaths occurred in obstetric wards or neonatal intensive care units (nicus) and often preceded by end-of-life decisions such as withholding or withdrawing life-sustaining treatments (1, 2). end-of-life decisions are usually considered when a neonate is at high risk of disability or death regardless of treatment approach. such decisions to save neonates' life are often faced with the dilemma of being unaware of the extent of neonates' suffering involved, and hence various consequences of each decision option need to be considered in decision-making (1, 3). nevertheless, how and when to discontinue treatment involve several controversial and complex ethical aspects, and thus end-of-life care constantly poses ethical challenges to healthcare professionals. the medical decisions for these neonates may affect the quality of care they receive in the last days or weeks and how parents experience such terrible situation (4-7). many theories have been published regarding decision-making criteria; however, few studies provided empirical data about decisions before intensive care. moreover, a few studies focused on the comparison of different cultures of various countries (8), and majority of studies focused on englishspeaking countries or netherlands where reasoning supporting non-prosecution of euthanasia for eligible adults is similarly applicable to neonatal decision-making (914). a research conducted in 1996-1997 in several european countries documented different self-reported practices and attitudes of neonatal nurses and physicians according to different national, cultural and legal frameworks (15, 16). parents, policy makers, and physicians should be aware of the current medical perspectives, attitudes, practices, and values regarding ethical decision-making as they can over time affect the laws and guidelines and even enhance or prevent their usage. such awareness is also required to find practical approaches to support parents and healthcare providers regarding end-of-life decision-making and develop appropriate comfort care plans for patients and their families. investigating how such attitudes and beliefs change over time is necessary (1719). hence, this work aimed at studying attitudes, practices, and treatment options of neonatologists regarding the followings: (i) parents' involvement in decision-making about intensive care for neonates at risk of severe disability or death, (ii) processes of ethical decision-making for such neonates considering controversial issues (e.g., identifying primary decision-makers, role of laws and guidelines, treatment controversy in european countries), and (iii) changes in withdrawing or withholding intensive care in nicus, (iv) changes in parents’ participation in decision-making, , and (v) changes in guidelines and laws. soltani gerdfaramarzi m., et al. 3 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 19 december 2020 method all original and review articles on pubmed, google scholar, web of science and scopus databases were searched using the following keywords: ethics, neonatal intensive care, end-of-life decision, guideline and laws. after excluding duplicate articles, the titles of the remaining articles were reviewed and the irrelevant were removed. then, the abstracts of the remaining articles were studied, and the reference lists were also assessed. differences in neonatal end-of-life decision management in europe this review presents differences in end-oflife care and neonatal decision-making approach in several european countries such as switzerland, germany, italy, united kingdom, france, the netherlands, sweden, and spain. this article reviews neonatologists ' perspectives on decisions that limit intensive, futile, or disproportionate interventions imposing burden on patients and their parents. most neonatologists in these countries stated that limiting intensive care to “let nature take its course” can be ethically justifiable in terminal and fatal disease conditions (fig.1) (17,19). neonatologists considered continuing treatment with no escalation and prohibiting intensive support from the beginning to restrict intensive care during such conditions (16-19). treatment prohibition was accepted in united kingdom, netherlands, germany, and sweden, but not completely in italy (table 1). in addition, administering paincontrol medication was less admissible in italy compared to other countries, when the hastening risk of death is possibly involved. defined as administrating medications to end a patient’s life, active euthanasia was assumed admissible by many doctors in netherlands and france (table 1). fig. 1proportion of making decision (alone or with others) to set limit to intensive interventions among physicians (*1996-1997 and 2016 charts were extracted from (17) and (19), respectively) 0 10 20 30 40 50 60 70 80 90 100 77 76 61 76 81 96 86 % of physicians (1996-1997) 0 10 20 30 40 50 60 70 80 90 100 germany austria swiss 90 88 88 % of physicians (2016) volume 13 number 19 december 2020 neonatal end-of-life decision and ethical perspective 4 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e table 1proportions of physicians reporting to have ever decided (alone or with others) to set limits to intensive interventions ** this table is from (16-19) decisions percentage of physicians (95% cl) who had ever made decisions (1996 – 1997) percentage of physicians who had ever made decisions (2016) u n it e d k in g d o m f ra n c e s p a in it a ly n e th e rl a n d s w e d e n g e rm a n y g e rm a n y (n = 7 1 ) a u st ri a ( n = 8 ) s w is s (n = 1 7 ) to continue current treatment 86 (7892) 83 (74 -89) 85 (79-90) 81 (76-85) 89 (8492) 95 (90-98) 95 (88 98) 97 (90 -99) 100 100 to withhold intensive care (e.g., resuscitation at birth, mechanical ventilation) 91 (7996) 67 (58 -89) 74 (67-8) 57 (49-63) 95 (87-98) 82 (69-90) 81 (76-86) 99 (92-100) 100 100 to withdraw life-saving drugs 97 (8799) 59 (48-69) 50 (38-61) 29 (21-39) 99 (95-100) 94 (85-97) 74 (61-85) 97 (90-99) 100 100 to withhold emergency treatment/mane uvers (e.g., resuscitation for cardiac arrest) 91 (8295) 66 (59 -73) 66 (55-75) 44 (38-51) 96 (96-98) 68 (53-79) 95 (90-97) 99 (99-100) 100 94 to withdraw mechanic ventilation 92 (8097) 82 (76-86) 63 (54-71) 53 (45-60) 95 (90-98) 88 (75-95) 82 (74-88) 96 (88-98) 88 100 to administer sedatives / analgesics to suppress pain even at risk of respiratory depression and death 93 (8996) 96 (91-98) 87 (81-91) 64 (5671) 98 (89-100) 95 (88-98) 86 (78-91) 97 (90-99) 88 100 to administer drugs with the purpose of ending life 15 (7-28) 73 (64 -80) 6 (3-12) 5 (39) 71 (53-83) 3 (1-9) 8 (4-14) 3 (1-10) 0 6 in a 2016 multi-center, online, anonymous study in nicus in switzerland, germany, and austria, 198 eligible neonatologists received questionnaires (19), and 96 returned their completed questionnaires. most neonatologists in germany, austria, and switzerland answered all items except the one referring to active euthanasia (table 1). french physicians, however, were against its legalization assuming that this illegality soltani gerdfaramarzi m., et al. 5 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 19 december 2020 status would limit abuses. in the netherlands, more than half of neonatologists agreed to legalization, thinking that public transparency was a better safeguard (20, 21). in germany, in 2016 (94%) compared to 1996 (69%), the number of physicians who have made the following decisions at least once in their professional life was remarkably high: limit intensive care, withhold resuscitation at birth or emergency interventions, as well as withdraw lifesupporting medicines or mechanical ventilation (19,22). in 2016 (97%) compared to 1996 (57%) significantly greater number of german physicians accept the risk of death as an analgesic complication for an infant in pain with a low probability of recovery (19, 22). shown in table 1, no significant differences were found in 1996 (22) and in 2016 (19) surveys regarding limiting intensive care for end-stage patients and medicine administration to end patient’s life (illegal in switzerland, austria, germany, and several other countries). parents’ role in neonatal end-life decisions in all countries except sweden and france, physicians believed that parents should be involved in ethical decisions (16-19). almost 80% of participants in france stated that parents’ role should not be direct, and instead their opinions should indirectly be considered by physicians. such attitude was also reported in netherlands and sweden. in italy, however, 13% of participant believed that parents should not be involved in such decision-makings. several physicians stated that although parents should seriously consider neonate’s prognosis and health, they should not decide whether to prohibit or limit treatment so as not to blame themselves and suffer the consequences of their decision in case of infant’s death. moreover, being involved in end-of-life decisions can put physicians in a difficult position, especially when they need to notify parents of their infant's death. however, openness in ethical decisions vanishes, when physicians report such death condition as an unexpected heart attack, as a convincing white lie (18). if parents participate in decision-making, conflicts between the physicians and parents could arise about making the most appropriate decision for the infant. however, such conflicts scarcely occur and often can be resolved. according to most physicians, parents’ opinions and opinions of parents should be agreed upon when they want to continue severe interventions. a physician said, “we need to consider parents’ viewpoints to withhold intensive care when we are those who have asked about it”. however, parents’ opinions do not receive similar consideration when they reject severe care (19). review of ethical and legal framework in nuffield council document, no survival chance was considered for neonates prior to 22 weeks of gestational age; however, at 22 and 23 weeks, they have extremely low weight such that resuscitation and critical care must be experimental and cautioned. at weeks 24–25, critical care must be supplied, volume 13 number 19 december 2020 neonatal end-of-life decision and ethical perspective 6 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e except when both doctors and parents accept that considering baby’s general health, no hope for survival due to the baby’s general health condition and probably high suffering level. after 25 weeks, intensive care is considered standard treatment approach (22). the revised swedish society of medicine’s guideline, on discontinuing life-sustaining therapy, in march 2007, supported the competent individual’s decision right as well as patient's right to make informed decisions about avoiding treatments such as mechanical ventilation, tube feeding, fluid resuscitation, and medications. however, proper sedative interventions should be prescribed. sedation at the time of stopping life-sustaining interventions raised challenges as it was regarded physician-assisted suicide (22). the national ethics committee in france published a document for involving parents in decision-making. leonetti’s law on patient rights at the end of life in 2005 and kouchner's law on patient rights in 2002 addressed overtreatment at birth and neonatal active euthanasia (22). these laws significantly changed the code of public health and restructured the physician-patient relationship guidelines and end-of-life care in france. the leonetti’s law prevents “unreasonably obstinacy” in researches and clinical settings as wells authorizes withholding or withdrawal of useless, disproportionate or artificially life-preserving treatments. however, pain relief and palliative care need to be provided when intensive treatment is stopped; for end-stage critically-ill patients with incurable disease, paint-relief medications are allowed if necessary, even if death is hastened as a side effect (22). recent laws enhanced patients’ autonomy to get informed decisions and provide consent to clinical measures. although parents or guardians make decisions for minors, in emergency and two other situations, medical authorities make decisions: (i) when parents and physicians’ disagreement may cause serious consequences for minor's health, and (ii) when decision to relinquish treatment becomes a risk, parents are entitled to be informed and consulted, but their consent is not required. decisions about any incompetent patient should be made through collegial procedure, including consultation with the healthcare team, external counselor, patient’s trustee, and family (22). in italy, in 2007 and 2008, resuscitation guidelines were provided for neonates at extremely low gestational age to determine where resuscitation and intensive care should be mandatory and when might such care could be useless or excessively challenging, contrary to patient expediency. these guidelines emphasize treatment in the early stages of pregnancy or regardless of gestational age, and parents should be notified; however, in case of disagreement, medical decision should be followed. such guidelines support treatment in the delivery room to provide each neonate the best survival chance, but in the event of treatment ineffectiveness, to consider compassionate care (22). in the netherlands, active euthanasia was legalized in 2002 for eligible adults and children over 12. despite general illegality of soltani gerdfaramarzi m., et al. 7 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 19 december 2020 neonatal euthanasia, the groningen protocol authorizes it in cases of “hopeless and unbearable suffering” under the following conditions: (i) definitive diagnosis and prognosis, (ii) confirmation of diagnosis, prognosis and unbearable suffering by at least one independent physician, (iii) informed consent of mother and father; and, (iv) performing euthanasia according to accepted medical standards. prior to decision of the public prosecutor, a specific advisory committee by the health ministry has assessed all cases since 2007 (22). the ethicists and physicians’ reactions to the groningen protocol were negative because they question measure of "hopeless and unbearable suffering" in presence of appropriate pain control and relief medications as well as using involuntary euthanasia instead of palliative care (22). despite objections, in 2005 dutch pediatric association approved the groningen protocol as a national guide and reviewed its guidelines for neonates’ resuscitation at early gestational age and suggested more active management at 25-24 weeks (22). discussion the 2016 study explains neonatologists’ practices and perspectives about nontreatment decisions and involvement of parents in taking care of neonates at higher death risk or severe illness (19). since 1996, many legal regulations and ethical recommendations have modified in european countries including swiss, german, and austria. the 2016 study indicated that neonatologists’ opinions, views, and practiced have changed over 20 years (19). almost all physicians have decided, at least once, to withhold intensive or emergency interventions, to withdraw life-saving medications and mechanical ventilation, or to use palliative care even at the risk of respiratory despair and death. moreover, life quality aspects and respect for parent’s opinions have affected the neonatologists’ decision-making (19). in a study conducted on neonatologists and nurses, most subjects (60%) agreed upon both neonatal end-of-life and parental decisions, although such high acceptance of end-of-life decisions did not fit within the framework of the law in several countries (1). medicationinduced end-of-life with life-shortening purposes was significantly more acceptable in physicians than in nurses. discussing non-treatment decisions in the public pediatric community has increased the inclination of neonatologists to limit treatments if it is in patient's best interest (19). moreover, in many countries courses in medical undergraduate curricula included the followings: clarification of medical treatment goals, discussions of life-sustaining treatment, development of a treatment plan, or implementation of a treatment program in palliative care conditions (19). in swiss, german, and austrian national guidelines, withholding and withdrawing life-sustaining medical treatment in neonates, if not in their best interest, are considered ethically and medically appropriate (19). the majority of 2016 study’s participants stated that the national guideline affected their volume 13 number 19 december 2020 neonatal end-of-life decision and ethical perspective 8 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e decision-making, and considered it useful in changing their perspectives. these national guidelines reduced physicians' fear of legal consequences when withdrawing and withholding life-sustaining treatments were necessary (19). neurologists are now more likely to include parents in deciding whether to start, continue, or leave intensive care. moreover, caring with the support of family including parents or guardians is mandatory in germany, switzerland and austria (19). in 2016, almost all neonatologists would pursue the parents’ desire to resuscitate the preterm neonate with gestational viability limits. however, if parents do not request resuscitation of the premature neonate, less than 20 percent of neonatologists stated that they would resuscitate the neonate despite the national guidelines and parents’ decisions; and hence, in practice, personal beliefs and attitudes could be prioritized over national policies and default options in decisionmaking about severely preterm neonate with viability limits (19). similarly, withholding treatment for sustaining life in the delivery room, when the pain of the new-born child is not clear and distinct yet, may bring about ethical challenges in physicians. moreover, predicting best interest of a patient is simpler for a patient with a certain diagnosis who deteriorates despite treatment. conclusion european countries’ legal and ethical background is not coherent. modifications introduced in several countries have followed directions determined by the neonatologists’ attitudes and beliefs documented by the available data. informing parents or guardians when decisions are made about children is required in almost all countries. while most countries request third-party counseling or intervention in the event of ongoing disputes between medical staff and parents, physicians often make the final decisions. according to the data of the 1996 and 2016 surveys, withdrawing and withholding intensive care in the nicu as well as involving parents in decision makings have become more accepted, which could be as a result of administration of medical guidelines over the past two decades regarding joint decision-makings and care options for neonates at high risk of severe disability or death. nevertheless, for some physicians, personal attitudes take precedence over parental decisions and national policies in resuscitating premature neonates with limited viability. guidelines and laws are not the only factors influencing behaviors and opinions, and viewpoints of physicians as well as society may change before reflected in legislations. future surveys need to explore such hypotheses. conflict of interests the authors have declared that no competing interest exists. soltani gerdfaramarzi m., et al. 9 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 19 december 2020 references 1. dombrecht l, deliens l, chambaere k, et al. neonatologists and neonatal nurses have positive attitudes towards perinatal end of life decisions, a nationwide survey. acta paediatr. 2020; 109(3): 494-504. 2. abdel razeq nm. end-of-life decisions at neonatal intensive care units: jordanian nurses attitudes and viewpoints of who, when, and how. j pediatr nurs. 2019; 44: e36e44. 3. abdel razeq nm. physicians’ standpoints on end-of-life decisions at the neonatal intensive care units in jordan. j child health care. 2019; 23(4): 579-95. 4. saigal s, doyle lw. an overview of mortality and sequelae of preterm birth from infancy to adulthood. lancet. 2008; 371(9608): 261-9. 5. catlin a, brandon d, wool c, mendes j. palliative and end-of-life care for newborns and infants: from the national association of neonatal nurses. adv neonatal care. 2015; 15(4): 239-40. 6. russo f, van mieghem t, deprest j. fetal medicine, fetal anaesthesia, and fetal surgery. in: oxford texbook of obstetric anaesthesia. uk: oxford university press; 2016. 7. catlin a, carter b. creation of a neonatal end-of-life palliative care protocol. j perinatol. 2002; 22(3): 184-95. 8. levin bw. international perspectives on treatment choice in neonatal intensive care units. social science & medicine. 1990; 30(8): 901-12. 9. ryan ca, byrne p, kuhn s, tyebkhan j. no resuscitation and withdrawal of therapy in a neonatal and a pediatric intensive care unit in canada. j pediatr. 1993; 123(4): 5348. 10. kelly np, rowley sr, harding je. death in neonatal intensive care. journal of paediatrics and child health. 1994; 30(5): 419-22. 11. bilgen h, topuzoglu a, kuscu k, altuncu e, özek e. end-of-life decisions in the newborn period: attitudes and practices of doctors and nurses. turk j pediatr. 2009; 51(3): 248-56. 12. wall sn, partridge jc. death in the intensive care nursery: physician practice of withdrawing and withholding life support. pediatrics. 1997; 99(1): 64-70. 13. de leeuw r, de beaufort aj, de kleine mj, van harrewijn k, kollée la. foregoing intensive care treatment in newborn infants with extremely poor prognoses. a study in four neonatal intensive care units in the netherlands. j pediatr. 1996; 129(5): 661-6. 14. van der heide a, van der maas pj, van der wal g, et al. medical end-of-life decisions made for neonates and infants in the netherlands. lancet. 1997; 350(9073): 251-5. 15. cuttini m, kaminski m, saracci r, de vonderweid u. the euronic project: a european concerted action on information to parents and ethical decision making in neonatal intensive care. paediatr perinat epidemiol. 1997; 11(4): 461-74. 16. mchaffie he, cuttini m, brölz-voit g, et al. withholding/withdrawing treatment from neonates: legislation and official guidelines across europe. j med ethics. 1999; 25(6): 440-6. 17. cuttini m, nadai m, kaminski m, et al. end-of-life decisions in neonatal intensive care: physicians' self-reported practices in seven european countries. euronic study group. lancet. 2000; 355(9221): 2112-8. 18. rebagliato m, cuttini m, broggin l, et al. neonatal end-of-life decision making: physicians' attitudes and relationship with self-reported practices in 10 european countries. jama. 2000; 284(19): 2451-9. volume 13 number 19 december 2020 neonatal end-of-life decision and ethical perspective 10 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e 19. schneider k, metze b, bührer c, et al. end-of-life decisions 20 years after euronic: neonatologists’ self-reported practices, attitudes, and treatment choices in germany, switzerland, and austria. j pediatr. 2019; 207: 154-60. 20. cuttini m, casotto v, kaminski m, et al. should euthanasia be legal? an international survey of neonatal intensive care units staff. arch dis child fetal neonatal ed. 2004; 89(1): f19-f24. 21. garel m, gosme-seguret s, kaminski m, cuttini m. [ethical decisions making in neonatal intensive care. survey among nursing staff in 2 french centers]. arch pediatr. 1997; 4(7): 662-70. 22. cuttini m, casotto v, de vonderweid u, et al. neonatal end-of-life decisions and bioethical perspectives. early human development. 2009; 85(10): s21-s25. journal of medical ethics and history of medicine viewpoint compassion as the reunion of feminine and masculine virtues in medicine kiarash aramesh associate professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran; scholar in residence, center for healthcare ethics, duquesne university, pittsburgh, pa, usa. corresponding author: kiarash aramesh address: no.23, 16 azar ave, keshavarz blvd, medical ethics and history of medicine research center, tehran, iran. email: kiarasharamesh@tums.ac.ir tel/fax: +98 21 66419661 received: 30 oct 2016 accepted: 20 aug 2017 published: 7 oct 2017 j med ethics hist med, 2017, 10:8 © 2017 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract the central role of the virtue of compassion in the shaping of the professional character of healthcare providers is a wellemphasized fact. on the other hand, the utmost obligation of physicians is to alleviate or eliminate human suffering. traditionally, according to the aristotelian understanding of virtues and virtue ethics, human virtues have been associated with masculinity. in recent decades, the founders of the ethics of care have introduced a set of virtues with feminine nature. this paper analyzes the notion of compassion as a common virtue between the traditional/masculine and care/feminine sets of virtues and shows that compassion is a reunion and merging point of both sets of human virtues. this role can be actualized through the development and promotion of compassion as an important part of the character of an ideal physician/healthcare provider. in addition, this paper argues that the notion of compassion can shed light on some important aspects of the contemporary debates on healthcare provider-patient relationship and medical futility. despite the recent technological and scientific transformations in medicine, the interpersonal relationship between healthcare providers and patients still plays a vital role in pursuing the goals of healthcare. the virtue of compassion plays a central role in the establishment of a trust-based physician-patient relationship. this central role is discernible in the debate of medical futility in which making difficult decisions, depends largely on trust and rapport which are achievable by compassion in the physician and the recognition of this compassion by the patients and their surrogate decision makers. keywords: compassion, virtue ethics, futility, doctor-patient relationship, end-of-life care j med ethics hist med 10: 8, october, 2017 jmehm.tums.ac.ir kiarash aramesh page 2 of 6 introduction compassion has been called “the emotional and virtuous core of the desired professional attitude” in medicine (1). the ethics committee of the american society of academic emergency medicine (saem) considers compassion “a part of professional competence” which is “perhaps as important as technical competence” (1). these instances of emphasis on the central role of compassion in the shaping of the professional character of healthcare providers show the crucial importance of this concept in medicine and medical ethics. compassion is the internal/subjective reaction to the suffering of another sentient being(s) and is conjoined with recognition of the suffering, detestation and disapproval of that suffering, the feeling of personal responsibility for and engagement with the experience, and tendency to relieve the suffering with good intentions toward the sufferer(s) (2). therefore, one can argue that compassion is always a good trait and there is not such a thing as “bad compassion”. from the ancient times, the utmost obligation of physicians has been to alleviate or eliminate human suffering (3). daniel callahan calls this obligation “a foundation stone of the practice of medicine” (4). patients’ suffering is not limited to pain or other symptoms of their diseases; it also encompasses their mental, social, and spiritual discomfort. this suffering originates from different sources including their disease, the treatment, their realistic or unrealistic fears and anxieties, their financial and social distresses, and other types of discomfort they experience through the course of their disease, treatment, and recovery (3). alleviating patients’ suffering in a professional manner – not as a business – necessitates an ethical backbone that is composed of virtues such as compassion. the broadness and existential importance of the concept of suffering and its importance in the life of a patient show how crucial the virtue of compassion is in the practice of medicine and in the pursuit of its goals (3). suffering elicits the “impulse of compassion” in almost every normal human being (4), but it should develop into a virtue in physicians in order to render them more similar to the ideal physician. this paper analyzes the notion of compassion as a common virtue between the traditional/masculine and care/feminine sets of virtues and shows that compassion as a reunion and merging point of both sets of human virtues has a crucial role in pursuing the goals of medicine and healthcare. this role can be actualized through the development and promotion of compassion as an important part of the character of an ideal physician/healthcare provider. in addition, this paper argues that the notion of compassion can shed light on some important aspects of the contemporary debates on healthcare provider-patient relationship and medical futility. compassion as a virtue the main goal of medicine is to alleviate or eliminate suffering. therefore, compassion is one of the most crucial virtues in pursuing the goals of healthcare and medicine. according to alasdair macintyre, a virtue is a developed trait of a human’s character that tends to qualify him/her to realize the goals of a certain practice (in our case, medicine and health care) with excellence (1). traditionally, according to the aristotelian understanding of virtues and virtue ethics, human virtues have been associated with masculinity (5). this notion of ethical virtues had bestowed by dominance in the realm of philosophy for several centuries. in the recent decades, however, the founders and advocates of the ethics of care have described and introduced a set of virtues with feminine nature (see below). this part of the paper portrays compassion as a common virtue between these two sets of universal virtues. both the traditional and feminist theories of virtue ethics emphasize the importance of the virtue of compassion when it comes to healthcare ethics and healthcare provider-patient relationship. at the end of this part, one can conclude that compassion as a virtue is the merging point of the masculine and feminine virtues in the realm of medicine and healthcare and is of crucial importance in shaping the character of a virtuous physician/healthcare provider. compassion as a masculine virtue the traditional masculine virtue ethics is a moral theory mainly formulated by aristotle. according to this moral theory, moral goodness and badness depends on the moral agent, and the development and establishment of moral virtues can empower a moral agent to act ethically in every practical situation. andre comte-sponville argues that contrary to sympathy, compassion is a virtue (6). other scholars have also noticed the difference of concepts like sympathy, empathy, and pity with the concept of compassion (1). this differentiation, as described briefly below, shows how one can consider compassion as a virtue, not a feeling that can be morally good or bad. comte-sponville differentiates sympathy and compassion in the following way. sympathy, which means “fellow feeling”, is not a virtue by itself. its goodness or badness depends on the “feeling” which is being shared between fellows. having sympathy to malice intents is not good; therefore, sympathy, by itself, can never be a virtue. compassion, however, is sympathy in suffering, and every form of suffering, even those originated from wrong causes such as wrongful jealousy or rivalry, deserves sympathy (6). in addition, compassion encompasses other specifics such as benevolence and an inclination to relieve the suffering (2). j med ethics hist med 10: 8, october, 2017 jmehm.tums.ac.ir kiarash aramesh page 3 of 6 comte-sponville brings christ’s compassion for his executioners as an example of the goodness of compassion even for evil people who suffer because of their evil and malice acts, intents, and character (6). andre comte-sponville argues that compassion, simultaneously, is a feeling and a virtue because we can feel it as a feeling and we can want and gain the capacity of being compassionate (6). in this sense, compassion is similar to love. in buddhism, compassion is regarded as a great virtue. in christianity and islam, charity has the same status. however, charity is not mutually exclusive to compassion. as a matter of fact, the feeling and capacity of compassion can lead to and resemble charity (6). as a virtue in its traditional/masculine sense, compassion is in close relation with biomedical and healthcare ethics. as mentioned above, the alleviation of suffering is a core obligation/goal in medicine and healthcare. the virtue which targets suffering is compassion. therefore, the pursuit and realization of this main goal of medicine depends on the establishment of this virtue in healthcare providers/physicians. feminine virtues vs. masculine ethics the ethics of care is among the most recently emerged moral theories and has attracted a large deal of attention in the recent decades (7). its new and innovative approach and viewpoint in dealing with ethical issues has shed light on some formerly dark and overlooked parts of human beings’ moral obligations and duties. as a moral theory, ethics of care has implications and influences on biomedical ethics. healthcare is one of the most prominent manifestations of care and caring relation in the world of humanity (8). therefore, it is evident that ethics of care has much to say when it comes to health, healthcare, and the goals of medicine. the ethics of care, as a distinct moral theory, was born inside the feminist ethics. the founders of this theory were feminist philosophers who found the caring nature of femininity of enormous ethical value (9). as described above, traditionally, in moral theories and even in moral psychology, it was taken for granted that ethical virtues are stronger in males (5). this was because ethical norms and virtues like justice and impartiality were consistent with the role of males as hunters and breadwinners. the role of females, as caretakers, had almost always been underestimated, morally speaking. according to the founders of the ethics of care, however, this caring nature of the female role is of utmost moral superiority and importance and can be considered as a basis for a self-sufficient moral theory. although some of them believe that the ethics of care is not a category of virtue ethics, still it is clear that this moral theory is founded based on considering care and compassion as unambiguous virtues. one of the main themes of the ethics of care is considering partiality as a virtue. in the traditional/masculine virtue ethics, justice and impartiality have always been indubitable virtues. however, in the ethics of care, special caring relations accompany the obligation of special care and partiality. this is true in the case of physicianpatient relationships. compassion as a feminine virtue medical ethics and professionalism ask physicians to always prioritize the health and health needs of their own patients. this priority stems from a relationship, the physician/doctor/healthcare provider-patient relationship. it seems that the typical model of the ethics of care shows itself in this case. the physician should be partial and prioritize his/her patients because of the specific relationship established between them. this partiality is demonstrated in the forms of care and compassion. therefore, one can argue that compassion is a virtue that has a central role in feminine virtue ethics or ethics of care. the virtues of care and compassion are aimed at the realization of the goals of medicine as described below. compassion and the goals of healthcare daniele callahan specifies the goals of medicine as the prevention of disease and injury and the promotion and safeguarding of health, relief from all kinds of suffering resulted by maladies, the treatment of disease and provision of care for non-curable diseases, and the evasion of a premature death and the pursuit of a serene death (10). it seems that the virtue of compassion plays crucial roles in the realization of all of these four goals of medicine/healthcare. in this part of this paper, the role of compassion in realizing these goals is described under two major topics of healthcare provider-patient relationship and medical futility. compassion and healthcare provider-patient relationship the root of the word “compassion” is in latin where it means “suffering with”, equal to the greek root of the word “sympathy” (2). it is interesting that compassion shares its latin root with the word “patient” meaning sufferer (6). this common root symbolically shows the relation between compassion and caring for parents and relieving their suffering as embodied in healthcare and medicine. medicine relies on science, but is not merely a sort of science. it is also an art; the art of establishing a healing and trust-based relationship with the patients. this art depends on certain virtues in physicians, among which is the crucial one of compassion. recent developments in medical technologies along with reliance on science have transformed the doctor-patient relationship in the post-world war ii era (3). however, these changes and evolutions have j med ethics hist med 10: 8, october, 2017 jmehm.tums.ac.ir kiarash aramesh page 4 of 6 not led to the elimination of humanistic aspects of the doctor-patient relationship and its transformation into a mechanical/machine-like relationship. therefore, the therapeutic relation still depends largely on development of trust and rapport between physician and patient. this trust and rapport are achieved when patients realize that their doctor recognizes their suffering, feels for them, and intends to alleviate or eliminate their suffering. this is the definition of compassion as previously described in this paper. therefore, it seems that despite all the evolutions and transformations in modern medicine, the cornerstone of the doctor-patient relationship is still personal virtues, and among them, the important one of compassion. compassion and the notion of medical futility medical futility refers to that sort of medical interventions that do not have any benefit for the patient, and therefore, should be forsaken (11). medical futility encompasses a wide range of routine and common instances of medical care such as prescribing antibiotics for the common cold to some sensitive and emotional instances like withdrawing a life sustaining treatment at the end of life (12). even if the patients or their families ask, the healthcare providers have no obligation to provide a futile treatment. instead, they are ethically obliged to refuse to provide any futile interventions (11). determining which intervention is futile for a given patient, however, is not always easy and straightforward and cannot be decided upon by only the physicians (12). as a matter of fact, both the technical/scientific knowledge of the physician/healthcare provider and the perception of the patient/surrogate decision maker(s) of his/her suffering are important in making an ethical decision. the virtue of compassion is crucial in optimizing the role of the physician in such a situation. the physician’s sympathetic and compassionate understanding of the patient’s suffering is the cornerstone of a constructive dialogue which leads all the involved parties through the difficult course of decision making on medical futility, especially in sensitive and emotional cases such as those related to end-of-life care and withholding or withdrawing lifesustaining interventions. it seems that compassion, as a virtue can be helpful in decision making regarding medical futility through the following aspects: 1compassion helps the physician to understand the needs, fears, urges, and desperations behind the decisions of the patient or the surrogate decision-maker. 2compassion, when realized and recognized by the patient and his/her surrogate decision-maker, helps to establish a relationship based on trust between two parties and facilitates dialogue, common decision-making, and the obtaining of a consensus. because in this case, the patient and his/her relatives feel that the decisions and suggestions of the physician are in the best interest of the patient. otherwise, they might doubt that there may be financial or other unrelated goals behind the suggestions of the physician that is very destructive to trust and relationship. conclusion taking a look at the history of debates in contemporary biomedical ethics clearly shows that no single moral theory has a monopoly on the realm of truth in biomedical and healthcare ethics. instead, in each situation and in analyzing each specific issue or searching for each specific ethical solution, one or more of ethical theories are shown to be helpful and reliable. in this paper, the viewpoint of virtue ethics has been used and analyzed to shed light on some aspects of biomedical ethics and to show that compassion as a virtue plays a vital role in the pursuit of the goals of healthcare and medicine. healthcare, in practice, involves a great deal of interpersonal involvements and interactions. therefore, the character of the physician/healthcare provider is of crucial importance. this importance paves the way for virtue ethics to play a considerable role in analyzing and problem-solving in healthcare provider-patient issues. in this context, compassion, as a virtue, is of importance in pursuing the goals of medicine/healthcare as described above. compassion is a common virtue between the traditional/masculine and feminist/feminine theories of virtue ethics and, according to both of them, is a crucial virtue in biomedical ethics and medical professionalism. the traditional/masculine sense of the virtue of compassion can strengthen the relationship between physician and patient with trust and mutual understanding. in addition, the partiality resulted from this relationship shows itself in the form of prioritizing one’s own patients and is compatible with the feminine account of virtues such as compassion and care. despite the recent technological and scientific transformations in medicine, the interpersonal relationship between healthcare providers and patients still plays a vital role in pursuing the goals of healthcare. the virtue of compassion plays a central role in the establishment of an effective and trust-based physician-patient relationship. this central role is discernible in the debate of medical futility in which making difficult decisions, especially in emotional situations such as end-of-life care, depends largely on trust and rapport which are achievable by virtue of compassion in the physician j med ethics hist med 10: 8, october, 2017 jmehm.tums.ac.ir kiarash aramesh page 5 of 6 and the recognition of this compassion by the patient and his/her surrogate decision makers. finally, compassion can be called the merging and reunion point of the feminine and masculine virtues in pursuing the goals of healthcare and medicine. developing and strengthening this virtue should be a part of both formal and hidden curriculums in medical education in every medical school all over the world. acknowledgement the author of this paper would like to extend his appreciation to dr. henk ten have and dr. joris gielen for their so valuable and helpful guidance and comments. j med ethics hist med 10: 8, october, 2017 jmehm.tums.ac.ir kiarash aramesh page 6 of 6 references 1. gelhaus, p. the desired moral attitude of the physician: (ii) compassion. med health care philos. 2012; 15(4): 397-410. 2. larkin gl, iserson k, kassutto z, et al. virtue in emergency medicine. acad emerg med 1996; 3(10): 961-6. 3. cassell e.j. the nature of suffering and the goals of medicine, 2ed. uk: oxford university press; 2004, p. 1-30. 4. callahan d. the troubled dream of life. usa: georgetown university press; 2000, p. 94, 95. 5. willows a. aristotle’s virtue theory. challenging religious issues. 2013; 3:7-12. 6. comte-sponville a. in a small treatise on the great virtues: the uses of philosophy in everyday life.usa: picador; 2002, p. 103-17. 7. held v. the ethics of care: personal, political, and global. uk: oxford university press; 2006, p. 3. 8. nortvedt p, hem mh, skirbekk h. the ethics of care: role obligations and moderate partiality in health care. nurs ethics. 2011; 18(2): 192-200. 9. tong r. the ethics of care: a feminist virtue ethics of care for healthcare practitioners. j med philos. 1998; 23(2): 13152. 10. callahan d. the goals of medicine-setting new priorities. hastings center report. 1996; 26(6). 11. kelly df, magill g, ten have h. contemporary catholic health care ethics, 2ed. usa: georgetown university press; 2013, p. 222, 223. 12. have ht, clark d. the palliative care. in the ethics of palliative care: european perspectives.. buckingham and philadelphia: open university press; 2002, p. 212-32. 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____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ 1 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e original article volume 13 number 22 december 2020 copyright © 2020 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. euthanasia and physician-assisted suicide: a systematic review of medical students’ attitudes in the last 10 years *corresponding author javier gutierrez-castillo av. ignacio morones prieto, 3000 col. los doctores. cp 64710 monterrey, nuevo león, méxico. tel: (+52) 81 27 31 63 87 email: javilegtz@gmail.com received: 25 dec 2019 accepted: 1 nov 2020 published: 12 dec 2020 citation to this article: gutierrez-castillo a, gutierrez-castillo j, guadarrama-conzuelo f, jimenez-ruiz a, ruiz-sandoval jl. euthanasia and physician-assisted suicide: a systematic review of medical students’ attitudes in the last 10 years. j med ethics hist med. 2020; 13: 22. alejandro gutierrez-castillo1, javier gutierrez-castillo1*, francisco guadarrama-conzuelo1, amado jimenez-ruiz2, jose luis ruiz-sandoval 3 1.researcher, school of medicine, monterrey institute of technology and higher education, nuevo león méxico, mexico. 2.neurology resident, department of neurology, national institute of medical science and nutrition salvador zubirán, ciudad de méxico, méxico. 3.professor, department of neurology, civil hospital of guadalajara “fray antonio alcalde”, jalisco, méxico. abstract this study aimed at examining the approval rate of the medical students’ regarding active euthanasia, passive euthanasia, and physician-assisted-suicide over the last ten years. to do so, the arguments and variables affecting students’ choices were examined and a systematic review was conducted, using pubmed and web of science databases, including articles from january 2009 to december 2018. from 135 identified articles, 13 met the inclusion criteria. the highest acceptance rates for euthanasia and physician-assisted suicide were from european countries. the most common arguments supporting euthanasia and physician-assisted suicide were the followings: (i) patient’s autonomy (n = 6), (ii) relief of suffering (n = 4), and (ii) the thought that terminally-ill patients are additional burden (n = 2). the most common arguments against euthanasia were as follows: (i) religious and personal beliefs (n = 4), (ii) the “slippery slope” argument and the risk of abuse (n = 4), and (iii) the physician’s role in preserving life (n = 2). religion (n = 7), religiosity (n = 5), and the attributes of the medical school of origin (n = 3) were the most significant variables to influence the students’ attitude. however, age, previous academic experience, family income, and place of residence had no significant impact. medical students' opinions on euthanasia and physicianassisted suicide should be appropriately addressed and evaluated because their moral compass, under the influence of such opinions, will guide them in solving future ethical and therapeutic dilemmas in the medical field. keywords: euthanasia; medical students; medical ethics; physician-assisted suicide; religion. euthanasia and physician-assisted suicide: a systematic review of … 2 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 22 december 2020 introduction death by itself is not part of an ethical dilemma, as all lives are bound to end since the moment of conception, and human beings confront death through their personal beliefs, religion, and cultural context. regardless of the natural and unavoidable causes of death, debate over death focuses on how to control it as well as on who and how should perform the death-related practices in medical field. the important role of physicians in this debate is that they are often both the judge and the executor of such practices (1). several physicians believe that the idea of promoting death is against hippocratic oath and their primary role as healer, while others may reject the idea based on their moral or religious values (1). the issues on control over death can be divided into two broad categories: euthanasia and physician-assisted suicide (pas). euthanasia is further divided into active euthanasia (ae) or passive euthanasia (pe), according to the role that the physician plays in the process. the term pe is no longer used in some countries, and the term therapy withdrawal (tw) is replaced as the physician’s role is limited to suspending treatment or stopping additional measures that artificially prolong life. in tw, the physician acts as a mere observer while the disease advances and ends the patient’s life. however, in ae, the physician operatively engages in ending patient's life by administering a toxic substance that accelerates death (2). in pas, the physician intentionally helps the patient to commit suicide by providing drugs for their selfadministration at the patient’s competent and voluntary request (3). the differences among aforementioned approaches have implications that surpass their moral approval, as the medical actions involved in these approaches are regulated by law. according to the american medical association (ama), ae and pas are in conflict with physicians’ healing role. furthermore, their management are quite challenging, if not completely impossible, and they entail grave risks to the society (4). however, pe, described as withdrawal or withholding life-sustaining treatment, is ethically acceptable for a patient capable of decision-making, and if an intervention is not expected to achieve the patients’ goals for care or desired quality of life (4). the contributions of this study are as follows: (i) quantitative assessment of medical students’ approval rate for ae, pe and pas over the last ten years, (ii) analysis of the most common arguments validating such practices, and (iii) evaluation of the variables that can influence a personal position on the topic. this study aimed at answering the following questions: what is the percentage of euthanasia or pae approval among medical students? what are the most common arguments associated with the approval or rejection of euthanasia or pae? what are the variables affecting the approval or rejection of euthanasia and pae? gutierrez-castillo a., et al. 3 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 22 december 2020 method this study was conducted following the preferred reporting items for systematic reviews and meta-analyses (prisma) (5) (figure 1). figure 1prisma flowchart the literature searches in april 2019, included articles published between january 2009 and december 2018, and focused on pubmed and web of science as the primary electronic databases. the databases were searched using the following search strings: s c re e n in g in c lu d e d e li g ib il it y id e n ti fi c a ti o n records identified through searching databases: pubmed (n= 63) web of science (n = 72) records after removal of the duplicates (n = 97) records screened (n = 97) records excluded (n = 72) full-text articles assessed for eligibility (n = 25) full-text articles excluded, with reasons *language (n=2) *unavailable online (n=3) *wrong population (n=3) *does not address focused question (n=4) studies included in qualitative synthesis (n = 13) https://pubmed.ncbi.nlm.nih.gov/ https://pubmed.ncbi.nlm.nih.gov/ https://pubmed.ncbi.nlm.nih.gov/ euthanasia and physician-assisted suicide: a systematic review of … 4 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 22 december 2020 (medical students) and (euthanasia or physician-assisted suicide). our review focused on original crosssectional descriptive studies in english whose main population, or part of it, was composed of medical students and quantified their personal views regarding the legalization or practice of pas or euthanasia. only original descriptive articles that quantitatively addressed the first focused question in the last ten years were included. the excluded cases were the followings: (i) review articles, book chapters, conference papers, and letters to the editor; (ii) nonneutral reports, where the authors expressed their views or stated an opinion on the topic; (iii) articles whose main population consisted of physicians, nurses, or any group other than undergraduate medical students; (iv) articles for which the complete text could not be found online; and, (v) articles written in languages other than english. records were initially screened according to the titles and abstracts. relevant abstracts and articles without an abstract were selected for full-text review. articles selected in the first screening were carefully read and analyzed to determine whether they addressed the first focused question and whether they fulfilled the inclusion criteria. further analyses were made to determine if they described any argument or variable that could persuade medical students to take a positive or negative side. results a total of 135 articles were identified after the database search (63 in pubmed and 72 in web of science); 97 non-duplicate documents were screened by the title and abstract. from the 25 articles eligible for full-text review, 13 fulfilled the inclusion criteria and were selected for further analysis (6-18). reasons for exclusion of 12 remaining articles were as follows: (i) use of a language other than english (n = 2); (ii) absence of a full-text version online (n = 3); (iii) inclusion of a study population different than undergraduate medical students (n =3); and, (iv) failure to address the first focused question (n = 4). from the 13 selected articles, seven (6-12) were published between 2014 and 2018 and six (13-18) were published between 2009 and 2013. two studies were from africa (7, 9), four were from america (6, 8, 12, 14), one was from asia (15), and six were from europe (10, 11, 13, 16-18). the countries involved included austria (n = 1) (18), belgium (n = 1) (11), brazil (n = 1) (12), canada (n = 1) (14), germany (n = 1) (10), greece (n = 1) (18), mexico (n = 2) (6, 14), pakistan (n = 1) (15), poland (n = 2) (13, 16), and south africa (n = 2) (7, 9). eight articles addressed the approval rate of medical students regarding legalization of ae, pe or pas (7-9, 11, 13, 15-17); ten stated a positive attitude toward ae exclusively (6-12, 15, 17,18); six addressed acceptance of pe (6, 9,10, 12, 14, 18); and, six addressed acceptance of pas (7, 8, 10, gutierrez-castillo a., et al. 5 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 22 december 2020 14, 15, 18). two articles addressed the students’ personal views on ae, pe or pas, whether exclusively or conjunctively (13, 16). the results are summarized in table 1. table 1percentage of approval for ae, pe, and pas, as well as the legalization of euthanasia or pas. percentage of approval article country n legalization of euthanasia or pas active euthanasia (ae) passive euthanasia (pe) physicianassisted suicide (pas) gutierrez and gutierrez, 2018 (6) mexico 1319 44.4% (n=586) 52.1% (n=687) jacobs and hendricks, 2018 (7) south africa 277 52.7% (n=146) 41.9% (n=116) 35% (n=97) bator et al, 2017 (8) canada 405 88% (n=354) 38% (n=153) 61% (n=246) marais et al, 2017 (9) south africa 481 44.6% (n=300) 36.2% (n=243) 67.3% (n=452) anneser et al, 2016 (10) germany 241 19.2% (n=46) 83.3% (n=200) 51.2% (n=123) roelands et al, 2015 (11) belgium 151 97.4% (n=147) 31.8% (n=48) lucchetti et al, 2014 (12) brazil 3630 41.4% (n=1503) 45.7% (n=1659) leppert et al, 2013 (13) poland 401 26% (n=104) 12%* (n=48) loria et al, 2013 (14) mexico 99 61% (n=60) 52% (n=51) hassan et al, 2013 (15) pakistan 493 27.2% (n=134) 14.2% (n=70) 32.8% (n=162) leppert et al, 2013 (16) poland 588 29.59% (n=174) 11.73%* (n=69) stronegger et al, 2011 (17) austria 694 30.8% (n=214) 25.5%† (n=122) kontaxakis et al, 2009 (18) greece 251 52% (n=130) 79.2% (n=199) 69.7% (n=175) * the authors grouped the approval for either ae and pe, or pas. † this question was addressed in a population of 478 students. out of eight articles that addressed the positive views on legalization of the procedures, the lowest acceptance rate was 26% (13) and the highest 97% (11). the lowest and highest acceptance rates were as follows: (i) 14.2% (15) and 52% (18) for ae, (ii) 45.7% (12) and 83.3% (10) for pe, and (iii) 32.8% (15) and 69.7% (18) for euthanasia and physician-assisted suicide: a systematic review of … 6 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 22 december 2020 pas. the highest acceptance rates in the four scenarios were observed among students in european countries (10-12, 15), while the lowest acceptance rates were related to pakistan (15) and brazil (12). eight articles (6-8, 11, 15-18) were related to second main question addressing students’ arguments for or against the practice of ae, pe or pas. the most common arguments supporting ae, pe or pas practice were as follows: (i) patients’ autonomy (n = 6) (6 8, 11, 16, 17); (ii) relief of suffering or beneficence (n = 4) (7, 11, 16, 17); and, (iii) the thought that terminally-ill patients are additional burden (n = 2) (11, 18). less relevant arguments included the followings: (i) legality of the procedure (6); (ii) educational or clinical experience (8); and, (iii) quality of life or life expectancy (18). the most common arguments against ae, pe or pas were the followings: (i) religious or personal beliefs (n = 4) (7, 8, 15, 18); and, (ii) “slippery slope” argument or risk of abuse (n = 4) (7, 8, 16, 18); and, (iii) physicians’ responsibility to preserve life (7, 18). the results are summarized in table 2. table 2students’ arguments in favor or against the practice of euthanasia or pas article country students’ arguments in favor of euthanasia or pas students’ arguments against euthanasia or pas gutierrez and gutierrez, 2018 (6) mexico legality of the procedure patient’s autonomy jacobs and hendricks, 2018 (7) south africa patient’s autonomy relief of suffering religion or personal beliefs physicians’ role in preserving life “slippery slope”/lead to abuse bator et al., 2017 (8) canada educational/clinical experience patient’s autonomy religion or personal beliefs teachings “slippery slope”/lead to abuse roelands et al., 2015 (11) belgium patient’s autonomy relief of suffering the patient is a burden leppert et al., 2013 (13) poland patient’s autonomy relief of suffering “slippery slope”/lead to abuse hassan et al., 2013 (15) pakistan religion or personal beliefs stronegger et al., 2011 (17) austria patient’s autonomy beneficence kontaxakis et al., 2009 (18) greece quality of life length of expected life financial burden physician’s role of preserving life “slippery slope”/lead to abuse religion or personal beliefs regarding the third focused question, 11 articles (6-9, 11, 12, 14-18) highlighted variables that could cause the medical students to approve or disapprove ae, pe or pas practices. religion was the most significant variable that had a negative gutierrez-castillo a., et al. 7 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 22 december 2020 impact (n = 7) (6 8, 11, 12, 14, 16), followed by religiosity (n = 5) (6, 12, 14,15,18) as the second most significant variable. moreover, university of origin for the medical students (n = 3) (12, 14, 16) and previous experience with euthanasia or palliative sedation in a relative (n = 1) (11) were other named variables. non-significant variables included the followings: (i) age (n = 3) (6, 12, 17); (ii) previous academic experience regarding end-of-life decisions (n = 2) (11, 16); (iii) family income (n = 1) (12); and, (iv) size or place of residence (n = 1) (16). variable of gender in influencing the students’ opinions showed mixed results: significant (6, 16) and non-significant (11, 12, 14, 17, 18). similarly, for variable of medical students’ current academic year, three studies considered it to be significant (9, 15, 17) and one study reported it as irrelevant (6). the summarized results are shown in table 3. table 3significant variables that affect the posture of medical students towards euthanasia or pas article country significant variables nonsignificant variables gutierrez and gutierrez, 2018 (6) mexico religion (affiliation), religiosity, gender age, level (preclinical) jacobs and hendricks, 2018 (7) south africa religion (affiliation) bator et al., 2017 (8) canada religion (affiliation) marais et al, 2017(9) south africa level (clinical/preclinical) roelands et al., 2015 (11) belgium religion (affiliation) previous experience with euthanasia/ palliative sedation in a relative gender, duration of education and having had a course about end-of-life decisions lucchetti et al., 2014 (12) brazil religion (affiliation), religiosity, university characteristics age, gender, family income loria et al., 2013 (14) mexico university characteristics, religion (affiliation), religiosity gender hassan et al., 2013 (15) pakistan religiosity, level leppert et al., 2013 (16) poland gender, religion (affiliation), university characteristics size/place of residence, palliative care classes stronegger et al., 2011 (17) austria level gender, age kontaxakis et al., 2009 (18) greece religiosity gender euthanasia and physician-assisted suicide: a systematic review of … 8 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 22 december 2020 discussion despite the great diversity of opinions regarding ae, pe and pas, the percentage of approval for ae was lower than those of pe or pas in all analyzed scenarios (6-18). regarding ae approval, the study of kontaxakis et al. was the only one that reported an acceptance percentage higher than 50%, under special circumstances (18). if these results are compared to those of other groups, such as general population (19) or post-graduate students (11), the approval rate is usually higher than 50%. in contrast, physicians tend to show a negative attitude toward the topic (19, 20). the relevance of clinical experience, as a variable that could influence the acceptance of euthanasia or pas, was discussed by marais et al. (9) and hassan et al. (15), who reported different results depending on whether the students were at preclinical level (without active experience with patients) or on clinical rotations. marais et al. stated that higher clinical-level correlated to medical students’ greater empathy towards patients and respect for their autonomy. this correlation was demonstrated by a 20% difference in acceptance rate for ae between preclinical and clinical students, which dropped to 10% when they were asked if they will perform an assisted-dying procedure (9). hassan et al. found lower acceptance rate for euthanasia or pas among senior medical students; the attitude toward euthanasia, however, split to 50% against and 50% undecided, highlighting a higher percentage of indecision among seniors than freshmen (15). seniors stated that through clinical exposure, medical students become more aware that some diseases are incurable (15). however, a 2018 study by the authors of article (6) did not identify academic rank as a variable that could influence medical students’ attitude toward this topic. that study focused only on preclinical students in the first three years of medical school, justifying the uniformity of opinions and highlighting that exposure to patients affected medical students’ views regardless of their academic school year. until now, ae has been legalized in belgium (11), the netherlands (19), luxemburg (19), colombia (21), uruguay (21), and canada (8); three countries where ae is legal are european (11, 19), which justify that why the majority of the papers that met the present study’s inclusion criteria were published in this continent where the debate is open. in belgium, the only country included in this study where ae is currently legalized, roelans et al. reported that the approval percentage of the legalization of euthanasia to be 97% (11); a real legal environment, along with personal or professional experience in scenarios of assisted death, can create more favorable attitude among medical students (11). in canada, another country where these practices are legalized, the study by bator et al. was performed a year before the canadian laws’ modification to abolish the penalization of euthanasia (8). these political discussions may affect medical students’ attitude toward acceptance. religion is defined as a moral institution with a unified system of values, beliefs and practices related to what is considered sacred (22-23). religion is one of the most common gutierrez-castillo a., et al. 9 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 22 december 2020 variables mentioned by researchers to influence medical students’ views on euthanasia (6-8, 11, 12, 14-16, 18). moreover, religion affects several other areas of medicine, such as adherence to treatment or the decision-making process in high-risk procedures (22). in seven studies that described religion as a relevant variable, five found catholicism to be the most frequently self-reported religion (6, 11, 12, 14, 16), and less frequently ones were christianity (7) and islam (15). conversely, the medical students who considered themselves atheists or those who did not actively practice any religion tended to have a more positive view towards ae, pe, and pas for both patients and themselves (8, 11, 12, 14-16, 18). different, sometimes conflicting views can be observed among various religions. in 2007, sprung et al. studied the attitude of physicians towards pe; catholics, protestants and those with no religious affiliation compared to jews, greek orthodoxies or muslims had higher acceptance rate for therapy withdrawal (23). according to the roman catholic religion, practitioners are not obligated to ward off death at all costs, but they should not deliberately intervene to accelerate this process (24). the principle of “sanctity of life” categorizes life as a basic value as it establishes a direct relationship with god, and condemns any intervention that seeks to end this relationship (24). this principle could explain a more negative attitude toward ae and a mildly open posture toward pe. studies that described a majority of the catholic population and addressed the attitude of pe had acceptance rate higher than 50%, except one study from poland (16). leppert et al. did not separate the opinions in favor of or against ae, pe, or pas, and considered that the students’ view could be influenced by the statements of the last polish pope, john paul ii (16). regarding islam, negative attitude is generally stated toward the topic (7, 15, 23). the quran forbids self-harm and consenting to end life, which can be related to terminally-ill patients consenting to euthanasia (25). in islam, death is not the final destination, and therefore a believer should keep facing difficulties despite suffering to stay alive (25). however, the concept of religion has to be differentiated from religiosity or religiousness, referring to the influence of religion on daily life and intrinsic values. a positive experience with religion, mainly described as a growing spirituality or closeness to god, empowers patients to undertake greater risks in their treatments (22). regarding euthanasia, the greater the religiosity, the more opposition towards euthanasia (6, 15). this association is in line with our previous study’s findings, where the participants who were described as strong believers showed a predominant negative view towards ae and pas as well as inflexibility to change their original position in different scenarios (6). similarly, hassan et al. reported the lowest acceptance rate for ae, in a study involving predominately muslim participants, which 17% of them identified themselves as very religious (15). euthanasia and physician-assisted suicide: a systematic review of … 10 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 22 december 2020 the main arguments on euthanasia are related to the bioethical principles. autonomy, the most common argument stated by the medical students to support this practice (6-8, 11, 16, 17), derives from the greek auto (self) and nomos (rule) and refers to the individuals’ ability to make independent choices about their treatment (7). however, the state of autonomy in relation to euthanasia varies depending on whether autonomy is considered an intrinsic or moral value. in the former, patients would have free will in decision-making about their life or death (26), and in the latter — according to the kantian perspective—death threatens autonomy by eliminating the individual who would otherwise exercise autonomy (27). another argument to support euthanasia is relief from suffering, based on the principle of beneficence, as it considers the induction of death as a better alternative to avoid unnecessary suffering (28). the opponents of euthanasia argue that the elimination of suffering by death may not be the best alternative considering the followings: (i) increasing interest and research on palliative care and (ii) management of patients’ psychiatric conditions (e.g., depression), which may adequately relieve their suffering (28, 29). the most common arguments against these practices were as follows: (i) personal and religious beliefs (7, 8, 15, 18); (ii) risk of abuse, sometimes referred to as the “slippery slope” argument (7, 8, 16, 18); and, (iii) the physicians’ role in preserving life (7, 18). according to the argument of the “slippery slope”, if specific types of actions receive permission, then society will be coerced in permitting further morally wrong actions (30, 31). as a classic example of this argument, in the netherlands, where initially euthanasia was only approved for terminally-patients, the criteria were later expanded to allow euthanasia for chronically-ill patients and those suffering from severe psychiatric conditions. subsequently, euthanasia was legally allowed for incompetent patients, including children (31). opponents of the “slippery slope” argument state that for euthanasia to be considered as part of the risk of abuse argument, it must initially be condemned as morally wrong, an argument that in their opinion is dependent merely on personal experience (31). the final argument against euthanasia is the hippocratic oath’s view of the physicians’ role as healers. the hippocratic oath was first proclaimed in 400 bc and established one of the earliest codes of ethics for the medical profession (32). because of its tradition and relevance, it is still frequently taken by medical students during their training or upon its completion. one of its lines states that physicians will not give poison to anyone though asked to do so, nor they would suggest such a plan (6), a line that contradicts modern-day views of euthanasia. this presumptive allegiance to the hippocratic oath may explain why students from newer, urban, public, and bigger universities usually have a more positive attitude towards euthanasia and pas than students from older schools with more traditional values (12, 14, 16). the relevance of understanding the medical students’ attitudes towards euthanasia and gutierrez-castillo a., et al. 11 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 22 december 2020 pas lies not only in their values as presenttime insights, but also as input data to generate strategies that optimize their education and address future medical dilemmas. even though medical students usually have sufficient knowledge about euthanasia (15), they lack understanding of end-of-life care. eyigör stated that most medical students believe that they have not received a complete education on palliative care or training on communication skills regarding palliative-care patients (33). a better understanding of end-of-life care, including euthanasia and pas, for medical students, is essential, even if these practices are not currently legalized in their countries as related debates on the topic are not expected to end shortly. a major limitation of this study was the use of non-standardized questionnaires to research the main focused questions, as they provide varied responses that are difficult to categorize and analyze adequately. even if a students’ view on euthanasia or pas is markedly positive or negative, the format of the questionnaire may not accurately address the real answer. moreover, questions asked directly may obtain different answers than those asked indirectly; questions with clinical case scenarios or with only binary true or false answers could further alter the results. another limitation was the use of only two electronic databases, which could narrow results. this limitation could also limit the number of countries included in the study, which may prevent the global perspective from being reflected. conclusion seeking a global perspective from medical students over a particular course and then describing that perspective is complex. this complexity is not only due to the great diversity of opinions, but also due to the geographical, social, cultural, and temporal context influencing their decisions. this study aimed to objectively describe the medical students’ attitude towards ae, pe, and pas practices as well as to analyze the variables and arguments surrounding these practices. to summarize, pe and pas are more accepted than ae, and the most critical arguments in favor of these practices are the respect for autonomy and the relief of suffering. personal beliefs and the social role of the physician as a healer are the most common arguments against these practices. even though a consensus may not be reached easily or soon, continuing the discussion about end-of-life decisions is essential because the debates over these practices and the necessity for such decisions will unavoidably linger. medical students must be aware of different perspectives on the topic to make an informed decision in related circumstances. conflict of interests the authors declare that they have no conflict of interests. euthanasia and physician-assisted suicide: a systematic review of … 12 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 22 december 2020 references 1. vizcarrondondo fe. euthanasia and assisted suicide: the physician’s role. linacre q. 2013; 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[active euthanasia in colombia and assisted suicide in california]. orv hetil. 2016; 157(5): 174-9. 22. van ness ph, towle vr, o’leary jr, fried tr. religion, risk, and medical decision making at the end of life. j aging health. 2008; 20(5): 545-59. 23. sprung cl, maia p, bulow hh, et al. the importance of religious affiliation and culture on end-of-life decisions in european intensive care units. intensive care med. 2007; 33(10): 1732-9. 24. gula rm. euthanasia: a catholic perspective. health prog. 1987; 68(10): 28-34, 42. 25. ayuba ma. euthanasia: a muslim’s perspective. scriptura. 2016; 115(1): 1-13. 26. daly b, gokhale s, ramos-estebanez c. clinical and ethical judgment: a profound dilemma. neurology. 2014; 83(15): 1369-71. 27. sjöstrand m, helgesson g, eriksson s, juth n. autonomy-based arguments against physician-assisted suicide and euthanasia: a critique. med health care philos. 2013; 16(2): 225-230. 28. schmidt u. euthanasia, autonomy and beneficence. studia theologica. 2002; 56(2): 13251. 29. anonymous. stanford encyclopedia of philosophy: the principle of beneficence in applied ethics. [cited on august 2020]; available from: https://plato.stanford.edu/entries/principlebeneficence/ 30. pereira j. legalizing euthanasia or assisted suicide: the illusion of safeguards and controls. curr oncol. 2011; 18(2): e38-e45. 31. benatar d. a legal right to die: responding to slippery slope and abuse arguments. curr oncol. 2011; 18(5): 206-7. 32. kumar a. hippocratic oath, 21st century. indian j surg. 2010; 72(2): 171–5. 33. eyigor s. fifth-year medical students' knowledge of palliative care and their views on the subject. j palliat med. 2013; 16(8): 941-6. journal of medical ethics and history of medicine bioethics science: is it? jayapaul azariah founder president, all india bioethics association; past president, asian association of bioethics. *corresponding author: jayapaul azariah address: new no. 4, 8th lane, indiranagar, chennai 600 020, india. e-mail: jazariah@yahoo.com received: 12 jun 2009 accepted: 26 sep 2009 published: 06 oct 2009 j med ethics hist med. 2009; 2:18. © 2009 jayapaul azariah; licensee tehran univ. med. sci. abstract keywords: science, scientists, bioethics, immoral sciences, evolutionary ethics, morals. introduction the question “when did science originate?” is a difficult question to answer. origin of science is linked with human civilization, seeking the acquisition of knowledge. without writing, there could be no accumulation of knowledge, no historical record, no science etc (1). in other words “science” started with the development of written script. the present paper explores this question on the origin of science and the coining of the word ‘scientist’. related information is analyzed in the context of job-generation, with special reference to india in particular and asia in general. human mind has always sought after know ledge. both in the east and west, such knowledge was concentrated in religious activities. religion was the base for knowledge-based valued forma both western and eastern civilizations have linked moral teaching with theology followed by philosophy. new-knowledge-seekers about natural world, were called ‘natural philosophers’. there was a paradigm shift during industrial revolution in western world which culminated in modern science. the word “scientist” was coined during the 19th century. the paper examines whether natural philosophers could be called ‘scientists’? a short history of philosophical paradigm shift is given. although written moral and “ethical principles” were in vogue from the time of hammu rabi (1750-1795 bc), the phenomenon of bioethics is very recent. bioethics is a bridge among different sciences and a bridge to the future. the question is: is bioethics, by itself, science? the present paper is concerned with the quality of bioethics and about the nature of science during the next 30-50 years. science is value-free but bioethics is value-loaded. science does not proclaim any value whereas bioethics underlines the moral life and its value to survive. the paper examines two issues: can science be bioethics-friendly? and (ii) can bioethics be science-friendly? it appears that both science and bioethics are incompatible. we need to develop a new system of knowledge to include/infuse the bioethical-notion of values in (into) science. such a move may necessitate the development of an alternate but new model. bioethics is not a science-discipline. a new term to replace science is needed. elevating bioethics as an academic science may create job openings in india. j med ethics hist med 2009, 2:18 jayapaul azariah page 2 of 7 (page number not for citation purposes) 0f tion. in the eastern civilization health-related knowledge was linked with cultural and religious practices (festivals). similarly, society was equipped with extensive knowledge about food and hygiene. all these tenets formed the religious text of ayur (life) veda (knowledge or science). sushruta samhita and the charaka samhita are the ancient indian science treatises which embody moral rules, food habits, culture, ethics and medical practices. hence, the history of science from an eastern perspective dates back to time immemorial (2). written moral and ethical principles were in vogue from the time of hammurabi (1750-1795 bc) and also during the time of greek philosophers like hippocrates. similarly, the medical science of the arab world was well advanced. avicenna alias abu ali al-husain ibn abdallah ibn sina (980 1038, 11th century) of medieval islamic era was a well-renowned medical philosopher, physician with an ethical concern and a healer. islamic medicine flourished under the expertise of avicenna who may be considered as the father of modern medi cine. from then on, amir kabir of qajar dynasty founded the dar-ol-fonoon school in 1851 in iran which played a key role in the development of modern medicine (undated publication of tehran university of medical sciences and health services). in this paper, the progress of science is viewed from a western viewpoint in contrast with the eastern eco-theology. first, special emphasis is given to the circumstances associated with the coining of the word “scientist”. secondly, this paper analyses the principle: whether a word (scientist) which was coined in a given time period, can be used by modern writers to occasions much earlier in time, may be centuries earlier than the coinage of a given word. divide between east and west moral values and religious teachings were the societal fabrics. in western civilization, moral teaching began in monasteries while in the east, a learning system of “guru-schiya” (guru = teacher; schiya = disciple) empowered the society with values. in western educational system, “industrial revolution (ir)” played a key role in shaping the progress of science. prior to ir, european science was not modern science. but there is no precise time by which we can identify the onset of ir (3) leading to the birth of modern science. in europe, ir may have started around 1760 and extended to around 1830. economic, social and technological changes that took place during this era very gradually assured in cultural changes. hence, philosophical and cultural shifts which took place during preand post-industrial revolution are of importance. usage of the word “biology” one is not sure who coined the word “biolo gy”. but the earliest usage of the word can be traced. the following discussion is based on the personal email sent by prof jan frings 1 , of educa tiecentrum voor biologie (may 24, 2000). frings, mentioned prof. zeiss (4), while trac ing the history of biology, puts the date of usage of the word biology around 1802. he based his conclusion on information appearing in a book written by a german physician called gottfried reinhold treviranus, who entitled his book (1802) as “biologie order philosphie der lebenden natur fur naturforscher und aerzte (biology or philoso phy of the living nature for scientists and physicians). the german word “naturforscher” is translated as “scientists”. in this personal commu nication, prof frings wrote, quoting jordanova (1984) in 1801, lamarck made distinction (in physics of the earth) between meteorology (the theory of atmosphere), hydrogeology (theory of the earth crust) and biology (theory of the living organisms), according to zeiss, who refers again to jordanova, l.j. (1984) lamarck, (oxford universi ty press). prof frings endorses the above view of jordanova. what is more interesting is that (i) there was uncertainty as to the use of the word “biology” or philosophy to describe knowledge dealing with living nature; (ii) they considered nature as a living entity; (iii) they used a german word that is translated in current english as “scientists”; and (iv) medical professionals were referred to as “physicians”. prof. frings writes “apparently in that time the word 'biology' was used in discussions between scientists”. he uses the word “scientists” for the elite natural philosophers or the men of science. when was the word “scientist” coined? religious endeavors gave way to philosophical thinking. during the centuries before copernicus, men who gained new body of knowledge (science), in any field, were either known as "natural philoso phers" or "men of science”. later william whewell (1794–1866) coined the new and the specific word “scientist” only in the 19th century. whewell also invented new words like physicist, consilience, catastrophism, and uniformitarianism. he also suggested to michael faraday new terms like ‘anode’ and ‘cathode’. the question is: whether a “natural philosopher” can be conferred with the title “scientist” when this specific term was not in vogue. is it justified? scientific revolution in the context of “scientific revolution”, two points need to be considered. firstly, foundational work for the emergence of “scientific revolution” 1 frings’ email: j.frings@hccnet.nl mailto:j.frings@hccnet.nl j med ethics hist med 2009, 2:18 jayapaul azariah page 3 of 7 (page number not for citation purposes) was laid down by the celestial work of nicolaus copernicus (on the revolutions of the heavenly spheres, 1543) and andreas vesalius (1514-1564 on the fabric of the human body 1543,). in line with such advancement, galileo galilei (1564 – 1642) developed a telescope in 1610 and by 1640 his contribution has changed our view of the universe. second, such developments started the scientific revolution! was galileo a scientist? currently galileo galilei (1564-1642) is con sidered as a world renounced ‘scientist’. though he has contributed much to the growth of modern science of astrophysics and astronomy, his life achievements covers a period before the coining of the word “scientist”. are we justified in calling him a ‘scientist’? was he then a scientist? yes! he was a scientist par excellence. rightly, modern writers identify galileo as a “scientist” and write “galileo galilei was an italian scientist who formulated the basic law of falling bodies, which he verified by careful measurements. he studied, with his telescope, lunar craters, and discovered four moons revolving around jupiter and espoused the coper nican cause (5, 6). galileo’s formulation agreed with the scientific findings of the modern science and hence it is justified to call him a “scientist”! when the church affirmed a geocentric planetary system, galileo’s findings supported copernican stand of heliocentric solar system. however, copernican-galileo’s contention fails to secure cosmic validity because our solar system is not at the centre of the milky way galaxy. our sun is neither the biggest in the cosmos nor located at the centre of the galaxy. our solar system is tucked only at a peripheral region of the galaxy. at the centre of the galaxy there is that massive black hole which is a death trap. if one scientific contribution, valid for one period, does not fit into a holistic concept developed at a later time period, then, is it scientific? or is copernicus/galileo a “scientist?” their findings were true to a subsystem but not valid in the total and a bigger holistic system; for our solar system is not in the center of the galaxy! yet the copernican-galileo’s contribution is science and their findings are scientific. similarly, land mark advancements were made in medical and other fields. for instance, the english physician, william harvey (1578 – 1657) was the first western scientist who described correctly the systemic circulation and properties of blood. but, these distinguished people were not known in their life time as “scientists” since there was no such word in their day to day usage; the word “scientist” was coined later in time by william whewell in the 19th century (1794 – 1866). although the words “scientist” and “scientific” were not in vogue, later authors do recognize copernicus and galileo and harvey as “scientists” and their works as “scientif ic” (6). was darwin a scientist? before the time of darwin there were no sepa rate disciplines of botany and zoology. darwin studied the natural world for five long years and was known as a “natural philosopher” or “man of science”. timings of the newly-coined word “scientist” of william whewell coincide with the time period of darwin’s study on the natural history of galapagos islands. did any of his contemporary researchers refer to him as a ‘scien tist’? in fact, was darwin a scientist in the modern sense of the word? it is subject matter for further study. in 1831, william buckland (theologian and a scientist) provided the first account of giant fossil reptiles the megalosaurus (giant lizards) for which the english paleontologist, richard owen, coined the word “dinosaur” in 1842. can these eminent personalities be called scientists? yes they can. going back in time and history ancient indians were expert metallurgists. about 1600 ago, they developed a technology to produce rust-free-iron. next to the famous qutub minaret in delhi in india, there stands a 7 meter high, 6 tonne iron pillar which has been rust resistant for the past 1600 years even though it is exposed to rain and atmosphere. analysis of the metal in the pillar has revealed that it contains a very high level of phosphorus which, on the surface of the pillar, reacts with air and water to produce a protective layer of a compound called iron hydro gen phosphate hydrate (7). but modern “material scientist” and metallurgy technology may not be able to produce such a corrosion resistant iron product. were these ancient indian iron smiths, who developed such a rust-free iron technology, scientists in the modern sense of the word? yes they were. puranic (ancient) statements – are they scientif ic? going back in history and in time, one may recognize puranic literature, which contains statements regarding the universe and creation. one such statement is “in the beginning god created the heavens and the earth…. (bible genesis 1: 1). the contrast is that the phrase “the heavens” is in plural and “the earth” is in singular, which means that there are many heavens and only one earth. science records (as far as we know) that there is only one biosphere (earth) which is habitable. what does science say regarding the number of un iverses? the string theory portrays the constituents of nature as tiny wriggling strings, an elegant idea that in principle explains all the forces of nature but in practice leads to at least 10 500 potential universes j med ethics hist med 2009, 2:18 jayapaul azariah page 4 of 7 (page number not for citation purposes) (8). it should be understood that the number 10 500 is only a very rough estimate. it is about definite that there is more than one heaven (universe), multiverse. our universe is just one tinny bubble in a large froth of universes. ancient traditions also say that there are seven heavens. modern science agrees with this ancient ‘scientific’ statement of genesis. hence, the statement recorded in genesis 1: 1 (bible) is scientific. history of philosophical shift theological basis for knowledge explosion soon led to a shift towards philosophy and then finally to scientific revolution. passing through an age of enlightenment it has now come to genomic era. in post genomic age many more new words will be coined such as bioethics which is also an offshoot of philosophy. hence a short history of philosophical shift is provided. this shift was characterized into different ages of thought process like the crisis of european consciousness, age of enlightenment and romantic age and the age of scientific revolution. paul hazard coined the phrase “crisis of euro pean consciousness” to characterize the period (1680-1715) of consolidation of skeptical and rationalist thought, accomplished by bayle and fontenelle (among others) that was to provide the foundation of enlightenment philosophy (9). it is a period of transient values in terms of woman, marriage and sexual desires. societal and family values were in ferment. philosophical paradigm shift the french word “philosophe(s), philoso phies” stands for the new intellectuals who advocated reason as the primary source and legitimacy for authority. they distinguished themselves from traditional philosophers who concerned with abstract theories; and they, as public intellectuals, dedicated themselves to solving the real problems of the world. (10). these distinguished intellectual enlightenment thinkers pervaded into key domains of the political and religious worlds like education, theocracy and aristocracy, and the divine right of kings. one of the outcomes of such a paradigm shift is that of “scientific revolution”. paradigm shifts – various shades along with ir, similar knowledge-explosion in physics, astronomy, biology, human anatomy and chemistry brought in new ideas. such a paradigm shift led to the rejection of doctrines that had prevailed from ancient greece through the middle ages. moreover, medical knowledge gained during middle ages was sidelined. such paradigm shifts laid the foundation of modern science (6). howev er, such a rational view of life and the world did not satisfy human inner quest, and a group of intellectuals who distinguished themselves as people of the romantic era emerged. their aim was to return to nature and to belief in the goodness of humanity; the rediscovery of the artist as a su premely individual creator; the development of nationalistic pride; and the exaltation of the senses and emotions over reason and intellect. and also romanticism was considered as a philosophical revolt against rationalism (11). it is evident from the foregoing review that the progress of human thought in science had its own problems in holistic thinking. the ethical movements of 1870s triggered the emergence of modern ethics and bioethics. these movements provided a nonreligious-ethical basis for virtuous behavior, without a need for superna tural concepts to bring out humanity's inherent goodness or suppress any inherent evil (12). growth of ecological philosophy ir merged technological skill with economic growth. mechanization and steam powered equipment made inroads into ecological stability. western civilization, dominated by exploits of ir, is anthropocentric in its approach while the eastern civilization is cosmocentric, inclusive of approach es like (i) theocentric; (ii) biocentric; and (iii) ecocentric. ir made the soil unproductive which urged ernest haeckel (1869), the german biologist, to coin the word “ecology” (13). the word “oikos (gr)” meaning house is the root word for the concept of housekeeping of energy and also the discipline of economics (eco = house; nomics = management), the housekeeping of currency. the word ‘ecumenism’, the integrity of humankind, also has the same root word. if a balance between the ecology and economics is to be maintained then much emphasis must be given to human beings. in earlier days, ecology failed to include human beings in its fold. hence a new discipline of “environmental biology” emphasized the inclusion of human beings as part of the house of ecology and not apart from it. but it was not enough to bring about the ecological balance. foundation for environmental ethics ecology took deep roots during 1900-1930. aldo leopold extended the moral thinking into environmentalism in the context of damage caused to ecosystems as a consequence of economic growth. ir led to economic growth but degraded the biotic community. leopold employed phrases like “conservation ethics” (1933), “land ethics” and right and wrong. he defined ‘a thing is right when it tends to preserve the integrity, stability, and beauty of the biotic community. it is wrong when it tends otherwise’ (14). a right approach leads to ecobalance while a wrong approach leads to pollution and depletion of natural resources. such a paradigm shift created the necessity to launch a j med ethics hist med 2009, 2:18 jayapaul azariah page 5 of 7 (page number not for citation purposes) new discipline of “environmental ethics” which is now a sub-discipline of the major subject of bioethics. much of the environmental damage happened during the last quarter of the 20th century which created a milieu for damage to health, necessitating the development of bioethics and to address the ethical problems created by rapid growth of modern science and technology. modern science and its collateral bioethical problems modern science has the following components: (i) observation; (ii) hypothesis; (iii) experimental design; (iv) repeated experimental verification; and (v) formulation of theories. such an approach is mainly characterized by objectivity. subjectivity has no room. if objectivity plays a major role in scientific development then there is no room for values, virtues and morals; for science is value free. but application of science in human lifestyle has values. hence, technology is value-laden and it is not value-free. this decade (2010-20) is a critical period. ear lier we were taught that science, on the basis of its objectivity is value-free. it describes scientific truths but does not prescribe any value system. currently, many would argue that science is not value-free (value-neutral). another difficult position is that of morals as opposed to ethics. are morals different from ethics? the polarized position of “morals” vs. “ethics” is reinforced in the recent publication (15) of jones, namely “immoral advances: is science out of control?” which is disturbing. by implication, one can ask “can science/scientific knowledge be immoral?” jones wrote (15) “leaving aside special interest attitudes such as the fundamentalist christian denial of evolution, many controversies over scientific advances are based on ethical concerns”. in the past, the main areas of contention have included nuclear weapons, eugenics and experiments on animals, but, in recent years, the list of "immoral" research areas has grown expo nentially. in particular, reproductive biology and medicine have become ripe for moral outrage: think cloning, designer babies, stem-cell research, human-animal hybrids, and so on. other trouble some areas include nanotechnology, synthetic biology, genomics and genetically modified organisms or so-called "franken foods” (15, emphasis is mine). challenge posed to bioethics is phenomenal! how could scientists who are engaged in the above disciplines with “immoral research areas” with a strong conviction in evolu tionary ethics, with no built-in moral component, be fully conscious of their ethical obligations? can we call bioethics as a science discipline? dr. van rensslaer potter ii of the department of oncology, university of wisconsin coined the word “bioethics” by combining two words: “bios=life” and “ethics” (moral actions; right or wrong), borrowing the word from moral philoso phy, applied philosophy and normative philosophy (16). bioethics is a bridge between arts and sciences. it should also serve as a bridge to the future and a bridge between sciences. but it heavily leans towards philosophy to solve bioethical problems that are raised by science and technology. potter did not mean to develop bioethics as another discipline of science. therefore, the question comes back: is bioethics, by itself, science? no, it is not! science is value-free but bioethics is value loaded. can science be bioethics friendly? it is predicted that the global population may reach 9 billion in 2050. it is almost equal to adding one more china and india. this population will look for water and food. but the water resources are fixed. water is not a renewable resource. per capita consumption will naturally be reduced and some section of the population will go thirsty all the time (17). this is a greater risk-in-waiting. this is related to food production. during the current year -2009about 246 districts in 10 major indian states have received deficient rain (29% less) affecting the rice production by 10 million tones due a shortfall of 5.7 hectares in paddy sowing (18). india will face a severe food shortage in 2030-2050. when its population reaches 1.5 billion, it may face a shortage of about 45 million metric tones of food grains. these hungry billions will be needing food, water and other resources which will be in acute shortage. whenever natural resources run short then distributive justice will be affected. such a situation will necessitate the introduction of genetically-modified (gm) food crops namely "franken foods”, which has an inherent risk of producing environmental mimic of the female reproductive hormone estrogen (17). innumerable number of environmental estro gen-mimics has brought forward the onset of early puberty in girls. when the natural or normal age of onset of puberty is between 13 and 15, is it moral to make a tender girl of seven years old to become sexually mature? a recent study of 17,000 girls in the usa indicated that 7 percent of white and 27 percent of black girls exhibited physical signs of puberty by age seven (17, 19, 20). these girls are “miniature-women” who can be made pregnant when they are still girls, before they reach the womanhood! what are the socio-bioethical impacts of such an early onset of puberty? environmental estrogen-mimics do have an impact on male reproductive capabilities. it subjects the society to a process of “feminization” of males. infertility among males will be on the rise and the society may move towards a unisex situation (17). j med ethics hist med 2009, 2:18 jayapaul azariah page 6 of 7 (page number not for citation purposes) can bioethics be science-friendly? bioethics is not the ethics of biology but it is included in its scope. it is neither the philosophy of biological sciences, but it can’t survive without it. hence, it is only a bridge between disciplines. science and bioethics are incompatible in terms of values. currently, some would say that modern science is replete with values and most scientists are conscious of their ethical obligations. there are many point of coherence/agreement between science and bioethics, especially in the science of environmental ethics, bioscience ethics, medical ethics, psychology and all sciences full of values (pollard, irina 2009 personal communication). there is a need to further reinforce and develop a new system of knowledge to include/infuse the bioethical-notion of values in (into) science. it is imperative that we identify the confounding factors that go against our value systems. evolutionary ethics with no morals! jones briefly touches the issue of “christian denial of evolution” (15). the foundational basis of evolution is natural selection (ns) which is blind, purposeless and nondirectional (21). both philosophers and scientists endorse that ns has neither intentionality nor planning since genes have no intentions to consider; genes are not conscious (22). it is absolutely clear that because ns does not distinguish between what is right and what is wrong or between good and bad, there is no room for a moral choice! the doctrine of evolutionary ethics stands on the following three pillars: (i) chance and necessity; (ii) selfish gene; and (iii) the law of “survival of the fittest” with no room for the weak and the needy. job generation in bioethics and india the obstacle for job creation is that science is objective whereas bioethics is subjective and the fusion of both spheres appears difficult. bioethics is not a science discipline! the barrier to elevate bioethics as an academic science discipline is fortified by the fact that if an indian student qualifies for a degree in bioethics, then he/she will not find a job since there are no job-openings in bioethics, neither in universities nor in any of the indian medical institutions. no indian educational institution has the discipline of bioethics in its regular academic curriculum leading to a terminal public written exam. in india, there is no “depart ment of bioethics” or chair in any of the universi ties. hence, if a student qualifies for phd degree in bioethics, he/she will not find a job since none of the jobs is earmarked for bioethics. in india, the era of pursuing knowledge for knowledge sake is a thing of the past. now it is knowledge for stomach (job) sake. during 1997, bioethics was introduced as an optional subjection in bachelors in zoology degree course of the university of madras. but no student has opted for the course for the simple reason it does not lead to find a job. if one takes the years 2030 or 2050 as future reference points, then will humanity be able to identify itself now, most if not all, the confounding factor that will go against all ethical norms? do we know what type of jobs we need to generate to match the type of science that may need to sustain the society? is it imperative to identify the con founding factors? what we know are the following three confounding areas: (i) immoral sciences as listed by jones (15), may be replete in academic circles; (ii) educational climate may be saturated by evolutionary ethics which has absolutely no moral component; and (iii) there will be a shortage of natural resources like food and water. hence, any job generation must be related and be linked to the above three areas. traditional subjects may have to be abandoned. conclusion therefore, there is a need to develop a new system of knowledge to include/infuse the bioethi cal-notion of values in (into) science. such a move may necessitate the development of an alternate but new model with a new definition of science and scientist, or a new term to replace the word “science” and a new phraseology; therefore, are needed. there are barriers and obstacles to make bioethics science-friendly or science bioethics friendly. “the best time to plant a tree is 20 years ago. the next best time is today.” what are the confounding factors that will go against all ethical norms during the years 2030/2050? in 20 years time, will the upkeep of social values and virtues be enhanced or deteriorated? if latter is true then what are the confounding factors? any remedial effort may have to begin now. j med ethics hist med 2009, 2:18 jayapaul azariah page 7 of 7 (page number not for citation purposes) references 1.robinson a. decoding antiquity: eight scripts that still can't be read. http://www.newscientist.com/article/mg20227106.000-decoding-antiquity-eight-scripts-that-still-cant-be read.html (accessed on sep 2009) 2. azariah j. the long history of indian medical system and current perspectives in health care bioethics. in: peppin jf, cherry mj, eds. the annals of bioethics. regional perspectives in bioethics.netherlands: swets & zeitlinger; 2003. 3. anonymous. industrial revolution. http://en.wikipedia.org/wiki/industrial_revolution (accessed on sep 2009) 4. zeiss f. natuurlijke historieën; geschiedenis van de biologie van aristoteles tot darwin. boom, meppel; 1995. 5. anonymous. galileo galilei. http://www.gap-system.org/~history/mathematicians/galileo.html (accessed on sep 2009) 6. anonymous. scientific revolution. http://en.wikipedia.org/wiki/scientific_revolution (accessed on sep 2009) 7. anonymous. a rust-free iron pillar yields its secret at last. the naked scientists: science radio & science pod casts 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1999, p. 400. journal of medical ethics and history of medicine original article an evaluation of adherence to ethical codes among nurses and nursing students mostafa bijani1, fariba ghodsbin2, sorur javanmardi fard3, fateme shirazi4, farkhonde sharif 5, banafsheh tehranineshat1* 1phd candidate in nursing, student research committee, shiraz university of medical sciences, shiraz, iran. 2phd candidate in nursing, student research committee, quality improvement in clinical education research center, school of nursing and midwifery, shiraz university of medical sciences, shiraz, iran. 3department of community health nursing, school of nursing and midwifery, shiraz university of medical sciences, shiraz, iran. 4student research committee, shiraz university of medical sciences, shiraz, iran. 5professor, community based psychiatric care research center, school of nursing and midwifery, shiraz university of medical sciences, shiraz, iran. corresponding author: banafsheh tehranineshat address: department of nursing, school of nursing and midwifery, shiraz university of medical sciences, zand st., nemazee sq., postal code: 7193613119 shiraz, iran. email: minatehrani51@yahoo.com tel/ fax: + 98 9177177786 received: 10 oct 2016 accepted: 5 jul 2017 published: 5 jul 2017 j med ethics hist med, 2017, 10: 6 © 2017 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract ethical codes are instructions that shape ethical behavior and determine which values and beliefs should be accepted. these codes act as a practical guideline in the nursing profession. the present study aimed to compare adherence to ethical codes between the nursing students and working nurses of valiasr hospital, affiliated with fasa university of medical sciences in fars province, iran. in this descriptive-analytical study, the data collection tool was nurses’ self-reporting questionnaire on adherence to ethical codes devised by mahdavi lenji and ghaedi heidari, who have also confirmed its validity and reliability. this questionnaire consisted of 3 sections: personal information, ethical codes related to clinical service provision (23 items), and relationship with the treatment team (8 items). a total of 400 individuals (178 nursing students and 222 nurses) were selected through census sampling method. data were analyzed through descriptive, anova and t-test statistical methods using spss 22 software. there was no significant difference between nurses and nursing students in terms of adherence to ethical codes related to clinical service provision, but the latter achieved a significantly higher score in codes on relationship with the treatment team (p = 0.04). although the score of nursing students was higher than nurses in comparison to the treatment team, they lacked the necessary technical competency to adhere to ethical codes. therefore, we recommend that nursing instructors and educational managers pay more attention to teaching nursing ethics and supervise their implementation and practicality in clinical environments. keywords: adherence, ethical codes, nursing students, registered nurse, nursing ethics j med ethics hist med 10: 6, july, 2017 jmehm.tums.ac.ir mostafa bijani et al. page 2 of 8 introduction in recent years, healthcare communities have decided to formulate their norms and values as codes of ethics (1). considering cultural differences, ethical values in nursing and healthcare as a humanoriented system have attracted a lot of attention (2). advancements in technology, increased costs of healthcare, and organizational changes in the society and the healthcare system have created significant problems and challenges for nurses. as a result, they need professional competence and a framework provided by code of ethics to make correct judgments during work, and that is why the development of ethical codes is considered so vital (3, 4). ethical issues are rather frequent in the nursing profession, and in order to resolve complicated ethical problems, we need a basic theoretical understanding of ethical decision-making (5). designing a nursing code of ethics is a way to express shared values and responsibilities specific to this profession (6). these values guide the decisions and actions of nurses and provide information to the nursing community throughout the world (4). ethical codes are principles and value systems in a profession based on which the ethical behavior of its members is evaluated (7). the code of professional ethics for nurses was first designed by the international council of nurses (icn) in 1953. this code specified the nurses’ professional responsibilities toward patients, the nursing profession, coworkers, other professional healthcare team members, and the society (3). in iran, there have been several attempts to design a code of ethics in medical fields, with an emphasis on religious values and their integration into these codes (8). the ministry of health and medical education (mohme) established the medical ethics research center in 1993 and formed medical ethics research committees on the national level in 1997 (9). another important measure in this regard was designing the national code of ethics delivered in early 2011(10) for professional nurses working in educational, research, management, health, and clinical sectors at all levels. this code has been revised and updated when necessary (11). studies have shown that knowledge and application of ethical codes is not so practical for nurses (12). many nurses do consider the code of professional ethics when faced with ethical issues, but do not act upon it. in most cases, they do not possess the power and support to react according to the code, and sometimes they simply do not know what to do (13). a few studies have been conducted on the level of adherence to ethical codes in nursing students and nurses, but the results are contradictory. for instance, according to one study, 70% of patients, 86% of nurses and 53% of nurse managers described nurses' adherence to ethical codes as satisfactory (14). yet another study showed that only 41.8% of patients found nurses' adherence to ethical codes to be satisfactory (15). joolaee et al. stated that only 39.7% of patients were highly satisfied with nursing services (16). according to borhani et al., although most nurses and nursing students were aware of nursing ethics and its significance in their profession, they were highly concerned about their own capability to implement ethical codes in clinical settings (17). if we can train strong nurses who are capable of providing comprehensive and holistic care, the nursing profession will improve. consequently, the nurse's influence on the healthcare system will increase, which can result in higher satisfaction of healthcare beneficiaries (18). nursing students constantly attend educational hospitals and encounter ethical issues involving nurses and patients (15). therefore, an appropriate plan to improve ethical performance, clinical decision-making and nursing services should be based on the required ethics and training needs. hence, it is vital to evaluate adherence to ethical codes among nursing students as the future employees of the healthcare system, and nurses as individuals offering healthcare services. the majority of the qualitative studies on nursing ethics conducted in iran did not investigate adherence to ethical codes and the effect on nursing students and nurses. thus, in order to provide a background and predict the performance of future nurses in terms of ethical codes, enhance the quality of clinical decision-making, offer safety care, and draw a comparison between the current and future nurses, this study was conducted using a quantitative method. the study aimed to compare adherence to the code of ethics among the nursing students and nurses in valiasr hospital, affiliated with fasa university of medical sciences in fars province, iran. method this was a descriptive-analytical study designed to compare and evaluate observance of ethical codes among the nursing students and working nurses of valiasr hospital, affiliated with fasa university of medical sciences. research population consisted of full-time working nurses holding a bachelor’s degree or higher, as well as nursing students in their junior and senior years. sampling was done via nonrandom census method across all valiasr hospital wards, except the vip (very important person) wards. as a result, 400 individuals (178 nursing students and 222 nurses) were selected to participate in the study. inclusion criteria for the nursing students were: enrollment in a bachlor’s program, not being a guest or transfer student, and having no prior work experince in official healthcare centers. inclusion criteria for the nurses were: a bachelor’s or j med ethics hist med 10: 6, july, 2017 jmehm.tums.ac.ir mostafa bijani et al. page 3 of 8 higher degree, and a minimum of one month’s experience as a professional nurse in different wards. researchers went to all wards in three working shifts from may to auguest 2016. they stated the aim of the study and collected data after obtaining a written informed consent form all participants. data were collected from the participants by a questionnaire consisting of 3 parts. in view of ethical considerations, permission was obtained from hospital management, and confidentiality of information was assured. the nurses' self-reporting questionnaire on adherence to ethical codes was used as the data collection tool, which was devised by mahdavi lenji and ghaedi heidari (8) based on the code of ethics published by the ministry of health and medical education (19). the questionnaire consisted of 3 sections: 1) demographic information such as age, gender, work experience, education and academic semester; 2) questions on ethical codes related to clinical service provision (23 items); and 3) codes related to the treatment team (8 items). responses were graded based on a five-degree likert scale (5: always, 4: often, 3: sometimes, 2: rarely, and 1: never). the minimum and maximum total scores were 23 and 115 for the second section, and 8 and 40 for the third section, respectively. the questionnaire was given to 7 nursing and medical experts in the field of professional ethics to confirm its content and face validity. the questionnaire was given to 15 nursing students and 15 nurses in order to verify its reliability, which was then calculated by cronbach’s alpha to be 0.90% (8). data were analyzed through inferential and descriptive statistical methods (anova and t-test) using spss 22. this study was approved by the research council and the ethics committee of fasa university of medical sciences, fars province, iran (code: ec-95090). results our findings showed that of the 400 subjects, 222 (55.5%) were nurses and 178 (44.5%) were nursing students. there were 145 men and 77 women among the nurses, with an average age of 31.36 ± 1.07, of which 210 had a bachelor’s degree in nursing and 12 had a master’s degree. moreover, 109 nursing students were men and 69 were women, with an average age of 22.83 ± 3.52. in the section related to clinical service provision, average total scores were 85.75 ± 13.20 and 84.52 ± 17.39 for nursing students and working nurses, respectively. the t-test did not show any significant difference between nurses and nursing students in this area. however, in the section related to relationship with the treatment team, average total scores of nursing students and working nurses were 30.18 ± 5.03 and 29.01 ± 6.23, respectively, and the t-test revealed a significant difference between the two groups (p = 0.04 and t = 2.04) (table 1). table 1 comparison between the average scores for adherence to ethical codes among nursing students and nurses adherence to ethical codes group mean ± sd t-test clinical service provision nursing students 85.75 ± 13.20 t = 0.77 p = 0.42 nurses 84.52 ± 17.39 relationship with the treatment team nursing students 30.18 ± 5.03 t = 2.04 p = 0.04 nurses 29.01 ± 6.23 p value < 0.05 was considered significant. sd: standard deviation in the section on ethical codes related to clinical service provision, average total scores were 86.70 ± 16.03 and 82.22 ± 14.52 for women and men, respectively. the t-test revealed significant differences in this area (p = 0.006, t = 2.76). as regards the relationship with the treatment team, average total scores were 30.28 ± 5.77 and 28.23 ± 5.49 for women and men, respectively. moreover, there was a significant difference between the two groups according to t-test results (p = 0.01, t = 3.45) (table 2). table 2 comparison between the average scores for adherence to ethical codes among nursing students and nurses based on gender adherence to ethical codes group mean ± sd t-test clinical service provision female 86.70 ± 16.03 t = 2.76 p = 0.006 male 82.22 ± 14.52 relationship with the treatment team female 30.28 ± 5.77 t = 3.45 p = 0.001 male 28.23 ± 5.49 p value < 0.05 was considered significant. sd: standard deviation the findings showed that the highest average scores for adherence to ethical codes pertained to "respecting the client/patients’ privacy when performing nursing interventions", which were 4.20±0.88 and 3.96 ± 1.01 for nursing students and nurses, respectively. additionally, the lowest average score of adherence to ethical codes pertained to "introducing themselves and stating their title and j med ethics hist med 10: 6, july, 2017 jmehm.tums.ac.ir mostafa bijani et al. page 4 of 8 professional role" (3.15 ± 1.16) in nursing students. for nurses, the lowest score belonged to "consulting the hospital ethics committee about decision-making when confronting ethical challenges" (3.09 ± 1.03) (table 3). table 3 the average scores for adherence to ethical codes in nursing students and nurses nurses nursing students items mean ± sd mean ± sd 3.45 ± 0.85 3.15 ± 1.16 introducing themselves and stating their title and professional role 3.85 ± 0.94 3.98 ± 0.82 providing all nursing interventions while respecting the clients/patients and preserving their dignity 3.91 ± 0.92 3.93 ± 0.88 considering the clients/patients’ demands regardless of their age, sex, race, economic status, lifestyle, culture, religion, political beliefs and physical abilities 3.84 ± 0.93 3.85 ± 0.81 performing nursing care based on current knowledge and common sense 3.82 ± 0.97 4.06 ± 0.80 establishing gentle behavioral and verbal communication with the clients/patients in a way that wins their trust, and attempting to understand their needs and concerns 3.56 ± 0.93 3.42 ± 0.96 obtaining the patients’ or their legal guardians’ consent before performing any nursing interventions, and providing sufficient information in the process 3.59 ± 0.95 3.29 ± 0.89 having a complete knowledge of the risks when presenting or applying a new product in clinical practice, and providing the client/patient with the necessary information about the benefits and disadvantages of the product to promote informed decision-making 3.73 ± 0.98 3.85 ± 0.71 being aware that no one has the right to consent in place of a competent adult. in case of children, giving the consent is one of the legal guardian’s responsibilities. 3.47 ± 0.95 3.26 ± 1.06 educating the clients/patients and their families in order to empower them within the framework of their specific care plan and discharge program 3.67 ± 0.99 3.77 ± 0.79 starting the necessary intervention without the client/patient’s consent only as an exception and in case of an emergency, when immediate therapeutic action is required to save the client/patient’s life 3.51 ± 1.01 3.69 ± 0.75 performing the appropriate intervention based on existing standards and client/patient’s higher interests when obtaining the informed consent or realizing the client/patient’s consent or wishes is not possible 3.58 ± 1.08 3.86 ± 0.82 applying safety measures to ensure that nursing interventions are harmless, and when necessary, consulting other health team members 3.56 ± 1.15 3.89 ± 0.83 considering all the information given or obtained during the care process as professional secrets, and not revealing them without the client/patient’s approval except in legally permissible cases 3.49 ± 1.09 3.88 ± 0.88 employing the medical information of clients/patients only for health-related purposes (such as treatment or research) and in the patients’ interest, and informing the clients/patients that part of their medical record might be disclosed to other team members for medical consultation 3.31 ± 1.20 3.65 ± 0.95 using the client/patient’s medical information in research or education only with their permission, and presenting the results without mentioning the name, address or any other information that could lead to identification of the patient 3.96 ± 1.01 4.20 ± 0.88 respecting the client/patient’s privacy when performing nursing interventions j med ethics hist med 10: 6, july, 2017 jmehm.tums.ac.ir mostafa bijani et al. page 5 of 8 3.80 ± 0.96 3.94 ± 0.80 respecting the patient’s bill of rights 3.66 ± 0.84 3.52 ± 0.98 providing care for injured individuals or clients/patients in emergency situations, even outside the workplace 3.73 ± 0.90 3.80 ± 0.92 respecting clients/patients’ right to change the charged nurse or other healthcare providers in case of dissatisfaction or any other problem, and trying to satisfy the clients/ patients in this matter as much as possible 3.82 ± 0.88 3.73 ± 0.89 informing the authorities who have sufficient power to improve the conditions in case of noticing a violation of standards of care 3.68 ± 0.86 3.71 ± 0.98 reporting any complaints or problems of the clients/patients to the ward supervisor 3.89 ± 0.96 3.96 ± 0.86 avoiding any action, even by the client/patient’s request, that requires ethical, legal or religious violation 3.63 ± 0.82 3.31 ± 1.17 assisting the clients/patients who spend the last days of their lives to accept the reality and to appropriately plan their demands, including performing religious practices or recording their wills 3.82 ± 0.88 3.75 ± 0.88 cooperating with medical team members, the clients/patients and their families to offer nursing interventions more efficiently 3.69 ± 0.87 3.56 ± 0.87 helping the clients/patients or their legal guardians make decisions about nursing interventions 3.73 ± 0.89 3.74 ± 0.94 sharing one’s professional knowledge and experience with other colleagues 3.75 ± 0.93 3.89 ± 0.82 establishing a good relationship based on mutual trust with the medical team 3.76 ± 1.01 0.86 ± 4.09 having a respectful conduct toward other nurses, professors and students 3.58 ± 1.00 3.93 ± 0.76 discussing any conflicts of interest in the care of clients/patients with senior colleagues and principals, and giving priority to preserving the clients/patients’ rights 3.60 ± 1.01 3.95 ± 0.81 establishing a respectful professional relationship with coworkers in various levels, including head nurses, supervisors, nursing directors and department heads 3.09 ± 1.03 3.27 ± 1.16 consulting the hospital ethics committee about decisionmaking when confronting ethical challenges sd: standard deviation the anova test did not reveal significant differences between the nurses’ education and work experience and the ethical codes related to clinical service provision or relationship with the treatment team. likewise, there was no relationship between the students’ semester and the ethical codes in the domains of clinical service provision and relationship with the treatment team. discussion findings of this study showed that there were no significant differences between the average scores of nursing students and professional nurses regarding their adherence to ethical codes related to clinical service provision. however, a significant difference was observed in the section on codes for relationship with the treatment team, denoting that the nursing students adhered to these ethical codes more than the working nurses. this could be due to the students’ academic training at the university and during training workshops on ethics. it is worth mentioning that unlike the students, nurses were faced with a heavy workload, low nurse to patient ratio, and lack of time. in mahdavi lenji and ghaedi heidari’s study in iran, there were no significant differences between the performance of students and nurses regarding codes related to clinical service provision, while nurses had better adherence levels in terms of codes pertaining to relationship with the treatment team (8). erdil and korkmaz believed that since nurses are faced with ethical problems in their work, they have to have the ability to identify them, and this can only happen when nurses learn the theoretical concepts of ethics during their academic education (20). verpeet et al. found that an ethical code could serve several functions, for instance support nurses’ professional identity, and provide directions for nursing practice. moreover, they expressed viewpoints on concept, including an investigation of nurses' duties in a communicative one, and proposed that particular attention should be j med ethics hist med 10: 6, july, 2017 jmehm.tums.ac.ir mostafa bijani et al. page 6 of 8 paid to the personality of nurses and to the nature of nursing practice as a communicative activity. verpeet et al. insisted that we need to develop effective and practical tools to enhance nursing ethics, for instance by developing workable methods and educational courses. such measures will empower nurses and encourage them to provide input as they reflect on the ethical issues that are dealt with in the code, and help them utilize the code in their practice (4). in this regard, hartrick doane stated that we need to focus on nursing teachers and cooperation among clinical training institutions, staff, and most importantly students, and these trainings need to be continuous and based on organizational and environmental factors (21). in this study, the highest average scores for adherence to ethical codes among both nursing students and nurses pertained to "respecting the client/patients’ privacy when performing nursing interventions”. the lowest average scores pertained to "introducing themselves and stating their title and professional role” in nursing students, and “consulting the hospital ethics committee about decision-making” when confronting ethical challenges" in nurses. in a dobrowolska et al. study on assessment and comparison of international council of nurses (icn) codes of ethics in uk, ireland, holland, and poland, findings indicated that in all those countries, respect for patients had the highest priority for nurses in their professional practice. in the present study, both groups achieved high scores with regard to respect for patients as well, which is demonstrated in the section related to clinical service provision (22). mohajjel aghdam et al. found that from the patients’ perspective, nurses’ highest performance pertained to "respectful behavior toward their colleagues, superiors and nursing students" (45.8%), and their lowest performance was related to “introducing themselves to patients by announcing their names, roles and job titles" (9.8%) (15). in a study by khaki et al., the highest average scores for adherence to professional ethics pertained to "preserving patients' privacy and respecting human rights as well as patients’ social values and religious beliefs when offering nursing care". in the same study, nurses achieved the lowest score in relation to "consultation with hospital ethics committees when confronted with ethical challenges, delivering care outside the work environment, and introducing themselves and announcing their professional roles to patients" (23). however, borhani et al. found that 81.2% of the patients were dissatisfied over the invasion of their privacy (17), and according to dadkhah et al., most patients believed that "nurses did not respect their privacy and boundaries" (24). these findings were therefore not in line with those of the present study, which could be due to the differences between the social and educational levels of the employed manpower. it is obvious that in spite of the managers’ and nursing educators’ emphasis on adherence to professional ethics, nursing education has been impractical, and measures will need to be taken to enable and empower students and nurses to resolve this issue. the results of this study revealed a significant relationship between gender and adherence to ethical codes related to clinical service provision and relationship with the treatment team. in both domains, women achieved higher average scores than men. in jafari et al. study the total average score for adherence to the nursing code of ethics was higher among female students in comparison to their male counterparts as well (18). quoting from docket et al., martin et al. stated that female students had a significantly higher moral reasoning score than male students at the time of initial registration and during academic education (25). di you et al. found that in the nursing profession, women have higher moral sensitivity in comparison to men (26). forte stated that gender differences with regard to adherence to codes of ethics and the ability to resolve ethical conflicts are caused by the different methods that men and women choose and implement to resolve conflicts (27). in the present study, no relationship was observed between age or work experience and the level of adherence to the code of ethics. in a study by numminen et al., no significant relationship was observed between age or gender and the students’ understanding of ethical codes (7). in another study by numminen et al., there was a significant relationship between age and work experience, and learning (28). a study by auvinen et al. revealed that students who had faced real ethical problems during their education had better judgment compared to students who had not; moreover, senior students showed better judgment in comparison to freshmen (29). the code of ethics used in the present study was published by the ministry of health and medical education in 2011 and was not new at the time of research. when we were explaining the aim of our study to the nurses, however, many of them did not even know that these codes existed, which indicates lack of a proper system of informing the nurses. tadd et al. surveyed the nurses’ views on the content and implementation of the codes and their usage in nursing activities in six european countries. most of the participants had little understanding of the codes. they were unfamiliar with the contents of the codes and believed they were of little clinical and practical value due to the numerous obstacles in their effective implementation (30). ethical codes are generally specific to the religion, culture and characteristics of a society, and therefore studies conducted in other countries are only appropriate in those contexts. consequently, we might not be able to draw an accurate comparison between those studies and the present research. in j med ethics hist med 10: 6, july, 2017 jmehm.tums.ac.ir mostafa bijani et al. page 7 of 8 any case, there are obstacles in applying these codes that have to be removed before we can expect their efficient implementation in clinical settings. enactment of nursing codes of ethics requires coordination and cooperation of all nursing officials and custodians toward removing the obstacles that hinder their application as a practical charter in hospitals. conclusion based on our findings, nursing students had better adherence to the ethical codes on relationship with the treatment team compared to nurses. nevertheless, they lacked the necessary know-how to adhere to the codes on clinical service provision, and were not much different from the nurses in this regard. therefore, to improve adherence to ethical codes, certain measures will need to be taken, for instance coherent training courses must be offered on professional ethics during academic years and continuing education. also, implementation of policies related to professional ethical codes should be enforced and supervised. hence, it is necessary that researchers investigate the effective factors on adherence to nursing professional codes of ethics through qualitative research. further studies need to be conducted in order to design and standardize nurses’ professional ethical practice assessment tools in accordance with the ethical codes for nurses in iran. in addition, nursing researchers should examine the facilitators and inhibitors of observing ethical codes among nursing students and nurses, and try to enhance implementation of nursing professional ethics in clinical environments. acknowledgement this study was financially supported by the department of research and technology vicechancellor of research at fasa university of medical sciences (grant no, 95090). hereby, the authors send their most sincere thanks and appreciation to assistants and all the working nurses at valiasr hospital, affiliated with fasa university of medical sciences, and the nursing students who participated in this research. the authors also wish to thank the research consultation center (rcc) at shiraz university of medical sciences for their invaluable assistance in editing this study. conflict of interest the authors declare no conflict of interest. j med ethics hist med 10: 6, july, 2017 jmehm.tums.ac.ir mostafa bijani et al. page 8 of 8 references 1. heymans r, van der arend a, gastmans c. dutch nurses’ views on codes of ethics. nurs ethics. 2007; 14(2):156–170. 2. shahriari m, mohammadi e, abbaszadeh a, bahrami m, fooladi mm. perceived ethical values by iranian nurses. nurs ethics. 2012; 19(1):30-44. 3. heikkinen a, lemonidou c, petsios k, 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procedures on nearly dead patients: part ii (shiite jurisprudents’ viewpoints) nazafarin ghasemzadeh1, fariba asghari2, mandana shirazi3, fatemeh faramarzi razini4, bagher larijani5* 1phd candidate in medical ethics, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. 2associate professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. 3associate professor, department of medical education, school of medicine, tehran university of medical sciences, tehran, iran. 4mentor, department of jurisprudence and islamic law, urmia university, urmia, iran. 5professor, endocrinology and metabolism research center, endocrinology and metabolism clinical sciences institute, tehran, iran; medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. corresponding author: bagher larijani address: no.23, 16 azar ave., keshavarz blvd., tehran, iran. email: larijanib@tums.ac.ir tel: (+98) 21 66 41 96 61 received: 23 jun 2018 accepted: 13 aug 2018 published: 25 dec 2018 j med ethics hist med, 2018, 11: 15 © 2018 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract part one of the present study presented practical islamic jurisprudential rules and investigated their application to performing medical procedures on nearly dead patients. it was contended that a dying patient could be used in medical education in cases where there is no alternative method, provided the patient voluntarily consents and is not offended. part two of the present study addresses the issue by referring to the opinions of islamic jurisprudents to find an appropriate solution to a challenging question in medicine, namely, whether clinical training of medical students on the dying person is permissible. for this purpose, istiftas (petitions or requests for a fatwa) were sent to prominent contemporary shiite jurisprudents to solicit their opinions on the use of dying patients for medical education. after exploring the existing views, it was finally concluded that the majority of the jurisprudents allowed the practice in cases of “necessity” and provided that the principles of “no harm” and “consent” were strictly observed. all these terms are found in jurisprudential rules, and we reached the conclusion that shiite jurisprudents considered this type of training permissible under certain circumstances and in accordance with jurisprudential rules. keywords: medical training, dying patient, opinions of contemporary shiite jurisprudents, islamic jurisprudential rules mailto:larijanib@tums.ac.ir j med ethics hist med 11: 15, december, 2018 jmehm.tums.ac.ir nazafarin ghasemzadeh et al. introduction new medical developments give rise to issues to which contemporary islamic jurisprudents cannot remain indifferent. the reason is that their opinions on upcoming matters are applied as guidelines in different disciplines, medicine included. the importance of jurisprudential rules is asserted in article 3 of the code of civil procedures of the islamic of republic of iran1, which requires judges to base their decisions on jurisprudence when statutes or codes provide no clear answer to the case in dispute (1). thus, it is important for the medical community to interact with jurisprudents and establish ethical policies to achieve the objectives of medical education and the health system while taking human dignity into account. this study presents the contemporary shiite jurisprudents’ opinions on the use of dying patients for medical education purposes. in this regard, the authors sent istiftas to contemporary shiite jurisprudents and analyzed their views and arguments in order to present a collective viewpoint on the issue. method the study consists of both a theoretical (part 1 which was published) and a field (part 2) section. in the field section, a qualitative investigation was conducted by sending istiftas (asking for a religious opinion) to prominent contemporary shiite authorities (maraje’ taghlid). we emailed and posted 6 istiftas (questions on religious matters) to religious shiite scholars considering the possibility and conditions of practicing and teaching medical procedures on nearly dead patients and the replies were received in a 6-month period. in addition, these questions contained the images of medical procedures for instance, endotracheal intubation, central venous catheter insertion and pericardiocentesis. religious scholars as sources of emulation who responded to our questions in the present study were ayatollah khamenei, ayatollah safi golpayegani, ayatollah alavi gorgani, ayatollah fazel lankarani, ayatollah makarem 1. article 3 of civil procedure code: judges of the courts are bound to deal with the cases in accord with the rules and issue an appropriate decision or terminate a dispute. if the statute laws are not complete or clear, or if they are contradictory, or there is no rule regarding the proposed proposition, these judges can issue verdicts drawing upon credible islamic sources or valid fatwas from religious scholars or legal principles on the condition that they are not against sharia laws. shirazi, ayatollah noori hamedani, ayatollah sistani, ayatollah mazaheri and ayatollah seyyed abbas modaresi yazdi. consequently, their viewpoints on performing training activities on nearly dead patients were explained and analyzed. finally, the results of both sections were summarized and a theory was presented with regard to medical training activities on dying patients. results views of prominent contemporary islamic jurisprudents in order to understand the religious opinions of contemporary shiite authorities (maraje’ taghlid), questions were drafted on using dying patients for medical education (table 1). the consensus among prominent contemporary jurisprudents indicates that it is often permissible to consider the use of a dying patient under such conditions as “a state of necessity”, “non-harassment” and “permission”. these conditions can be derived from a number of jurisprudential rules. it should be remembered that the discussion of issues such as the rule of authority or the permission and consent expressed by some jurisprudents should not create doubts that autonomy can be reconciled with free will. discussion as shown in table 1, the majority of prominent shiite jurisprudents declared the use of a dying person for medical education permissible under certain conditions, including “necessity”, “no harm” and “consent”. in this regard, they proposed the conventional concept of necessity, which is applicable to particular examples; for instance they believed that medical training on a dying person should be confirmed by conventional medicine. on the other hand, although the jurisprudents recognized the educational value of such activities, they were of the opinion that “necessity must only be assessed proportionately”, which exerts limitations on the whole issue. thus, medical procedures on dying patients are only acceptable in cases of necessity, and undue implementation or perpetuation of such measures is prohibited. the important question is, what are the criteria and diagnosis authority for the necessity? in other words, who determines the necessity of these activities? it is clear that time and place requirements are involved here, which adds to the sensitivity of the issue. page 2 of 10 j med ethics hist med 11: 15, december, 2018 jmehm.tums.ac.ir nazafarin ghasemzadeh et al. table 1the rights of near-death patients regarding using their bodies for medical training purposes according to prominent shiite scholars based on the obtained istiftas ayatollah seyyed abbas modaresi ayatollah mazaheri ayatollah safi golpayegani ayatollah alavi gorgani ayatollah fazel lankarani ayatollah makarem shirazi ayatollah noori hamedani ayatollah sistani ayatollah khamenei answer question it is not permissible, because humans’ lives and bodies are respectable, whether they are muslims or nonmuslims, dying or already dead, warm, or cold corpses. it is permissible if useful or necessary for the patient, but if it is done merely for the purpose of training and entails harm to the patient, it is not allowed, unless the patient gives his/her consent. there is no problem if such actions are performed for resuscitation or rescue of a person, but in case of soley training purposes, the medical practice is forbidden to be done and this opens up to liability. it is not religiously correct and not permissible if performed merely for training (and not therapeutic) purposes, or if there is a noticeable physical damage, or the procedure is painful. it is forbidden in case of physical harm or disrespect to the dying patient. in the absence of harassment or disrespect, if it causes suffering for the patient due to placing a heavy object on his/her body, it is still makruh (undesirable, detestable). it is only permissible in cases of necessity and to the extent of that necessity. it is not permissible if the aforementioned training is not a conventional necessity. it is permissible with the patient’s consent, even if it does not have any benefit for the patient. however, it should not expedite death or cause defects to the patient’s organs. there is not a problem if the dying patient allows it or has previously given the permission to perform such activities on him/her for medical training purposes; otherwise, it is not permissible. clearly, a haram (forbidden) look and touch should be avoided unless there is a necessity. is it permissible to use a dying (nearly dead) patient for medical training in skills such as “endotracheal intubation”, “pericardiocentesis” (a pericardium or external membrane of the heart), or “central venous catheter insertion”? it should be noted that some of these actions affect the patient’s appearance (by puncturing the body, etc.), while others do not change the patient’s appearance. --- it is permissible for the same sex and for the opposite sex if it involves no looking and touching, unless there is a necessity. the rule is the same as mentioned in the answer to the first question, even if they are of the same sex. in case of patient-trainee sex disconcordance, medical practice is intensely forbidden. it is forbidden to perform actions that lead to patients’ harassment, whether they are of the same or opposite sex as the performer of the acts. moreover, if the trainee’s actions involve looking at or touching a nonmahram (forbidden) dying patient, then the trainee is a sinner. it is permissible if the training is necessary for a person of the opposite sex, that is, if without such training the trainee will not acquire the required knowledge to protect patients against a threat or disease. it is not permissible if it results in harassment to the dying patient. it is permissible if they are not of the same sex, but the education is effective in protecting muslims’ lives or improving their level of knowledge. there is not a problem if the dying patient allows or has previously allowed such procedures for medical training purposes; otherwise, it is not permissible. clearly, a haram (forbidden) look and touch should be avoided unless there is a necessity. 2. what is the religious law regarding performing the abovementioned procedures on a dying patient in case the patient and the trainee are of the same or different sexes? page 3 of 10 j med ethics hist med 11: 15, december, 2018 jmehm.tums.ac.ir nazafarin ghasemzadeh et al. ayatollah seyyed abbas modaresi ayatollah mazaheri ayatollah safi golpayegani ayatollah alavi gorgani ayatollah fazel lankarani ayatollah makarem shirazi ayatollah noori hamedani ayatollah sistani ayatollah khamenei answer question ----it requires permission. the aforementioned procedures must be performed with the patient’s consent, provided that they do not expedite death; however, if the patient is not fully conscious, his/her consent or the consent of the relatives is not beneficial. the will or consent of the patient’s guardians does not affect the religious ruling. it is forbidden in case of harassment and suffering for the patient. moreover, the guardians of a dying or nearly dead patient are not allowed to give permission for training activities to be performed on him/her, as they simply cannot make a decision at that moment. permission is not required in case of necessity; otherwise, there should be consent. ---- guardians’ consent does not suffice. there is not a problem if a dying patient allows or has previously allowed such procedures for medical training purposes; otherwise, it is not permissible. clearly, a haram (forbidden) look and touch should be avoided unless there is a necessity. 3. is it necessary to obtain the consent of the patient or that of his/her guardians to perform these procedures? is this legitimately applicable? ---- it is applicable. the patient’s will is only acceptable after his/her death. the will or consent of the patient’s guardians does not affect the religious ruling. there is not a problem in case the patient has drawn up a will and if there is not a particular mafsadah (harm, evil); clearly, it is permissible to act upon the patient’s will. it is permissible in case the patient is informed, his/her consent is obtained, and there is no harm to his/her health or no delay in the process of recovery; otherwise, it is not permissible. it is permissible if specified in the will and with the consent of the patient’s guardians. the patient can make such a will and it is acceptable if the conditions in the answer to the first question are met. there is not a problem if a dying patient allows or has previously allowed such procedures for medical training purposes; otherwise, it is not permissible. clearly, a haram (forbidden) look and touch should be avoided unless there is a necessity. 4. can patients allow the abovementioned procedures to be performed on their nearly dead bodies by writing a will? will this be a legitimately acceptable or valid will? ---- it is permissible with the patient’s consent and if performed for medical training purposes, or to rescue other people’s lives in order to avoid further threat or harm. there are no exceptions regarding this issue. the patient should not be harassed if the procedure is merely educational. it is not permissible under any conditions if it results in the patient’s harassment and distress. it is acceptable, however, in case there is no suffering or mafsadah for the patient. it is permissible in case the patient is informed, his/her consent is obtained, and there is no harm to his/her health or no delay in the process of recovery; otherwise, it is not permissible. it is permissible in cases of necessity and with the consent of the patient’s guardians. the answer has been clarified. there is not a problem if a dying patient allows or has previously allowed such procedures for medical training purposes; otherwise, it is not permissible. clearly, a haram (forbidden) look and touch should be avoided unless there is a necessity. 5. are there islamic conditions or considerations regarding the use of a dying patient for educational purposes? what are those conditions? page 4 of 10 j med ethics hist med 11: 15, december, 2018 jmehm.tums.ac.ir nazafarin ghasemzadeh et al. ayatollah seyyed abbas modaresi ayatollah mazaheri ayatollah safi golpayegani ayatollah alavi gorgani ayatollah fazel lankarani ayatollah makarem shirazi ayatollah noori hamedani ayatollah sistani ayatollah khamenei answer question it is imperative that the corpse be a nonmuslim, and this is the rule of god and tauzeeh-ulmasail (islamic jurisprudence laws). however, velaee (guardianship of the islamic jurist) government law is another issue. the consent of the patient’s guardian as well as that of the religious ruler, and coordination with legal medicine organization is required. it is not permissible and requires diyah (compensation or blood money). the abovementioned activities cannot be performed even for training purposes if the corpse is cold. ---- it is not acceptable to cause any deformations in a dying patent’s body unless he/she has consciously consented, or the activities are done for his/her benefit. there is also no difference between a muslim’s warm or cold corpse in this regard. it is not permissible if it results in desecration of a believer. there is not a problem provided that following the patient’s death, there is no amputation, bleeding, or disrespect. there is not a problem if such procedures are aimed at rescuing a respectable individual, making medical discoveries, or obtaining information about a disease that threatens other people’s lives. 6. what are the answers to the abovementioned questions regarding a muslim patient’s warm corpse (that is, the body of a person who has just died, while it is still warm)? page 5 of 10 j med ethics hist med 11: 15, december, 2018 jmehm.tums.ac.ir nazafarin ghasemzadeh et al. therefore, if the clinical instructor is allowed to practice freely and with no disturbances, the community will benefit from these training activities, and many medical challenges that cannot be addressed by using artificial training alternatives such as manikins, simulators and so on will be resolved. although some jurisprudents (alavi gorgani and abbasi modaresi and safi golpayegani) have prohibited the use of a dying person for educational purposes, the practice is permissible based on the rule of necessity, as the majority of the jurisprudents have endorsed it (see table 1). it should be noted that alavi gorgani and safi golpayegani consider these activities acceptable on the condition that they are performed for resuscitation or to rescue a patient. in response to the istiftas most jurisprudents (sistani, khamenei, mazaheri, & nouri hamedani) stated that in order to perform educational procedures on a dying person, it is necessary to obtain their permission. moreover, the permission must be given by the person himself, and the consent of relatives is not sufficient (safi golpayegani, sistani & fazel lankarani). it can be concluded that based on the principles of ibaha and hilliat (permissiveness), such procedures are permissible only with the patient’s consent. according to the rule of la-zarar (no harm, i.e., there must be no injury or loss in islam) as well as the necessity of respect for human dignity, prominent authorities have implicitly granted the permission to use a dying patient for training purposes, provided that the procedures do not ensue physical or mental harm. when all aspects are taken into consideration, however, trainers are guaranteed for any harm incurred on patient during training period. some of the jurisprudents (for instance safi golpayegani) have ruled in favor of guaranty in the form of the principle of la-zarar for all personal and social interactions of human beings. this ethical principle, which pertains to human behavior in relation to oneself and others, can be extended to the field of medical education as well. since human wisdom decrees no harm to others, it rules for compensation and the responsibility to redress the loss (2). although certain circumstances and conditions are required, education on the bedside of a dying patient is acceptable in the light of the principle of expediency, because the benefit of the community is important. based on indications of conscience, necessity and wisdom, the sort of relationship that humans have with their bodies is of ownership and monarchy type, which has also been confirmed by jurist-consults and lawyers (3). in juridical texts, the nature of this relationship is described as ownership (inherent property and credit) and monarchy (authority). there are different views in this regard, for instance some jurisprudents have identified a relationship (ownership) between human beings and their body parts (4), although there is no general consensus on the issue. in addition, allameh tabatabai in the interpretation of the first verses of hamd surah and the term “malik” (owner), has pointed out that things like body parts and the five senses have no selfdependent existence. in other words, they have no self-dependent existence and do not belong to the person independently, but they are his property. in fact, we are the true owners of our body parts due to existential domination (5). this attention to the human developmental state emphasizes an intrinsic relationship between a person and his/her body parts and consequently ownership of the body. therefore, ownership of body parts could be regarded as a relationship of domination or a permanent right established between a human being and his/her body members, which has also been validated by the legislator. moreover, the person might, by virtue of such a right, assume control of his/her body parts so that he/she uses all the benefits and no one can prevent it (3). some jurisprudents also believe that in certain cases the title of right and property does not apply to a trader in an act of exchange, and prefer the title monarchy instead. the domination of people over their bodies is the same as property ownership, and can be exercised under any circumstances, provided that it is not forbidden by wisdom and the religion (6). in self-ownership, the principle is a strong endorsement of sovereignty of the individual, and it is applicable unless there is a religious law against it (7). in contrast, some other jurisprudents do not believe in a person’s ownership of his/her body due to reasons such as the meditation of the self, in the sense that the human self is not an efficient cause for the body, and only god can control human body affairs. they consider god to be the efficient cause of creation and the true owner of the body and soul of a human being, whom they regard only as a trustee. for this reason, suicide is not permissible and human beings cannot dominate themselves and their organs because there is no justification for this domination (8). moreover, they consider organ donation as a case of desecration and self-harm (9). jurisprudents have expressed different opinions in this regard in cases such as the dissection of a deceased muslim’s body and diyah (wergild, blood money, mulct or compensation for manslaughter in islam), organ transplant from a corpse, and organ donation as presented in table 2. page 6 of 10 j med ethics hist med 11: 15, december, 2018 jmehm.tums.ac.ir nazafarin ghasemzadeh et al. table 2religious fatwas of prominent shiite scholars on dissection of corpses and organ donation by the deceased fatwa ayatollah dissection of a muslim’s dead body dissection based on a person’s will diyah for dissection organ transplant from a corpse a will/certificate of organ donation for postmortem transplant javad tabrizi (10) if a non-muslim’s corpse is not available, delay the dissection upon prudence until a non-muslim’s corpse is found even by payment of any type. will is not valid --------- -------will is not valid montazeri it is acceptable if it is established that a muslim’s life depends on it and there is no other alternative. otherwise, it is not permissible (11). it is not unlikely to be permissible and acceptable (11). diyah is obligatory if dissection is performed for educational purposes and a muslim’s life does not depend on it (12). it is permissible in case it may protect a muslim’s life, but diyah is required (12). --------- vahid khorasani (13) it is not permissible. however, if the life of a muslim depends upon it and there is no other alternative, dissection is acceptable, but diyah is required. ------ diyah is required. it is not permissible. if a muslim’s survival is at stake, the transplant of the body organ is allowed, but diyah is required. the validity of the will is questionable. khoei it is permissible if a muslim’s survival depends on it and dissection of a nonmuslim’s body or that of a suspicious of being muslim is not possible and there is no other alternative to keep the muslim alive (14). the will could permit both the practice and removal of the diyah since they are both related to respect for a muslim’s body and there is no disrespect in acting upon the will (11). diyah is required (14), but if there is a will, there is no need for diyah (11). it is permissible if the survival of a muslim depends on it, but the person who performs the procedure must pay diyah (14) it is allowed and in this case there is no need to pay diyah (14). imam khomeini (15) dissection is forbidden and not permissible for educational purposes, and if it is not performed to save a muslim’s life, then diyah is required. ------ if the survival of a muslim depends on dissection, it is not unlikely that diyah is not required; however, diyah may be required upon prudence. it is allowed only to save the life of a muslim, but diyah is required upon prudence. ----- madani tabrizi dissection of a deceased muslim’s body is not permitted even for the purpose of acquiring knowledge in medicine (16). the will is not legitimate and the act is not lawful (11). diyah is required (16). it is not permissible and diyah is required. if a muslim’s survival is at stake, however, organ transplant is allowed, but diyah is required (16). the validity of the will is questionable (16). mousavi ardebili (17) it is acceptable if used for diagnostic purposes and to acquire knowledge in medicine, or to save other people’s lives, provided that it is the only way to achieve the mentioned skills. the consent of the patient or his/her guardian is required if ------ ------ it is permissible if it will preserve a muslim’s life and diyah is not required. it is permissible if the maintenance of an important and effective organ of a muslim depends upon it, especially if the dead patient has allowed it in his/her will. page 7 of 10 j med ethics hist med 11: 15, december, 2018 jmehm.tums.ac.ir nazafarin ghasemzadeh et al. fatwa ayatollah dissection of a muslim’s dead body dissection based on a person’s will diyah for dissection organ transplant from a corpse a will/certificate of organ donation for postmortem transplant possible. fazil lankarani if saving a muslim’s life depends on dissection and a non-muslim’s corpse is not available, then it is acceptable. however, it is not permissible merely for educational purposes and if the life of a muslim does not depend on it (18). it is not unlikely that the will is valid (18). if the patient has made a will to allow an act that entails rational benefits, dissection is acceptable, and execution of will is apparently obligatory (11). diyah is required upon prudence (11). it is not permissible to remove the organs of a deceased muslim unless another muslim’s life or health depends on it, and a nonmuslim’s corpse is not available, which would be permissible in this case. diyah, however, is required upon prudence (18). if preserving a muslim’s life depends on an organ transplant from a muslim’s corpse and a non-muslim’s corpse is not available, the transplant is permissible and the will is valid. diyah is required upon prudence under the circumstances (18). bahjat (19) the dissection of a deceased muslim’s body is permissible under two conditions: 1) if the life of one or more muslims depends on it. 2) if the dissection of a non-muslim is not possible. therefore, if the dissection is merely for educational purposes and no muslim’s life is at stake, it is not permissible to dissect the muslim, and diyah is required. the will is not valid. if the dissection is merely for educational purposes and no muslim’s life is at stake, it is not permissible and diyah is required. transplant from a muslim’s corpse is permissible only if another muslim’s life depends on it and it is not possible to find a non-muslim donor. obtaining permission from the dead person’s guardians is needed upon prudence. if a person wants to donate an organ such as the kidney, or expresses a wish to do so after his/her death by writing a will, whether in exchange for money or for free, it is permissible if a muslim’s life depends on receiving that organ and it is not possible to obtain it from a nonmuslim. araki (11) it is not permissible to dissect a muslim’s corpse. the will is not valid. --------- it is not allowed to dissect, cut off, or obtain an organ from a muslim’s corpse. -------- khamenei (20) there is no problem in dissecting the corpse if it is done to rescue a respectable person, make medical discoveries that are necessary for the community, or obtain information about a disease that threatens people’s lives. however, it is imperative not to use a muslim’s corpse as far as possible. it is inconsequential in case of necessity of the dissection. if possible, a nonmuslim’s body must be used rather than a muslim’s, and diyah is not required if the dissection is absolutely necessary. it is acceptable to use a dead person’s organs for transplant to save another person’s life or to treat his/her disease. it is permissible to use the organs of the deceased for transplant to save another person’s life or to treat his/her disease. there is no problem if a person wishes to make a will regarding this issue, unless the removal of those organs causes mutilation or disrespect of a corpse by convention. according to table 2 above, most of the jurisprudents did not allow the dissection of muslim bodies and ordered diyah to be paid. nevertheless, they mostly declared it permissible where necessary, that is, if a muslim’s life depended on it and there were no other alternatives. moreover, they did not consider organ transplant from a corpse permissible and found it acceptable only when performed to preserve the life of a muslim, and they did not confirm the validity of a will written about the issue. on the other hand, according to table 1, in the light of the rule of authority, the consent of the dying person is page 8 of 10 j med ethics hist med 11: 15, december, 2018 jmehm.tums.ac.ir nazafarin ghasemzadeh et al. applicable in education. in other words, it is advised to respect the patient’s rights and to obtain his/her consent (21), that is, to observe the right of decisionmaking and free will. there is also a conflict between the two views expressed in table 1 (on the educational use of a dying person, which is permissible by consent) and table 2 (on the dissection of a muslim’s body, which is not permissible unless it is necessary). it can be concluded that because of the social benefits of clinical education as well as the right that a person has on his physical integrity, injury, battery or any physical harassment is forbidden and results in civil and penal liability (22). moreover, it is inferred from the granting of retaliation, pardon or diyah in the case of crimes against the self that human beings have a legal right to their bodies throughout their lifetime (23), and these rights are transferable. patients’ consent to allow the educational use of their bodies is also acceptable in the light of this right, and therefore training activities are in accordance with this right of patients if they express their consent in their will. conclusion an investigation of islamic jurisprudential rules and the views of prominent contemporary shiite jurisprudents obtained through istiftas regarding medical procedures on dying patients indicate that patients’ rights should in no way be violated. some jurisprudents do not recognize the validity of a dying patient’s will regarding training activities on his/her body. considering the different viewpoints described above, it can be concluded that on the one hand, medical training is permissible on a nearly dead patient especially if he/she has allowed it by writing a will. it may also be inferred from the opinions of the jurisprudents that using dying patients for teaching medical procedures is contingent on conditions such as necessity and lack of harm. thus, in order to preserve public interest and to protect the integrity of the dying person, medical training is permissible under certain circumstances. nevertheless, no specific authority has been specified to identify issues such as necessity, which is a matter of expediency based on time and place requirements, and normally determined by the medical trainer. in addition, lack of a comprehensive and transparent law in this area also causes challenges because juridical provisions may or may not be compatible with the norms of medical ethics. therefore, it is essential to codify a law in accordance with the following matters: aims of sharia, personal characteristics and identity, training transcendental students, providing community benefits and islamic system. it is necessary for medical teachers and staff to be informed on the islamic issues concerning the use of a dying patient for medical training so they can consider islamic teachings while providing suitable education for trainees. although it is the responsibility of specialists in this field to identify instances of harm in medical affairs, a strong relationship between the two areas of medicine and jurisprudence will result in more successful medical education. therefore, a better interaction between medicine and jurisprudential rules requires that recommendations of the latter be more prominent in medical education. as a result, a dying patient may be used for medical education only when all the following conditions are met: 1. the necessity of performing medical procedures on a dying patient is established; 2. no alternative method is available; 3. the training procedure is carried out to the extent of necessity; 4. the patient’s informed consent or will is obtained in advance to perform the medical procedures; 5. the patient’s dignity is preserved; 6. the procedure is performed under the supervision of a clinical practitioner; 7. harassment and any form of harm or distress resulting in a prolonged dying process are avoided. acknowledgements the paper is extracted from nazafarin ghasemzadeh’s ph.d. dissertation entitled “compiling national ethical guidelines for medical teaching based on religious and cultural beliefs in iran”, supported by tehran university of medical sciences. conflict of interests the authors declare that there is no conflict of interests regarding the publication of this paper. page 9 of 10 j med ethics hist med 11: 15, december, 2018 jmehm.tums.ac.ir nazafarin ghasemzadeh et al. references 1. zahedi, a. collection of law. tehran: jungle publication; 2013, p.2. 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____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ 1 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e © 2019 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. original article volume 12 number 12 october 2019 validity, reliability and acceptability of professionalism mini-evaluation exercise (p-mex) for emergency medicine residency training *corresponding author leila amirhajlou third floor, no. 57, hojat doust st., keshavarz blvd., department of medical education, school of medicine, tehran university of medical sciences,tehran, iran. tel: (+98) 88 95 57 12 email: l-amirhajlou@alumnus.tums.ac.ir received:11 nov 2018 accepted:15 sep 2019 published:15 oct 2019 citation to this article: amirhajlou l, bidari a, alipour f, yaseri m, vaziri s, rezai m, tavakoli n, farsi d, yasinzadeh mr, mosaddegh r, hashemi a. validity, reliability and acceptability of professionalism minievaluation exercise (p-mex) for emergency medicine residency training. j med ethics hist med. 2019; 12: 12. leila amirhajlou1*, ali bidari2, fateme alipour3, mehdi yaseri4, samira vaziri5, mahdi rezai6, nader tavakoli7, davood farsi8, mohammad reza yasinzadeh9, reza mosaddegh10, akram hashemi11 1.researcher, department of medical education, school of medicine, tehran university of medical sciences, tehran, iran. 2.professor, department of emergency medicine, school of medicine, iran university of medical sciences, tehran, iran. 3.associate professor, department of ophthalmology, school of medicine, tehran university of medical sciences, tehran, iran. 4.associate professor, department of biostatistics, school of public health, tehran university of medical sciences, tehran, iran. 5.assistant professor, department of emergency medicine, school of medicine, iran university of medical sciences, tehran, iran. 6.assistant professor, department of emergency medicine, school of medicine, iran university of medical sciences, tehran, iran. 7.associate professor, trauma and injury research center, iran university of medical sciences, tehran, iran. 8.associate professor, department of emergency medicine, school of medicine, iran university of medical sciences, tehran, iran. 9.assistant professor, department of emergency medicine, school of medicine, iran university of medical sciences, tehran, iran. 10.assistant professor, department of emergency medicine, school of medicine, iran university of medical sciences, tehran, iran. 11.assistant professor, department of medical ethics, school of medicine, iran university of medical sciences, tehran, iran. abstract professionalism is a core competency in the medical profession. in this paper, we aimed to confirm the validity, reliability and acceptability of the professionalism mini-evaluation exercise (p-mex) instrument for the emergency medicine (em) residency program. twenty-two em attending physicians completed 383 p-mex forms (the persian version) for 90 em residents. construct validity was assessed via structural equation modeling (sem). the reliability coefficient was estimated by the generalizability theory, and acceptability was assessed using two researcher-made questionnaires to evaluate the perspectives of residents and assessors. there was a consensus among the participants regarding the content of p-mex. according to the results of sem, the first implementation of the original model was associated with a moderate fit and high item loadings. the model modified with correlated error variances for two pairs of items showed an appropriate fit. the reliability of p-mex was 0.81 for 14 occasions. the perception survey indicated high acceptability for p-mex from the viewpoint of the residents and increasing satisfaction with p-mex among the assessors over time. according to the results of the research, p-mex is a reliable, valid, and acceptable instrument for assessing professionalism in em residents. keywords: medical professionalism; emergency medicine; residency program; workplace-based assessment mailto:l-amirhajlou@alumnus.tums.ac.ir validity, reliability and acceptability of professionalism mini-evaluation exercise … 2 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 12 october 2019 introduction professionalism is a core characteristic of the medical profession (1). in recent years, increasing attention has been paid to professionalism due to concerns regarding the decline of professional and ethical values (2). one responsibility of medical schools is determining whether such competencies have been achieved (3). over the last three decades, various instruments have been developed to assess medical professionalism (4). recognizing the observation of students’ performance as the most efficient technique to evaluate professionalism in real clinical practice led to the identification of the professionalism mini-evaluation exercise (p-mex) as the core of any assessment strategy (5). introduced by cruess et al., p-mex measures four areas of professionalism skills: doctor-patient relationship, reflective skills, time management, and interprofessional relationship skills (6). the necessity to reevaluate professionalism assessment scales before application in a new country has been emphasized due to cultural and contextual differences (7,8). for instance, tsugawa modified the instrument so that it could be applied to japanese medical students (9,10). unfortunately, no observational instrument has been validated for the assessment of the professionalism of emergency medicine (em) residents (11,12). working as a resident in the em department is more stressful compared to other departments due to the unique features of this ward, e.g. heavy workload, uncontrolled environment, and an unlimited number of patients with a vast spectrum of diseases and a short-term stay (13). studies have shown that professional values are violated by residents who suffer from burnout due to prolonged exposure to stress. formative assessment of behavior facilitates early identification of unprofessional behavior before it becomes a significant issue. it also assists trainers in opening the dialogue on signs of burnout with residents through feedback for minimizing professionalism lapses and ameliorating burnout. therefore, it is essential to apply effective assessment strategies in the clinical workplace (14,15). considering the differences between the em department and other clinical settings, this study aimed to confirm the reliability, validity, and acceptability of the p-mex for em residents in iran. methods this study was conducted in the em departments of four teaching hospitals in iran from july 2017 to january 2018. the research was approved by the institutional review board of the school of medicine of tehran university of medical sciences. in translating the p-mex from english to persian, the guidelines for the translation and adaptation of tests developed by the international test commission (itc) were followed (16). first, two experts conducted a forward translation, which was then evaluated by an expert panel consisting of five professionals. this evaluation led to the formation of a single persian translation by consensus. second, the persian version was amirhajlou l., et al. 3 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 12 october 2019 back-translated into english by two bilingual native english speakers. third, richard cruess and sylvia cruess (the two developers of the p-mex) discussed the discrepancies in the two backward translations. based on their recommendations, a final draft of the persian p-mex was prepared. fourth, cognitive debriefing interviews were conducted with a sample of participants, consisting of six assessors and six em residents, to assess the comprehension and face validity of the translated p-mex. all em residents (n = 90) and 22 attending physicians voluntarily participated in the study. non-monetary incentives were used to encourage participation in the research. participants were first instructed to perform the p-mex exercise through weekly meetings, in which they received a booklet containing an instruction guide and the pmex forms. the p-mex comprises 20 minutes of observing clinical encounters followed by five minutes of immediate feedback. in the present study, the full 24item p-mex scale was used, scored based on a four-point likert scale with the options of exceeded expectations (score 4), met expectations (score 3), below expectations (score 2), and unacceptable (score 1). the fifth category was entitled “not observed” or “not applicable”. the original p-mex form (questionnaire) is presented at the end of the paper as an appendix. analysis the structural equation modeling (sem) was utilized to investigate the construct validity of the p-mex. the following indices of sem were applied in the present study to evaluate the model’s goodness-offit: comparative fit index (cfi > 0.90 indicative of a good fit), the root-meansquare error of approximation (rmsea < 0.08 indicating acceptable fit), and chisquare (χ2 / d.f. ≤ 3 ratio). sem statistics were also conducted using the stata/ic (14.2) (statacorp, college station, tx, usa). moreover, the generalizability theory was used to evaluate the reliability of the scores. to this end, the generalizability coefficient (g) was estimated for a one-facet crossed design, in which resident (r) was the object of measurement and occasions (o) were facets of measurement using the gstring iv version 6.3.8 (bloch & norman, 2011). furthermore, the g study was performed followed by the decision study to identify the number of occasions (pmex) per resident required to achieve the highest level of reliability. after the completion of the p-mex assessment process, residents and faculties were asked to complete a questionnaire on their perception of the p-mex from various aspects, including the feasibility, content, fairness, and educational impact of the assessment. the questionnaire for residents contained 52 items, whereas the scale for assessors encompassed 37 items, both scored based on a five-point likert scale ranging from “strongly disagree” (1) to “strongly agree” (5). the face and content validity of the questionnaires were confirmed by a group of experts consisting of two medical education faculty members and four validity, reliability and acceptability of professionalism mini-evaluation exercise … 4 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 12 october 2019 emergency medicine specialists who participated in the study as assessors. in order to determine the stability of the questionnaires over time, test-retest was used by pearson's correlation coefficient. consequently, the questionnaires were readministered to 21 residents and 8 assessors two to three weeks later. in the current study, pearson's correlation coefficient was between 0.726 and 0.943 for the residents’ questionnaire (p < 0.01), and between 0.779 and 0.906 for the assessors’ questionnaire (p < 0.01), which suggested satisfactory stability. furthermore, the reliability of the questionnaires was estimated at the cronbach's alpha of 0.88. data analysis was performed in spss 22. results in total, 383 p-mex forms were completed by 22 em faculties for 90 residents during a seven-month period. the mean number of evaluations per resident was 4.26 (range of 1 11). in addition, the range of the p-mex completed per rater was 1 46, with an average of 17.41 (+/2.68 sd). moreover, the mean of the evaluation scores of all residents for overall competency was 3.32 (± 0.04 sd) out of 4. according to the results, the mean observation time equaled 128.3 minutes (median of 120 and range of 10 600) and the mean feedback time equaled 13.06 minutes (median of 10 and range of 1 35). in the present research, the residents received the lowest scores on items 10 (23.8%), 8 (21.4%), 17 (14.9%), and 13 (12.5%), which pertained to soliciting feedback, warning about the limitations, addressing the gap between knowledge and skills, and maintaining composure in difficult situations, respectively. in 11% and 8.6% of the assessments, item 23 (using health resources appropriately) and item 22 (maintaining patient confidentiality) were rated as not-applicable by the assessors, respectively. these items were reconsidered for their additional value in the assessment of the em residents in this research. however, item 22 was more applicable in over-an-hour-long observations. it should be noted that the correlation between intra-item subscales was evaluated using the pearson product-moment correlation coefficient, and results were indicative of a significant and strong correlation between items 2 and 3 (r = 0.774, p < 0.005). moreover, item 5 was highly correlated with items 4, 6, and 7 (r = 0.773, 0.864 and, 0.743, respectively). in addition, sem was used to confirm the model’s goodness-of-fit. as presented in figure 1, factor loadings for all items were significantly above kline’s cut-off point (>0.50) (17). however, item 12 (appropriate boundaries with patients/colleagues), had been cross-loaded on two latent variables (i.e. patient-doctor communication skills and interpersonal skills in the original model), and was barely loaded on factor 1 (loading value 0.096) but mostly on factor 4 with a value of 0.65. amirhajlou l., et al. 5 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 12 october 2019 figure 1hypothetical measurement model therefore, based on the results, this item should only be correlated with factor 4 in the modified model. as shown in figure 1, the hypothetical model had a mediocre goodness-of-fit with the following indices: (χ2 = 1124, 964, rmsea = 0.09, cfi = 0.87, tli [nnfi] = 0.86). therefore, we utilized the modification indices given by the stata/ic software package to provide a model with a better goodness-of-fit. modification indices suggested that the value of the model’s goodness-of-fit be elevated by allowing the error term correlations between two sets of items. the error terms of item 2 (showing interest in patient as a person) was correlated with the error term of item 3 (showing respect for patient) by the highest m.i. of 99.431. moreover, correlations were added across the error terms of items 22 and 23 (maintained patient confidentiality and used health resources appropriately, respectively). the modified model and the correlated errors are illustrated in figure 2, according to which better fit indices were obtained as follows: χ2 = 955.422, rmsea = 0.087, cfi = 0.900, tli [nnfi] = 0.887. these indices demonstrated a slight improvement in the model’s goodness-of-fit. validity, reliability and acceptability of professionalism mini-evaluation exercise … 6 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 12 october 2019 figure 2the modified measurement model with correlated error terms, indicating best fit with the study data with χ2 = 955.422, rmsea=. 0.087, cfi= 0.900, tli (nnfi)= 0.887. based on the literature, correlated error terms are often caused by item wording, item placement, double-barreled questions, or the effects of missing variables. in order to address the issue of correlated error terms, researchers recommended removing or merging items with the correlated error terms and proposing new items (1721). the error correlation between items 2 and 3 could be justified by referring to the same concept of respect for patients with both items. item 2 was removed from the scale due to the failure of the evaluators to differentiate between the items after scoring the performance of the residents. additionally, the error terms of items 22 and 23 were allowed to correlate. however, item 23 did not apply in our setting since it is not the responsibility of residents to use or allocate health resources. as a result, item 23 was eliminated from the scale. the reliability of p-mex scores was measured by the generalizability theory using a onefacet (the resident by form) crossed design. the g coefficient was estimated at 0.647 based on the six levels of the forms crossed with residents. the d study results (table 1) revealed that the optimal number of occasions required for reaching acceptable reliability on the p-mex assessment was 14 occasions with the g coefficient equal to 0.81. amirhajlou l., et al. 7 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 12 october 2019 table 1d study results for s×o design based on table 2, the acceptability of the pmex was measured by a post‐intervention questionnaire. the results indicated that all of the participants were satisfied with the content of the p-mex. in this regard, 56.6% of the residents responded “strongly agree”, whereas 43.3% selected the option “agree”. on the other hand, 55.6% and 44.4% of the faculties chose “strongly agree” and “agree”, respectively. table 2faculties’ and residents’ perception of p-mex strongly agree% moderatel y agree% disagree % strongly disagree% undecided % statements f* r** f r f r f r f r p-mex included appropriate content. 55.6 56.6 44.4 43.4 0 0 0 0 0 0 length of the assessment time was appropriate. 38.9 39.6 38.9 34 16.7 15.1 5.6 5.7 5.6 5.7 length of the feedback time was appropriate. 44.4 32.1 27.8 15.1 22.2 28.3 0 11.3 5.6 2.1 3 assessment was done easily. 22.2 50.9 61.1 26.4 11.1 17 5.6 1.9 0 3.8 the busy em had a negative effect on the assessments. 33.3 32.1 27.8 22.6 27.8 26.4 11.1 18.9 0 did you have enough time for the assessment? 38.9 39.6 44.4 41.5 5.6 3.8 11.1 13.2 0 1.9 assessment had an adverse effect on the patient care process. 0 9.1 16.7 13.2 44.4 58.5 27.8 24.5 11.1 1.9 the feedbacks were useful. 30.2 32.1 17 11.3 9.4 previous raters' perception of residents had an impact on the rating scores. 38.9 41.5 0 32.1 33.3 17 27.8 7.5 0 1.9 occasions level 30 28 25 14 12 10 8 4 2 0.902 0.895 0.884 0.810 0.786 0.753 0.710 0.550 0.379 𝐄𝐩𝟐 0.004 0.004 0.005 0.008 0.010 0.011 0.014 0.029 0.57 𝛔𝟐(𝛔) validity, reliability and acceptability of professionalism mini-evaluation exercise … 8 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 12 october 2019 strongly agree% moderatel y agree% disagree % strongly disagree% undecided % the quality of the relationship between raters and residents affected the rating scores. 50.9 28.3 15.1 3.8 1.9 the raters were fair on scoring the performance. 11.3 39.6 28.3 1.9 18. 9 do you prefer studentcentered approach for the assessment process? 22.2 26.4 33.3 24.5 5.6 24.5 33.3 24.5 5.6 0 the rater should not make the residents aware that they are being observed, and should use the indirect observation approach. 50 49.1 27.8 18.9 16.7 15.1 5.6 13.2 0 3.8 identity of raters should be unknown to residents. 50 3.8 16.7 3.8 22.2 35.8 11.1 54.7 0 1.9 em= emergency ward; * = faculties; ** =residents as presented in this table, the majority of the participants “agreed” and “strongly agreed” that the p-mex was easily administrated in em clinical settings, and confirmed adequacy of the time allocated for completing the questionnaire. nevertheless, it seems that in some cases, the assessment process was negatively affected by the heavy workload in overcrowded em settings. in addition, it was found that feedbacks were recorded in only 12% of the p-mex forms. moreover, a small number of residents reported only receiving general verbal comments on their performance. most of the residents and some of the faculties believed that raters’ prior knowledge about resident’s performance creates a positive or negative halo, influencing the grading of the latter’s professional behavior. they also mentioned the effect of the quality of the relationship with raters on the rating scores. furthermore, more than half of the faculty members preferred the indirect observation of professional behavior in which residents are unaware that they are being observed; most of the residents, however, selected the options “disagree” and “strongly disagree” regarding this statement. discussion to the best of our knowledge, this was the first psychometric study of the p-mex in the em clinical setting. in total, two items were identified as “unfitting and problematic” in the divergent validity analysis. items 2 and 23 were removed due to the error correlation observed for similar wording and non-applicability. moreover, item 12 was only loaded on the interpersonal factor. finally, data were fitted to the proposed model by removing two items. amirhajlou l., et al. 9 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 12 october 2019 according to the previous studies by cruess (6) and tsugawa (9,10), three doublebarreled questions (3,7,12), which were confusing and caused bias, had to be divided into six items (6, 9, 10). in the final edition of p-mex, we corrected these three doublebarreled questions. in the present study, when assessments were performed during the day when patient flow was lowest, time was not a significant issue for either the faculties or the residents. however, they believed that situations with clinical overload or high stress conflicted with the implementation of the p-mex, since assessment had an adverse effect on the patient care process in life-threatening situations. providing feedback was the most significant factor faced by assessors in implementing pmex in the present study. while feedback is an essential component of this formative assessment, provision of feedback on the observed clinical performance was inadequate. since professionalism is subjective in nature, different assessors judge behaviors in different ways and may give different feedbacks, so residents are likely to view a low score and constructive feedback as unfair. in interviews, assessors expressed their interest in providing feedback but had concerns about the emotional and defensive reactions of residents to criticism, which could lead to poor performance in clinical settings. moreover, they believed that it could potentially cause tension in the supervisory relationship. the working relationship between faculties and residents over an extended period caused leniency bias in ratings in this face-to-face assessment. to address the dilemma existing between the necessity of providing feedback and preventing tension in the busy and stressful emergency setting, assessors suggested the anonymity of raters whereby residents would be aware of the scores and feedbacks but the identity of raters would remain confidential. nevertheless, the residents stated that they were enthusiastic about having an opportunity to learn from feedback and even criticism because it made them understand expectations and identify their own weak points. these findings are consistent with those of colletti et al. (22) who found that while medical students desire more timely (22), direct observation and feedback on their clinical performance, faculties are unwilling to point out students’ weaknesses face-to-face, particularly when it involves negative feedback, resulting in score inflation. therefore, there is an obvious need for residents to improve their feedback solicitation skills, and for faculty members to develop their observation and feedback skills with an emphasis on creating a feedback-friendly environment and professional support with mutual trust. another phenomenon observed in the present study was that the mean time of observation was about one hour and a half. although all raters were instructed on the principles of this assessment, a few were still unfamiliar with the p-mex instrument and validity, reliability and acceptability of professionalism mini-evaluation exercise … 10 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 12 october 2019 its ultimate goal that is formative coaching rather than assessing, and tended to implement it using the classical global rating methods. they applied the instrument for assessing residents in one shift using the multiple mini-observations technique for the completion of each p-mex, so that their recorded observation time was about five to ten hours. this affected the total observation time and led to an increase in the average time. they thought that observation should take as long as possible until all items are observed and scored. according to them, some items on p-mex such as respect for hospital rules, maintaining composure in difficult situations, and ensured continuity of patient care needed an observation time of more than 20 minutes to accurately detect and rate performance. also, the assessors preferred an indirect approach in which residents are unaware of observation, which was inconsistent with the opinion of the residents. assessors believed that the residents altered their behavior due to the observer's presence, thus undermining the validity of scores. even though direct observation instruments promise to assess real behavior in workplace situations, observer effects, referred to as hawthorn or reactivity effect, will somehow create bias and make it impossible for raters to rate and document the natural behavior of residents. this is consistent with the findings of watling et al., exploring the influence of professional culture on the use of direct observation within medical training (23). raters and residents also mentioned that assessors were affected by the halo effect in performance ratings. this means that they applied their general impressions rather than objective ratings of specific behaviors when residents were well known to them. this result is in contrast with the findings of lie et al., showing accuracy of halo effect with no overall tendency to overestimate the skills of medical students (24). furthermore, residents mostly agreed with the statement that the quality of the relationship with raters affects their scores. all the issues, including lack of feedback, residents’ inflated view of their own professionalism, poor reflective skills, halo effect, and the effect of the relationship with raters influenced the residents’ views of the fairness of the assessment. this led to a distrustful relationship between residents and faculties, so that most of the residents preferred the student-centered approach in which they had the opportunity to choose lenient and safe raters for increasing their scores. a review of feedback from trainers demonstrated that the expectations of the attending physicians from residents are beyond the observable behaviors presented on the p-mex. some items highly expected of residents were: showing self-confidence; not being either overor under-confident (grandiosity or low self-esteem, respectively); not being irritable, defensive, depressed, stressed or anxious; being selfmotivated; having a sense of responsibility; and actively soliciting and responding to amirhajlou l., et al. 11 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 12 october 2019 feedback by making action plans for improvement. these expectations were associated with mental health and stability. studies have shown that there is a correlation between positive mental health and professional behaviors among medical students. on the other hand, students suffering from burnout are more likely to have engaged in unprofessional behaviors, which subsequently leads to inadequate development of personal and professional identity (25, 26). cruses et al. stated that the ultimate goal of any professionalism teaching and assessment activity should be personal and professional identity formation (27, 28). personal identity allows a person to have a sense of uniqueness through a complex combination of socio-demographic and personality characteristics, values, and beliefs (28). the biological perspective on personality confirms that individual characteristics can partially be traced back to the brain and genetic factors; however, through the socialization process, people gain values and beliefs from the society and life experiences, and thus professional identity is shaped (29-33). therefore, relying on professionalism assessment using only one instrument like p-mex, which merely measures observable behaviors, may reduce attention to other underlying factors affecting professionalism, and subsequently its final goal, that is, personal and professional identity formation. we propose a more extended model of professionalism measurement in future studies in order to assess the effect of other latent factors (figure 3). figure 3factorial model for assessing professionalism in future studies validity, reliability and acceptability of professionalism mini-evaluation exercise … 12 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 12 october 2019 conclusion according to the results of the present study, the p-mex is a valid instrument on the condition that several modifications are made, including removal and addition of some items. moreover, the reliability and feasibility of the instrument were confirmed in em settings. while the p-mex was highly accepted by residents, faculties were not initially comfortable with the instrument. it became progressively easier as the assessors observed that residents were showing more interest in receiving and soliciting feedback. to accurately assess professionalism among residents, we need to go beyond traditional methods. if consensus is achieved on the fact that the importance of any professionalism assessment lies in professional identity formation, educational goals should be modified so that challenges in the emergency ward, such as heavy work-load and stress, become educational opportunities for residents, resulting in the development of their professional identity rather than burnout and professional insufficiency. it is believed that developing the faculty’s perception of this issue with an emphasis on enhancing their knowledge and skills regarding principles of effective feedback and assessment methods in clinical settings can play an important role in the improvement of the feasibility, acceptability, and validity of the p-mex. conflict of interests the authors declare that there is no conflict of interests funding tehran university of medical sciences funded this research. acknowledgements we acknowledge dr. professors richard cruess and sylvia cruess for contributing to the development of our research proposal, assisting in the backward translation of the p-mex, and for all valuable feedbacks and encouragements. we are also grateful to dr. rex kline, psychology professor in concordia university, for providing generous and valuable feedback on the development of the drafting proposal for our study. moreover, we acknowledge the contributions of the faculty members of emergency medicine at iran university of medical sciences for participating in our study as raters (dr. mohammad amin zare, dr. peyman hafezimoghadam, dr. peyman erfantalab avini, dr. mani mofidi, dr. hasan amiri, dr. mohammad hosseini kasnavieh, dr. mojtaba chardoli, dr. keivan elchian, dr. hamed basir ghafouri, dr. gholamreza masoumi, dr. fatemeh mohammadi, dr. hamid khoshnezhad, and dr. mahsa mahmoodi nejad). we would also like to thank all the em residents at iran university of medical sciences for participating in this study. finally, we are grateful to dr. azim mirzazadeh, director of medical education department at tehran university of medical sciences, for assisting in obtaining approval for our project amirhajlou l., et al. 13 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 12 october 2019 references 1. papadakis ma, loeser h, healy k. early detection and evaluation of 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n/a or n/o factor 1: doctor–patient relationship skills      1. listened actively to patient.      2. showed interest in patient as a person.      3. showed respect for patient      4. recognized and met patient needs.      5. accepted inconvenience to meet patient needs.      6. ensured continuity of patient care.      7. advocated on behalf of a patient and/or family member.      12. maintained appropriate boundaries with patients/colleagues.      factor 2: reflective skills      8. demonstrated awareness of limitations.      9. admitted errors/omissions.      10. solicited feedback.      11. accepted feedback.      13. maintained composure in a difficult situation.      factor 3: time management      15. was on time.      16. completed tasks in a reliable fashion.      validity, reliability and acceptability of professionalism mini-evaluation exercise … 16 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 12 october 2019 question exceeded expectations met expectations below expectations unacceptable n/a or n/o 18. was available to patients or colleagues.      factor 4: interprofessional relationship skills      12. maintained appropriate boundaries with patients/colleagues.      14. maintained appropriate appearance.      17. addressed own gaps in knowledge and skills.      19. demonstrated respect for colleagues.      20. avoided derogatory language.      21. assisted a colleague as needed.      22. maintained patient confidentiality.      23. used health resources appropriately.      24. respected rules and procedures of the system.      journal of medical ethics and history of medicine caring relationship: the core component of patients' rights practice as experienced by patients and their companions joolaee s 1 , joolaei a 2* , tschudin v 3 , bahrani n 4 and nikbakht nasrabadi a 5 1.assistant professor, nursing care research center, school of nursing and midwifery, iran university of medical sciences, tehran, iran. 2.assistant professor, mahdieh women hospital, shahid beheshti university of medical sciences, tehran, iran. 3.surrey university, guildford, united kingdom. 4.faculty member, shahid sattary university, tehran, iran. 5.associate professor, nursing and midwifery faculty, tehran university of medical sciences, tehran, iran. *corresponding author: azadeh joolaei address: mahdieh women hospital, shahid beheshti university of medical sciences, tehran, iran. e-mail: jazadeh@yahoo.com received: 07 sep 2010 accepted: 28 sep 2010 published: 09 oct 2010 j med ethics hist med. 2010; 3:4. © 2010 joolaee s et al.; licensee tehran univ. med. sci. abstract keywords: caring relationship, lived experiences, patient’s companion, patients’ rights. introduction “caring is not unique to nursing, but is unique in nursing. caring is something done with people, for people, to people and as people and this is what makes it unique” (1). “caring is considered to be a the aim of this article is to describe how iranian patients and their companions explain their lived experiences with caring relationships in a central teaching hospital in tehran, iran. despite a large number of theoretical articles on this topic, the meaning of caring is still ambiguous, particularly in specific cultures. in iran, there is not enough qualitative evidence on this topic to indicate what patients actually mean when they refer to caring relationship. this article explores how iranian patients and their companions perceive and describe caring relationships as an element of patients' rights practice. this is part of a phenomenological research on patients’ rights practice in iran conducted during 2003-2006. semi-structured interviews were conducted with 16 pa tients/companions, and van mannen’s approach was used for thematic analysis. the ethics committee of tehran university of medical sciences approved the study. patient-centered care, compassion, effective communication, support/advocacy, informed participation and meeting patients' basic needs were found to be the key elements in defining caring relationships. these themes were all described as elements of patients’ rights practice issues. the results indicated that it is necessary for care givers/nurses to understand the person who will receive care in order to provide zealous and authentic care, because feeling “to be cared for” is even more important than providing the “care” itself. j med ethics hist med 2010, 3:4 joolaee s et al. page 2 of 7 (page number not for citation purposes) universal and culturally derived phenomenon (2, 3).”it has mostly been seen as a nursing term, including all aspects of delivering nursing care to patients (4). despite a large number of theoretical papers (5, 6) and some impressive literature reviews (7-11), the meaning of caring is still ambiguous because of its complex nature. some nursing theories believe that caring is the essence of nursing practice (12-16). according to nightingale, it is one of the most familiar nursing roles and the most important work in nursing (17). boff states that originally providing care to a person in a situation of disease reveals the meaning of the existence of nursing itself. the care provided to these patients’ beings maintains nursing as a profession. by giving care, nursing creates and re-creates the culture of care itself, which is essentially ethical. caring is more than an act, it is an attitude. therefore, it covers more than a moment of attention, zeal and unveiling. it represents an attitude of occupation, concern, responsibility and affective involvement with the other (18). since the 1990s, a considerable amount of re search has been conducted dedicated to explaining what caring practices are from the nurses’ perspec tive (19-21). however, in studying caring issues, exploring the patients’ perception of the concept is as important as exploring the nurses’ views. it is necessary to understand the person who will receive care in order to provide zealous and authentic care. this requires the caregiver to carefully research the existential experience of the being who needs care (18). many studies used qualitative approaches to investigate nurses’ perceptions of what constitutes ‘caring for patients’ and patients’ perceptions of what is important in making them feel cared for (8, 9, 22-24). despite an increasing focus on patients’ rights by iranian researchers and policy-makers (25-28), there is not enough evidence that the concept of caring is discussed and understood in iran. in an extensive phenomenological study by joolaee et al. in 2006 in iran, caring relationship was found to be one of the sub-themes of patients’ rights practice (29). the aim of this article is to describe how iranian patients and their companions (each patient is expected to have a ‘companion’ constantly at the bedside) perceive and describe their lived experiences with caring relationships as a component of patients' rights practice. this may help to highlight probable similarities and differ ences between iranian /muslim patients and patients of other cultures in a multi-cultural era. method this is part of a phenomenological study of patients and their companions’ lived experiences with patients’ rights, which was conducted as the first author's phd dissertation during 2003-2006 in tehran, iran. purposeful sampling method was used and semi-structured interviews were conducted with patients and their companions in a central teaching hospital in tehran. the interviews were continued until data saturation (16 interviews were con ducted). each interview lasted an average of 30-60 minutes and was done by the first author in a time and place appropriate for the participants (mainly in their bedside or the hospital’s yard). the main research question was “what is the meaning of patients’ rights for the patients and their companions?” and since “caring relationship” was one of the captured themes, participants were asked to talk about caring relationship and their experience with the feeling of being cared for, during their hospitalization. more specific ques tions such as “when do you feel that a nurse is caring for you?” and “would you please explain a situation in which you felt non-caring behaviors of a nurse?” they were also asked to focus on the specific behaviors of nurses that could make them to feel they have or have not been cared for. the interviews were tape-recorded and transcribed verbatim for further analyzing. van mannen’s holistic and selective thematic analysis was utilized to analyze the transcripts. van mannen stated that ‘the purpose of phenomenolog ical reflection is to try to grasp the essential meaning of something. this process is considered a thoughtful attempt to discover, or reach the essence of the phenomenon. to follow van mannen’s approach, the researchers read and re-read the transcribed interviews to achieve a holistic mean ing of what participants stated. this is called “holistic thematic reflection” (30).the next stage was reading the texts, line by line and highlighting the meaningful parts to capture the essence of the lived experience. the researchers then returned to the whole meaning they captured and this cycle was repeated constantly during data gathering and analyzing. this final step of hermeneutic phenomenolo gy requires ‘creating a state of homogeneity between the research sections by considering the whole and relevant parts’ (31). this process of continuous attempt to create a balance and congru ence among research units by moving from the whole to the parts and vice versa makes the themes meaningful as they gradually emerge until no new themes can be captured. to ensure trustworthiness of the data, the transcribed texts were analyzed by the research team to achieve consensus on each theme and then these were returned to some participants for confirming or revising. some slices of texts were also given to external readers to see whether the process of analysis makes sense or needs more j med ethics hist med 2010, 3:4 joolaee s et al. page 3 of 7 (page number not for citation purposes) clarification. revisions in each stage of data analysis were carried out by the research team. ethical considerations study was approved was by the ethics com mittee of tehran university of medical sciences. participants were fully informed about the study purpose and oral informed consent was obtained for participation. they were also assured regarding anonymity and their right to withdraw from the study at any time without recrimination. results in the context of nursing, caring involves a personal relationship. the interpersonal process of caring is based on an exchange of energy and information between the one providing care and the one being cared for (32). in this research, a caring relationship (as one of the elements of patients' rights practice) was perceived by patients and their companions as: receiving comprehensive patient centered care together with compassion, support, and effective communication by health care providers; it was also seen as involving them in their care process and meeting their basic needs (table 1) patient-centered care the participants reported a negative expe rience as a feeling of being treated as an object. they indicated that they need to feel a whole person and at the centre of the activities undertaken by the care providers, rather than merely as an entry on their task list. [nobody sees you…but rather they see your illness, your body, your wound, your cannula…; you are nothing more than the sum of your parts…] stated a participant while his companion declared [the one being forgotten is the patient…; everyone is just trying to finish his/her tasks and does nothing more!] compassion the need to sense that someone understands and cares about them was an important subtheme of a caring relationship from the patients’ perspec tive. a lack of such a compassionate approach was a source of distress and anguish. [… she was giving me an iv injection, i was experiencing great pain, but she was still carrying on, she didn't even glance at me to see my pain. i don't know if she couldn't see my agony or was pretending not to see it]. in sharp contrast, another patient referred to a positive experience that had made a lasting impact. [one of the junior doctors, who realized none of my family and friends was available to buy my medications, took my prescription and brought in the medica tions the following morning. i shall never forget his understanding and kindness. i was really impressed by his caring manner….] effective communication effective communication was found to be an important element of caring relationships. the participants indicated that good communication is sometimes more significant than the physical care they receive. nurses were perceived as being very busy people, without time to talk to patients. one patient stated that: [talking with and listening to patients is not always time consuming if they want to see us…]; and an elderly participant said: […she (the nurse) didn't even look at me…; i tried to look at her eyes…; i needed just a short eye contact. i wanted to say hello…, to thank her for all she was doing…, but she didn't look at me. instead, she looked carefully after my iv and did something for it…; i, as a person, was not as important as any problems that my iv might present. she needed no more time to look at me than checking my iv line]. a patient’s companion, helping his father to get out of bed, stated: [sometimes, patients are just looking for a facial expression for feeling to be seen… or to be cared for; …sometimes, they need a moment of silence to feel they have been heard…and, when this occurs, there is a sense of being cared for, a caring relationship is established.] another participant with a language problem (from azarbaijan, speaking azari), explained how the nurse who admitted him to the ward tried to find another azari nurse to facilitate communicat ing with him: [i was so depressed. i could not clearly explain to them what i was suffering from. she (the nurse) was so alert. she didn’t understand my language but tried to prepare my needs and requirements, and contacted the supervisor and asked for help from an azari nurse. i couldn’t believe this could be happening to me. my happi ness didn’t last long, though, because the nurse on the next shift was only concerned with the technical routines and not my feelings, and when i asked for an azari nurse, she explained with her hands and face that there is no need for this as the tasks could be done without any need for words!] support/advocacy entering any health care delivery system makes patients and their families face a world of unknown events. participants frequently stated that dealing with this perplexity and bureaucratic maze was not less vexing than their main health problem. a young woman explained this helplessness as follows: [i couldn’t understand the situation; i was admitted in this ward without being informed about j med ethics hist med 2010, 3:4 joolaee s et al. page 4 of 7 (page number not for citation purposes) what was going to happen…; the nurses asked my husband to leave the ward and i didn’t know that just a minute later i would need a lot of things to do with the nursing or medical procedures planned. i really felt lost and there was nobody to support me in that situation of helplessness.] however, a 76-years old man explained his positive experience regarding some nurses’ behavior: [they are god’s hands…; when you are most helpless they are here to support you… to make you feel that someone is taking care of you… and this is on top of all the other things they have to do (with his eyes he pointed to the nurses moving around).] informed participation usually people do what health care profes sionals ask of them during illness and hospitaliza tion. this stance, typical of traditional paternalism is dominant in many health care delivery systems, leaves patients unaware of what is going on, and unable to be involved in decision making regarding their health problems. one patient’s companion expressed this as unbelievable ignorance through out the whole system. she explained how the staff took her father for colostomy surgery without informing them about the detailed diagnosis, prognosis and alternative possibilities. she ex pressed with anger that: [i couldn’t believe what happened to my father. how could they do this without previous discussion? how can he now adapt with this (she referred to the colostomy bag on her father’s abdomen) to the end of his life?]. another young man who was confused about his physician’s behavior in not informing him about his diagnostic surgery and letting him suffer from pain and using self-prescribed sedatives for a long time, complained: [i have been in pain for a long time taking sedatives. nobody explained to me that i should have diagnostic surgery before any other pain management is decided. i had taken a lot of pain killers during this time and i didn’t know how dangerous this could be for me.]. all these beha viors make for a sense of mistrust between patients and care providers and make for feeling not being cared for. meeting patients' basic needs patients suggested that they expected caregiv ers to understand and satisfy their basic needs even without their request. they believed that meeting these basic needs is an important part of a caring job. one elderly male participant stated: [i am ashamed to ask help with changing my position frequently. i wish i could do this myself, but unfortunately, i can't…; i wish someone could understand how difficult it is for me to ask for help and could help me without asking.]. he continued after pointing to his full urine bag: [i'm really sorry that, sometimes, i'm not seen as a person who needs to be helped in meeting very simple basic needs.] a man with a plaster on his fractured arm and an intravenous catheter in his other hand explained what an acrobatic and difficult procedure the eating could be, with both hands limited in function, and how nice it would be to feel that someone might help him with this simple act. [i cannot do even basic things such as eating and personal hygiene. i feel somebody should see this….] discussion the findings of this study revealed some very important insights into the way that iranian patients and their companions perceive the interpersonal caring relationship with health professionals. these findings coincide with other studies investigating caring in nursing and highlight how both physical and emotional aspects are essentials of caring. the participants frequently emphasized real or genuine care when explaining their experiences, indicating that they expected something beyond routine tasks that were labeled ‘care’. they want to say that the word ‘caring’ has been misused and to demonstrate what it ‘should really be’; more reflection is necessary both by the professionals engaged in providing and those who are receiving this care. nursing and caring are closely linked in the literature (33) and, sometimes, uncaring behaviors of a nurse may still be called ‘caring’. this should make us as nurses to use this term with caution and accuracy. because the process in which nurses demonstrate authentic caring is an intentional interactive communication that conveys physical care as well as emotional concerns and promotes a sense of security in another (23). in this study, the participants' perception of receiving information and support in an effective communication supports the debate led by kitson who believed the aims of caring in nursing is meeting patients’ informational, emotional and physical needs and for nurses to have appropriate knowledge, attitudes and skills to meet these needs. the caring relationship described by iranian patients and their companions is confirmed by the findings of nurse researchers in hong kong and thailand who, by referring to patient-centered care as an important aspect of caring, explained this term as ’treating each patient as an individual who has his/her own needs’. this is also supported by mc cane et al, who found that patients believe that caring should be provided in a person-centered way. other researchers emphasized the importance of families in helping patients to be cared for (34 36). given the iranian families’ cultural attach ment, we can justify our decision to interview both j med ethics hist med 2010, 3:4 joolaee s et al. page 5 of 7 (page number not for citation purposes) patients and patients’ companions regarding this issue. a significant divergence of perceptions be tween patients and nurses regarding the priority of caring aspects is reported in basset’s findings in which the most highly valued aspect of care for nurses was creating a strong relationship with patients, whereas patients valued a high level of competency and skills in nurses (37). the incon gruence between nurses and patients’ perceptions of caring is also evident in this study. they found that professional competence and interpersonal skills as the main focus of nurses, but for patients, being involved in care and decision making were more important aspects of caring relationship (38). this differs from our findings, in which partici pants (both patients and their companions) showed great concern regarding nurses’ attention and emotional support above skillful task performance. bassett claimed that, in reality, patients are unlikely to say that they are not concerned about their relationship with nurses. they would clearly want both aspects of care, as even the most skilled and competent nurses could not deliver care properly without the ability to comfort, and create strong relationship with, patients and their families (37). participants in this study explained how they were in constant need of communication with nurses and exchanging information in a friendly climate. their need for eye contact, being seen or listened to, and receiving verbal and nonverbal caring signs is supported by many study findings that suggest patients and family members’ intention and desire to share personal thoughts and feelings in an open and honest manner (39-42). these can sometimes be demonstrated by simple gestures such as attentive listening (33), making eye contact (15, 43), touching (35), and offering verbal reassurance (10, 35). henderson et al. suggests that nurses should discuss with patients about appropri ate times when they can interact with them, learn about their specific needs and inform them about the long-term management of their conditions. this could potentially contribute in trust and connection between patients and nurses (44). our participants revealed that they wish their basic needs to be seen and met by nurses. they explained that they are not comfortable to make frequent requests and prefer to be understood by the nurses spontaneously. this perhaps seems unrealistic in western culture, in which a logical reciprocity is expected. however, special attention to a sick person is part of the iranian muslim culture in which this study was conducted. cortis showed similar findings regarding caring expecta tions by muslim pakistani patients living in the uk. those patients experienced incongruence between their expectations and the care received by nurses because of cultural differences that had not been taken into account (47). tschudin argued that caring is a response to someone who matters, simply because the person is there (1). we respond to each person and situation differently but, in order to be truly human, we need to respond. this response requires a comprehensive attention to patients and their context. according to the first researcher’s experience as a nurse and nursing educator, iranian patients trust health professionals implicitly and do not like to complain. as shown in this study, they have clear expectations of being cared for what, in most cases, are not even verbally expressed. this indicates that nurses should be more sensitive to unexpressed needs of patients. it means that they should not wait for patients’ request for care. however, this may seem not to be congruent with principles of medical ethics, in nurse-patients relationships, in which nurses are expected to be present whenever vulnerability is exposed, a simple human response is more frequently demanded than a technical or scientific approach (1). regarding the negative experiences of pa tients and their companions during hospitalization, the unexpressed considerations of them is one of our study’s limitations. the other was related to the nature of the qualitative approaches. this was also a relatively small study in just one health care facility and the findings can not be generalized. conclusion caring is a mixture of physical and emotional attentive communication, which patients and their companions expect from health professionals particularly nurses. the study also revealed that the iranian patients, sometimes, prefer their needs to be seen and heard by health professionals without asking. these types of unexpressed needs or 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53-62. journal of medical ethics and history of medicine the implementation of the sharia law in medical practice: a balance between medical ethics and patients rights hossein dargahi associate professor of allied health sciences, tehran university of medical sciences, tehran, iran. *corresponding author: hossein dargahi address: no.13, fardaanesh, qods st., enghelab ave., tehran, iran. tel: (+98) 21 88 96 56 08 fax: (+98) 21 88 99 70 50 e-mail: hdargahi@sina.tums.ac.ir received: 10 nov 2010 accepted: 15 jul 2011 published: 27 jul 2011 j med ethics hist med. 2011; 4:7. http://journals.tums.ac.ir/abs/18793 © 2011 hossein dargahi; licensee tehran univ. med. sci. abstract keywords: cadaver, medical ethics, patient's right, adjustment plan, hospital, attitude. introduction spirituality and medical ethics has recently emerged as an important topic in the health care provision and there exists a heated debate sur rounding the issue. medical ethics is in the curricu la of virtually all medical schools all around the world. on the other hand, spirituality and religion is considered as an inextricable part of almost all medical codes of ethics. therefore, one could as medical ethics indisputably needs to consider patients' religious beliefs and spiritual ideas, one can suggest that hospitals are responsible for not only patients' rights and dignity, but also for her/his religious concerns and expectations. the current study is designed shed some light on the patients' view of the implementation of religious law in iranian hospitals, specifically, the right of patients to be visited and delivered health services by professionals from the same sex. this protocol is proposed by the ministry of health and medical education of the islamic republic of iran as a response to the increasing demand for implementation of the religious law by iranian patients. this research is a cross-sectional study which was conducted at four teaching general hospitals in tehran, iran. the data was collected by the means of a questionnaire distributed to 120 women who were admitted to different wards of the hospitals. these women were asked to express their opinion of the implementation the same sex health care delivery (sshcd) system in iranian hospitals. all analyses were performed with the use of spss software, version 16.0. the results indicate that half of the hospitalized women believed that being visited by a physician from the same gender is necessary who advocated the implementation of sshcd in a clinical setting; and most of their husbands preferred their wives to be visited exclusively by female physicians. this study highlights the view of the iranian patients towards the issue and urges the ministry of health and medical education of the islamic republic of iran to accelerate the implementation of this law. sshcd is what the majority of iranian patients prefer, and, considering patients' rights and the medical ethics, it should be implemented by iranian policy makers. http://journals.tums.ac.ir/abs/18793 http://journals.tums.ac.ir/abs/18793 j med ethics hist med 2011, 4:7 hossein dargahi page 2 of 8 (page number not for citation purposes) suggest that patients' religious ideology and beliefs should be taken into account in any clinical setting (1, 2). spirituality is usually defined as the aspect of humanity that refers to the way an individual seeks to follow in life. it is supposed to add meaning and purpose to life, and facilitate the connection with the moment, self expression, and attitude towards other human beings, nature and the sacred (3). spirituality and religious beliefs have been shown to have an enormous impact on how people can cope with serious illness and life threatening stresses (4, 5). spirituality if often claimed to give people a certain feeling of wellbeing, improve the quality of life, and provide social support through spiritual social activities (6, 7). new advances in medical sciences have made it more than obvious that including moral issues in this profession is indispensable. as medical profession deals with individuals' bodies and lives, it needs to consider morality and dignity of human beings (8). therefore, medical practice is inter linked with a great deal of responsibility as it deals with human beings' physical and mental health; consequently, it should take all considerations into account including spirituality and religion (9). in today's world, medical ethics has been the subject of considerable attention due to the mentioned issues and it is the subject of heated debates. medical ethics include a set of values and codes which aim to build trust and confidence in physi cians, patients, and the society as a whole. a physician's competence depends not only on his medical knowledge, clinical decision making, and practical skills, but also, on his ideology and practice of medical ethics (10, 11). as one of the four basic principles of modern ethics is respect to patients' choice in clinical practice, physicians should respect patients' religious and spiritual choices (12). patients are only one side of the interaction in a clinical setting; physicians too, may have religious ideas and beliefs which may influence their practice. the religious ideology and beliefs of physicians can even more complicate the issue when patients' religious choices come into play (12). as argued, the concept of morality and medi cal ethics has become the focus of attention in medical practice, and, its implementation is furiously advocated (13). therefore, hospitals need to consider all aspects of patient's rights including the right to be treated based on their religious ideology. in fact, respecting all aspects of patients' rights such as their participation in decision making, respect for privacy and dignity, and interpersonal relationships are considered inter twined with several different aspects of health care delivery (14). the u.s. legal system has been pioneer in implementing a robust approach to a health care provision system respecting all aspects of patients' rights such as their special religious demands, while pursuing excellence in all aspects of health care delivery (15). in addition to considering moral issues and respecting religious beliefs of patients, public and governmental hospitals need to promote accounta bility. respect for patients' rights and enhanced communication with patients can pave the way for development of moral competence (16). in fact, it is argued that undermining medical and moral accountability in some countries has resulted in patients' loosing their confidence in the system regarding moral, legal, monetary, and political affairs (17). moral accountability in governmental hospitals is defined as the extent to which they implement and monitor adhering to moral princi ples by the authorities and staff (18). the need for defining a role for religion in human beings' everyday tasks is not limited to a specific religion, a certain geographical area, or a particular time period in the history. in fact, it can be argued that man has always felt this need all through the human history including the present time. islam, as both an ideology and a practical way of life, is argued by its followers, to provide solid foundation for different aspects of life (19, 20). the clinical setting and medical affairs seem to be in priority when implementing the religious law is concerned. islam treats physicians and health care professional with an utmost dignity. this dramatically increases the physicians' responsibil ity. as islam is all about faith, dignity, honesty, and mutual trust, medical ethics is of paramount importance for muslims as it needs to protect them from anything that might endanger the islamic principles (21, 22). in this study, we aimed to conduct a poll to find out what female iranian patients think about the implementation of the same sex health care delivery system (sshcd) in accordance with the religious law in a number of teaching general hospitals of tehran, the capital of iran. this plan was first proposed by ministry of health and medical education of the islamic republic of iran due to increasing demand of patients and policy makers, and, consequently, the supreme council of sshcd was established in 1997. the parliament of the islamic republic of iran passed the bill of this plan in 1998, and, in the same year, it was commu nicated to all healthcare organizations in iran. also, the supplement to this law was approved in 2006 (23). this study is the result of all endeavors to clarify whether the project can be implemented in iranian hospitals or not, and whether the patients would prefer and embrace it. this project is supposed to encompass all aspects of religious law j med ethics hist med 2011, 4:7 hossein dargahi page 3 of 8 (page number not for citation purposes) regarding medical practice including the need for female patients to be visited and cared for, exclu sively, by health care providers from the same sex (24, 25). the plan of sshcd project also includes a different part which is designed to define medical practice codes based on the religious law. this project is supposed to be followed by all medical practitioners practicing in the islamic republic of iran (26). the first step of the project is intended to sep arate women and men in hospitals (21). moreover, physicians should be required to visit patients from the opposite sex only when it is inevitable. this way, any unnecessary contact of the health care provider with the patient from the opposite sex is minimized (24). finally, physicians' bedside manner and their conduct toward their patients need to be according to the religious law (22). materials and methods this research was a cross-sectional, descrip tive – analytical study which was conducted at teaching general hospitals in tehran, iran. in this study, we chose four hospitals from different neighborhoods of tehran which were similar in terms of size, number of beds, number of patients admitted during a particular period of time, number of staff, and the health care services delivered. the questionnaires were to be answered anonymously, and, in order to protect their confidentiality, the names of the participating hospitals were not disclosed. the cochran formula was used to calculate the number of female patients as the research cohort. in each hospital, 30 female patients were selected from different wards using cluster sampling method. the assessment tool was a questionnaire comprised of 18 questions and the questions had a focus on demographic information, the preferred gender of the visiting physician, the importance of being visited by a physician from the same sex, and the most important moral issue they faced during their hospitalization. before the commencement of the study, a pi lot study was performed to check the reliability of the questionnaire. in order to ensure that, some of the patients were asked to complete the question naire randomly two weeks prior to the study. the results obtained from testretest method were studied and compared with those of the main study. the reliability coefficient for this measurement was relatively high (cronbach alpha=0.85). also, the face and coincidental validity were performed. therefore, it was ensured that the questions of the questionnaire were highly valid. the questionnaires were distributed among 120 women who were admitted to different wards of the hospitals. also, we asked the patients to mention their husbands’ opinion about their wives being visited exclusively by female physicians and they were asked to express their opinion about the questions. in order to specify the degree of the agreement the three – level likert scale was used as "agree", "disagree" and "neutral". the spss software was used, and the descriptive data were prepared. the statistical analysis, chi-square and pearson tests were used to analyze the data. as it was difficult to analyze patients' opinions by direct observation, the attitude was assessed using measurable bits of evidence such as the expression of beliefs and emotions (27). result most of the patients were 20 – 40 years old, 89% were married and 79.3% were housewives. 30% of them were illiterate and the remaining had high school diploma, bachelor’s degree, master's degree or doctorate degree. 60% of the patients lived in the capitals of the provinces and 40% lived in towns and rural areas. the results indicated that most of the hospitalized women's husbands preferred female physicians to visit their wives. half of these patients believed being visited by a female physician is necessary. in contrast, 14.8% believed it was not necessary, and 36.5% did not answer this question. almost, half of the patients believed that fe male physicians were available, 37.2% of them expressed that female physicians were not availa ble, and the rest expressed that they had not noticed it. most of the patients believed that they mostly felt embarrassed when male medical students were present by their bedsides. as it is tabulated in table 1, more than half of the hospitalized women believed in the competency of the female physicians and staff and preferred to be visited by them even when male physicians were being present. most of the hospitalized women in this study, expressed their concern and dissatisfaction about a number of issues in the questionnaire. most notably, they felt uncomfortable during physical examinations performed by male medical students. moreover, they expressed their feeling embarrassed by being visited by male physicians of their own family members or relatives (to whom marriage is prohibited by the religious law). they also opposed to a number of services delivered by male staff, including nursing care, housekeeping services, changing position, being helped with personal activities, urethral catheterization and intramuscu lar injections. they also were against presence of male medical students during medical examina tions, failure of patient's covering during radiology and laboratory services provided by the technicians or technologists, and the presence of male nurses and staff members of close relationship (to whom marriage is prohibited) during physical examina tions. in addition, the majority of the hospitalized j med ethics hist med 2011, 4:7 hossein dargahi page 4 of 8 (page number not for citation purposes) women were in favor of the separation of men and women's rooms at the hospital wards and the presence of a chaperone during medical examina tions. according to table 2, 3/4 of the hospitalized women were in favor of implementation of the sshcd project in tehran, iran. we analyzed the dependency or independency of the variables based on pearson test, and, it was demonstrated that there was significant relationship between the level of education of the studied women and their opinion about the gender of their physician (p=0.041) and being delivered nursing care by male nurses (p=0.045). therefore, it can be concluded that more educated patients preferred to be visited by male physicians and received health care by male nurses. also, there was a significant correlation between the age of the participants and their opinion of the presence of male physicians during physical examinations (p=0.002), being examined by male medical students (p=0.002), and receiving personal services by male hospital staff (p=0.019). older patients were in favor of being visited by male physician, being examined by male medical students, and receiving personal services by male hospital staff. moreover, there was a significant correlation between the incidence of hospitalization and the patient’s opinion about receiving nursing care provided by male nurses (p=0.04), and sharing their personal private issues with male physicians and other medical staff (p=0.01). it was observed that increased incidence of hospitalization was positively correlated with preferring to receive nursing care by male nurses and the other male medical staffs. there was also considerable correlation between the occupation of patients and their attitude towards the presence of male staff during their examinations by male physicians (p=0.01) and the implementation of adjustment plan. there was also correlation between marital status of the hospitalized women and their attitude toward being examined by male medical students (p=0.025). thus, the hospitalized women with higher job positions preferred to be examined by male physicians; in other words, woman with higher job positions were not in favor of the implementation of the sshcd project. most interestingly, there was a direct relationship between the opinion of the husbands and the patients, and the patients themselves regarding the preferred gender of physicians as well as being examined by male medical students. discussion the current study has several unique features. firstly, it had a focus on sshcd according to the religious law from a different point of view which is based on medical ethics and patients' rights. secondly, this study is one of the few studies conducted on the need for implementation of the sshcd according to the free will and respect to the choice of iranian female patients and their family. thirdly, in this article, the researchers analyzed the demographic characteristics of the hospitalized women (such as age, education, occupation, the incidence of admission to hospitals, marital status and the opinion of their husbands) with regard to the implementation of the sshcd. approximately, half of the hospitalized women believed it necessary to be visited by female health care professionals and they consid ered it as their indisputable right. zare dehabadi has suggested that patient's rights to choose their physician is in accordance with the who declara tion and that of the world medical association. this is also considered in patient's rights charters in malaysia, new zealand, and slovakia (28). waseem et al. have analyzed several points regarding patients' preferences for the gender of their health care deliverer. among the study subjects, 80 percent of the women preferred a female doctor, and when it came to the choice between more experienced and female physicians, none of them chose the doctor who had more experience. they researchers hypothesized some potential underlying basis for the results and suggested the possible implications. however, several studies conducted on hospitalized women's opinion about their preferences for the gender of health care deliverers found that characteristics such as interpersonal communication and clinical skills had priority over physician's gender. moreo ver, a significant numbers of patients did not express any preference. the aforementioned results are in congruence with those of the current study (29, 30). the subject of the gender related issues in medical practice and research has been the subject of considerable amount of debate recently. sex and gender related laws and regulations do not only affect the patient, but also include the relationship amongst practitioners themselves. considering the important role it plays in daily activities of medical practitioners and its legal, political, philosophical, and moral consequences, the gender related interpersonal communication issues should be taken into account more seriously (31). the most frequently expressed concern of the patients in this study was the issue of a male medical student's being present during physical examinations and ward rounds. the participants also expressed their dissatisfaction with the health care services rendered by male nurses and allied health professionals. moreover, they were strongly in favor of the separation of female patients' rooms in hospitals. it is universally acknowledged that patients and their families should have the right to choose their health care providers (32). therefore, hospi j med ethics hist med 2011, 4:7 hossein dargahi page 5 of 8 (page number not for citation purposes) tals bear the responsibility of providing patients with their preferred health care services. these services need to respect patients' choice of the clothing, head cover or hijab, and carrying religious relics or other symbolic items, as long as they do not interfere with diagnostic procedures or treatment options. many even argue that such issues need to have priority over medical procedure with more favorable outcomes. privacy, confidenti ality of clinical information, the presence of a chaperone during clinical examinations, and having the right to be visited and cared for by health care providers of one's own sex are usually considered as patient' indisputable rights (33,34). yarsis surakarta hospital in indonesia that is a private healthcare facility with 219 beds and zhejiang woman hospital in china that was founded in 1951 and fit, the local healthcare demand for women and babies, with nearly 1000 staffs, 750 bed, for women and 250 beds for babies, are examples of the world’s attention to human rights (35, 36). although the results of our study clearly demonstrated that most of the hospitalized women were in favor of the implementation of the sshcd project according to the religious law, one should consider several different factors when its imple mentation is concerned. azari argues that one of the most important strategies in this regard is to employ proportionate workforce, especially nursing staff and allied health care professionals (37). shojaie and ghofranipour indicated that a con servative and tolerant approach should be consid ered so that to avoid fierce opposition by those who disagree with this plan, and, also, to prevent extremism. it should be also taken into account that the implementation of the sshcd requires deep and sincere faith of both policy makers and health care providers, and, the strategy of its implementa tion must be similar to that of the islamic ethics. taking these into consideration, sshcd seems easy to be implemented and requires sincere faith and dedication (38, 39). one of the most important limitations of the present study was that it was conducted over a specific time period. it could be argued that an increased duration of the study might have demon strated different results. secondly, as all patients were recruited by means of a questionnaire, it is possible that during the information collection process some data are missed. finally, one could suggest that some other factors influencing health care provision for the hospitalized patients that have not been taken into account in our study. considering mentioned limitations further studies with a larger cohort and extending over a longer period of time seems to be of great importance before implementation of the sshcd or any such comprehensive plan at a national scale. it is noteworthy that written informed consent was obtained from all patients and every single aspect of academic honesty has been taken into account to avoid plagiarism, misconduct, data fabrication and / or falsification, and double publication. conclusion apparently, although a decade is passed since the proposal of the implementation of the sshcd in iranian hospitals, iranian patients and their families are still in favor of its implementation. in fact, the advocacy of its implementation has increased during the recent decade. moreover, the results of previous studies and those of the present one conclude that not only patients are in favor of the sshcd project, but also a great majority of health care providers advocate it. as a result, we hope that a new common issue about patients’ rights and medical ethics has opened. therefore, the results of this study, in accordance with those of the previous ones, indicate that iranian health care policy makers need to consider accelerating the implication of the sshcd plan. acknowledgement the authors would like to thank the staff of the medical ethics and history of medicine research center of tehran university of medical sciences as the study could not be conducted without their kind assistance. the current research was supported by tehran university of medical sciences and the authors declared that they had no conflicts of interest. page 6 of 8 (page number not for citation purposes) j med ethics hist med 2011, 4:7 hossein dargahi table 1: absolute and relative distribution of the hospitalized women's attitude toward each element total raw attitude no idea total frequency type of question n u m b e r p e r c e n ta g e n u m b e r n u m b e r p e r c e n ta g e p e r c e n ta g e n u m b e r p e r c e n ta g e 1 being visited by male physicians 27 22.5 57 47.5 36 30 120 100 2 female physicians' ability 28 23.3 69 57.6 23 19.1 120 100 3 male physicians of close relationship (to whom marriage is prohibited) 10 8.3 26 21.4 84 70 120 100 4 examination by male medical students 17 14.1 19 15.9 84 70 120 100 5 providing nursing care by male nurses 23 19.1 15 12.6 82 68.3 120 100 6 providing housekeeping services by male staff 30 25 24 20 66 55 120 100 7 changing position and helping with personal activities by male staff 16 13.3 7 5.9 97 80.8 120 100 8 presence of male staff during medical examinations 4 3.3 3 2.6 113 94.1 120 100 9 urethral catheterizations and intramuscular injections by male nurses 3 2.5 4 3.4 113 94.1 120 100 10 separation of female patients' rooms in wards 12 10 102 85 6 5 120 100 11 separation of bathrooms 1 0.8 111 92.6 8 6.6 120 100 12 medical examination behind screens in general rooms 17 14.1 97 80.1 6 5 120 100 13 presence of one of family members or close relatives during medical examination 11 9.1 77 64.3 32 26.6 120 100 14 presence of strangers during medical examinations 17 14.1 7 5.9 96 80 120 100 15 transportation by male staff 37 30.8 33 27.6 50 41.6 120 100 16 the way a patient's body is exposed during diagnostic procedures provided by male paramedical staff 24 20 37 30.9 59 49.1 120 100 17 patient’s covering during radiology laboratory services provided by the technician or technologists 21 17.5 16 13.4 83 69.1 120 100 18 male nurses or staff of close relationship (to whom marriage is prohibited) 25 20.8 29 24.2 66 55 120 100 page 7 of 8 (page number not for citation purposes) j med ethics hist med 2011, 4:7 hossein dargahi table 2: absolute and relative distribution of the hospitalized women's opinion of the implementation of the sshcd raw attitude frequency number percentage 1 no idea 2 1.7 2 agree 90 74.4 3 disagree 29 24 4 total 121 100 page 8 of 8 (page number not for citation purposes) j med ethics hist med 2011, 4:7 hossein dargahi references 1. puchalski cm. spirituality and medicine: curricula in medical education. j cancer educ 2006; 21(1): 14-18. 2. puchalski cm, mcskimming s. creating healing environments. health prog 2006; 87(3): 30-5. 3. puchalski cm, ferrell b, virani 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a qualitative study in medicine *corresponding author leila afshar department of medical ethics, shahid beheshti university of medical sciences, shams alley, valiasr ave., tehran, iran. tel: (+98) 21 88 77 35 21 email: leilaafshar@sbmu.ac.ir received: 17 jan 2019 accepted: 29 april 2020 published: 10 may 2020 citation to this article: yazdani s, andarvazh mr, afshar l. what is hidden in hidden curriculum? a qualitative study in medicine. j med ethics hist med. 2020; 13: 4. shahram yazdani1, mohammad reza andarvazh2, leila afshar3* 1.professor, school of medical education sciences, shahid beheshti university of medical sciences, tehran, iran. 2.phd graduate of medical education, school of medical education, shahid beheshti university of medical sciences, tehran, iran; assistant professor, nasibeh school of nursing and midwifery, educational development center, mazandaran university of medical sciences, sari, iran. 3.associate professor, department of medical ethics, shahid beheshti university of medical sciences, tehran, iran. abstract the hidden curriculum is considered to be between the designed and experienced curricula. one of the challenges that medical educators face is to understand what students learn in real clinical settings. the aim of the present study was to answer this question: what is hidden in hidden medical curriculum? this study was a qualitative content analysis. participants were selected through purposive sampling. data collection was performed through unstructured interviews and continued until data saturation. data were analyzed simultaneously with data collection using maxqda10 software. data validity was confirmed based on the proposed lincoln and guba criteria. the main theme that emerged in this study was implicit learning. professional ethics, spiritual, social and cultural issues, and clinical skills are the five major themes that were presented in this study. these themes and their subthemes are transferred during an implicit learning experience in hidden curriculum. since a wide range of issues are mostly transferred by hidden curriculum, it is essential to have a dynamic approach to educational environments. this is especially important in clinical settings, as the process of learning is constantly happening in the backyard. keywords: hidden curriculum; medical education; professional ethics; implicit learning; content analysis what is hidden in curriculum? a qualitative study in medicine 2 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 4 may 2020 introduction two decades after the introduction of hidden curriculum by philip jackson in 1968, hafferty put this concept forward in medical education (1). he stated that hidden curriculum is responsible for most of the material that is learned in medical schools(2). analyzing hidden curriculum is neither simple nor without challenge. what is directly understood from such an analysis might be odd and shocking or inconsistent with common sense(3). medical students learn many key and important issues from hidden and informal curriculum and not from formal medical curriculum(4). in the recent years, curriculum is no longer a term that clearly incorporates formal and genuine documents into all planned and unplanned experiences conducted under the supervision of an educational institution(5).much of what educational systems teach is planned and explicit, but there are topics that are implicit, unplanned and hidden, and can be found in hidden curriculum(6). some of the learners’ attitudes and behaviors are shaped by hidden curriculum in an institution’s learning environments(4).economically, hidden curricula impose a lot of health care costs on the society(5). in medical science education, hidden curriculum has the most impacting clinical education settings(7). it has a very powerful influence on the formation of students' professional development and may change their general ideas about career and clinical practice (8). in iran, educational researchers have not neglected studies of hidden curriculum and have added to the literature through their research results(9).most of this research, however, has been done in middle and high schools, and a small part pertains to higher education, especially in the medical education system. considering the importance of hidden curriculum in medical education, especially clinical education, the present study was conducted. the aim of this study was to analyze the content of hidden curriculum in order to determine what it conveys to students in clinical educational environments. the study was a qualitative inquiry based on students’ and faculty members’ experiences and aimed to grasp their viewpoints on the issue. methods this research was a content analysis designed to help understand the concepts in qualitative analysis(10).what made it suitable for qualitative research was the fact that it provided clear evidence of a phenomenon(11). content analysis has been described as a qualitative study method for subjective interpretation of text data by means of systematic categorization of coding and determining patterns and themes (12). eighteen faculty members and medical students voluntarily participated in the study. for maximum variation, they were recruited by purposive sampling from different specialties and levels. the study was conducted between may 2016 and february 2017. in terms of inclusion criteria, the yazdani s., et al. 3 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 4 may 2020 faculty members had to have a minimum of five years’ work experience as clinical teachers in medical schools, and the medical students were selected from undergraduate and postgraduate levels in the general clinical fields. data were collected through unstructured interviews. the main questions included: “what do students learn in clinical settings?” (asked from teachers), and “what do you learn in clinical settings?” (asked from students). the probe question was “what do you learn in clinical settings apart from formal curriculum? “each interview lasted 45 120 minutes. interviews were transcribed verbatim immediately after being recorded and were then analyzed. the interviewer had formal qualitative curriculum education and several years of experience in academic teaching, which would help in establishing trustworthy communication. the interviewer did not have any relation to the interviewees. participants’ selection, data collection and analysis continued until data saturation and a rich explanation of participants’ experiences were achieved. data collection was completed after 22 interviews (four participants were interviewed two times), when no new concepts emerged. five steps of "framework" process in the conventional content analysis approach were utilized to analyze data in this study.(10). the first step was familiarization, in which the audiotape recordings were transcribed word forward. the authors began data analysis immediately after the first interview. to get a sense of the whole subject, the transcribed interviews were read several times. in the second step, or thematic framework identification, the researchers analyzed the data word by word and line by line to identify the meaning units in order to determine the important concepts, themes and issues. next, they abstracted reduced meaning units and coded them top resent the content. in the third step, the various codes were compared based on differences and similarities, and the emerged codes were sorted into subcategories and categories. the fourth step consisted of applying the thematic framework to individual transcripts and making a picture of the data. collected extracts for each category were read by the authors to form a coherent pattern. then, the validity of each category was evaluated in connection to the data set and selected categories. two researchers examined the data for the categories independently. in the fifth step, or mapping and interpretation, the categories were defined and further refined. we used maxqda 2010 software to facilitate analyzing the data. the criteria of guba (1981) were applied in this study to ensure trustworthiness(13). credibility was achieved through variation in participants’ work experience, gender, type of specialty and grade of education among the faculty members, and type of specialty, area and grade of education and gender among the students, to get an extensive explanation of the phenomena. the main researcher used field notes to increase data quality and had prolonged engagement with the study fields. for peer checking, five experts with phd degrees or medical specialties controlled and confirmed what is hidden in curriculum? a qualitative study in medicine 4 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 4 may 2020 the coding and categorization process. all the peer checkers were faculty members with considerable experience in performing and teaching qualitative studies. for member checking, the abstracts of the interviews were returned to the participants and they verified the results. the research committee of shahid beheshti university of medical sciences issued the ethical approval for the study protocol (no. 130, date: 26/10/2015). the nature and aim of the study were explained to the participants, and their verbal and written consent were obtained. furthermore, study subjects were assured of confidentiality and voluntariness of participation. results ten faculty members (3 females and 7 male) and eight students (4 females and 4 male) were interviewed (table 1). table1-participants’ demographics number gender area of practice age (years) academic degree work experience (years) 1 female cardiology 45 associate professor 13 2 male psychiatry 57 professor 26 3 male anesthesiology 47 professor 20 4 male emergency medicine 47 assistant professor 13 5 male rheumatology 52 associate professor 23 6 female psychiatry 42 associate professor 10 7 male immunology 43 assistant professor 7 8 female pathology 45 assistant professor 10 9 male orthopedics 51 associate professor 17 10 male internal medicine 48 assistant professor 12 11 female emergency medicine 31 student not applicable 12 male internal medicine 46 student not applicable 13 male internal medicine 38 student not applicable 14 female anesthesiology 32 student not applicable 15 female undergraduate 23 student not applicable 16 male undergraduate 24 student not applicable 17 female undergraduate 24 student not applicable 18 male undergraduate 25 student not applicable yazdani s., et al. 5 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 4 may 2020 data analysis resulted in 119 open codes from which 13 sub-themes and 5 themes were derived. the five themes consisted of professional ethics, spiritual, social, cultural and clinical skills, with subcategories. implicit learning was recognized as a main theme (table 2). table2main theme, themes and sub-themes of implicit learning through hidden curriculum main theme themes sub-themes implicit learning professional ethics educational ethics research ethics clinical ethics spiritual issues belief in the hereafter lack of belief in the hereafter social issues career path hierarchy teamwork lifestyle clinical skills correct medical procedures incorrect medical procedures cultural issues intra-organizational culture extra-organizational culture the main theme derived from the whole interview was implicit learning, which consisted of 5 categories including professional ethics, spiritual, social and cultural issues and clinical skills, with subcategories. below, the participants' statements about themes and subthemes are explained. 1) professional ethics in this theme the participants provided examples that were then put under the subthemes educational, research and clinical ethics. the message in each theme demonstrate the perceived degree of ethical importance of the issue. the following are some of our participants’ statements: "one of my teachers was very rude and did not respect any of the students or other teachers. most of his trainees imitated this type of behavior. the fellows who are now working or have worked under him have what is hidden in curriculum? a qualitative study in medicine 6 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 4 may 2020 acquired his rude behavior.” [participant no. 12] "if student is doing dissertation with me, i supervise exactly what he/she is doing, and we work together. after he/she completes the work, i ask for the sources of information, the file numbers and everything, and then all the information and data are entered into spss under my supervision or that of an expert. in this manner, the student realizes that working accurately is an important issue in research."[participant no. 1] "teaching medical ethics should not be the way it is commonly done, it’s not like writing a book or making a lecture. these are things that really need to be taught through teachers’ behaviors, and behavior is not verbal, it is non-verbal." [participant no. 2] 2) spiritual issues the participants stated that spiritual issues could be transferred through hidden curriculum. this theme is divided into two parts: belief in the hereafter, and lack of belief in the hereafter. the participants’ statements in this regard were as follows: "belief in the hereafter affects teacher’s behavior, and this behavior has the highest influence on students. whether or not a teacher has religious or spiritual beliefs can be influential."[participant no. 2] "if i do not believe in god and do not consider his consent in my work, it will affect my relationship with the patient; i will measure everything according to money, and my students will see and learn." [participant no. 9] 3) social issues the results of implicit learning can be found in social matters and life in the social environments of a hospital, or even outside of it. learning about issues such as career path, hierarchy, teamwork and lifestyle occurs via hidden curriculum in clinical situations. in this regard some participants said: "students compare my financial status as a specialist in a discipline with another colleague who has another specialty, and see that i have a cheap car, but he has an expensive car. they conclude that they should choose a field that ensures better financial position. this has not been taught to the students, but they draw conclusions .” [participant no. 5] "when we see students walking at a distance behind the teacher, the message is that the position of the professor is much higher than the students."[participant no. 6] "the routine in the medical profession is that we work as team members. i always try to visit my patients with a nurse and a psychologist. it’s not that they are with me, but their opinion is important to me. my professors did this and i learned from them." [participant no. 6] "students are psychologically very capable of modeling. they are not hereto just attending a medical course; they see their teachers and learn from them life lessons." [participant no. 7] 4) clinical skills it is said that many techniques are learnt implicitly. this learning can be right if yazdani s., et al. 7 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 4 may 2020 students see the right methods in the department, and wrong if they see wrong ones. participants stated: "we learn a lot about interviewing patients. for instance, nobody teaches us not to laugh at patients and their company; also, we learn what to do and how to ask questions so we won’t annoy the patients and obtain their history in order to treat them better. although the professors give us a brief academic description of the process, they don’t tell us how to do it. we learn all this in departments."[participant no. 18] "spoke for many years about ethics and techniques: you have to stick to sterilization... you should wear gloves… bring the book and teach it and then do not attend the patient’s bedside. if i put the cvp line for a patient without wearing gloves, forty years of training collapses and disappears." [participant no. 3] 5) cultural issues culture is one of the issues transmitted by hidden curriculum in the hospital environment, and can be divided into intraorganizational culture and extraorganizational culture. the following are some statements made by our participants: "all professors have social, cultural and technical characteristics beside their medical characteristics. you can find it absolutely anywhere, even in the best centers you can find mean people, you can see both mean and kind attending doctors, organized or disorganized ones. all of these people together determine the potentiality of the center’s culture and its outcome. these things are clear…"[participant no. 3] "patients and their family, even colleagues, bring the outside world culture into the hospital. we learn a lot about the cultures of the external community from them."[participant no. 11] discussion the present study was based on a qualitative inquiry and showed that the content of hidden curriculum could be categorized as: professional ethics, spiritual issues, social issues, clinical skills and cultural issues. this categorization would help educators and educational organizations to better manage the effects of hidden curriculum. as mentioned earlier, the first theme of the present study was one of the consequences of hidden curriculum, which is transferring professional ethics. there is an agreement between educators that hidden curriculum has a significant role in shaping the professional identity of students (14). in line with the present study, jafree et al asserted that medical trainers, instructors and senior licensed practitioners influence the future of the moral behavior of their students and colleagues through hidden curriculum(15). olthuis and dekkers stated that medical training is a process of moral enculturation in the medical community. this process is not often explained clearly in formal curriculum(16). in transferring norms, rules and beliefs, as kently quoted; henry siouxs referred to what is hidden in curriculum? a qualitative study in medicine 8 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 4 may 2020 hidden curriculum as the norms, values and beliefs that are embedded in it and are transferred to students through regulations, structures and social relationship in schools and classes(17). concerning the transfer of professional values, thiedke et al. asserted that most professional values are conveyed through hidden or informal curriculum, a social setting that is broader than medical training, and lies outside of formal teaching(18). many authors declared hidden curriculum is declared that hidden curriculum is the impalpable informal and implicit teaching of values, norms and attitudes that are created and transferred by the medium of instructors, practitioners, informal teaching processes, students’ interactions and their interpretation of organizational events and environments(1, 2, 16, 19). stanek et al. stated that hidden curriculum indirectly alters the interactions, beliefs and practices of medical practitioners during their education(19). in addition, some studies showed that values, norms and belief systems are transmitted through hidden curriculum(17, 19). concerning the significance of professional behavior in the professional development of students, john ston et al. found that observing teachers acting un-professionally has a potential damaging impact on the professional development of students. the negative consequence of hidden curriculum arises when there is a contradiction between students' feelings and what they need to do in order to conform to the medical culture. this can lead to failure to address complicated moral occasions appropriately, despite having the required knowledge(21). azmand et al. concluded in their study that hidden curriculum has an effect on the development of the present “ethical climate”, by which medical students’ professional and ethical identities are shaped. in addition, specific plans regarding the institutional settings may provide opportunities to increase professionalism in institutions for medical educators(22). the second theme that was explored in the present study was spiritual issues. in line with our study, balboniet al. stated that religion/spirituality possibly has an effective role in the socialization of medical students, but has been largely unstudied. therefore, further research is needed to find its effect on hidden curriculum(23). the third theme in the present study was social issues. as quoted by other researchers, jackson said that students must learn to demonstrate appropriate social abilities(24). according to hashemiet al. social skills are transferred through hidden curriculum (25). the fourth theme in the present study was clinical skills. rojas stated that skills are learned through hidden curriculum during the clinical practice period(26). moreover, some studies indicated that practices (24) and behaviors (27) are transferred by hidden curriculum. the fifth theme was cultural issues. wear and skill corn stated that hidden curriculum includes a set of unwritten rules, social and cultural values, expectations and assumptions, and is more influential in comparison with formal curriculum(5). besides, some studies asserted that cultural yazdani s., et al. 9 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 4 may 2020 norms and customs(28) and social and cultural values, rules, and assumptions(29) are transmitted by hidden curriculum. acknowledgements we are thankful to all medical students and professors who have participated in this research. this study was part of a comprehensive research on hidden curriculum, conducted as a phd dissertation in medical education in shahid beheshti university of medical sciences. the research team has been working to develop an instrument for measuring the aspects of hidden curriculum in educational environments based on the findings of this study. conflict of interests none declared. what is hidden in curriculum? a qualitative study in medicine 10 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 4 may 2020 references 1. philip w. jackson. life in classroom. usa: holt, rinehart and winston; 1968. 2. woloschuk w, wright b, mclaughlin k. debasing the hidden curriculum academic equality among medical specialties. can fam physician. 2011; 57(1): e26-30. 3. hafferty fw. beyond curriculum reform: confronting medicine's hidden curriculum. acad med. 1998; 73(4):403-7. 4. haidet p, kelly a, bentley s, et al. not the same everywhere. patient-centered learning environments at nine medical schools. j gen intern med. 2006; 21(5): 405–9. 5. wear d, skillicorn j. hidden in plain sight: the formal, informal, and hidden curricula of a psychiatry clerkship. acad med. 2009; 84(4):451-8. 6. johnston wf, rodriguez rm, suarez d, fortman j. study of medical students' malpractice fear and defensive medicine: a “hidden curriculum?”. west j emerg med. 2014; 15(3):293-8. 7. chuang aw, nuthalapaty fs, casey pm, et al. to the point: reviews in medical education—taking control of the hidden curriculum. am j obstet gynecol. 2010; 203(4):316. e1-6. 8. rogers da, boehler ml, roberts nk, johnson v. using the hidden curriculum to teach professionalism during the surgery clerkship. j surg educ. 2012; 69(3):423-7. 9. ebadi sh. hidden curriculum: an apparent challenge or an unexplored opportunity. international journal of academic research in progressive education and development. 2013; 2(3):62-75. 10. burgess b, bryman a. analyzing qualitative data. uk: routledge; 1994. 11. elo s, kyngäs h. the qualitative content analysis process. j adv nurs. 2008;62(1):10715. 12. hsieh hf, shannon se. three approaches to qualitative content analysis. qual health res. 2005; 15(9):1277-88. 13. guba eg. criteria for assessing the trustworthiness of naturalistic inquiries. ectj. 1981; 29:75. 14. cruess rl, cruess sr, steinert y. teaching medical professionalism: supporting the development of a professional identity, 2nd ed. uk: cambridge university press; 2016. 15. jafree sr, zakar r, fischer f, zakar mz. ethical violations in the clinical setting: the hidden curriculum learning experience of pakistani nurses. bmc medical ethics. 2015; 16(1):16. 16. olthuis g, dekkers w. medical education, palliative care and moral attitude: some objectives and future perspectives. med educ. 2003; 37(10):928-33. 17. kentli fd. comparison of hidden curriculum theories. european journal of educational studies. 2009; 1(2): 83-8. 18. thiedke c, blue av, chessman aw, keller ah, mallin r. student observations and ratings of preceptor's interactions with patients: the hidden curriculum. teach learn med. 2004; 16(4):312-6. 19. safaei movahed s, bavafa d. towards another meta-theory for understanding the hidden curriculum. curriculum planning knowledge& research in educational sciences. 2013; 10(10(37)):76-96. 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7:94-107. 25. hashemi as, fallahi v, aojinejad a, samavi sa. the role of the hidden curriculum on social education of high school students. journal of life science and biomedicine. 2012; 2(5):255-9. 26. rojas a. the hidden curriculum in medical teaching. rev med chil. 2012; 140(9): 1213-7. 27. dutton l, sellheim d. the informal and hidden curriculum in physical therapist education. journal of physical therapy education. 2014; 28(3):50-63. 28. hafler jp, ownby ar, thompson bm, et al. decoding the learning environment of medical education: ahidden curriculum perspective for faculty development. acad med. 2011; 86(4):440-4. 29. karimi z, ashktorab t, mohammadi e, abedi h. influential factors on learning through the hidden curriculum in the perspective of undergraduate baccalaureate nursing students. j adv med educ prof. 2014; 2(2):53-7. ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ 1 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e original article volume 13 number 5 june 2020 copyright © 2020 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. comparison of the importance and observance of the patient's bill of rights from the perspectives of patients and personnel of hospitals in kerman *corresponding author roghayeh mehdipour-rabori nursing research center, kerman university of medical sciences, haft bagh, alavi road, kerman, iran. tel: (+98) 34 31 32 52 19 email: r_mehdipour@kmu.ac.ir received: 18 may 2019 accepted: 6 may 2020 published: 2 june 2020 citation to this article: dehghan m, mehdipour-rabori r, rayani m, zakeri ma, mobasher m, iranmanesh m, rezai n. comparison of the importance and observance of the patient's bill of rights from the perspectives of patients and personnel of hospitals in kerman. j med ethics hist med. 2020; 13: 5. mahlagha dehghan1, roghayeh mehdipour-rabori1*, masoud rayani1, mohammad ali zakeri2, mina mobasher3, maryam iranmanesh4, narges rezai4 1.assistant professor, nursing research center, kerman university of medical sciences, kerman, iran. 2.researcher, non-communicable diseases research center, rafsanjan university of medical sciences, rafsanjan, iran. 3.assistant professor of medical ethics, faculty of iranian traditional medicine, kerman university of medical sciences, kerman, iran. 4.researcher, nursing research center, kerman university of medical sciences, kerman, iran. abstract patients’ rights are among the most important criteria for evaluating the quality of health services. the current study aimed to determine the importance and observance of the patient's bill of rights. this cross-sectional study was done in kerman, iran. the research samples were 217 patients and 204 personnel. the data collection tool was a researcher-made questionnaire in the scope of the patient's bill of rights, and data were analyzed by spss 15. the results showed a significant difference between patients and the personnel on the subject of the patient's bill of rights and most of its dimensions (p < 0.01). however, no significant difference was found between their views on the observance of the patient's bill of rights and its dimensions. also, 35.9% of patients as well as 25% of personnel considered the observance of patients’ rights unfavorable. the participants were aware of the importance of the patient's bill of rights. it is necessary, however, to codify and approve the laws related to the rights of patients. keywords: patients’ rights; clinical ethics; patients’ bill of rights. comparison of the importance and observance of the patient's bill of rights from … 2 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 5 june 2020 introduction in recent years, societies have focused on individual and social ethics and rights, as well as the dignity of human beings. as a result, the concepts of patients’ rights and their support have been considered (1). the universal declaration of human rights in 1948 has defined patients’ rights based on the concept of equality of all human beings (2). patients’ rights refer to specific legal privileges related to patients’ physical, psychological, spiritual and social needs that the healthcare system and the medical team observe them. (3, 4). on account of the increasing ethical challenges in medical care, policies have been devised to pay more attention to human rights, especially for patients as vulnerable individuals with significant needs (5). healthcare providers must respect the patient more than ever (6), and in most countries throughout the world, they are required to observe some patients’ rights (7). therefore, the role of professional healthcare is to protect people who cannot defend themselves. the patient's bill of rights (pbr) is a guide to choose and ensure the best future decisions for patients' benefits, and can be the starting point for full attention to patients' rights and a correct definition of the relationship between healthcare clients and providers (8). according to the laws of the american medical association, physicians must protect patients and promote their basic rights (9). the patient's bill of rights has been addressed in a lot of countries, so hospitals and healthcare facilities must observe it (10). in iran, the health deputy at the ministry of health and medical education compiled the patient’s bill of rights in 2002 and sent it to the subordinate organizations (11, 12). the bill of rights includes the following topics: receiving proper services, patient's independence and decision-making rights, respect for the patient, privacy, and access to a complaints system. in some countries, the bill of rights also includes high-quality care, awareness of rights, pain relief, and easy death. (5). patient's bill of rights creates a sense of security and increases satisfaction, while patient participation in therapeutic affairs reduces the cost of treatment and the length of hospital stay, and also prevents the occurrence of irreversible physical and emotional injuries (13, 14). additionally, observing patients' rights will help improve and control their condition. dissatisfied patients hardly follow the treatment orders and show fewer signs of recovery, and may leave or change the treatment center with an incomplete course of treatment (15). therefore, non-compliance with patients' rights can endanger the health, life and safety of patients and weaken the relationship between healthcare personnel and patients, leading to less effective care and services to patients (16). unfortunately, healthcare providers and clients do not have a proper relationship in many aspects of the patient's bill of rights (17). studies have shown that in many cases, the patient's bill of rights is not implemented. according to these results (1, 18, 19), physicians, nurses and hospital managers did not have sufficient knowledge of patients’ rights, and these rights were not fully respected in the studied hospitals. in another study, despite dehghan m., et al. 3 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 5 june 2020 the excellent knowledge of physicians, the results reported poor observance of the patients’ rights (20). given the importance of patients' rights and the different degrees of observance of the patient's bill of rights in different societies, the iranian ministry of health has focused on the obsevance of the patient's bill of rights in recent years. furthermore, few studies have been conducted on the importance and observance of the patient's bill of rights from the viewpoints of patients and healthcare personnel. the current study compared the importance and observance of the patient's bill of rights from the viewpoints of patients and healthcare personnel in kerman. therefore, the results can serve as a guide for authorities and professors at universities and improve patients’ condition, the quality of health care services, and the professional position of doctors and nurses. method this cross-sectional study was conducted in kerman hospitals in 2018-2019. there are 4 governmental hospitals, 3 semigovernmental hospitals, and 2 private hospitals in kerman, all of which were included in the research setting. a cluster sampling method was used to collect data. governmental, semigovernmental, and private hospitals were considered as a cluster, and sampling was then done according to the number of beds in each cluster. a pilot study with a sample size of 20 people (10 personnel and 10 patients) was carried out to estimate the sample size. the mean and standard deviation of observance of the patient's bill of rights from the viewpoints of personnel and patients were 2.84 ± 0.48, and 2.66 ± 0.72, respectively. the confidence coefficient was 95%, with the confidence range of 1.96, and type ii error was 20% (0.84). therefore, the sample size for each group was estimated to be 136, which, according to the cluster sampling method, was multiplied by 1.5. finally, the sample size for each group was 204. the study population consisted of patients admitted to hospitals in kerman, aged ≥16, who were mentally and physically capable of answering questions, as well as the healthcare staff (nurses, midwives and doctors). the researchers started cluster sampling after obtaining permission from the kerman university of medical sciences, and explaining their goals to the participants. a self-report questionnaire was used to collect information. in the case of illiterate patients, the researcher interviewed them and completed the questionnaire for them. a two-part questionnaire was used to collect information. the first part of the questionnaire collected demographic information, including: 1) age, sex, marital status, level of education, occupation and income level for the patients, and 2) age, sex, marital status, level of education, occupation, type of employment and work experience for the staff (nurses, midwives, and doctors). the second part, a researchermade questionnaire, was related to the ethics comparison of the importance and observance of the patient's bill of rights from … 4 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 5 june 2020 in the area of the patient's bill of rights and was completed by the patients and the staff. therefore, focusing on the patient's bill of rights, the researchers formulated a questionnaire containing 20 items in 5 areas: "receiving optimal healthcare services" (9 items); "information provision" (4 items); "free decision-making" (2 items); "privacy and confidentiality" (2 items); and "access to an effective complaints handling system" (3 items). each statement of the questionnaire was measured based on a two-point likert scale. the significance of each phrase was measured using a 5-point likert scale (very important = 4, important = 3, somewhat important = 2, not important = 1, and i have no idea = 0). the observance rate of each statement was also measured using a 5-point likert scale (always observed = 4, often observed = 3, sometimes observed = 2, rarely observed = 1, and not observed at all = 0). the mean score was used to calculate scores. therefore, the score range of significance and observance rate of the patient's bill of rights varied from 0 to 4, with higher scores indicating more important ethics and better observance. also, in the area of observance of patients’ rights, mean scores of 0 1.34, 1.35 2.67 and above 2.67 were rather unfavorable, undesirable, and desirable, respectively. to determine the validity of this questionnaire, 5 experts in the field of medical ethics reviewed it, and their opinions were used to complete and correct the items. internal consistency was used for reliability. the questionnaires were then distributed to 20 target people (10 patients and ten personnel), and cronbach's alpha was calculated. the cronbach's alpha values for the importance and observance of the patient's bill of rights were 0.88 and 0.81 from the staff’s point of view, and 0.87 and 0.85 from the patients’ point of view. data analysis spss 15 was used to analyze the data. descriptive statistics (frequency, percentage, mean, and standard deviation) was used to describe the characteristics of the participants. since the importance and observance scores of the patient's bill of rights were not within the normal distribution range in either group, nonparametric inferential statistics was used (mann-whitney u and spearman correlation coefficient). ethical considerations the permission and a written letter of introduction were obtained from the research dean of kerman university of medical sciences and the ethics committee of afzalipour hospital (ir.kmu.rec.1395.11) during data collection. the researchers fully respected the principles of data confidentiality. results a total of 217 patients and 204 healthcare personnel participated in this study. the demographic characteristics of patients and healthcare personnel were reported in tables 1 and 2, respectively. the mean age of the patients was 43.88 ± 18.5, and the mean age of the healthcare personnel was 30.1 ± 6.92. dehghan m., et al. 5 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 5 june 2020 table 1demographic characteristics of patients (n = 217) variable frequency valid percent healthcare provider centers private hospitals semi-governmental hospitals governmental hospitals 41 27 149 18.9 12.4 68.7 age (year) less than 31 between 31 40 between 41 50 between 51 60 over 60 68 34 27 30 45 33.3 16.7 13.2 14.7 22.1 sex male female 89 125 41.6 58.4 marital status single married other 36 168 12 16.7 77.8 5.5 education illiterate reading & writing literacy diploma college education 28 46 81 51 13.6 22.3 39.3 24.8 job housewife/unemployed employee self-employed retired 112 20 48 23 55.2 9.9 23.6 11.3 comparison of the importance and observance of the patient's bill of rights from … 6 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 5 june 2020 table 2demographic characteristics of personnel (n = 204) variable frequency valid percent place of service private hospitals semi-governmental hospitals governmental hospitals 42 25 137 20.6 12.2 67.2 age (year) less than 31 between 31 40 over 40 103 62 15 57.2 34.4 8.4 sex male female 31 164 15.9 84.1 marital status single married other 70 124 4 35.4 62.6 2 education diploma associate degree bs*. ms**. phd*** specialized degree 24 3 153 7 13 3 11.8 1.5 75.4 3.4 6.4 1.5 profession midwife nurse doctor 29 157 16 14.4 77.7 7.9 type of employment permanent temporary-to permanent contractual human source plan 38 29 52 67 20.4 15.6 28 36 work experience (year) less than/equal to 5 between 6 and 10 over 10 90 35 39 54.9 21.3 23.8 *bachelor of science ** master of science *** philosophy doctor the table 3 shows the importance and observance rate of the patients’ bill of rights from the view point of the study participants. according to table 3, a significant difference was found between the patients and the personnel in the importance of the patient's bill of rights and most of its dimensions, since patients' rights were more important to the patients. no significant difference was found between the patients and the personnel in the observance of the patient's bill of rights and its dimensions, except in "access to an effective complaints handling system". also, 3.2% (n = 7) of the patients considered dehghan m., et al. 7 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 5 june 2020 observance of patients’ rights rather unfavorable, 32.7% (n = 71) unfavorable, and 64.1% (n = 139) desirable. one percent (n = 2) of the personnel considered observance of patients’ rights very undesirable, 24% (n = 49) unfavorable, and 75% (n = 153) desirable. table 3the importance and observance rate of the patient's bill of rights and its dimensions from the viewpoints of all participants patient's bill of rights importance rate observance rate patients (mean & standard deviation) personnel (mean & standard deviation) test statistic p patients (mean & standard deviation) personnel (mean & standard deviation) test statistic p total score 3.56±0.44 3.47±0.42 2.52 0.01 2.91±0.74 3.02±0.57 1.3 0.19 receiving optimal healthcare services 3.65±0.42 3.61±0.37 1.93 0.05 3.11±0.72 3.09±0.59 0.99 0.33 information provision 3.52±0.61 3.39±0.57 3.08 0.002 2.81±0.98 2.92±0.75 0.45 0.65 free decisionmaking 3.33±0.84 3.25±0.81 1.46 0.14 2.68±1.21 2.73±1 0.33 0.82 privacy & confidentiality 3.65±0.62 3.39±0.63 5.58 < 0.001 3.21±0.79 3.19±0.73 0.66 0.51 access to a complaints handling system 3.44±0.85 3.39±0.7 2.07 0.04 2.37±1.19 3.01±0.83 5.52 <0.001 mann-whitney u the perspectives of study participants about the importance and observance rate of ethical case law of the patients’ bill of rights were presented in table 4 and 5. according to table 4 and 5, in terms of the importance of the patient's bill of rights, the mean score of all items was higher than three from the viewpoints of all participants (minimum score of 0 and maximum score of 4). in the area of observance of the patient's bill of rights from the viewpoint of patients, the highest average scores were related to the items "privacy during treatment and confidentiality" (3.11), "respecting patients and being kind to them" (3.07), "skills of the healthcare team" (3.05), and "respecting the patient’s beliefs and religious and cultural values" (3.02). also, in the area of observance of the patient's bill of rights from the patient's point of view, the lowest average scores were related to the items "compensation for medical errors" (2.05), "how to handle patient's complaints" (2.18), and "patient's right to complain" (2.4). from the viewpoints of patients, the mean scores of 16 items were less than 3, while from the viewpoints of personnel, only eight items were lower than 3. comparison of the importance and observance of the patient's bill of rights from … 8 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 5 june 2020 table 4the importance and observance rate of ethical case law of the patient's bill of rights in dimension receiving optional healthcare service from the perspectives of patients and health care personnel case laws of patient's bill of rights importance rate observance rate patients personnel p patients personnel p r e c e iv in g o p ti m a l h e a lt h c a r e s e r v ic e s respecting patients and being kind to them 3.81±0.52 3.81±0.42 0.40 3.07±1.03 3.32±0.59 0.14 respecting the patients’ beliefs and religious and cultural values 3.36± 1.02 3.62±0.53 0.11 3.02±0.99 3.32±.64 0.005 being honest with patients 3.62±0.75 3.5±0.75 0.004 2.95±1.06 3.14±.73 0.28 nondiscrimination among patients for healthcare services 3.48±1.0 3.69±0.7 0.05 2.75±1.22 3.19±0.84 0.001 the skills of the healthcare team 3.69±0.76 3.82±0.4 0.3 3.05±0.93 3.26±0.77 0.03 paying attention to health, therapeutic and emotional benefits of the patients when providing services 3.66±0.68 3.53±0.7 0.01 2.98±1.03 3.18±0.73 0.15 providing wellbeing facilities 3.58±0.79 3.44±0.66 0.001 2.57±1.28 2.67±1.01 0.84 respecting patients’ time and providing fast services 3.7±0.67 3.49±0.64 0.001 2.62±1.28 2.96±0.96 0.02 paying attention to the needs of dying patients and their families 3.6±0.78 3.67±0.64 0.54 2.61±1.25 3.11±0.81 0.001 dehghan m., et al. 9 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 5 june 2020 table 5the importance and observance rate of other dimensions ethical case law of the patient's bill of rights from the perspectives of patients and health care personnel case laws of patient's bill of right importance rate observance rate patients personnel p patients personnel p in fo r m a ti o n p r o v is io n providing information about treatment costs and insurance codes 3.57±0.76 3.3±0.76 0.001 2.77±1.18 2.92±0.86 0.76 introduction of medical personnel to patients 3.36±0.89 3.47±0.7 0.42 2.63±1.24 3.15±0.9 0.001 providing adequate information about diagnostic methods and therapeutic measures 3.55±0.77 3.53±0.69 0.38 2.71±1.18 2.96±0.88 0.10 providing information about how to access the doctor 3.52±0.84 3.41±0.67 0.00 2.47±1.3 2.96±0.92 0.001 f r e e d e c is io n m a k in g a n d se le c ti o n freedom in selecting physicians 3.51±0.84 3.29±0.91 0.002 2.51±1.36 2.6±1.18 0.88 the right to accept or reject treatments or therapeutic offers 3.17±1.12 3.26±0.97 0.82 2.65±1.21 2.94±1.02 0.02 p r iv a c y a n d c o n fi d e n ti a li ty privacy during treatment and confidentiality 3.63±0.83 3.75±0.55 0.25 3.11±0.97 3.35±0.81 0.001 the right to having visitors 3.54±0.8 3.04±0.96 0.001 2.92±1.16 3.09±0.94 0.31 a c c e ss t o a n e ff e c ti v e c o m p la in ts h a n d li n g sy st e m patients’ right to complain 3.35±0.98 3.38±094 0.71 2.4±1.32 3.24±0.84 0.001 how to handle patients’ complaints 3.36±1.06 3.39±0.18 0.22 2.18±1.33 3.13±0.99 0.001 compensation for medical errors 3.66±0.84 3.53±0.75 0.001 2.05±1.5 2.88±1.07 0.001 discussion the current study compared the importance and observance of the patient's bill of rights from the viewpoints of patients and staff in hospitals of kerman. the results showed a significant difference between patients and personnel in terms of the importance of the patient's bill of rights and most of its dimensions, as it was found to be more important to patients than personnel. a statistically significant difference was found between patients and personnel in "access to an effective complaints handling system". also, 35.9% of the patients and 25% of the personnel considered the observance of the patients’ rights very undesirable or unfavorable. in the present study, the personnel and patients’ mean scores of the importance of patients’ rights were above three. the great comparison of the importance and observance of the patient's bill of rights from … 10 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 5 june 2020 importance of the patient's bill of rights to patients could be due to the fact that based on accreditation, hospitals are required to hold annual courses on patients' rights for personnel, and they have to complete them (21). also, a study conducted in izmir on physicians' awareness of the patients’ rights showed that 40% of the physicians were not aware of the patients' rights guidelines, and 63% of the participants did not even read them (3). according to rashtabadi's study, nurses' attitudes toward patients’ rights will have a positive effect on their performance (22). in the present study, patients' rights were more important to patients than personnel, and since they are the healthcare recipients, the personnel must observe their rights. the present study showed that from nurses' and patients' viewpoints, the most important aspect of the patient's bill of rights is receiving optimal healthcare services. this has also been demonstrated in a study by bazmi et al. (23). doctors and nurses in hospitals are expected to provide healthcare services for patients; therefore, favorable healthcare services are the most important for patients (24). in this study, the total score for the observance rate of the patient's bill of rights was not good from the viewpoints of the patients and the staff. various studies have been carried out in iran, indicating undesirable observance rates of the patient's bill of rights (25, 26). studies have shown that 55.56% of the doctors in saudi arabia (27), 50% of the doctors and nurses in egypt (28), 51% of the nurses and midwives in turkey (29), and 31.2% of healthcare staff in finland were not aware of the patient's bill of rights (30). studies in different cities of iran such as yazd, shiraz and hamedan have reported observance of patients' rights to vary between 50.2% and 53.2% from the viewpoints of nurses and the healthcare team (31,32). kazemnezhad and hesamzadeh reported that the observance of patients' rights from the viewpoints of physicians and nurses was 33.3% at the poor level and 49.6% at the average level (18). basiri moghadam et al. in gonabad (2011) showed that although the patients and staff had a good knowledge of the patient's bill of rights, the observance rate was not optimal (33). a study in uganda found that at least 36.5% of the patients encountered a challenge when claiming their rights, while 81.5% did not know anything about the patient's bill of rights (34). also, 92.8% of patients in sudan (35), and 75 % of patients and their companions in egypt had no information about the patient's bill of rights (29). in a study by nekoei moghaddam et al., despite the desirable knowledge of patients and nurses (81.5%), the rate of observance of the patient's bill of rights was not favorable (66.92%) (25). in babamahmoodi et al. study in mazandaran, the lowest observance rate of the patient's bill of rights from patients' viewpoints was 14.59 (36). although the observance of the patient's bill of rights has been highlighted in iranian hospitals, the performance of healthcare personnel must be changed, and health managers must emphasize the observance of the patient's bill of rights in hospitals. from the viewpoints of staff and patients, the highest score in the observance of the patient's bill of rights was related to privacy and confidentiality. humayun et al. showed that privacy and confidentiality were rarely dehghan m., et al. 11 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 5 june 2020 observed in hospitals, and staff needed more training in observing ethics and patient privacy (37). the lowest score in the observance of the patient's bill of rights was related to free decision-making. according to this study, patients cannot freely choose their physicians, and the patient's right to either accept or reject proposed treatments was not scored favorably. sultan ahmadi et al. evaluated the rights of pregnant women in kerman and obtained the lowest mean score in the area of decision-making (38). therefore, appropriate action should be taken to ensure that patients can enjoy this right. meanwhile, the low number of doctors may be one of the reasons why this has not been the case. patients may be free to accept the proposed treatment, but they are unlikely to be aware of this right, and the information needs to be provided for patients. in the present study, a statistically significant difference was found between the viewpoints of patients and personnel on accessing an effective complaints handling system and compensation for medical errors. according to patients, these two areas were often not observed. studies have shown that access to an effective complaints handling system is important for patients (39,40). friele and sluijs showed that although only 7% of patients requested financial compensation, most patients expected impartial judgments about complaints in hospitals (39). the current study had some limitations. this article cannot be generalized because of the cultural difference between iranians and people in other countries, as the expectations of patients and personnel are different in various countries. conclusion in the present study, the importance of the patient's bill of rights was above moderate for both patients and personnel in kerman. also, a statistically significant difference was found between patients and personnel in the observance rate of the patient's bill of rights. the score of the observance of the patient's bill of rights was higher from the personnel's point of view compared to the patients' views, but not satisfactory in general. the current study can be used clinically and help hospital managers and macro managers to take steps and enforce laws to better comply with the patient's bill of rights. the results can also be used to train nurses because they showed that the patient's bill of rights was observed from the personnel's perspective, but not from the patients' viewpoint. acknowledgements the researchers would like to thank very much professor ali akbar haghdoost, doctor of philosophy in epidemiology and bio-statistics in kerman university of medical science, who tirelessly efforted for this study. the researchers also express their sincere appreciation to the patients and personnel who had contributed to this study. conflict of interests the authors declare that there is no conflict of interests. comparison of the importance and observance of the patient's bill of rights from … 12 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 5 june 2020 references 1. nasiriani k, farnia f, nasiriani f. study of respecting patients’ rights from nurses point of view employed in yazd hospitals. iran j forensic med. 2007; 13(1): 33-7. 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________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ 1 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e original article volume 13 number 8 august 2020 copyright © 2020 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. policy considerations to achieve practical ethics: closing the gap between ethical theory and practice mansure madani1, nazafarin ghasemzadeh2, ali dizani3, ahad faramarz gharamaleki4, bagher larijani5* 1.phd candidate in medical ethics, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran; phd candidate in medical ethics, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran; department of medical ethics, school of medicine, tehran university of medical sciences, tehran, iran. 2.researcher, department of medical ethics, faculty of medicine, urmia university of medical sciences, urmia, iran. 3.researcher, qom seminary and department of islamic knowledge and humanities, amirkabir university of technology, tehran, iran. 4.professor, department of islamic theology and philosophy, university of tehran, tehran, iran. 5.professor, endocrinology and metabolism research center, endocrinology and metabolism clinical sciences institute, tehran university of medical sciences, tehran, iran. abstract social and professional behaviors are driven by extrinsic as well as intrinsic factors including executive rules and regulations enacted by extrinsic agents through coercion, police force and penalties. despite their effectiveness, these mechanisms undermine the fact that ethics is an intrinsic human quality. the present study seeks strategies to apply extrinsic coercion as an incentive to direct ethics as an intrinsic value. ethical behaviors driven by intrinsic motivations are more permanent and less costly. legal force can either strengthen or weaken intrinsic requirements. extrinsic conditions such as considering the interests, attitudes and preferences of others, involving people in the regulation and execution of law, justification of law, avoiding excessive punishment or rewards, and indirect support of ethics by establishing the appropriate social context can help boost intrinsic requirements in individuals. ethics will not be practically established unless we harness individuals’ ‘willingness to act’ as an essential determinant for ethical behavior. this requires adoption of a more psychological approach to ethics. if this aspect of ethical behavior is considered in regulations and executive processes, extrinsic forces can strengthen intrinsic requirements and spread ethics. keywords: intrinsic and extrinsic coercion; ethics and law interaction; policies and intrinsic motivation; social ethics. *corresponding author bagher larijani no. 10, jalal al-ahmad st., next to shariati hospital, chamran hwy., tehran, iran. tel: (+98) 21 88 63 12 96 email: emrc@tums.ac.ir received: 11 nov 2019 accepted: 1 aug 2020 published: 25 aug 2020 citation to this article: madani m, ghasemzadeh n, dizani a, gharamaleki af, larijani b. policy considerations to achieve practical ethics: closing the gap between ethical theory and practice. j med ethics hist med. 2020; 13: 8. policy consideration to achieve practical ethics: closing the gap between … 2 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 8 august 2020 introduction voluntary behaviors occur when an individual is willing to do something. any factor, whether intrinsic or extrinsic, that affects individual willingness to do something can lead to a certain behavior. intrinsic factors are numerous, and sometimes inconsistent, factors that drive our desires from within. they are basic needs that make an individual perform an action to gain pleasure or relieve pain. these basic needs are not negligible and play a significant role in forming our decisions and behaviors. later on, higher-order needs such as eagerness to know, aestheticism and humanitarianism inspire human actions (1). nevertheless, not all these factors lead to action and some may even contradict each other. it is our values and preferences that provide the motivation for actions (2). ethics is an intrinsic factor that controls social behavior and is guaranteed by individual conscience. we accept ethics when we prioritize moral behavior over our values and desires. some of these values are imposed by others and are internalized and personalized. effects of intrinsic factors and desires on human behavior have been mostly neglected in the literature. in the 18th century, the correlation between intrinsic factors such as emotion and character and human behavior was studied and interventive measures in philosophy (3), psychology (4), professional ethics (5, 6) and medical ethics (7) were seriously initiated. extrinsic factors include law enforced by the police force and penalties, as well as customs imposed through social pressures such as reprimand and humiliation. these factors may be internalized and turn into individual values to direct human actions. on the other hand, the individual may inwardly reject them but feel obliged to accept them out of fear or due to external coercion (1). law enforcement is a mechanism to control individual, professional and organizational behavior. executive laws and regulations use rewards or punishment to control human behavior and establish social order. it is a powerful means with a relatively predictable control outcome. enforcement of law is an essential aspect of human relations because justice cannot be established solely by common sense and human accountability (8). however, despite its high costs, law alone is insufficient in controlling all behaviors (9). thus, two sets of intrinsic and extrinsic factors determine human behavior, as illustrated in figure 1. figure 1turning theory to practice (law and custom as extrinsic factors, and ethics as an intrinsic factor) madani m., et al. 3 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 8 august 2020 intrinsic motivation is strong and persistent and needs no external force for action, but extrinsic motivation is temporary and weak. a law is more likely to be ignored when people abide by it out of fear without really believing in it. any sort of behavior that is controlled by such external forces may be performed in secret and may even return to its earlier state when the force in action subsides, for example when there is no policeman or the law is abandoned (1, 10). therefore, it is suggested that strong intrinsic motivations be employed to control human behaviors, and other costly/inefficient mechanisms of law be reserved for more risky cases. moreover, law and executive processes should be redesigned to reinforce intrinsic motivation and inflict the least possible damages. one significant and unpleasant detail that is often neglected in controlling behavior is that extrinsic intervention programs (punishment or reward) seriously damage or eradicate intrinsic motivation. the individual will gradually substitute intrinsic motivation with an extrinsic factor and violate law when there is no police officer or human observer (1,10, 11). in other words, when law intervenes, a persistent and strong motivation turns into a temporary and inadequate obligation. there is ample psychological proof for this issue. for instance, children who receive prizes for studying will stop it when they are not rewarded anymore. those who are interested in studying will do it for a prize (free pizza) rather than their own interest. this implies that rewarding has in some cases reverse effects and weakens intrinsic desire for an action, such that the individual abandons the action when he feels he will not be rewarded (1). this is also true for big punishments. small punishments may change a person’s attitude, but big ones, though more effective in changing behavior, have little impact on individual willingness to do something (1,11,12). psychologists have proposed some theories, including the cognitive dissonance theory, attribution theory, and self-justification theory to explain this issue. they briefly note that people generally tend to justify their actions by reasons that seem logical to them. they carry a self-conception that is always positive and gives them a sense of self-esteem. therefore, they try to do things that are consistent with their self-conception (i am a respected person and never do anything to hurt my reputation). otherwise, they will be distressed and anxious (1, 13). moreover, people process and associate information to be consistent with each other. that is to say, a new perception needs to be consistent with earlier ones and not hurt one’s self-esteem (13). excessive reward or punishment systems make individuals adapt themselves to those extrinsic factors (i will do something to be rewarded), and once the system is no longer in place, they will feel less obliged to do the same thing. but when the reward or punishment system is not excessive, individuals will attribute their following social norms to their own willpower rather than external factors, and will feel bound to the law even if there is no observer (i am not so cheap to be by inspired by such an incentive; i like it and i do it) (1, 12). similarly, it has been shown that people are less likely to follow rules when the regulatory system is weak compared to when there is no system (14). this psychological evidence explains why attitudes need to be internalized. policy consideration to achieve practical ethics: closing the gap between … 4 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 8 august 2020 however, external interventions are not all negative. studies show that laws and rules help internalize positive behaviors and reinforce ethics under certain circumstances. when the logic behind rules is explained, justified, taught and enculturated, self-control is strengthened among people and they automatically perform the action, even when the external force is removed (12). ethical behaviors will be driven by intrinsic incentives when people are appropriately informed about the logics behind ethics, or are actively involved in the process of providing ethical training (15). once ethics is internalized, extrinsic forces can be applied with care to guide and reinforce intrinsic incentives but not turn them into external obligations. the present study focuses on social and professional ethics. ethical behaviors are formed by intrinsic incentives and willingness to do things. therefore, the present study seeks to find mechanisms to modify laws and executive processes to lead to ethical behaviors. it examines the effects of extrinsic coercion on ethical behaviors and the way laws and executive processes can be designed to trigger intrinsic incentives. to our knowledge, this has not been carefully examined in the literature and is occasionally referred to in social psychology. in this study, we intend to discuss the issue and offer some solutions. here, law refers to any obligation with executive guarantee/control, including regulations, processes, etc. method this is an interdisciplinary and analytic study. the following keywords were first explored in valid databases in psychology, sociology, and ethics: ethical knowledge, ethical practice, ethical weakness, motivation, willpower, and awareness. the resulting essays were filtered and irrelevant ones were removed. the remaining essays were carefully studied and the authors’ viewpoints were extracted. related books on the topic were used in the course of our analysis, and considering the interdisciplinary nature of the study, reference books were also used to increase the validity of the study. when the primary search and analysis was done, new keywords were obtained, including internalizing ethics, moral development or ethical growth, socialization, structure and agency, intrinsic and extrinsic incentives, psychology of policy-making, and the unconscious. these keywords were further used to achieve better search results across different fields. results the interaction between law and ethics and its effects on ethical behavior the relationship between ethics and law can be investigated from different aspects: 1. legal enforcement of ethics the simplest way to guarantee ethics is to legally enforce ethical behavior by setting rewards or punishment in connection with any ethical rule. this is accompanied by some problems, both in theory and in practice. laws essentially restrict individual freedom and have to be minimized. it is sometimes unethical for law to intervene in private aspects of human life and make regulations for humanitarian and self-sacrificing acts. in addition, laws are administered by force, which can be abused and should therefore be limited to certain cases. on the other hand, they are costly and it is difficult in many cases to provide lawful basis, supervisory madani m., et al. 5 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 8 august 2020 administration and punishment for ethical concerns such as telling lies (9). laws are essentially inefficient in the field of human emotions such as abhorrence and jealousy, and can only cover a limited number of ethical issues. intrinsic incentives such as emotions and sentiments often instigate actions that cannot be regulated and modified by reward or punishment. 2. ethical audit of law laws can be regulated and audited based on ethical considerations. in fact, laws attract individual compliance and obedience because they are supported by ethics; also, the law claims legitimacy and morality of its orders (9). however, even an ethically-passed law may lead to unethical problems when enforced in practice. for instance, documentation in nursing practice is only a recording of unusual events, wearing out the time and energy of healthcare providers. thus, ethical audit is necessary but not sufficient on its own. 3. creating an ethical atmosphere/ climate it is very important and valuable to raise ethical humans, but sociopsychological studies show that it would be nearly impossible unless we create the infrastructural requirements and background (1). in other words, we can use laws and regulations to reform social structures and provide an atmosphere in which unethical people are compelled to act ethically. the opposite is also true, i.e., ethics is fostered and facilitated when the costs of unethical behavior rise. laws and executive processes can provide a framework for social interactions through effective management of political decision-making, conducting appropriate educational programs, and establishing positive incentives such as rewards for voluntary community services, in order to persuade unethical people to adhere to ethics. laws can also engage people in self-sacrificing ethical acts like helping the needy. these are voluntary activities and cannot be legally enforced, but can be ethically organized. laws can indirectly support such charitable acts by making them taxfree (9). 4. contribution of law to self-control laws and processes can significantly contribute to establishing ethical habits and characters. one key cause of unethical action is that the individual feels unwilling to do something but cannot help himself. disciplinary rules enhance self-control and self-regulation, and help establish and internalize ethics (12). however, we should bear in mind that these interventions are temporary and only aim to internalize ethics. extrinsic factors, such as laws that are intended to establish ethical habits, are most effective when coupled with training, enculturating and convincing the target population. fastening seatbelts is an example of how enculturating and coercion worked together to make drivers abide by the law. in this regard, excessive reward or punishment systems should also be avoided. 5. policies that maintain or reinforce intrinsic incentives another key aspect in the interaction of ethics and laws, which is mostly neglected, is to pass laws and executive processes that reinforce or at least do not harm internal and policy consideration to achieve practical ethics: closing the gap between … 6 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 8 august 2020 ethical motivations. this is a complicated issue and policy-makers can make better decisions if they become more informed about harmful and useful policy-making capabilities and solutions. for example, people rarely agree to obey rules that are against their religious beliefs (16). the present study adopts a psychological approach and offers a host of effective mechanisms based on the distinction between internal and external obligation. below, policies with the least effects on intrinsic incentives are examined. a. passing laws with highest compatibility with individual attitudes and values: laws need to be at least partially in accordance with individual attitudes and ethics to be accepted and effective. otherwise, they will cause conflicts, biases, ambivalence and pangs of conscience in people and will be rejected, which will finally harm intrinsic motivations (16). b. serving and supplying the interests of the majority of people: most people work for their interests and do whatever they can to maximize their personal profit or benefit. an efficient legal system supplies the interests of the majority and allows even profiteers who have little ethical concerns to achieve what they like. by doing so, it strengthens intrinsic motivations. if agents of a party (physicians, nurses, etc.) partake in regulating meetings, their interests might be represented. however, it is a relative objective and may not be realized in all cases (9) because sometimes individual and social interests are in conflict. in such cases, the law should be justified and people should be convinced to believe that abidance by law brings them more benefit. c. justification of law: laws need to be ethically justified to be valid. it is essential to convince people of the significance of having a legal system that safeguards community life and serves the benefits of the majority (17). justification of law and enculturating are necessary for ensuring that laws comply with social interests, which is realized when policy-makers convince people and attract their cooperation. this will decrease cognitive dissonance, which will otherwise give rise to social and individual conflicts and lead to anxiety, ambivalence and bias. in fact, justification of law aims at boosting intrinsic incentives and reducing extrinsic coercion. for example, some physicians never obtain patients’ informed consent because they think it is not required or even against patients’ well-being. if they are convinced of its effectiveness for treatment, they will surely feel more inclined to cooperate (9, 16). d. involvement in policy-making: involving people in policy-making activities (such as formulating, approving or enforcing the law) contributes significantly to inspiring intrinsic incentives. the more people are engaged in these activities, the more likely it will be to achieve practical ethics and implement laws. when people are involved in an activity, they feel motivated and try their best to show greater levels of commitment. in group or participatory activities, people are involved both mentally and physically, feel more attached to the group and work towards collective objectives. internalization of ethics occurs when people are given a chance and a role in the group and feel qualified in contributing to the community. cooperation madani m., et al. 7 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 8 august 2020 has been proved to enhance self-esteem, selfefficacy and self-sufficiency, and makes the individual feel motivated to freely engage in group work (18-20). it also helps people be more considerate and tolerant towards others and their rights because they will be more inclined to understand them (21). studies show that cooperation improves learning and modifies radical attitudes (22-24). a cooperative atmosphere affects incentives and helps decision-makers gain an insight into the reality of the society and make realistic decisions (25) while delivering more skillful and empowered individuals (26). in such an atmosphere, cognitive assonance will also increase. as mentioned earlier, people always try to justify their behavior and tend to associate different perceptions that form their attitudes. when individuals participate in making regulations, they can hardly justify any act of their own that violates the law because doing so would be in contrast with their sense of self-esteem. cooperation is achieved by vote, survey or similar means. in an organization, for example, staff representatives participate in decision-makings (19). delegation of authority to lower ranks in an organization is another form of cooperation that makes the staff feel worthy and perform their duties better (27-29). other types of organizational cooperation include forming working committees, educating managers and supervisors, identifying and engaging qualified staff in organizational affairs, and persuading the staff to express their opinions and come up with new ideas (30). lack of formal and informal mechanisms to get feedback from the system makes the staff feel detached from their managers and stay silent. when they feel their voices are not heard by their top managers, they feel indifferent towards organizational goals (30). this silence will drive the organization away from its planned objectives and will provide little information for managers to intervene and make the required reformations (31, 32). e. avoiding excessive reward or punishment systems: big rewards and demanding or strict rules may control behaviors but will kill intrinsic motivation and behaviors will be driven by extrinsic incentives. there is enough evidence for this fact: children who are punished slightly for playing with a toy are less likely to play with it in secret (1). this has been explained in the introduction section. f. facilitating social solidarity: any community can provide the setting for social solidarity and foster ethical virtues. it can also support ethical behavior by appropriate education, persuading desirable social activities, and rewarding voluntary activities (9). social systems have been shown to be highly influential in creating an environment that boosts intrinsic incentives. common ethical values rely on social solidarity and a sense of commitment and belonging to the group. laws and executive processes can create an appropriate framework for social cooperation and solidarity and contribute to ethics (33). laws can organize certain institutes such as non-governmental organizations (ngos) and professional associations that strengthen solidarity. people policy consideration to achieve practical ethics: closing the gap between … 8 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 8 august 2020 voluntarily join such institutes and, once they are in, follow the rules. these groups are democratic and nongovernment-backed. therefore, individual factors such as fear of press disclosure of news make people control their behavior. ngos have multiple channels to professional ethics. they support ethics in society, associations and professions, and their existence relies heavily on adhering to ethics (34). psychological studies confirm internalization of group rules. people tend to identify with and follow group disciplines. they comply with group standards and imitate others’ behaviors, and internalize collective norms as their own beliefs. they also perform their pre-defined roles and are ready to pay any costs to preserve the group. this implies that institutional norms are powerful entities that shape and direct individual desires (1). professional ethics will be further strengthened if nogs become more active and participate in administrating their own affairs. conclusion the gap between ethical theory and practice is a problem in many aspects of social sciences. it is yet to be found why people do something against their own beliefs. a host of schools in psychology and philosophy have considered the process of turning theory into practice and have provided a medium to intervene and reduce this gap. the two most important mediators are will and intention. knowledge and awareness will end in action when individuals have enough motivation and willingness to do it. moreover, they should have the ability to do the action and obstacles should not be so big that they feel demotivated. figure 2 shows the process of turning theory to practice. figure 2turning theory to practice ethical judgment is acquired by direct or indirect education, which will end in action if coupled with individual willingness. therefore, laws and executive processes can help actualize practical ethics in two ways: strengthening/weakening intrinsic incentives, increasing/decreasing practical obstacles. laws are essential extrinsic forces and have nothing to do with intrinsic incentives. however, studies indicate that they mutually affect each other. external obligations can either strengthen or suppress intrinsic incentives. however, they should be applied with caution because laws have potential drawbacks and human emotions are significant factors in performing ethical acts. considering individual attitudes and interests, justifying and enculturating laws, promoting cooperation, appropriate use of reward and punishment, and facilitating madani m., et al. 9 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 8 august 2020 social solidarity are mechanisms that help boost ethics. creating an ethical atmosphere facilitates ethical behaviors and lowers the costs of ethical behavior while increasing the costs of unethical actions. in fact, people realize that doing ethical acts is more beneficial. correct laws and executive processes can create such an atmosphere and ethical auditing can gradually remove potential obstacles. this is mostly achieved by providing the required infrastructures to develop professional associations and ngos. these institutes are run by people and have great roles in promoting ethics. they also facilitate ethical and even self-sacrificing behaviors. passing laws and applying coercion can help turn them into routine ethical behaviors, which are later internalized by training and enculturating. figure 3 shows the effects of policies on the gap between theory and practice. figure 3 the process of turning theory into practice laws are imposed on people by force and make them avoid wrong doing, but ethics can cause people to voluntarily do the right thing. regulators are urged to avoid passing laws that damage intrinsic incentives. instead, they should, pass laws that strengthen intrinsic motivation removing obstacles and facilitating action ethical audit of law involvement in policy-making justification of law enculturating strengthen selfcontrol legal and moral judgment •knowledge desire •want intention •can act •do charecter •habit policy consideration to achieve practical ethics: closing the gap between … 10 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 8 august 2020 incentives to decrease the likelihood of violating laws and increase voluntary abidance by rules even in the absence of laws. in promoting ethics, policy-makers can benefit from psychological insights to achieve effective rules and laws. conflict of interests the authors declare that there is no conflict of interests regarding the publication of this paper. madani m., et al. 11 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 8 august 2020 references 1. nolen-hoeksema s, fredrickson bl, 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[in persian] ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ 1 © 2019 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. review article j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 19 december 2019 from prussia to russia: russian critics of “aerztliche ethik” *corresponding author boleslav lichterman b. patriarchiy per., no.3, str. no.1, moscow 123001, russia. tel: +7(916) 91 41 409 email: lichterman@hotmail.com received: 20 aug 2019 accepted: 27 dec 2019 published: 31 dec 2019 citation to this article: lichterman b. from prussia to russia: russian critics of “aerztliche ethik”. j med ethics hist med. 2019; 12: 19. boleslav lichterman* professor, department of humanities, the im sechenov first moscow state medical university, moscow, russia. abstract the aim of this paper is to compare “zapiski vracha” (“confessions of a physician”, first published in 1901) by vikenty veresaev to “aerztliche ethik” (“doctors’ ethics”, first published in 1902; two russian editions were published in 1903 and 1904) by albert moll. it starts with an overview of medical ethics in russia at the turn of the 20th century in relation to zemstvo medicine, followed by reception of veresaev’s “confessions of a physician” by russian and german physicians, and of moll’s “doctors’ ethics” in russia. comparison of these two books may serve as a good example of a search for common philosophical foundations of medical ethics as well as the impact of national cultural traditions. keywords: history of medical ethics; russia; germany; v. veresaev; a. moll from prussia to russia: russian critics of "aerztliche ethik" 2 volume 12 number 19 december 2019 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e a russian landscape of medical ethics at fin de siècle zemstva or elected local self-governing councils emerged in many russian regions after krepostnoe pravo (serfdom of peasants) was abolished in 1861. they were in charge of rural health care and started to build hospitals in the larger villages. a majority of zemstva had one physician for every 25,000 30,000 people, who lived in areas as large as 25 30 square kilometres without proper roads. apart from working at the hospital (which usually had about 20 beds), a physician had to see between 80 and 100 ambulatory patients daily (up to 20,000 outpatient visits annually). with this patient load a zemsky physician would take as little as 2 3 minutes to examine a patient. he also had to travel to remote villages to deliver babies, fight epidemics, and supervise the sanitary conditions of 15 16 rural schools. the working day of a typical zemsky physician lasted for 10 hours. nevertheless, his average salary of 1200 1500 roubles a year was insufficient and would comprise about half of the budget of a middle class family in germany (1). in such circumstances many doctors were involved in private, fee-for-service practice1. the trend towards private practice provoked severe criticism from more idealistic colleagues. for example, d. n. zhbankov 1. according to the official report of the medical department of the ministry of internal affairs, the total number of medical doctors in russia in 1881 was 14.488; out of this number, 2629 were private practitioners (18%). in 1907 these figures were 18215 and 5291 (29%) respectively. claimed that private practice undermines the foundations of zemstvo medicine, which is based upon the principle of equal treatment for all. he stressed that “the communal (obshinnye) foundations of russian life, which came to the surface with zemstvo, revealed the evil and abnormality of private [medical] practice” (1). patients’ fees for medical care were condemned as “a tax on the misfortunes of a fellow creature”. two evils were thought to result from private practice: a waste of time for the society, and the loss of trust among the population. moreover, zhbankov objected to any increase in a doctor’s salary: “a workman for the poor and among the poor should not differ from the population from the material standpoint. otherwise he will not be trusted and his activity will not be productive” (1)2. zemskaya medicine was based upon the principles of free and accessible health care and preventive medicine. these principles were later adopted by soviet healthcare. according to m. s. uvarov, yesterday’s slaves treated with mistrust and suspicion everything that originated from their former lords, and this included the suspicion that doctors were poisoning the people (4). cholera riots during the reign of nikolas i in 2. as zhbankov wrote earlier (2), “the patient’s suffering and the doctor’s labor should not be brought to the market and become an issue of demand and supply; honorarium, private practice and all bargains between a patient and a physician must be eradicated, and medical care should be provided free of charge…”. in his article “on the purpose of science and art”, leo tolstoy also wrote that true medical assistance will start only when a physician provides it for free and will live among the working people in the same conditions (3). lichterman b. 3 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 19 december 2019 1830s, and the killing of doctors during cholera epidemics in the 1890s serve as vivid examples of these attitudes. “under such circumstances the western european pattern of doctor-patient relationships (that is, the relationship between a vendor and a customer) would be difficult to imagine…. there were vendors, but customers were unlikely to come” (4). most zemskie physicians were idealists who viewed their work as public duty. they shared the idea of caring for the people and a sense of indebtedness to the people. ethical issues were widely discussed in the medical journals of the late nineteenth century. in just one year, 1894, more than 60 books and articles on medical ethics were published in russia (5). a weekly periodical, “vrach” (medical doctor) was particularly influential. it was edited by professor v. a. manassein (1841 1901), who was nicknamed “a knight of medical ethics.” the objectives of this periodical were characterized by manassein as follows: 1) to be a true mirror of everything that constitutes real progress in clinical medicine and hygiene; 2) to attract to a cooperative scientific work the maximum number of medical doctors from different regions of russia; 3) to provide a constant critical, independent and impartial analysis of all aspects of education, daily life and practice of a medical doctor; manassein was strongly opposed to private practice: “the complete trust and purity of the relationship necessary to a doctor for treatment and to a patient for recovery will be impossible unless the doctor’s labor is paid by the society or the state” (5). in 1884 this periodical published a russian translation of the “ethical code of the warsaw medical society” (warsaw at the time being part of the russian empire). according to the editor’s footnote, “if in the future ethical codes for all russian doctors are going to be elaborated, irrelevant paragraphs have to be modified”. two sections of the code were severely criticized: a statement that a physician may breach confidentiality upon the demand of the authorities or when dictated by public interests (article 2), and the obligation of a physician to inform authorities about cases in which he learns about actual or planned criminal activities (article 73). manassein called for absolute confidentiality in all circumstances. he was also against unethical human experimentation. for example, manassein mentions professor gübbenet from kiev who inoculated syphilis into healthy soldiers: “i would like to know if prof. gübbenet would inoculate syphilis into his son even if the latter gave his consent” (6). according to manassein, “no human experiment is permitted unless you are convinced of its complete safety. but even then you should obtain consent from a subject of experimentation” (6). he opposed private practice by university professors for two reasons. first, they have other obligations that they often sacrifice for from prussia to russia: russian critics of "aerztliche ethik" 4 volume 12 number 19 december 2019 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e private practice (we call it conflict of interest nowadays). second, they deprive of income those physicians who earn money only by private practice. as manassein’s biographer wrote, “many doctors, especially the old ones, have narrow corporate views. they assume that doctors should be focused on physicians’ interests and even cover the mistakes of their colleagues as if the public and doctors were two enemy camps. hence there is a special doctors’ ethics. in this regard manassein was not a physician, but a human being first and foremost, and for this reason he acknowledged human ethics but not corporate ethics” (7). sankt-peterburgskoe vrachebnoe obshestvo vzaimnoi pomoshi (physicians’ society for mutual help of st. petersburg) was established in 1890 for “moral mutual support and fostering of doctors’ unity”. initially it was supposed to be named the “society for the protection of physicians’ rights”. this society organized regular meetings (tovarisheskie besedy comrades’ talks) to discuss the public aspects of medical life. at the first meeting, held on november 18, 1900, dr. evgeny botkin posed the following question: “would it be reasonable and possible at all to form a code of medical ethics?” (8)1. botkin himself gave a positive answer because he believed this would: a) provide physicians with the opportunity to know the opinions of their colleagues about a particular article of the code; b) help medical doctors gain the trust of the 1. see also: vrach, 1901; 2: 63 64 general public, as the latter would learn what things doctors consider to be their obligations; and c) help doctors find out if others have their own professional codes, which is particularly necessary for medical doctors who often treat patients with abnormalities. those who supported the code advanced the following arguments: 1) an ethical code would assist in resolving difficult or complex cases; 2) it would constrain weak-willed colleagues; and 3) it would offer the public a more realistic conception of medical practice. during the discussion that followed, the following opposing views were presented: 1) no code can cover all specific cases, and codification poses the danger that what is not explicitly prohibited will be considered implicitly permissible; 2) such a code would hardly reconcile the public with the medical community; 3) medical ethics is being treated as a special subject when all the guidance that a doctor needs is a well-known commandment “to love one’s neighbor as oneself”; and 4) one’s moral instincts speak louder than volumes of ethical codes. one of the opponents, piotr borisov, his position in the following fashion: “we commit sins not because we do not know a code. any code that we create could easily serve as a screen sheltering improper actions” (8). the question was eventually put to a vote and the lichterman b. 5 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 19 december 2019 majority of those present voted in favor of the code of medical ethics. the questions addressed at the next meeting were: “what is the significance of a code which determines the relations between medical doctors and between doctors and the public?” and “should such a code be obligatory or just have a moral significance?” it was decided that a code should be obligatory for members of the physicians’ society for mutual help of st. petersburg, and have moral significance for non-members. topics in medical ethics such as a doctor’s obligation to attend a patient upon his or her first request, confidentiality, and how to behave during consultations with other doctors were also discussed. the society’s by-laws included a court of honor “in order to resolve misunderstandings between members and review accusations against members concerning deeds that are blameworthy and incompatible with doctors’ dignity.” the court of honor consisted of three members and two candidates who were elected for one year at the annual meeting of the society. appeals to the court of honor were rare – there were only 16 cases for the 10-year period from early 1890s until early 1900s. (9). according to dr. fainshtein, a critic, “a court of honor cannot exist [in russia], because we do not share similar views on doctors’ ethics; this subject is not taught at the university and it is underdeveloped, and only few doctors are participating in medical societies where they might have had a chance to learn more about ethics” 1. veresaev’s “confessions of a physician” and its critics "zapiski vracha" ("confessions of a physician", also translated as “memoirs of a physician”) by vikenty veresaev (smidovich) (1867 1945) published in 1901 in a russian literary periodical “mir bozhy” provoked an enormous interest both among the general public and medical community, and triggered discussions on medical ethics. vikenty vikentievich smidovich (veresaev was his pen name) was born in 1867 in tula, a provincial city 200 km south of moscow, 1. courts of honor originated from arbitration courts in the beginning of the 19th century amidst military corporation, which was very concerned with matters of honor, in the motherland of militarism, prussia, and from there they came to russia. gan compared a court of honor to “a shield, which should break waves of calumnies”. according to gan, medical doctors are trusted by the public because of “the confidence that all dead-wood, everything negative would be eradicated by doctors themselves from their community, that there is a controlling and retributive organ of doctors’ morality” (10). the jurisdiction of a court of was limited to ethical issues dealing with relationships of a physician to science (e.g. quackery), to a patient and to another physician. see also a book by a. h. maehle on german medical courts of honor (11). it is interesting to note that courts of honor were revived in the ussr after wwii. in may 1947 there was a joint decree of the council of ministers of the ussr and the central committee of all-union communist party “on establishment of courts of honor in ministries of the ussr and central governmental agencies” in order to “investigate antipatriotic, anti-government and antisocial actions” (12). eighty-two courts of honor were established. the most striking example in this regard is a process on klueva and roskin by the court of honor of the ministry of health in june 1947 (9). after stalin’s death in 1953 the decree on courts of honor and their decisions were abolished. the evolution of courts of honor in russia in the 20th century is beyond the scope of this paper. from prussia to russia: russian critics of "aerztliche ethik" 6 volume 12 number 19 december 2019 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e into a doctor's family1. in 1888 he graduated from the philological faculty of st. petersburg university and decided to study medicine at dorpat (yurjev) university. on passing the qualifying examination in 1894, veresaev began working as a resident doctor at the s. p. botkin barracks hospital for the poor in st. petersburg and at the same time joined a marxist literary circle. like chekhov, veresaev started to publish short stories and novels, and became a professional writer. in 1901 he was fired from his hospital job by order of the city governor, and by decree of the minister of internal affairs he was prohibited from living in st petersburg or moscow for two years. he was mobilized to the russian-japanese war where he served as a physician from 1904 to 1905. he wrote many novels and short stories, but considered his best book to be “zhivaya zhizn’” (“alive life”). the first part, published in 1910, was dedicated to the writings of fedor dostoevsky and leo tolstoy, and the second part, published in 1914, to hellenic tragedies and friedrich nietzsche. during the last decades of his life veresaev translated homer’s “iliad” and “odyssey”. he died while editing the last song from “iliad”. nonetheless, veresaev is first and foremost known as the author of “zapiski vracha” (“confessions of a physician”). in the early decades of the 20th century the book had 16 russian editions and was translated into many languages, including german (eight 1. for a short biography of veresaev in english – see naomi raskin’s paper (14). editions), french, english, and japanese2. "i am but an average practitioner. i am about to describe my emotions on my first acquaintance with medicine, what i expected of it, and how it actually affected me. i will endeavor to set down all, hiding nothing, and i will strive to write with absolute frankness", veresaev writes in the introduction (15). in the book he describes his experience of working among the poor. he writes about the unsatisfactory medical education system and discusses medical errors, autopsies and vivisections, private practice, and philanthropy. a separate chapter is dedicated to experimentation on humans, mostly in venereology, because "many questions which, in other branches of medicine, find their answer in experiments on animals can, in venereology, only be decided through human inoculation, and venereologists have not hesitated to take the plunge: crime stains every step taken by their science."(15). veresaev provides numerous cases of inoculation against gonorrhea, soft ulcer and syphilis in men, women, and children in different countries in the 19th century3. 2. a british edition: veresaeff v., the confessions of a physician (translated from russian by s. linden), london: grant richards, 1904. an american edition: veresaev vv., memoirs of a physician. new york: knopf, 1916 (15). all citations from veresaev’s book are taken from the american edition, which can be downloaded for free from www.archive.org. 3. j. katz checked all references and confirmed their accuracy in his “experimentation with human beings” published in 1972. according to the editor of the american edition of veresaev’s book (dr. henry pleasants, jr.) “in this country, conditions are not the same as those in russia twenty years ago [….] public spirited men and women all over the country are working for the advancement of our profession. will it alter their lichterman b. 7 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 19 december 2019 veresaev’s book provoked controversial reviews. as a rule, it was highly praised in the press for the general public but severely criticized by medical press. one popular newspaper called the book “a public confession of one for all”. the weekly medical periodical, vrach, praised the talented young author and the truthfulness of many of his statements. later a reviewer in the same periodical accused veresaev of evident exaggerations "that may only bring harm by dissemination of mistaken views in our society, which trusts quacks and medical doctors equally"1. the president of the st. petersburg medico-chirurgical society, prof. n. a. vel'yaminov, delivered a speech at the annual meeting in which veresaev was described as a person with "huge selfimportance who is constantly in doubt about his knowledge and his power, indicating an evident egotism with evident nervous irritability. that is why this book is unhealthy" (16). the success of veresaev’s book was explained by the fact that a physician echoed thoughts of the lay public about “the essence of medicine”. many critics accused veresaev of public revelation of problems and mistakes in medical practice. one of them compared the book to introduction of viewpoint if they know that ten or fifteen years ago certain science-mad individuals on the other side of the atlantic inoculated healthy children with syphilis to prove whether or not the disease was contagious in the secondary stage? (15) no”. “the tuskegee study of untreated syphilis in the negro male” will start in tuskegee, alabama in 1932. 1. see also comments in vrach, 1901; 14:459 and 16:528. fine arts to russian peasants by demonstrating pictures of naked women. the english translation was critically reviewed in the british medical journal (17). an anonymous reviewer wrote, "we find a russian physician washing his dirty linen in public with every sensational accompaniment that is calculated to attract attention to the nasty business", whereas problems of medical ethics should be discussed only among professionals. "the proper place for veresaeff's ‘confessions’ is not the drawing room-table, but the dustbin," concluded the review (17). two german physicians also wrote critical pamphlets on veresaev’s book. these were immediately translated into russian and published as separate brochures. dr. l. külz from leipzig addressed veresaev in the following fashion: “your confession is a purely russian matter. it is so russian that we, germans, cannot understand it. such cases would be impossible for a german physician. but you repeatedly dare to touch issues of international medical importance and quote our german authorities. thus your writings concern us german physicians. why do you initiate profanities into our problems?” (18). he underlines that the situation in germany is different from russia, because by russian law a physician is obliged to provide medical help. külz comments on horrible figures of suicide rates of russian physicians (3.4% of the total number of russian medical doctors committed suicide and for zemskie physicians this figure rose to 10%). from prussia to russia: russian critics of "aerztliche ethik" 8 volume 12 number 19 december 2019 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e “german physicians do not come across such blind hatred and animosity as their russian colleagues” he argued. however, he agreed with veresaev that doctors’ financial situation is very bad, but thought that most german physicians would be happy with the russian practice of immediate payment from the patients rather than wait to receive money for a job that was done a long time ago. külz admits that he would prefer that a physician be as well-paid as civil servants, but it would be unthinkable to charge the state with payment of doctors’ honorariums “because then physicians would be equaled to civil servants. and this does not require objections since everyone would understand what harm it might bring” (18). he suggests comparing russian patients with the german ones who are protected by sickness funds (krankenkassen). külz writes that veresaev’s comparison of a patient to a clock-work is incorrect. it would be more accurate to compare a patient to a growing tree. a physician is like a gardener who must water his “tree” and provide it with access to the sun, and one who “has a right and even obligation to cut off ill branches and bad spears” (18). with regard to medical experimentations he accuses vereaev of exaggeration and opening old sores. according to külz, the main mistake of veresaev is his fascination with philosophy. he quotes a latin proverb (“ne sutor supra crepitam”), and states, “medicine is an objective science and should not be spoiled by philosophical teachings”. similar to vel’jaminov, külz diagnosed veresaev as neurasthenic and a “niktalop, who is blinded by daylight and can orient himself only in the shadow of our science”. veresaev is called “an ill bird that fouls its own nest”. “dr. külz in his answer to veresaev speaks on behalf not only of german but of russian physicians as well”, wrote a russian publisher in his preface to külz’s brochure (18). another critical german brochure was authored by w. von holst from riga (19). von holst sides with many russian critics that the problems raised by veresaev should be discussed intra muros. he assumes that a physician can just treat a patient, but only the nature can cure. doctor-patient relationships are similar to relations between a teacher and a pupil. that is why a patient should strictly follow the doctor’s instructions. in reply to his critics veresaev published a pamphlet “po povodu ‘zapisok vracha’: otvet moim critikam” (“a propos ‘confessions of a physician’: a reply to my critics”). according to veresaev, the relationship between medical science and patient’s personality is a key issue: “ethical problems of our profession may not be settled by a tiny codex of professional ethics. sadly, we should admit that our science does not have ethics yet. one cannot mean by ethics that special corporate doctors’ ethics which just regulates (the) relationship between doctors and (the) public, and between doctors themselves. ethics in a broad, philosophical sense is needed. such ethics should cover in full the above-indicated problem of the relationship between medical science and a living lichterman b. 9 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 19 december 2019 personality” (20). veresaev argues that a problem “of borders beyond which (the) interests of an individual might be sacrificed to the interests of science […] is not a specific problem of some special doctors’ ethics, but a great, eternal, fundamental problem of the relationship between personality and higher categories such as society, science, law etc.” (20). as veresaev writes, “narrow problems of medical practice first and foremost should be resolved from the philosophical standpoint” (20). russian critics of “aerztliche ethik” in 1902 physicians’ society for mutual help of st. petersburg started to publish its periodical “vestnik sankt-peterburgskogo vrachebnogo obshestva vzaimnoi pomoshi”. the first paper in the first issue of this periodical recommended that society members and readers pay attention to the “gigantic work by albert moll, ‘aerztliche ethik’ (doctors' ethics), which was just published” (21). moll’s book was extensively reviewed in leading russian medical periodicals. a weekly periodical entitled “russky vrach” (“russian medical doctor” – a successor of “vrach”, printed from 1902 to 1918) published a review by piotr borisov1, who 1. piotr yakovlevich borisov (1864 1916) was the son of a merchant. he graduated from the military medical academy in st. petersburg in 1889 cum eximia laude and worked there at a chair of physiology. his doctoral thesis defended in 1891 was dedicated to pepsin properties. in 1895 he was elected privat-docent (associate professor) at this chair and worked under ivan pavlov from 1895 to 1903. in 1903 he was elected a chair of pharmacology and stressed the importance of moll’s book for russian physicians. borisov provided a brief overview of the problems covered by the book under review and concluded that "the author did not find a solid foundation of doctors' ethics in any [philosophical] system and founded it upon everyday practice" (22). he considered this foundation as shaky since moll himself admitted that the same action might provoke different feelings among different people, and moral feeling is often influenced by traditions and etiquette. the reviewer disagreed with the author that ethics cannot be based on the theory of general progress since treatment supports the lives of disabled and weak persons. physical strength could not be viewed as a core of progress: “a sick writer would do for general progress more than the strongest and healthiest manual worker”. another example is an idiot who provokes feelings of compassion in ordinary people. according to borisov, ethics is based on two laws: 1) continuation and preservation of the human race; and 2) preservation of the life of every living being. “vestnik sankt-peterburgskogo vrachebnogo obshestva vzaimnoi pomoshi” published a lengthy, 9-page critical review of moll’s book by n. g. balneotherapy (ordinary professor since 1904) of novorossiysk university in odessa where he stayed until his death from stroke in 1916. he authored more than 40 scientific publications. being a member of the party of constitutional democrats (kadety) he actively participated in political life during elections to russian parliament (gosudarstvennaya duma). from prussia to russia: russian critics of "aerztliche ethik" 10 volume 12 number 19 december 2019 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e freiberg1. he wrote that moll erroneously applied the term ‘ethics’ to practical problems such as doctors' obligations to the public, to colleagues, to the state: "all these problems might be covered by teaching about obligations of a physician by medical deontology" (23). although deontology is based upon ethical grounds, it is not ethics. ethics is a science about the laws of manifestations of moral feeling and is the same for all professions. thus the term ‘doctors' ethics’ represents a logical contradiction. feinberg is also critical of the concept of a tacit contract between doctor and patient advocated by moll. moll’s arguments are labeled as scholastic, and he mixes up the principal problem and its practical consequences. feinberg concludes, “if you throw out of moll’s book elements of abstract ‘doctors’ ethics’, there will be some very interesting reasoning on different problems of doctors’ activity” (23). the third detailed review of moll’s book 1. nikolai gustavovich freiberg (1859 1927) was born in a family of intellectuals in st. petersburg where he studied at petri-schule (a famous german gymnasium). he graduated from military medical academy in 1883 and worked as a surgeon at a military hospital until 1892 when he joined the medical department of the ministry of interior. he was appointed a chief of administration of the commission on revision of medical and sanitary laws. freiberg was elected a co-editor of “vestnik sankt-peterburgskogo vrachebnogo obshestva vzaimnoi pomoshi” from 1904 to 1906. he represented russia at the international sanitary conferences for almost 10 years (from 1908 to 1917) and was a national delegate at the permanent committee of the international bureau of public hygiene. in 1918 he was appointed a chief of administration of the russian ministry of health (narkomzdrav). he suggested a new branch of hygiene named administrative hygiene and coauthored “a short textbook of hygiene”. was published in 1903 in “bol’nichnaya gazeta botkina” (botkin’s hospital newspaper) by v. b-kov and was focused on the interplay of doctors’ ethics and medical care (24). limitation of doctors’ ethics to bona fide execution of doctors’ responsibilities is considered as a one-sided approach. moll mistakenly declares that doctors’ ethics is interesting for physicians only whereas in real life non-physicians are also working in this domain. for example, russian lawyer and senator a. f. koni wrote on the subject of confidentiality and became a recognized authority in medical ethics. the reviewer also mentions neisser’s medical experiments criticized by moll. on the other hand, moll considers it unjust to rebuke some personalities when the whole system requires radical change. the reviewer disagrees with moll on many occasions. it is impossible to plan a doctor’s actions in all cases of his or her practice. doctors’ ethics should be based on general human ethics: “morals is universal. in doctor’s activity it might be diversified but it might not be changed” (24). the review ends with critical remarks addressed to “confessions of a physician” by vikenty veresaev which shook fundamental morals and was especially harmful for female students. the reviewer is convinced that moll was also impressed by veresaev’s book but could not digest it and stand above it. there were two russian translations of moll's book. the moscow edition was edited by v. veresaev, who also provided a critical preface (25). veresaev pointed out the major shortfalls of “aerztliche ethik”, stating that lichterman b. 11 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 19 december 2019 the main “external” shortfall is the “extreme circumlocution and ample style” of moll’s book (26). “dr. moll meticulously communicates his thoughts that would be more suitable for copy-books for schoolchildren rather than for a serious work on ethics” (26). but more important is the “internal” shortfall due to moll’s mentality. vereasev accused moll of philistinism: "everywhere, as soon as moll goes beyond purely medical ethical matters, we can see a cautious, moderate and prudent philistine, who is devoid of noble purpose, without a wide range of interests, whose only ideal is to honestly earn a piece of bread for himself and his people" (26). in accordance with the author’s spiritual outlook, individual names are almost lacking in “aerztliche ethik”. for example, moll condemns human experimentation and provides a lengthy list of such experiments during the last years. but “nomina sunt odiosa” according to moll’s “practical morals” and, veresaev notes, “the careful author writes about these experiments in the following manner: ‘one physician in one municipal hospital performed such (an) experiment’. this spirit of deep petit bourgeois philistinism comprises the most repulsive side of moll’s work. luckily, this spirit is mostly alien to the russian medical community and we hope that at least some of our readers would forgive us for omitting in this translation extensive deliberations by moll which are of interest solely as material for characteristics of bourgeois outlook of the modern ordinary german physician” (26). that is why the chapter about the physician’s private life was omitted in this russian edition. despite all the above mentioned shortcomings, moll’s book has several advantages. “the book by dr. moll is a book about real doctors’ ethics. that is its main advantage” (26). another big advantage is the book’s human approach. when dealing with ethical problems, a physician should stand above the narrow professional standpoint. for example, vereasev mentions “an exemplary paragraph on confidentiality”, which is devoid of the schematism of professional ethics. according to veresaev, preservation of confidentiality should be counterweighted by the other human and civil duties of a physician. the chapter on risky medical procedures is called “one of the best chapters of the book”. but veresaev objects to moll’s view that the human fetus is not a human being. he argues that a human being appears at the moment of conception and equals termination of pregnancy (abortion) to homicide. a st. petersburg edition of moll's book was translated with a commentary by dr. ya. l. levenson and had a revealing subtitle: "for medical doctors and general public" (27). as levenson noted in his preface, the art of healing is imperfect and for this reason a physician should have a very high level of bona fide moral purity in order to do everything possible for a patient, or at least to avoid inflicting any harm. these qualities are especially important for russian physicians due to the deficiencies in our social fabric such as poverty and lack of from prussia to russia: russian critics of "aerztliche ethik" 12 volume 12 number 19 december 2019 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e enlightenment of the people: “(the) russian physician should understand that he is not only a physician strictu senso but also a citizen […] and his task is not only to prescribe a drug or treat a disease of a patient, but also to enlighten and support him” (28). however, there are often fierce but fruitless debates on problems of medical ethics. according to levenson, such situations can be explained by the lack of philosophical foundations of ethical judgments. the aim of moll’s book is to provide these foundations both to the public and medical doctors. “aerztliche ethik” is the most complete publication on medical ethics and it clearly distinguishes pure ethical concepts from problems pertaining to doctors’ etiquette and medical politics. another advantage is the author’s impartiality. moll is not afraid of being accused of washing his dirty linen in public. the german edition was aimed mostly at medical doctors. for the russian edition, levenson excluded everything of local (german) interest. numerous footnotes were added and all special terms were replaced by words in general use in order to make moll’s book accessible for public. the book has a supplement on public health in russia written by m. s. uvarov (see above) and based on zemstvo medicine (4). as levinson noted, “under the close links that exist between physicians and general public, mutual mistrust and misunderstanding might be removed only in case that both sides would be acquainted with their moral rights and obligations” (28). conclusion at the turn of the last century we see a considerable interest in problems of medical ethics both among the general public and medical community. these problems were approached differently in russia and in germany due to the different social and political contexts. in russia the ideas of freely accessible medical care were rooted in zemstvo medicine, whereas in germany medical doctors were primarily private practitioners. comparison of veresaev’s “confessions of a physician” to moll’s “doctors’ ethics” may serve as a good example of the search for the common philosophical foundations of medical ethics as well as the impact of national cultural traditions. the discussions provoked by these two books are also relevant for modern bioethical discourse. conflict of interests none. acknowledgements i would like to thank prof. a. h. maehle and his colleagues for inviting me to the 7th international workshop on the topic "sex, ethics and psychology: the networks and cultural context of albert moll (1862 1939) " in november 2009 in durham, uk. the paper is based on my talk at this conference. i would also like to express my gratitude to prof. f. steger from ulm university who encouraged me to submit this paper for publication. lichterman b. 13 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 19 december 2019 references 1. zhbankov dn. [zemskaya medicine and private practice]. [obshestvennyi vrach]. 1911; 8: 14-28. [in russian] 2. zhbankov dn. [on physicians]. moscow; 1903. [in russian] 3. lobanov sv. [a physician and medicine in leo tolstoy’s writings]. tomsk; 1912. [in russian] 4. uvarov ms. [standing of public health physicians. in: moll a. doctor’s ethics. obligations of a physician in all spheres of his activity. for physicians and lay audience]. saintpetersburg; 1903, pp. 143-155. [in russian] 5. korotkikh rv. [theoretical rational for development of doctors ethics and medical deontology in soviet healthcare]. dissertaton for a degree of doctor of medical sciences (habilitaton thesis). moscow; 1989. [in russian] 6. manassein va. [lectures on general therapy]. saint-petersburg; 1879. [in russian] 7. zhbankov dn. [in memory of vyacheslav avksent’evich manassein]. [vrachebnoe delo]. 1926; 1:3-16. [in russian] 8. borisov pya. [a review of activity of comrades’ talks of members of st. petersburg physicians society of mutual help]. [vestnik sankt-peterburgskogo vrachebnogo obshestva vzaimnoi pomoshi]. 1902; 1: 28-38. [in russian] 9. fainshtein. [meeting of the board of the society on january 13, 1904]. [vestnik sanktpeterburgskogo vrachebnogo obshestva vzaimnoi pomoshi]. 1904; 9-10: 58-67. [in russian] 10. gan ak. [fundamentals of a court of honor]. [vrachebnoe delo]. 1919; 19: 751-54. [in russian] 11. maehle ah. doctors, honour and the law: medical ethics in imperial germany. usa: palgrave macmillan; 2009. 12. esakov vd, levina es. [stalin’s courts of honor]. moscow: nauka; 2005. [in russian] 13. krementsov nl. the cure: a story of cancer and politics from the annals of the cold war. usa (chicago): university of chicago press; 2004. 14. raskin n. doctors afield: vikenti vikentievich veresaev (smidovich) 1867-1945. new england journal of medicine. 1961; 265 (23): 1154-55. 15. veresaev vv. memoirs of a physician. new york: knopf; 1916. 16. vel'yaminov na. [a speech at annual meeting of petersburg medico-surgical society] [vrach]. 1901; 49: 1529-1530. [in russian] 17. anonymous. a review of "the confessions of a physician" by v.veresaeff (translated from russian by s.linden, london, grant richards, 1904). bmj. 1904; 1 (2261): 10201022. 18. külz l. [a response to confession of doctor veresaev]. moscow; 1903. [in russian] 19. von holst w. [objections and impressions of an old physician]. [riga]; 1904. [in russian] 20. veresaev vv. [a propos ‘confessions of a physician’: a reply to my critics]. saintpetersburg; 1903. [in russian] 21. nizhegorodtsev mi. [st. petersburg society of physicians’ help and medical corporation]. [vestnik sankt-peterburgskogo vrachebnogo obshchestva vzaimnoi pomoshchi].1902; 1: 3-16. [in russian] 22. borisov pya. [a review of albert moll’s “aertzliche ethik”]. [russkii vrach]. 1902; 17: 66970. [in russian] 23. freiberg ng. ["aertzliche ethik" von albert moll]. [vestnik sankt-peterburgskogo from prussia to russia: russian critics of "aerztliche ethik" 14 volume 12 number 19 december 2019 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e vrachebnogo obshestva vzaimnoi pomoschi]. 1902; 4: 304-13. [in russian] 24. b-kov v. [a review of albert moll’s “aertzliche ethik”]. [bol’nichnaya gazeta botkina]. 1903; 1: 373 [in russian] 25. moll a. [doctor’s ethics. obligations of a physician in all spheres of his activity]. moscow; 1904. [in russian] 26. veresaev vv. [a preface to russian edition. in: moll a. doctor’s ethics. obligations of a physician in all spheres of his activity]. moscow; 1904, pp. i-x. [in russian] 27. moll a. [doctor’s ethics. obligations of a physician in all spheres of his activity. for physicians and lay audience. translation from german and notes by ya.i.levenson]. saint-petersburg; 1903. [in russian] 28. levenson yai. [a preface. in: moll a. doctor’s ethics. obligations of a physician in all spheres of his activity. for physicians and lay audience. translation from german and notes by ya.i.levenson]. saint-petersburg, 1903, pp.iii-v. [in russian] journal of medical ethics and history of medicine original article the relationship between human dignity and medication adherence in patients with heart failure seyedeh somayeh amininasab1, hamideh azimi lolaty2, mahmood moosazadeh3, vida shafipour4* 1msc student of intensive care nursing, student research committee, school of nursing and midwifery, mazandaran university of medical sciences, sari, iran. 2assistant professor, department of psychiatric nursing, psychiatry and behavioral sciences research center, addiction institute, mazandaran university of medical sciences, sari, iran. 3assistant professor, health sciences research center, faculty of health, mazandaran university of medical sciences, sari, iran. 4assistant professor, department of medical-surgical nursing, nasibeh nursing & midwifery faculty, mazandaran university of medical sciences, sari, iran. corresponding author: vida shafipour address: nasibeh nursing & midwifery faculty, mazandaran university of medical sciences, sari, iran. email: vidashafipour@yahoo.com tel/ fax: + 98 113 336 7342 received: 18 dec 2016 accepted: 28 may 2017 published: 18 jun 2017 j med ethics hist med, 2017, 10:5 © 2017 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract medication adherence is a behavior that is influenced by several factors, and maintaining patients’ dignity is an important issue that needs to be considered in the course of treatment. the present study aimed to determine the relationship between human dignity and medication adherence in patients with heart failure. this was a cross-sectional study. a total number of 300 patients with heart failure admitted to the mazandaran heart center, iran, participated in this study by census. samples were selected based on inclusion criteria such as an hf diagnosis by a cardiologist for a minimum of 6 months, and taking at least one cardiac medication. data were collected through demographic, clinical, human dignity, and medication adherence questionnaires over a period of three months in 2016. this study was approved by the ethics committee of mazandaran university of medical sciences. consents were obtained from patients and the medical center, and necessary explanations were given about the confidentiality of information prior to completing the questionnaires. the mean score of medication adherence was 5.82 suggesting low medication adherence among the patients, and the mean score of human dignity was 81.39. there was a negative relationship between medication adherence and threat to human dignity (r = 0.6, p < 0.001), i.e., the higher the scores of threat, the lower the medication adherence of the patients. after adjusting the effects of potential confounding variables, there still was a correlation between medication adherence and the variables of human dignity and its dimensions. based on the findings, an increase in patients’ dignity can enhance medication adherence, which can theoretically improve patients’ health and reduce frequent hospitalization. keywords: human dignity, medication adherence, heart failure, nursing. j med ethics hist med 10: 5 ,jun, 2017 jmehm.tums.ac.ir seyedeh somayeh amininasab et al. page 2 of 8 introduction heart failure (hf) is a disorder of the heart structure and function that leads to failure in the transport of proper amounts of oxygen to tissues according to their metabolic needs. clinically, hf is a syndrome in which patients demonstrate symptoms such as dyspnea, swollen ankles and fatigue, and signs such as jugular venous pressure, and crackles in the lungs as a result of abnormal heart structure and function (1). hf is a growing heart problem in the united states (2) where it is estimated to be affecting more than 5.8 million people; moreover, there are 23 million people suffering from the disorder worldwide. hf prevalence is expected to increase to 46% by 2030, i.e., about 8.5 million people (3). based on the studies in iran, 25% of the patients admitted to cardiology wards are diagnosed with hf, which indicates that it is a pandemic disease (4). readmission of patients with hf dramatically increases patients’ costs, and one of the main reasons for this is their lack of adherence to the prescribed medication regimen(5). adherence to medication regimen is a diseaserelated behavior that predicts successful treatment outcomes and reduces the adverse effects and severity of the disease (6). medication adherence may be defined as compliance with all medication orders (7, 8) or consumption of more than 80% of the prescribed medicines, but the definite cause is not certain (9). medication non-adherence is the failure to comply with healthcare recommendations and refusal to follow the medication regimen by individuals (6). it is a complex behavioral process influenced by many factors, and according to the who model, its predictors include 5 dimensions: 1) healthcare system factors (health team members’ communication skills and patient satisfaction); 2) patient-related factors (age, gender, beliefs and attitudes); 3) socioeconomic factors (education, income and social support); 4) treatment-related factors (complexity and side effects of the treatment); and 5) condition-related factors (illness severity and comorbidities) (10). identification of these factors improves patients’ adherence to treatment regimens, and enhances care providers decisions and performances (3). despite its importance, patients’ adherence to medication regimen is 25% 50%, which can lead to adverse consequences, including poor clinical results, readmission, and increased healthcare costs (11). it is estimated that adherence to the prescribed regimen could prevent 54% of hf cases (5). according to who, the mean medication adherence of patients with chronic diseases is 50% in developing countries. medication non-adherence remains a major barrier to increasing the effectiveness of treatments (12) and results in poor treatment, imposes billions of dollars of excess costs a year, causes 125,000 deaths per year, and is the reason for 10% of all hospitalizations in the united states (13). human dignity is considered one of the most important features and ethical concerns in healthcare and nursing care. there are two types of human dignity: absolute and relative dignity. the former pertains to the essence of each creature, and the latter is influenced by the society and human relations (14). dignity is described as a human characteristic in professional care (15). based on the definition of dignity, all human beings are created free and equal in rights (4). in fact, respect for human dignity is observance of individuals’ basic rights in different environments (16). human dignity is related to the property of being a human, and is of the essence in healthcare systems (17). it has a prominent position in the studies and discussions on healthcare, as well as health equity (18). patients may be among the most vulnerable social groups, as they not only have lost their physical abilities, but also are under the particular psychological, social and economic pressures imposed by their illness. compared to other chronic diseases, heart failure has a more noticeable impact on the individual’s performance in social, family, and marital relationships (19). the primary goal of hf care is to increase patients’ life expectancy (20). care providers need to maintain an honest communication with the patients and respect their personal rights and professional values such as human dignity, and be sensitive to the existing differences (21). respect for patients’ dignity plays an important role in their treatment and increases their quality of life (9, 18). moreover, healthcare system related factors such as communication between patient and provider could enhance medication adherence (22), and improve patient dignity (23). as a result, the researchers investigated the probable relationship between preservation of human dignity and incentives to increase patient adherence to medical recommendations. furthermore, a literature review revealed studies about the relationship between medication adherence and cognitive impairment in the elderly (11), selfmanagement interventions (24), awareness of disease (25), health literacy (26), anxiety and psychosomatic disorders (13), and patients’ beliefs and attitudes (27); however, the researchers were unable to find studies on the relationship between human dignity and medication adherence. therefore, the present study focused on the importance of maintaining patients’ dignity and the essential role of medication adherence in the successful treatment of hf. thus, the researchers aimed to determine the relationship between human dignity and medication adherence in patients with heart failure. methods this cross-sectional study recruited patients with heart failure on their first day of admission to ccu wards of mazandaran heart center in 2016. census j med ethics hist med 10: 5 ,jun, 2017 jmehm.tums.ac.ir seyedeh somayeh amininasab et al. page 3 of 8 sampling method was used to select all patients with heart failure that met the inclusion criteria. in order to determine the sample size, the number of patients admitted with heart failure in a month per year was first established through hospital medical records. sampling was carried out based on that figure for three months. then, the sample size (α = 0.01, β = 0.1, r = 0.25) was determined at 300 patients using gpower software. inclusion criteria were: being older than 18 years, iranian nationality, residing in sari, mazandaran province, speaking persian, hf diagnosis from a cardiologist for a minimum of 6 months, taking at least one cardiac medication, classes ii and iii of the new york heart association classification, ejection fraction higher than 30%, lack of sensory perception disorder or mental retardation, full consciousness and the ability to answer questions. data were collected by demographic and clinical questionnaires, patient dignity inventory, and the morisky medication adherence scale (mmas-8) revised in 2008. clinical and demographic questions included age, sex, marital status, income, number of children, education, occupation, location of residence, comorbidities including diabetes and hypertension, and the number of pills consumed per day. in order to measure human dignity, the patient dignity inventory (pdi) developed by chochinov et al. in 2008 was used. the reliability and validity of the pdi were reported as cronbach’s alpha coefficient of 93% and 0.85 (28). abbas-zadeh et al. in 2015 translated the pdi into persian and evaluated its validity and reliability in patients with coronary heart diseases such as myocardial infarction, heart failure, and acute coronary syndrome (cronbach’s alpha = 0.85) (29). the questionnaire consists of 25 items in five domains, including distress symptoms (items: 3, 5, 6, 7, 8, 9), existential distress (items: 4, 11, 12, 13, 14, 18, 19), dependency (items: 1, 2, 10, 20), peace of mind (items: 15, 16, 17) and social support (items: 21, 22, 23, 24, 25). questions were scored in likert scale from 1 to 5 (1: not a problem; 2: a slight problem; 3: a problem; 4: a major problem; and 5: overwhelming problem). the scores ranged from 25 to 125, with 25 showing the highest, and 125 showing the lowest degree of dignity, and the score of 75 and above represented a threat to the patients’ dignity. the score of 18 in distress symptoms (score range: 6 30), 9 in peace of mind (score range: 3 15), 12 in dependency (score range: 4 20), 15 in social support (score range: 5 25), and 21 in existential distress (score range: 7 35) represented a threat to the patients’ dignity. reliability was determined at 0.87 through the interclass correlation coefficient of cronbach’s alpha coefficient. medication adherence was calculated by morisky medication adherence scale (30). the 8-items form was validated by rashedi et al. in 2011, and the cronbach’s alpha was reported to be 0.83 (31). this self-report scale consists of 7 items answered with yes or no, and 1 item with a 5-point likert scale (never = 0, rarely = 1, sometimes = 2, often = 3, always = 4). the minimum score was 0 and the maximum score was 11. the cut-off point was 6 and a score less than 6 was considered medication nonadherence (31). as the first step of the research, the participants were briefed on the purpose of the study, received instructions on how to complete the questionnaires, and were assured of the confidentiality of their responses. subsequently, the questionnaires were completed after obtaining patients’ consent. data were analyzed in spss version 16 using descriptive statistics and pearson’s correlation test. results based on the results obtained in this study, the participants’ mean age was 64.15, men and women equally comprised the study population, most (50.3%) were illiterate, and 49.3% had poor income (table 1). table 1. personal characteristics of the patients with heart failure personal characteristics frequency percent age group 35 44 14 4.7 44 54 50 16.7 55 64 99 33 56 74 72 24 > 74 65 21.7 gender male 150 50 female 150 50 education illiterate 151 50.3 under high school diploma 88 29.3 diploma and advanced diploma 47 15.7 bachelor’s degree and above 14 4.7 marital status single 1 0.3 married 293 97.7 divorced 3 1 widowed 3 1 j med ethics hist med 10: 5 ,jun, 2017 jmehm.tums.ac.ir seyedeh somayeh amininasab et al. page 4 of 8 occupation employee 34 11.3 laborer 30 10 farmer 25 8.3 housewife 135 45 self-employed 31 10.3 retired 45 15 number of children less than 2 30 10 2 5 187 62.3 more than 5 83 27.7 place of residence urban 191 63.7 rural 109 36.3 income poor 148 49.3 fair 136 45.3 good 16 5.3 frequency of hospitalization less than 2 46 15.3 2 5 161 537 more than 5 93 31 comorbidities diabetes 69 23 hypertension 93 31 diabetes and hypertension 77 25.7 no underlying disease 61 20.3 severity of the disease (lvef) 50 60 124 41.3 40 50 110 36.7 30 40 66 23 the number of pills consumed per day less than 5 86 28.7 5 10 143 47.7 more than 10 71 23.7 lvef=left ventricular ejection fraction the mean medication adherence in this study was 5.82 in patients with hf, which is considered low according to the research tool. the mean score of human dignity was 81.39. table 2 shows the mean, standard deviation, and range of the pdi scores for human dignity and its dimensions, that is, distress symptoms, peace of mind, dependency, social support and existential distress. according to pdi, a higher score represents a greater threat to patients’ dignity. there was a negative relationship between medication adherence and threat to human dignity (correlation coefficient r = 0.6, significance level p < 0.001), (table 2). table 2. mean and standard deviation and correlation between medication adherence and human dignity, and the factors threatening it variable questionnaire range obtained range mean sd correlation coefficient (r) p-value human dignity and its dimensions 25 125 37 125 81.39 16.52 0.66 < 0.001 distress symptoms 6 30 8 30 19.06 4.21 0.65 < 0.001 peace of mind 3 15 4 15 9.38 2.32 0.61 < 0.001 dependency 4 20 6 20 14.37 2.38 0.66 < 0.001 social support 5 25 5 25 14.95 3.45 0.62 < 0.001 existential distress 7 35 11 35 23.62 5.03 0.60 < 0.001 in other words, the higher the score of threat to dignity, the lower the medication adherence. even after adjusting the potential confounding variables in this study (age, sex, marital status, place of residence, occupation, education, number of children, frequency of hospitalization, comorbidities, ejection fraction severity, and the number of pills consumed per day), there still was a correlation between the variables of human dignity and its dimensions, and medication adherence (table 3). j med ethics hist med 10: 5 ,jun, 2017 jmehm.tums.ac.ir seyedeh somayeh amininasab et al. page 5 of 8 table 3. partial correlation between medication adherence and human dignity (after adjustment of confounding variables) variable correlation coefficient (r) p-value human dignity and its dimensions 0.66 < 0.001 distress symptoms 0.65 < 0.001 peace of mind 0.49 < 0.001 dependency 0.65 < 0.001 social support 0.60 < 0.001 existential distress 0.59 < 0.001 discussion the main finding in this study was the significant relationship between medication adherence and human dignity and its dimensions (distress symptoms, peace of mind, dependency, social support and existential distress), so that even by eliminating potential confounding variables, the relationship still existed. the patients in this study had reduced human dignity, and consequently low levels of medication adherence were reported. even though studies have been conducted on the dimensions of human dignity and medication adherence separately, none were found on the connection between the two on available databases. this research revealed a significant relationship between medication adherence and distress symptoms, which is in line with the findings of previous studies on the relationship between psychological distress and medication adherence. the following authors have worked in this regard: alosco et al. studied the relationship between cognitive dysfunction and treatment adherence in patients with heart failure (32). gehi et al. and van der wal et al. investigated the relationship between depression and medication adherence (33, 34); and schweitzer et al. examined the impact of psychological factors on treatment adherence behavior in patients with heart failure (35). in addition, some studies were conducted on the relationship between distress symptoms and medication adherence in patients with chronic diseases (36), acquired immune deficiency syndrome (aids) (37, 38), epilepsy (39), and children receiving transplants (40). a few studies showed that there were no significant associations between depression (41) and anxiety (13, 42), and medication adherence, but overall it seems that the higher the distress is, the lower the medication adherence will be. in this study, there was a significant relationship between the peace of mind dimension of patient dignity and medication adherence in hf patients. this is consistent with the findings of another study, which showed that respect for the patients and their experiences and interests increased their confidence and consequently medication adherence (43). there was a significant relationship between the dependency dimension and medication adherence in this study. similarly, maeda et al. (20) and criswell et al. (44) revealed a relationship between selfefficacy and medication adherence among heart failure, and hypertension patients, respectively. heydari et al. examined “self-concept” in the two domains of challenges and threats. they reported that threat to self-concept invoked a response based on a feeling and led to an individual’s non-adherence to treatment regimens (5). the present study showed that there was a significant relationship between social support and medication adherence, which is backed by studies on different patients (20, 44-50). on the other hand, there are studies on patients with heart diseases that found no significant relationship between social support and medication adherence (12, 51-53). beals et al. even reported that social support decreased medication adherence (54). these differences could point to certain psychological aspects of social support that cause some patients not to adhere to medications in order to gain support and fulfill their psychological needs. the findings of this study demonstrated a significant relationship between the existential distress dimension of patient dignity and medication adherence. this dimension is associated with the reduced ability of patients to do their daily activities as a major threat to human dignity. a study showed that diminished performance and activity had a significant effect on medication adherence in patients with hf (32). similarly, other studies on patients with diabetes and hyperlipidemia indicated that reduced strength and performance was related to low medication adherence (32, 55). based on these results, the more serious the patients’ disabilities are, the lower their medication adherence will become. this study was conducted in only one medical center, and it is recommended to perform further studies in multiple centers in order to investigate the generalizability of the findings. conclusion medication adherence is a multidimensional behavior influenced by several factors. therefore, care providers need to first identify these factors and then consider them in training and treatment planning for patients in order to increase their medication adherence. based on the results, it is recommended to maintain patients’ dignity as an important factor that should be considered in the course of treatment, and can improve patients’ recovery and their return to normal life. j med ethics hist med 10: 5 ,jun, 2017 jmehm.tums.ac.ir seyedeh somayeh amininasab et al. page 6 of 8 it is therefore recommended to study the effects of dignity therapy on patients with heart failure, and the role of education in improving medication adherence further. also, it is suggested that similar studies be conducted on patients suffering from other chronic diseases such as diabetes or multiple sclerosis, and those who have undergone surgery or are receiving hemodialysis. conflict of interest the authors declare that there is no conflict of interest. acknowledgments this article was extracted from a student thesis coded ir.mazums.rec.94.1991. hereby, we extend our gratitude to the research deputy of mazandaran university of medical sciences for funding this study. we would also like to thank all the patients and hospital staff who assisted us in this research project. j med ethics hist med 10: 5 ,jun, 2017 jmehm.tums.ac.ir seyedeh somayeh amininasab et al. page 7 of 8 references 1. mcmurray jj, adamopoulos s, anker sd, et al. esc guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: the task force for the diagnosis and treatment of acute and chronic heart failure 2012 of the european society of cardiology developed in collaboration with the heart failure association (hfa) of the esc. eur j heart fail. 2012; 14(8): 803-69. 2. wu j-r, moser dk, lennie ta, peden ar, chen yc, heo s. factors influencing medication adherence in patients with heart failure. heart lung. 2008; 37(1): 8-16. 3. ruppar tm, delgado jm, temple j. medication adherence interventions for heart failure patients: a meta-analysis. europ j cardiovasc nurs. 2015; 22(2): 54-63. 4. bagheri h, yaghmaei f, ashktorab t, zayeri f. patient dignity and its related factors in heart failure patients. nurs ethics. 2012; 3(1): 316-27. 5. heydari a, ahrari s, vaghee s. the relationship between self-concept and adherence to therapeutic regimens in patients with heart failure. j cardiovasc nurs. 2011; 26(6): 475-80. 6. masror roudsari d, dabiri golchin m, parsa yekta z, haghani h. relationship between adherence to therapeutic regimen and health related quality of life in hypertensive patients. iran journal of nursing. 2013; 26(85): 44-54. 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20(3):58-68. 25. heydari a, ziaee es, gazrani a. relationship between awareness of disease and adherence to therapeutic regimen among cardiac patients. int j community based nurs midwifery. 2015; 3(1):23-30. 26. noureldin m, plake ks, morrow dg, tu w, wu j, murray md. effect of health literacy on drug adherence in patients with heart failure. pharmacotherapy. 2012; 32(9):819-26. 27. dias a, pereira c, monteiro mj, santos c. patients’ beliefs about medicines and adherence to medication in ischemic heart disease. aten primaria. 2014; 46:101-6. 28. chochinov hm, hassard t, mcclement s, et al. the patient dignity inventory: a novel way of measuring dignity-related distress in palliative care. j pain symptom manage. 2008; 36(6):559-71. 29. abbaszadeh a, borhani f, rabori r. patient dignity in coronary care: psychometrics of the persian version of the patient dignity inventory. british journal of medicine and medical research. 2015; 8(5):463-9. 30. morisky de, ang a, krousel‐wood m, ward hj. predictive validity of a medication adherence measure in an outpatient setting. j clin hyperten. 2008; 10(5):348-54 31. rashedi e, sohrabi f, shams j. a study of the efficacy of cognitive behavior therapy in replace prevention of bipolar disorder. clinical psychology & personality. 2011; 2(5):49-64. j med ethics hist med 10: 5 ,jun, 2017 jmehm.tums.ac.ir seyedeh somayeh amininasab et al. page 8 of 8 32. alosco ml, spitznagel mb, van dulmen m, et al. cognitive function and treatment adherence in older adults with heart failure. psychosom med. 2012; 74(9):965-73. 33. gehi ak, ali s, na b, whooley ma. self-reported medication adherence and cardiovascular events in patients with stable coronary heart disease: the heart and soul study. arch internal med. 2007; 167(16):1798-803. 34. van der wal mh, jaarsma t, moser dk, veeger nj, van gilst wh, van veldhuisen dj. compliance in heart failure patients: the importance of knowledge and beliefs. eur heart j. 2006; 27(4):434-40. 35. schweitzer rd, head k, dwyer jw. psychological factors and treatment adherence behavior in patients with chronic heart failure. j cardiovasc nurs. 2007; 22(1):76-83. 36. grenard jl, munjas ba, adams jl, et al. depression and medication adherence in the treatment of chronic diseases in the united states: a meta-analysis. j gen intern med. 2011; 26(10):1175-82. 37. ebrahimzadeh z, goodarzi ma, joulaei h. the clarification of depression and social support's contribution to the prediction of antiretroviral medication adherence and the rate of cd4 in people with hiv. glob j health sci. 2016; 8(9):54842. 38. adewuya ao, afolabi mo, ola ba, et al. the effect of psychological distress on medication adherence in persons with hiv infection in nigeria. psychosomatics. 2010; 51(1):68-73. 39. chen h-f, tsai y-f, lin y-p, shih m-s, chen j-c. the relationships among medicine symptom distress, self-efficacy, patient–provider relationship, and medication compliance in patients with epilepsy. epilepsy behav. 2010; 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al. social support, positive states of mind, and hiv treatment adherence in men and women living with hiv/aids. health psychol. 2004; 23(4):413. 46. rueda s, park‐wyllie ly, bayoumi a, et al. patient support and education for promoting adherence to highly active antiretroviral therapy for hiv/aids. cochrane database syst rev. 2006; 12(4):325-34. 47. edwards lv. perceived social support and hiv/aids medication adherence among african american women. qual health res. 2006; 16(5):679-91. 48. simoni jm, frick pa, huang b. a longitudinal evaluation of a social support model of medication adherence among hiv-positive men and women on antiretroviral therapy. health psychol. 2006; 25(1):74-81. 49. scheurer d, choudhry n, swanton ka, matlin o, shrank w. association between different types of social support and medication adherence. am j manag care. 2012; 18(12):e461-7. 50. wu j-r, moser dk, lennie ta, burkhart pv. medication adherence in patients who have heart failure: a review of the 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________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ 1 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e original article volume 13 number 6 august 2020 copyright © 2020 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. medical students' knowledge and attitudes toward history of medicine alireza salehi1, hourieh afsharipur 2, hossein molavi vardanjani3, mina vojoud4, leila bazrafkan5, mohammad hossein sharifi6* 1.associate professor, research center for traditional medicine and history of medicine, shiraz university of medical sciences, shiraz, iran. 2.researcher, research center for traditional medicine and history of medicine, shiraz university of medical sciences, shiraz, iran. 3.assistant professor, mph department, shiraz medical school, shiraz university of medical sciences, shiraz. 4.researcher, research center for traditional medicine and history of medicine, shiraz university of medical sciences, shiraz, iran. 5.assistant professor, medical education department, medical education development center, shiraz university of medical sciences, shiraz, iran. 6.assistant professor, research center for traditional medicine and history of medicine, shiraz university of medical sciences, shiraz, iran. abstract attention to the history of medicine (hm) has been increasing enormously among the scientific community. history of culture and civilization of iran and islam (hccii) is taught in medical schools as a required course. however, data on medical students' level of knowledge and attitude about hm is limited. this is a cross-sectional survey conducted between 2016 and 2017. a multi-stage random cluster sampling was done in which 230 medical students were asked to fill a standardized self-administered questionnaire. univariate statistical tests and ordinary multivariable linear regression were applied. medical students' knowledge level was 50.8%, which is considered fair and weak. interestingly, the knowledge score of those who attended only in hccii course did not differ significantly from those who did not attend this course (p = 0.163). the results showed that knowledge scores were considerably greater in those who participated in related volunteer workshops than those who did not (p = 0.0001). the mean score of attitude toward hm was significantly higher in female subjects than male subjects (p = 0.028). moreover, data indicated that attendance at the hccii course and workshops was not associated with improvement in attitude. according to the outcomes, the authors recommend revising the content, teaching method and structure of the hccii course curriculum. keywords: medical students; medical education; history of medicine; iran. *corresponding author mohammad hossein sharifi school of medicine, imam hussain square, zand st., shiraz, iran. tel: (+98) 71 32 08 40 28 email: sharifiimh@sums.ac.ir received: 24 sep 2019 accepted: 3 aug 2020 published: 25 aug 2020 citation to this article: salehi a, afsharipur h, molavi vardanjani h, vojoud m, bazrafkan l, sharifi mh. medical students' knowledge and attitudes toward history of medicine. j med ethics hist med. 2020; 13: 6. medical students’ knowledge and attitudes toward history of medicine … 2 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 6 august 2020 introduction knowledge of the history of medicine (hm) is valuable for scientists and experts to open up new aspects of medicine (1). the history of science shows how societies have changed and evolved from ancient times to the present in medical science, revealing its great values in the community. it is possible that knowledge of hm can also prevent repetition of past mistakes in science because progress is made through error detection (2). in addition, by applying our knowledge of the past history of medicine, we can improve the future. exploration of and attention to hm to motivate the scientific community has been taken into consideration for several decades (3). in europe and the united states, there are specialized medical journals on hm dating back several decades ago; for example, "journal of the history of medicine and allied sciences " has been published since 1946 (4). iran is rich in experiences, opinions and medical beliefs due to its ancient civilization as well as its long history in medicine. the history of medicine in iran has been an important part of the history of both the country and the world as a result of the contribution of iranian people to the growth and completion of medical sciences for centuries (5, 6). although some medical schools do not pay enough attention to teaching hm and physicians might never have the time to study it, this field has grown rapidly in recent years (7). a lot of researchers and physicians in many countries have become progressively interested in hm (3,8). also, teaching hm has long been a scientific subject in the field of medical education. for instance, the university of birmingham medical school started to teach this subject in the medical curriculum during the academic year 1996 1997 (9), and historical discussion was presented as a seminar for fourth-year medical students at the university of arkansas in the 20th century (10). the medical education program was also expanded at stanford medical school in 2000 (11). moreover, history of medicine is available in the first year of the medical curriculum at minnesota medical school (12). hm is not a part of medical school curriculum in iran, but is included in the history of culture and civilization of iran and islam (the hccii course). it seems that the main goal of hccii is to raise the level of knowledge and change the attitude of students and the medical community. based on previous studies, the hccii course has pros and cons ranging from agree to completely disagree among faculty members as well as medical students (13). according to the obtained data, the levels of knowledge and attitude about hm have not been studied in medical students so far. the aim of this study is to determine medical students’ level of knowledge and attitude about history of medicine. moreover, there is an attempt to know whether the information received by medical students during the hccii course affects their knowledge and attitude about history of medicine. researchers have not investigated knowledge and attitudes about hm in much detail, and since the topic is very essential due to the growing importance of medical history, this study was conducted for the first time in iran. salehi a., et al. 3 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 6 august 2020 method a cross-sectional study design was used among medical students of shiraz university of medical sciences (sums). the participants were the medical students studying in all academic years from october 2016 to october 2017. any medical student in sums during the mentioned period of time was eligible for inclusion in this study. the sample size was determined by considering the size of the society (1200 people). two hundred and sixty-three (263) medical students were selected using the cochran statistical formula (a confidence interval of 95% and power of 80%). based on their academic years, subjects were divided into two educational categories: basic sciences level (academic year 1 4) and clinical courses level (academic year 5 7). the sample size was selected proportional to the volume from each category. after the convincing sampling method was performed, two expert researchers explained the purpose of the research to the subjects. it should be added that all medical students must take the hccii course between the 2nd and 3rd academic years. however, it is voluntary to participate in workshops such as persian medicine (pm) and history of medicine (hm). data collection and questionnaire since there was no standard questionnaire in this field, data collection was done through a researcher-made questionnaire. ten questions were prepared about knowledge and ten about attitude; the questionnaire was developed during 3 meetings with three 3 expert faculty members. finally, content validity of the questionnaire was confirmed by four expert faculty members of sums. the reliability of the questionnaire was also measured by a test-retest method on 20 medical students and repeated within an interval of two weeks, and cronbach's alpha was measured at 0.79. the questionnaire was classified into three components. the first part included demographic information, academic level, and participation in the hiicc course, pm workshop and hm workshop. the second part of the questionnaire consisted of 10 questions regarding knowledge and 10 about attitude. the knowledge section consisted of seven likert scale questions (4 = very high, 3 = above average, 2 = average, 1 = below average, 0 = very low) and 3 yes/no questions (correct answer = 1 and false answer = 0). the third part, i.e. the section regarding attitude, consisted of ten likert scale questions (4 = strongly agree, 3 = agree, 2 = undecided, 1 = disagree, 0 = strongly disagree). notably, the 2 attitude questions were negatively designed to determine the accuracy of the responses in completing the questionnaire. in order to take account of ethical considerations, the questionnaires were anonymous and were identified by code. confidentiality was maintained and the students participated in this research willingly. ethical approval was received from shiraz university of medical sciences (9801-64-20586). data analysis mean and standard deviation (sd) of knowledge and attitude scores were presented. independent t-test, anova, and medical students’ knowledge and attitudes toward history of medicine … 4 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 6 august 2020 simple linear regression tests were used to analyze the data using spss software version 19. a significance level of 0.05 was applied. according to quartile participant knowledge scores, the knowledge level was divided into four cutoff points including knowledge scores of 14 30 (very good), 9 13 (good), 6 8 (fair), and 0 5 (weak). according to quartile participant attitude scores, the attitude level was divided into four cutoff points including attitude scores of 29 39 (very good), 26 28 (good), 21 25 (fair), and 0 20 (weak). results table 1 shows the demographic characteristics of the medical students who had attended the hccii course, pm workshop, and hm workshop. data indicated that 63.9% of the students were in basic sciences level. one hundred and thirty-three participants were male (~ 50%), and the average ages of the participants who were in basic and clinical level were 20.45 ± 0.20 and 24.6 ± 0.23 years, respectively. table 1demographic characteristics of the medical students based on academic level academic levels number (%) gender number (%) mean age (sd) attendance at the hccii course, pm and hm workshops (yes no) number (%) basic sciences level 168 (63.9) male 88 (52.4) 19.63 ± 0.173 hccii course yes 15 (17) no 73 (83) pm workshop yes 7 (8) no 81 (92) hm workshop yes 8 (9) no 80 (91) female 80 (47.6) 20.65 ± 0.216 hccii course yes 32 (40) no 48 (60) pm workshop yes 2 (2.5) no 78 (97.5) hm workshop yes 4 (5) no 76 (95) clinical level 95 (36.1) male 45 (47.4) 24.98 ± 0.154 hccii course yes 45 (100) no 0 pm workshop yes 7 (15.6) no 38 (84.4) hm workshop yes 16 (35.6) no 29 (64.4) female 50 (52.6) 24.54 ± 0.320 hccii course yes 48 (96) no 2 (4) pm workshop yes 4 (8) no 46 (92) hm workshop yes 11 (22) no 39 (78) hccii: history of culture and civilization of iran and islam; pm: persian medicine; hm: history of medicine. salehi a., et al. 5 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 6 august 2020 among the participants, 50.3% (n = 140) reported that they had passed at least one unite of hcci during their education. the level of knowledge in both male and female students was 19.4% (very good), 29.8% (good), 19.8% (fair), and 31.0% (weak). but the level of attitude was 22.3% (very good), 21.5% (good), 26.0 (fair), and 30.2% (weak). figures 1 and 2 show the details of knowledge and attitude levels in male and female students, separately. figure 1level of atitiute in medical students figure 2level of knowledge in medical students table 2 reveals the association of student’s knowledge and attitude score with independent variables. although the results did not show significant differences between medical students’ knowledge and attitudes toward history of medicine … 6 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 6 august 2020 male and female participants’ knowledge scores (p = 0.205), there was a significant difference between their attitude scores (p = 0.028), in that it was higher in female subjects. the results also showed that there was a significant difference between the knowledge scores of those who had participated in the optional volunteer workshops of pm and hm and those who had not (p = 0.0001 and p = 0.0007, respectively). however, the knowledge scores of those who had participated in optional volunteer workshops were higher, but the knowledge scores of those who had participated only in the hccii course did not differ significantly from those who had not (p = 0.163). interestingly, the students' attitude scores decreased after attending the hccii course, even though not significantly (p = 0.109). the students’ attitude scores decreased significantly after participation in the pm workshop (p<0.001), and their attitude scores also decreased after participating in the hm workshop, but this was not a significant decrease (p = 0.144). table 2the mean ± sd student’s knowledge and attitude item subgroup number knowledge attitude mean ± sd p* mean ± sd p* gender male 133 9.22 ± 0.48 0.205 22.34 ± 0.76 0.028 female 130 8.39 ± 0.43 24.47 ± 0.57 hccii course yes 140 9.23 ± 0.49 0.163 22.71± 0.69 0.109 no 123 8.13 ± 0.40 24.28 ± 0.66 pm workshop yes 20 14.84 ±1.94 <0.0001 17.42 ± 2.52 0.001 no 213 8.43 ± 0.31 23.80 ± 0.48 hm workshop yes 39 11.36 ± 1.03 0.0007 21.72 ± 1.54 0.144 no 194 8.33 ± 0.32 23.70 ± 0.49 *independent t-test. pm: persian medicine; hm: history of medicine; hccii: history of culture and civilization of iran and islam. tables 3 and 4 show the association of knowledge and attitude with independent variables in an adjusted regression model. in this model, students who attended the pm workshop were 7.9 times more likely to have “very good knowledge” than those who did not. the likelihood was significantly different from those who did not participate in this workshop (p = 0.014). also, there was a 3.6 times greater chance for students attending the hm workshop to have “very good knowledge” than those who did not. the likelihood differed significantly from those who did not attend this workshop (p = 0.027). students who were taking basic sciences were also 3 times more likely to have “very good knowledge” than those in clinical levels (p = 0.045). nevertheless, data indicated that attendance at the hccii course, pm workshop, and hm workshop was not associated with improving medical students’ attitudes (table 4). salehi a., et al. 7 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 6 august 2020 table 3correlates of knowledge levels with independent variables in the final adjusted regression model independent variables subgro up fair knowledge good knowledge very good knowledge adjusted or 95% ci p adjusted or 95% ci p adjusted or 95% ci p gender male 1.804 (0.840-3.876) 0.130 1.054 (0.541-2.053) 0.877 1.291 (0.562-2.966) 0.547 female 1 1 1 hccii course yes 0.975 (0.345-2.757) 0.962 0.699 (0.264-1.848) 0.470 1.456 (0.494-4.297) 0.496 no 1 1 1 pm workshop yes 3.623 (0.604-21.749) 0.159 1.828 (0.313-10.673) 0.503 7.938 (1.509-41.756) 0.014 no 1 1 1 hm workshop yes 0.961 (0.245-3.766) 0.954 2.628 (0.952-7.254) 0.062 3.685 (1.162-11.690) 0.027 no 1 1 1 academic levels basic sciences 2.264 (0.771-6.647) 0.137 0.948 (0.367-2.449) 0.912 3.026 (1.026-8.928) 0.045 clinical 1 1 1 * multinomial logistic regression; the reference category is weak; pm: persian medicine; hm: history of medicine; hccii: history of culture and civilization of iran and islam. table 4correlates of attitude levels with independent variables in the final adjusted regression model independent variables subgroup fair attitude good attitude very good attitude adjusted or 95% ci p adjusted or 95% ci p adjusted or 95% ci p gender male 0.619 (0.300-1.276) 0.619 0.486 (0.225-1.050) 0.066 0.752 (0.349-1.622) 0.468 female 1 1 1 hccii course yes 1.355 (0.499-3.675) 0.551 0.641 (0.209-1.961) 0.435 1.154 (0.402-3.311) 0.790 no 1 1 1 pm workshop yes 0.696 (0.218-2.219) 0.696 0.152 (0.018-1.292) 0.084 0.566 (0.154-2.087) 0.393 no 1 1 1 hm workshop yes 0.883 (0.319-2.443) 0.811 1.084 (0.346-3.396) 0.890 1.021 (0.343-3.034) 0.971 no 1 1 1 academic levels basic sciences 1.033 (0.400-2.666) 0.946 0.694 (0.233-2.072) 0.513 1.239 (0.445-3.447) 0.681 clinical 1 1 1 * multinomial logistic regression; the reference category is weak; pm: persian medicine; hm: history of medicine; hccii: history of culture and civilization of iran and islam. medical students’ knowledge and attitudes toward history of medicine … 8 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 6 august 2020 discussion medical students’ information on knowledge and attitude toward history and medical history is limited. the findings showed that half of the students in hm did not have desirable knowledge and attitude, and the hccii course, as required in the educational curriculum, had no effect on improving the attitude or knowledge of medical students. studies on the knowledge and attitude of medical students toward complementary medicine somewhat include hm because traditional medicine is a part of complementary medicine (14). we found numerous articles in the literature study that emphasized the value of teaching hm to medical students. studies showed that most medical students were in favor of introducing complementary medicine and entering these subjects in the academic curriculum (15, 16). in iran, application of complementary medicine to various diseases is increasing, and over the past decade, traditional persian medicine has progressed as part of the complementary medical curriculum in universities (17). it is essential to evaluate the achievement of the goals of each course or seminar in order to modify the structure or content of the curriculum. however, the authors of the study did not investigate medical students' knowledge and attitude about hm in literature. there are various approaches to teaching hm at medical science universities (18). in england, medical students attend an hm course in the second academic year at birmingham university and will present a paper on this topic the next year (9). likewise, the northwestern university feinberg school of medicine is offering a seminar on the history of medicine as part of its educational curriculum. in recent decades, the hccii course has been added to the medical education curriculum of medical students in iran and now it is a required course for all medical students. this course comprises two major sections. in the first section, it introduces the background of the population’s culture, islamic civilization, development of science in islamic civilization, etc. the second section involves the background of muslim achievements by researchers who lived a few centuries ago. considering the topics covered in the hccii course, it was expected that the level of knowledge and attitude of students who passed this course would be improved compared to the rest of the students. however, there was no research to evaluate the effect of the hccii course on medical students' knowledge and attitude in iran. students' knowledge of hm may be an important target in enhancing the self-esteem of any community (9). medical students' knowledge of hm can be a crucial point in increasing their self-esteem. the findings of this research showed that only 49.2% of the students had a favorable level of knowledge concerning hm (50.4% in men and 47.8% in women). in other words, more than half of the medical students did not have a favorable level of knowledge about hm. it is noteworthy that the level of knowledge among the students who attended the required hccii course did not differ significantly from those who did not. these results salehi a., et al. 9 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 6 august 2020 indicated that the hccii course is probably not able to enhance the students’ knowledge to a desirable level. this may be due to a lack of qualified educators, educational resources and educational facilities, limited lecture times, and the inefficient organization of education. it is therefore essential to review and reconfigure the structure, content or manners of the hccii course. of course, the level of knowledge was higher among students who participated in voluntary educational workshops such as hm or pm than students who did not. this indicates that workshops have been effective in enhancing students’ knowledge and should therefore be held more often. these findings are consistent with those of darby’s study (19), a comparison between three groups of students involved in obligatory courses and three groups of students involved in elective courses. the results showed that the increase in the knowledge of students who participated in elective courses was more favorable. different variables such as psychological, family, community and even financial factors affect individuals’ attitudes. in education, three important factors that can change attitudes are the personality of the audience, the skill of the educators, and the characteristics of the message. this research showed that 47% of the female and 40.7% of the male participants had a favorable attitude toward hm. it is noteworthy that attitude toward hm was lower in students who attended both elective workshops and obligatory courses than those who did not, but the difference was not significant. this suggests that these courses cannot influence the attitudes of students. however, hackler (10) argued that teaching hm to medical students improved thinking, enhanced critical and analytical approaches, and increased their social knowledge and consequent attitudes. sokol (20) also argued that hm education could enhance the students' interest in research and curiosity (21). the reasons for the findings of the present study are not clear, but there are a number of potential explanations for the results. firstly, this may be linked to the way that history of medicine is taught and conveyed. historical subjects covered in this program are only taught in the form of lectures and not interactively. obviously, dynamic and communicative methods of teaching could enhance attitude and motivate learning. second, teachers at pm workshops probably lecture about past physicians’ methods of diagnosis or treatment that are not compatible with the modern approach, without sufficient and convincing explanations for students. finally, evidence indicates that students’ attitude in different eras of science tend to be mainly context-dependent (22). hence, there are different factors that affect students’ attitude toward history of medicine such as gender, teachers, curricula, culture, socio-ecnoimc status and so on (22, 23). given the fact that the knowledge of students in this research did not change considerably after attending the required courses, it is suggested that voluntary workshops be held in this area. moreover, fundamental modifications in the content and structure of the required courses are clearly needed. one of the limitations of this study was a lack of similar studies to compare the results. medical students’ knowledge and attitudes toward history of medicine … 10 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 6 august 2020 conclusion teaching hm to medical students can be a great opportunity in every country to increase the student's knowledge of medical science history. hm training may even be effective in students' intention to do research. since the present study showed that only about half of the students had a relatively good attitude toward hm, there is a need to review the construct and content of the educational curriculum to enhance the quality of the course. while the involvement of students in hm workshops is helpful in enhancing their knowledge, further studies are required to establish this. acknowledgments the authors would like to express their sincere gratitude to dr. mahdi shahriari and dr. mostafa nadim for their time and efforts in this manuscript. the authors also wish to thank dr. nasrin shokrpour at the research consultation center (rcc) of shiraz university of medical sciences for her invaluable assistance in editing this manuscript. conflict of interests all authors declare no sources of funding. salehi a., et al. 11 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 6 august 2020 references 1. pearson d, gove s, lancaster j. history of medicine. health information and libraries journal. 2001; 18(3): 135-6. 2. waller j. lessons from the history of medicine. j invest surg. 2008; 21(2): 53-6. 3. bynum wf, porter r. companion encyclopedia of the history of medicine. new york: routledge; 1997. 4. fridenberg p. journal of the history of medicine and allied sciences. archives of ophthalmology. 1946; 36(3): 371-2. 5. nayernouri t, azizi mh. history of medicine in iran the oldest known medical treatise in the persian language. middle east j dig dis. 2011; 3(1): 74-8. 6. zargaran a. ancient persian medical views on the heart and blood in the sassanid era (224– 637 ad). int j cardiol. 2014; 172(2): 307-12. 7. paterson gr, neilson jb, roland cg. history of medicine. can med assos j. 1982; 127(10): 948. 8. cox c. discursive essay: a better known territory? medical history and ireland. proceedings of the royal irish academy section c: archaeology, celtic studies, history, linguistics, literature; dublin, ireland; royal irish academy; 2013; 113(-1): 341-62. 9. arnott r. the university of birmingham medical school and the history of medicine. medical humanities. 2002; 28(1): 33-4. 10. hackler c. university of arkansas college of medicine, division of medical humanities. acad med. 2003; 78(10): 1059. 11. shafer a. stanford university school of medicine, arts and humanities medical scholars program. acad med. 2003; 78(10): 1059-60. 12. anonymous. medical school university of minnesota curriculum. [cited 2020 august]; available from: http://www.med.umn.edu/admissions/curriculum/years-1-and-2/ 13. shedlock j, sims rh, kubilius rk. promoting and teaching the history of medicine in a medical school curriculum. j med libr assoc. 2012;100(2):138-41. 14. rosenbaum cc. the history of complementary and alternative medicine in the us. ann pharmacother. 2007; 41(7-8):1256-60. 15. ameade epk, amalba a, helegbe gk, mohammed bs. medical students' knowledge and attitude toward complementary and alternative medicine–a survey in ghana. j tradit complement med. 2015; 6(3): 230-6. 16. akan h, izbirak g, kaspar eç, et al. knowledge and attitudes toward complementary and alternative medicine among medical students in turkey. bmc complement altern med. 2012; 12(1): 115. 17. dastgheib l, farahangiz s, adelpour z, salehi a. the prevalence of complementary and alternative medicine use among dermatology outpatients in shiraz, iran. iran j med sci. 2016 may; 41(3 suppl): s70. 18. armocida e, aldini nn. teaching and learning the history of medicine in the university: some considerations after the students' final exams. medicina historica. 2018; 2(1): 41-8. 19. darby ja. the effects of the elective or required status of courses on student evaluations. journal of vocational education and training. 2006; 58(1): 19-29. 20. sokol dk. perspective: should we amputate medical history? academic medicine. 2008; 83(12): 1162-4. medical students’ knowledge and attitudes toward history of medicine … 12 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 6 august 2020 21. bârsu c. history of medicine between tradition and modernity. clujul medical. 2017; 90(2): 243 22. osborne j, simon s, collins s. attitudes toward science: a review of the literature and its implications. international journal of science education. 2003; 25(9): 1049-79. 23. donohue sk, richards lg. factors affecting student attitudes toward active learning activities in a graduate engineering statistics course. proceedings of 39th ieee frontiers in education conference; san antonio, texas, usa; american society for engineering education; 2009, p. 1-6. journal of medical ethics and history of medicine donated materials in assisted reproductive technologies: an ethico legal analysis of art legislations worldwide majdah zawawi department of islamic law, ahmad ibrahim kulliyyah of laws, international islamic university malaysia, kuala lumpur, malaysia. *corresponding author: majdah zawawi address: department of islamic law, ahmad ibrahim kulliyyah of laws, international islamic university malaysia, jalan gombak, 53100 kuala lumpur, malaysia. tel: (+603) 61 96 43 51 fax: (+603) 61 96 48 54 e-mail: z.majdah@iiu.edu.my received: 01 feb 2010 accepted: 15 jun 2010 published: 21 jun 2010 j med ethics hist med, 2010, 3:2 © 2010 majdah zawawi; licensee tehran univ. med. sci. abstract keywords: reproductive techniques, assisted, plant gametes, embryo, ethics. introduction decisions regarding matters affecting family life such as whether or not to have children, with whom to have them and when and how to have them are considered as personal matters. this is so because such issues are intricately connected to human emotions and human nature. therefore, these issues are considered as ‘private matters’ that only the individuals involved may decide on freely and without any undue interference. as such, governmental intrusion by the way of regulating or curbing this freedom through legislation has been met with some resistance. this belief is grounded primarily on the basic notion of liberalism which gives primary respect to individual freedom. this is the foundation of the notion of reproductive rights as understood by western standards today. assisted reproductive technologies originated in the west. therefore, it is mainly western countries that have considered it as necessary to legalise art services. countries enjoying art legislations have tried to protect the right of infertile couples to reproduce while at the same time doing their best to protect the interests of children born as a result of art procedures (1). this paper analyses art legislations around the world. the main aim of this endeavor is to see how these legislations address the drastic changes occurring in familial relationships when art involves the use of donated materials (2). this analysis is important to show that most of these legislations have attached primary importance to the reproductive autonomy of couples wishing to reproduce whilst sidelining other ethical principles such as beneficence, non-maleficence and justice, especially to the resulting child and the traditional concept of the family. the paper is divided into three parts. the first will discuss legislations on art from around the this paper provides an appraisal of countries that have legislations pertaining to assisted reproductive technologies (art). in doing so, the paper highlights the emphasis on the protection of reproductive freedom of the couples seeking art treatment. this belief is grounded primarily on the basic notion of liberalism that attaches primary importance to respect for individual freedom, which is the foundation of the notion of reproductive rights as understood by western standards today. the main aim of the appraisal is to see how these legislations address the drastic changes in familial relationships when art involves the use of donated materials. j med ethics hist med 2010, 3:2 majdah zawawi page 2 of 9 (page number not for citation purposes) world, whereby a classification of the legislation is made. this will lead to the second part where an analysis will be made to see how far these legisla tions will be effective in establishing new familial relationships, protecting the rights of the resulting child and affecting the rights of the community as a whole. hereafter, the discussion proceeds to the third part of the chapter which leads to the above conclusion. art legislations around the world the use of art coupled of donated materials has indeed challenged many natural and traditional notions of motherhood, fatherhood and the concept of family as a whole. many countries around the world have come to realise the pertinent need for regulating art services. most of these countries try their best to grapple with the respect to be given to individual reproductive rights on the one hand and, on the other hand, the need to protect the rights of the resulting child and how the use of art affects the society as a whole. countries that have legalised art services are mainly western countries that give primary respect to the couples to decide freely what type of art service to choose from, and whether or not to use donated materials should they be resorted to. the traditional concept of the family in the west has been altered in order to accommodate individu al choices by allowing couples to use donated materials by use of art in order to have children (3). this change may be considered as ethical to western writers and legislators. this is due to the western ethical stand that it is a right to give primary respect to the choices made by the infertile couples. respect for a person’s autonomy has long been one of the most important ethical positions in many western countries. although the principles of beneficence, non-maleficence and justice are also considered as important ethical principles to be considered, nonetheless, many western writers are of the opinion that, in the area of reproductive rights, primary respect must be given to individual autonomy. changes in the concept of the family the traditional or classical understanding of the ‘family’ has always associated individuals within the bounds of marriage and any children resulting from them (4). dickens, for example explains that the classical understanding of the family includes “associations of persons related genetically or by marriage and identified by their interaction and affinity” (5). he continues to explain that, historically, the family was “a genetic and marital line traceable back through earlier generations” (5). in the west, the institution of marriage ensured that the resulting child was legitimate and this allowed the succession of power and wealth (4). the existence of an illegitimate child would threaten the “smooth operation of the system”; therefore, legal rules were created to exclude them from being able to benefit from the system (4). according to bainham, in the modern west, the change in perception was noticeable during the 1970s, when a decrease in marriage and increase in the birth of children out of wedlock had resulted in a shift in social and legal attention (4). due to its common occurrence, this resulted in less social stigma attached to extra-marital sex, cohabitation and procreation than thirty years before (6, 7). meanwhile, according to barton et al., the recogni tion of these new familial forms is “influenced by a growing emphasis on the freedom of the individual, and the right to do as one pleases, so long as it harms no one else”. this is reminiscent of the liberal teachings of locke and mills. the acceptance of these new family forms had necessitated a change in the family law and the law related to the parent and child relationship in many western countries. previously, marriage provided the legal framework for legal responsibili ties towards each other and any resulting children. in the absence of marriage, the state had to resolve the issue of responsibility based on the contractual model for the couples (3). nevertheless, with regards to the children, the state still looked at the existence of genetic ties in order to establish the responsibilities of the parents (7). the availability of art procedures has created an even greater change in the understanding of the concept of the family. now, with the availability of art and the ability to use donated gametes and embryos, even the existence of genetic ties no longer sufficiently establishes responsibility toward the resulting child (3). the creation of new familial forms is one of the main concerns of countries that have allowed the use of art with donated materials. countries that have legalised art services have concentrated on five important aspects of legislation. the first is the establishment of a monitoring body to issue licences for art centres and ensure professional treatments for the public. safety requirements are also given primary importance to ensure that the procedures offered to the public are safe for human application. second, prohibitions on certain types of procedures could either result in criminal prosecutions in some countries or the cancellation of the licence in other ones. the third are the provisions which allow access to art treatments whereby certain countries are seen to attach importance to the couples being married and infertile, whilst other countries allow infertile heterosexual couples in a stable relationship to have similar access to these treatments. the fourth j med ethics hist med 2010, 3:2 majdah zawawi page 3 of 9 (page number not for citation purposes) is the creation of new definitions for the legal concept of “father” and “mother” as well as the legal relationship that flows from the creation of these new definitions. finally, the fifth aspect is the legal and moral status of the human embryo and the treatment that must be accorded to these embryos which relates directly to the concept of human dignity. most countries that have specific legislations on art have established ethics committees that are responsible for collecting public opinions and conducting meetings attended by the experts in the field of art as well as religious and non governmental organisations (ngos). the reports issued by these ethics committees then made the basis for legislations. therefore, the legislations reflected the national policy of a certain country, each being unique in the sense that it reflected the historical influences and social as well as religious sensitivities of the people of that country. an analysis of the legislations from various parts of the world shows that only a fraction of the countries around the world, of about ten percent, have specific legislation on art whilst only six percent have some kind of regulation and the remaining eighty four percent of countries around the world still do not have any legislations pertain ing to art. the majority of these countries are developed western countries that have been practicing art for more than three decades. classifications of legislations countries that have legislations on art may be classified into four different categories, accord ing to the level of permissibility of art proce dures and the types of persons that may have access to it. the first category may be called countries with liberal legislations. the art legislations under this category give full respect to ‘the right to reproduce’ of infertile couples. these countries include australia (8, 9), canada (9-11), denmark (9, 12), the netherlands (9, 13), new zealand (9, 14), portugal (14, 15), south africa (16), spain (17) and the united kingdom (9, 18). countries having art legislations that fall under this first category try to balance the primary respect given to the right of individuals to repro duce with the responsibilities owed to the child. this is done by recognising the new types of familial relationships that have been formed as a result of art procedures using donated gametes, embryos and even surrogacy. the second category of legislation involves countries that may be considered as the moderate regulators. these countries include australia (8), france (9), hong kong (19), iceland (12), israel (9, 20) and sweden (12). under this category, these countries are seen to be quite permissive in certain areas whilst prohibiting other procedures. the states of queensland and victoria in australia, france, iceland and sweden for example have strictly prohibited any form of surrogacy. on the other hand, other countries such as hong kong and israel, while permitting non-commercial surrogacy, set the condition that such services may only be made available to married couples and using the gametes of these couples only (19,20). hong kong also allows information on the identities of donors to be released to the resulting children as soon as they reach the age of sixteen (19). meanwhile, israel is very strict with regards to the conditions concerning the use of donated sperm but surpri singly allows single women to opt for art as a way of having children (9). israel also allows non commercial surrogacy but with specific directions that only the couple’s gametes are used to be implanted in a single woman who is not a relative of either of the couple and who must be of the same religion as the couple (9). it is clear that in these countries, reproductive rights of individuals are to be given due respect. however, at the same time, these countries try to balance this respect with the need to respect the cultural and religious sensitivi ties prevalent in each of their societies. the third category of legislation concerns strict regulators. countries that fall under this category include austria (21, 22), germany (9, 23 26) and norway (12). these countries are seen to only allow the use of donated sperm in any of the art procedures that may be offered. all three countries do not allow the use of donated eggs and donated embryos. the storage of embryos is not permitted. instead, art practitioners are only allowed to create enough embryos that are safe for transplantation to the womb in a single cycle. in germany, for example, embryo cryopreservation is only allowed if the woman seeking treatment suffers from ovarian hyperstimulation or refuses to have the embryos transferred into her. meanwhile, cryopreservation of gametes is only allowed for the gametes of the couples seeking treatment and may not be used for donation. nevertheless, despite these restrictions, art services are offered to married couples and heterosexual couples who are in a stable relationship. these countries are strict regulators due to historical, cultural and religious reasons. the fourth and final category of legislation involves countries that are considered as very strict regulators. the countries that abide by this catego ry of legislation are italy (27, 28) and turkey (9). both countries only allow living infertile married couples to have access to art services. however, italy is seen to be stricter than turkey with regard to the storage of embryos. while turkey permits storage of embryos during the lifetime of the couples or during the subsistence of the marriage, italy is seen to prohibit it altogether, permitting only the creation of embryos that are safe for j med ethics hist med 2010, 3:2 majdah zawawi page 4 of 9 (page number not for citation purposes) implantation. these two countries have legislated primarily based on the religious sensitivities of their people. the above classification shows differing trends in legalising art. each county has a legislation that reflects the social, cultural and religious situations that are unique to that particular country. for the purposes of the present paper, when necessary, direct reference shall be made to the united kingdom’s human fertilisation and embryology act, 2008. this analysis illustrates the difficulties faced in resolving conflicts between the respect that is to be given to the right of individuals to reproduce and the responsibilities that come with reproducing. changes in the concept of parenthood it is evident that in the west, the availability of art and the choices it had provided for infertile couples was not the main reason for the changes in the traditional concept of the family. the change was in fact a gradual process that came in the wake of the industrial revolution and then the sexual revolution (3). hence, at the time when art was introduced to the western world, the concept of the family and the family law had already transformed. this transformation in turn challenged the mean ings of familial relationships. this is the main reason why many western countries do not oppose the changes in the shift in moral and legal respon sibility residing in the notion of parenthood and the changes in the familial status that is induced by the use of “collaborative” art (4) ethical and legal issues in collaborative art the use of third party materials in art treatments has created new meanings for the concept of motherhood and fatherhood. aside from that, the use of third party materials brings about the issue of the rights of the resulting child to know his or her genetic identity. this goes back to the root of their existence. aside from that, the issue also brings up questions as to whether or not this will affect their emotional and psychological development in the future. new definitions of “motherhood” the discussion begins with the change in the concept of “motherhood” and how the use of donated eggs causes drastic changes in the tradi tional meaning of motherhood. a “mother” is generally taken to be the woman who carries and gives birth to a child as a result of the fertilisation of her ovum by the sperm of her husband. once born, she will also be the one to raise and nurture the child (29). according to robertson, this situation would be the ideal concept of “mother hood” (4). however, since the availability of art has made it possible to segregate the different stages of motherhood, he further contends that each stage is important in its own right. a process that used to occur on one woman can now be made to happen on three different women. blank has clearly made the following observations on the different “types” of mother as a result of certain art procedures; “the genetic mother is the woman who supplies the egg to be fertilised by in vitro fertilisation or the embryo for transfer. she might or might not be the carrying mother in whose womb the embryo implants and develops to term. finally, the nurturing mother is the woman who cares for the baby once it is born.”(29) the above scenario shows the possibility of a child having up to three “mothers”. this shows how the use of collaborative art has led to the questioning of an issue that was once unquestiona ble. from the above, the issue of motherhood comes into question in three situations. the first situation is where the husband’s sperm is used to fertilise a donated egg and the resulting embryo is transferred into the wife. the second situation is where the wife is given a donated embryo. the third situation is where a donated embryo is implanted in a surrogate but the child will be raised by the commissioning couple. the third situation will not be discussed here. in the first and second situations, the commis sioning wife will be the birth mother of the resulting child although she did not provide the genetic material. the issue that arises here is ‘should motherhood be attributed to genetic constitution or to the act of giving birth?’ this issue has not been fully settled even in countries that have legalised art procedures. the confusion arisen in the definition of “motherhood” as a result of the use of donated eggs and embryos has led countries such as austria, germany, italy, norway and turkey to prohibit both the use of donated eggs and donated embryos. even in countries that do allow the use of donated eggs and donated em bryos, there are differences in the way “mother hood” has been defined. lee and morgan admit that existing provi sions pertaining to the definition of “mother” remains unclear (9). this is because, “the question of genetic status and personal identity is a complex, intermeshing construct of psychological, philo sophical, historical, cultural, ethical and legal matters. in the united kingdom, statutory provi sions of the hfe act, 1990 (revised in 2008), override the common law rules related to the presumption of parenthood based on the genetic link. section 33(1) of the hfe act, 1990 mentions; j med ethics hist med 2010, 3:2 majdah zawawi page 5 of 9 (page number not for citation purposes) “the woman who is carrying or has carried a child as a result of placing in her of an embryo or of sperm and eggs, and no other woman, is to be treated as the mother of the child.” this shows that in the united kingdom, the status of the mother would remain in the woman who gave birth to the child. despite the liberal attitude toward legalising art services, section 33 seems to show that importance is still placed on the biological relationship established between the mother and child during pregnancy. the hfe act, 2008, clearly gives recognition to the gestational mother whilst providing an exception in cases of surrogacy. on the surface, the act does not seem to provide any new definition of mother, as section 33 still recognises the woman giving birth as the mother of a child. nevertheless, underneath this surface lies the truth whereby the genetic mother remains in existence. this brings up issues as to the right of the resulting child to know of the existence of their hidden mothers. this will be discussed further in the paper. for now, there is a need to look at the new definitions of the notion of fatherhood. definitions of “fatherhood” the use of donated sperm has also resulted in confusion with respect to the notion of “father hood”. a ‘father’, in the case of art involving donated sperm, does not only mean the man who has produced the sperm having fertilised the egg of the woman carrying the child to term wherein both “despite the widespread use of aid (artifi cial insemination by a donor) during the last three decades, legal questions abound. be cause the children resulting from aid are not the complete biological offspring of the parents, the legitimacy of aid progeny has been frequently questioned, often in estate or divorce proceedings.” (29) most of the countries that have art legisla tions allow the use of donated sperm as a method of treating infertility. even in countries such as austria, germany and norway where the use of donated eggs and embryos are banned, sperm donation and use is generally allowed. with regard to the legal mechanism used in settling the issue of who is to be regarded as the legal father of the resulting child, an example could be taken from the position in the united kingdom. section 35 of the human fertilisation and embryology act, 2008, mentions that if a child is carried by a woman as a result of an embryo transfer or artificial insemina tion by a donor, and at that time she was “party to a marriage”, then sub-section (1) (b) provides that, “…then, subject to section 38 (2) to (4), the other party to the marriage is to be treated as the father of the child unless it is shown that he did not consent to the placing in her of the embryo or the sperm and eggs or to her artificial insemination (as the case may be).” there have been cases that illustrate the do nor’s wish to identify his progeny and have a say in the bringing up of the child or at least visitation 1 will rear the child. again, blank was correct in rights0f nevertheless, this case cannot be said to pointing out that the responsibilities of production of the sperm and the rearing of the child can be placed on different males. there can now be three different types of fathers. there is the complete father, i.e. “the man who performs both singular roles” of producing the sperm and nurturing the child (29). then, there is also the genetic father, have set a precedent for situations where the donors are anonymous and insemination or ivf is carried out by a proper physician. this is the position that has been followed in legislation. in the united states, thirty states have passed statutes to clarify the status of the child, the status of the donor and the status of the husband of the woman receiving 2 who supplies the sperm. this second type of father treatment1f (26). nevertheless, situations where only produces the sperm without having any intention of rearing the resulting child. the third type of father is the nurturing father, the man who cares for the child even in the absence of any biological ties with the child. ironically, in many cases, it is the nurturing father that art is said to provide assistance for. it is the nurturing father who is infertile. in relation to use of donated sperm, in coun tries which do not have a specific legislation delineating the status of sperm donors and the relationship of the resulting children to couples who accept it as a treatment is based on court decisions and legislations. in the united states for example, blank has pointed out that; known donors are used remain uncertain. 1 see the case of c.m v. c.c. (1979). in this case c.c. had inseminated herself with the sperm of c.m. upon the birth of the child c.m. sought visitation rights which were objected by c.c. the court held in favor of c.m. that since he was the natural father of the child, they granted him the privileges as well as responsibilities of being a father. 2 these states include alabama, alaska, arkansas, california, colorado, connecticut, floridaa, georgia, idaho, illinois, kansas, louisiana, maryland, michigan, minnesota, montana, nevada, new jersey, new mexico, new york, north carolina, ohio, oklahoma, oregon, tennessee, texas, virginia, washington, wisconsin and wyoming. all the statutes in these states legitimize aid j med ethics hist med 2010, 3:2 majdah zawawi page 6 of 9 (page number not for citation purposes) the position of the donor is much more pre cise in the united kingdom and australia. section 38 of the uk hfe act, 2008, and section 60h of the family law act, 1975, clearly establishes the recognition given to the husband or the partner of the woman receiving treatment as the legal father of the resulting child if the treatment takes place in a licensed centre and the husband consents to the 1 , 2 these approaches clearly uphold the tendency to trump the reproductive rights of infertile couples over and above other ethical principles. aside from ignoring the principles of beneficence and non-maleficence, it also ignores the principle of justice. legislations that allow the use of donated sperms create havoc to the concept of family and create an illusory relationship between the father procedure2f 3f (30). this provision automatically and the child. excludes any donors, be it anonymous or known, from being able to seek any rights over the result ing child. paragraph 3(1)(1) of schedule 3 of the human fertilisation and embryology act, 2008, specifically states that consent must be made in writing and must be signed by the person giving it. a more interesting change in the 2008 act is the recognition given to same sex couples who wish to use art in order to form a family. the act has given recognition to same-sex couples as legal parents of children conceived through the use of donated sperm, eggs or embryos. these provisions enable, for example, the civil partner of a woman who carries a child via ivf to be recognised as the child’s legal parent (17). these changes again show that the change in legislation reflects the situation of a particular society. the same changes could not be imported wholly into any other countries wishing to legalise the use of art as there are many countries which still do frown upon same sex relationships. children by providing that the sperm recipient and her husband are the legal parents if the husband consented to the procedure. nevertheless, as of 1990, only eleven statutes recognize these children as legitimate if the recipient is married. 1 this presumption may however be rebutted, but he must show that he had not consented to the art procedure on his wife or partner to have taken place (s.28 (2). should the presumption be rebutted by him proving that he had indeed refused to give consent prior to the procedure; the child will be declared as “legally fatherless”. 2 the position is somewhat different in australia where although the husband can contend that he had not consented to the procedures, he could still be made the legal father of the said child under state law. see status of children act 1974, victoria, the family relationships amendment act 1984, south australia, the artificial conception act, 1984, new south wales, amendment to the status of children act 1974 which was amended in 1985, tasmania, the artificial conception act, queen sland and the artificial conception act 1986, west australia. other countries that have similar legislations include belgium, bulgaria, czechoslovakia, greece, hungary, new zealand, norway and sweden. countries that have regulations include israel, italy, portugal and south africa. the difficulties in resolving these issues, when donated materials are used through legisla tion, would serve as a very strong reminder to the society and legislators, that not everything may be solved by the way of legislation. it also shows that respect must be given to not only the reproductive choices of infertile couples, but there is also a need to balance that with the principles of beneficence to the resulting child. this also is in line with the principle of non-maleficence where, in exercising their right to reproductive choice, must not cause harm to the resulting child or the society through the disintegration of the concept of the family. right to genetic information aside from the issue of donors wishing to ac knowledge their progeny, another unsettled problem in the use of donated sperm is the right of privacy of the donor as opposed to the right of the resulting child to know his or her genetic parent. generally, couples seeking art treatments, especially those using donated gametes, wish to keep such information a secret. roberts has rightly pointed this fact out when she observes; “medically assisted reproduction has tradi tionally been shrouded in secrecy. concern has been with protecting the anonymity of the donor, in order to ensure a constant supply of gametes…the medical profession has concentrated on the patient (the pros pective parents) and the donor, who enables treatment to take place. insufficient atten tion has been given to the child. the use of donated gametes and embryos raises issues about the interests and needs of children by donation to be told about their genetic background. (30)” the warnock committee, which had come with proposals leading to the hfe act, felt that gamete donation should be allowed and encouraged in order to help infertile couples. that is why they had recommended that donors must not be bur dened with any legal responsibilities or obligations towards the resulting children. however, in ensuring that the social parent is recognised as the legal parent, the law tends to create an element of secrecy and dishonesty (31). it has been suggested that this denial of the truth that the child is actually the child of another, has the j med ethics hist med 2010, 3:2 majdah zawawi page 7 of 9 (page number not for citation purposes) potential of resulting in future psychological problems towards the child should he find out the truth about how he was conceived (31). at this point, legislation and even court decisions which try to legitimise children born as a result of donated gametes and embryos have actually focused more on the needs and wishes of those seeking art treatment. not enough thought has been given to the welfare of the resulting child. these laws clearly seek to recognise and promote the use of donated sperm as a form of valid and viable treatment for male infertility. these steps ensure the legitimacy of the child and allow the flow of responsibility to be shifted from the biological father to the nurturing father. despite these attempts at resolving the issues concerning the status of the child and the husband, there remains “lingering questions concerning the …rights and responsibilities of sperm donors” and “have yet to be clarified in many jurisdictions.” (29) this unsettled situation is reflected in the different ways in which the countries that have allowed use of donated sperm handle the issue of information. indeed, certain legislations do mention that consideration must also be given to the welfare of 1 not the resulting child has the right to know that they were born as a result of art using donated materials and/or surrogacy and also whether or not they have a right to know who their genetic parents were. legislations in australia, in all its states except western australia, allows identifying information of the donor to be released to a child upon reaching eighteen years of age. other countries such as the netherlands, norway and sweden (31) also have similar positions. hong kong has recently followed this trend by allowing information to be released when the child reaches sixteen. meanwhile countries such as canada and iceland have adopted the double track approach whereby identifying information will only be released to donors who have consented to it. there are countries which opt to maintain the position of secrecy. in countries such as austria (which only allows donated sperms), denmark, france, germany (also allows donated sperm only), israel, new zealand, portugal, south africa and spain have all ensured donor anonymity. if looked from the ethical standpoint, leg islations pertaining to art treatments using donated gametes, embryos and surrogacy seek to the resulting child4f (9). despite the existence of fulfil the wishes of infertile couples to have such provisions, what exactly amounts to the welfare of the child has not been specifically defined. the hfe authority’s code of practice provides some guidance on how the welfare of the child may be assessed. among others, it recognises the “child’s potential need to know about their origins and whether or not the prospective parents are prepared for the questions which may arise while the child is growing up” (hfea code of practice, 2006). previously, there is nothing in the hfe act which makes it compulsory for the authority to supply information with regard to the identity of the donor to the resulting child (once they reach 18 years old). the 2005 code of practice only encourages parents to tell their children of the way they were conceived. however, as of april 2005, an amendment to section 31(5) of the hfe act enables any child who has reached the age of 18 to obtain identifying information on their genetic parent(s). this move in giving recognition to the rights of the child to know of their genetic history is not new. many countries that have legalised art services are concerned with the issue of whether or 1 section 13(5) of the human fertilisation and embryol ogy act, 1990 for example mentions, “a woman shall not be provided with any treatment services unless account has been taken of the welfare of any child who may be born as a result of the treatment (including the need of that child for a father), and of any other child who may be affected by the birth.” children despite the social and legal changes to the traditional notion of the family. the provisions which shift the legal responsibility from the sperm and egg donors deny the truth that has been established genetically. it allows donors to repro duce without having any responsibility towards the child. while parental relationships may be shifted, the fact that a genetic link exists creates a false sense of security for the infertile couple and the resulting child. this in turn harms the children’s right to information as well as harms them psycho logically once they know the truth of their creation. the practice also creates a very real danger of incest marriages. legislations vary as to the number of families to whom a donor may donate. in the u.k. a man may donate his sperm to ten different families. despite the fact that a register is kept it depends very much on whether or not these children are told of the fact that they were created with donated materials or surrogacy. it is also not yet known how many will seek for information on their genetic parents. there exists a huge possibili ty that they may never know that they were in fact created as a result of art treatment services and thus finds no reason to seek information of their past. this also shows that legislations which seek to legalise use of donated materials fail to fulfil the ethical principles of beneficence and non maleficence. j med ethics hist med 2010, 3:2 majdah zawawi page 8 of 9 (page number not for citation purposes) conclusion in view of the above, it could be concluded that many western countries have chosen to discard the traditional model of family as a sign of respecting the individual right to reproduce. they do so because of their ultimate respect for individ ual liberty which is actually a result of occurrences which are unique to the social history of the west. by giving primary respect to individual reproduc tive rights and the principle of autonomy, other ethical principles such as beneficence, non maleficence and justice have largely been ignored. as titus puts it; “those who seek to redefine marriage and the family claim that a variety of sexual relation ships serve the sociological and psychologi cal functions of the traditional family. law, to these reformers, is only an instrument to bring about the desired social changes. no questions are asked whether any proposed change, violates any legal or moral order imposed on mankind by god or nature. (32)” j med ethics hist med 2010, 3:2 majdah zawawi page 9 of 9 (page number not for citation purposes) references 1. guiseppe b, luca g. regulating in vitro fertilization – the risks of over-regulation: italy. in: brinsden pr. textbook of in vitro fertilization and assisted reproduction: the bourn hall guide to clinical and laboratory practice. london: taylor & francis; 2005. 2. derek m, linda n. law, technology, reproduction and european ethics. in: wheeler s, mcveigh s. law, health and medical regulation. aldershot: dartmouth publishing co.; 1992, p. 54. 3. dolgin jl. defining the family: law, technology, and reproduction in an uneasy age. new york: new york university press; 1997. 4. eekelaar j. family law and social policy. london: weidenfeld and nicolson; 1994, p. 5. 5. bernard md. reproductive technology and the new family. in: sutherland e, mccall smith a. family rights: family law and medical advance. edinburgh: edinburgh university press; 1990. 6. barton c, dougas g. law and parenthood. london: butterworths; 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31(9): 536-9. 28. turone f. italy to pass new law on assisted reproduction. bmj 2004; 328(7430): 9. 29. blank rh. regulating reproduction. new york: columbia university press; 1990, p. 9. 30. roberts m. a right to know for children by donation – any assistance from down under? child fam law q 2000; 12(4): 371. 31. jean-marie t. the rights of children to information following assisted conception. in: evans d, pickering n. creating the child: the ethics, law and practice of assisted procreation. the hague: martinus nijhoff publishers; 1996. 32. henry wt. gays, lesbians and the meaning of family: defining marriage and the family. william & mary bill rights j 1994; 3: 327-9. journal of medical ethics and history of medicine euthanasia attitude; a comparison of two scales naser aghababaei 1* , hojjatollah farahani 2 , javad hatami 2 1.ma in general psychology, department of psychology, faculty of psychology and education, university of tehran, tehran, iran. 2.assistant professor, department of psychology, faculty of psychology and education, university of tehran, tehran, iran. *corresponding author: naser aghababaei address: al-ahmad ave, tehran, iran. postal box: 14155-6456 tel: (+98) 21 88 25 00 62 e-mail: naseragha@gmail.com received: 09 jul 2011 accepted: 08 oct 2011 published: 12 oct 2011 j med ethics hist med. 2011; 4:9. http://journals.tums.ac.ir/abs/19413 © 2011 naser aghababaei, hojjatollah farahani and javad hatami; licensee tehran univ. med. sci. abstract keywords: euthanasia, attitude towards euthanasia, personality. introduction in the last 20 years, the controversy surrounding euthanasia has grown remarkably and it has been a subject of debate amongst scholars and philoso phers in different areas of science such as medi cine, psychology, psychiatry, ethics, sociology, and philosophy. numerous surveys have been carried out in different regions of the world to evaluate the attitude of the public and professionals towards euthanasia (1). it is been argued that significant advances in medical technology (2-8) and social movements which emphasize on identity, individu ality and control of one's body (9-12) resulted in the emergence of this issue. it is argued that if a social movement is to be successful in initiating the main purposes of the present study were to see how the term “euthanasia” influences people’s support for or opposition to euthanasia; and to see how euthanasia attitude relates to religious orientation and personality factors. in this study two different euthanasia attitude scales were compared. 197 students were selected to fill out either the euthanasia attitude scale (eas) or wasserman’s attitude towards euthanasia scale (ate scale). the former scale includes the term “euthanasia”, the latter does not. all participants filled out 50 items of international personality item pool, 16 items of the the hexaco openness, and 14 items of religious orientation scale-revised. results indicated that even though the two groups were not different in terms of gender, age, education, religiosity and personality, mean score on the ate scale was significantly higher than that of the eas. euthanasia attitude was negatively correlated with religiosity and conscientiousness and it was positively correlated with psychoticism and openness. it can be concluded that analyzing the attitude towards euthanasia with the use of eas rather than the ate scale results in lower levels of opposition against euthanasia. this study raises the question of whether euthanasia attitude scales should contain definitions and concepts of euthanasia or they should describe cases of it. http://journals.tums.ac.ir/abs/19413 http://journals.tums.ac.ir/abs/19413 j med ethics hist med 2011, 4:9 naser aghababaei, hojjatollah farahani, javad hatami page 2 of 6 (page number not for citation purposes) and maintaining social change, it needs to develop a public opinion in favor of its particular cause. the uncommitted or bystander public have always been an important target group for different social movements. in the recent years, publicizing results of public opinion polls has been used in stabiliza tion of different movements. pro-euthanasia social movements not only publicize the results, but also regularly commission such polls. these activities are meant to highlight the issue in the public eye, and this alone can facilitate the public’s acceptance of it. for pro-euthanasia movements, which tend not to mobilize their members in conventional public activities such as street marches and protests, polls have become a particularly attractive option, serving as a mass demonstration of public determination (10, 11). such activities have been considerably successful. as a result, euthanasia has become one of the most important topics of interest and debate (13). many studies have demonstrated that the public has become more supportive of euthanasia in the past few years (14). however, using different scales makes it difficult to compare the results of research carried out on the attitude towards euthanasia. in fact, many have questioned the validity of the findings of studies aiming at assessing the attitude of the public towards euthanasia as different studies have shown different results based on the precise wordings and defini tions used in their questionnaire (15, 16). for example, some scales describe cases of euthanasia without mentioning the term “euthanasia”. a scale developed by wasserman et al. (5) could be considered an example of such questionnaires. other scales are designed according to the explana tion of the term or based on the assumption that the respondent is already familiar with it. the euthana sia attitude scale (eas) which was originally developed and validated by tordella and neutens is an example of such questionnaires (3). to our knowledge, there are not any studies conducted on the differences between the abovementioned attitude scales. this study aims to elucidate the difference between two scales in terms of their ability to demonstrate the level of support for euthanasia. methods a convenient sample of 197 female students from the university of tehran and islamic azad university were recruited. all participants were volunteers and their ages ranged between 19 and 43 [21.6± 3.04 (mean±sd)]. a between-group design was applied; and subsequently, participants were randomized into two groups: a total number of 100 participants filled out the eas and the rest (97 students) completed the ate scale form. the results of previous studies have suggested that variables such as age, gender, education, religion, and personality have influence on the attitude towards euthanasia (17). in order to ensure that two groups were well matched in terms of other variables, all of the participants were required to fill out 50 items of international personality item pool, 16 items of the hexaco openness, and 14 items of religious orientation scale-revised. persian version of all measures were used with previous iranian samples and proved to be highly valid (17-21). euthanasia attitude scale (eas) in 1979, tordella and neutens reported the development and initial reliability analysis of a euthanasia attitude scale. the original pool of the eas items was generated by a group of 150 college students and was edited into 74 statements. these statements were rated by a group of 19 judges who were expert in the area of thanatology. twenty one of the original items were selected as statistically representing the greatest consensus of the judges. a one-week test-retest analysis produced a reliability estimate of 0.84. rogers and his colleagues edited the eas items for gender-biased language. they reported an internal reliability of 0.85 and a positive correlation with the right to die scale (3, 6). as for the persian version which was consisted of 20 items, cronbach’s alpha in a sample of 233 students of university of tehran was 0.88 (17). the scoring method used in this study was similar to the original design. the scores for the 20-item ranged from 1 to 5, with 5 indicating strong support for euthanasia, 3 indicating neutral, and 1 indicat ing strong opposition to euthanasia. attitudes towards euthanasia scale (ate scale) wasserman and his colleagues designed this 10 item scale which was intended to measure attitude towards euthanasia in regards with different issues such as severity of pain, no recovery, patient’s request, and doctor’s authority. an internal consistency of 0.87 was reported. construct external consistency was established by correlating the scale with other predictors such as race and spirituality (5, 22). cronbach’s alpha for the persian version of this scale in a group of iranian students was 0.90 (18) and the scoring method used in this study was similar to the original design. the scores for the 10-item ranged from 1 to 5, with 5 indicating strong support for euthanasia, 3 indicating neutral, and 1 indicating strong opposition to euthanasia. international personality item pool (ipip) this well-validated 50-item inventory assess es the big five factors; namely, emotional stability (reversed neuroticism), extraversion, agreeable ness, conscientiousness, and openness to experi ence with 10 item per factor. internal consistencies ranged from very good to excellent, cronbach’s j med ethics hist med 2011, 4:9 naser aghababaei, hojjatollah farahani, javad hatami page 3 of 6 (page number not for citation purposes) alpha ranging was from 0.85 to 0.94 (23, 24). cronbach’s alpha for the persian version of this scale in a sample of 94 philosophy teachers and 397 philosophy students ranged between 0.50 and 1.70 (19). the scoring method used in this study was the same as the original design. the scores for the 50-item ranged from 1 to 5, with 5 indicating totally accordance of an item to one’s personality, 3 indicating neutral, and 1 indicating conflict of an item to one’s personality. the hexaco personality inventory-revised (hexaco-pi-r) the hexaco model of personality structure is an alternative framework based on six personali ty dimensions. considering our research and different aspects of it, and for brevity, only the 16 items of openness were used. this subscale had a cronbach’s alpha of 0.90 and a positive correlation of 0.68 with the ipip openness (25, 26). cronbach’s alpha for the persian version of this scale in a sample of 711 iranian students from five different universities in five different cities of iran was 0.88 (20). the scoring method used in this study was similar to the original design. the scores for the 16-item ranged from 1 to 5, with 5 indicat ing totally accordance of an item to one’s personal ity, 3 indicating neutral, and 1 indicating conflict of an item to one’s personality. religious orientation scale-revised (ros-r) this scale is a revision of the age-universal religious orientation scale, which is an updated version of allport and ross’s original measure. this 14-item scale consists of intrinsic, social extrinsic, and personal extrinsic items. internal consistency of its subscales in iran and the united states ranged between 0.62 and 0.84. positive correlation of this scale with muslim-christian religious orientation scales in iran and the united states can be supportive of its validity (21, 27). the scoring method used in this study was similar to the original design. the scores for the 14-item ranged from 1 to 5, with 5 indicating totally accordance of an item to one’s religiosity, 3 indicating neutral, and 1 indicating conflict of an item to one’s religiosity. for all the items in negative-worded statements, the scoring orders were reversed. after providing demographic information, participants completed research booklets that included the detailed questionnaires. for all questionnaires, a five-point likert-type scale was used. the cut-off point for determining euthanasia attitude in this study was set at <3 to account for the negative attitude towards euthanasia. all data were analyzed using spss software version 16. applied statistic methods and indices include mean, standard deviation, t-test, and pearson correlation coefficient. results table 1 shows that regarding the age, person ality and religiosity of the participants, there is no significant difference between two groups showing that two groups are matched in age, religion and personality (in addition to gender and education). however, the eas’s mean score (2.66±0.75) was significantly higher than that of the ate scale (2.01±0.91) (t= 5.42, p<0.01). respondents to the ate (82.5%) and eas scales (65%) respectively had a less than 3 point mean score. cronbach’s alphas for the eas and the ate scale were 0.88 and 0.90 respectively. table 2 demonstrates the inter-correlations (pearson correlation) of euthanasia attitude with personality and religiosity variables. euthanasia attitude negatively correlated with religiosity and conscientiousness, and positively correlated to psychoticism and openness. discussion this study, which aimed to compare two scales of assessment of the attitude towards euthanasia, showed significant differences between the results of them. mean score on the eas was significantly higher than that of the ate scale. this finding raises the issue of whether concepts or cases should be considered in order to assess attitude towards euthanasia. the results of our study demonstrated a significant difference in the results of the assessment of attitude towards euthanasia; and the intriguing finding was that if mean score of scales is used as the criteria for support or opposition to euthanasia, the two scores demonstrated a 17.5 percent difference. the negative relationship between religiosity and euthanasia attitude was in accordance with previous studies (2, 14, 17, 18, 22, 28-35). alt hough religious orientation has become the dominant paradigm in the study of religious motivation and of the psychological study of religiousness in general (36), such paradigm has hardly ever been applied in euthanasia studies. intrinsic orientation refers to a mature form of religious sentiment that serves as a master motive and guide for one’s way of life, while extrinsic orientation addresses the issue of immature faith that serves as a means of convenience for self serving social or psychological ends (37). the different relationships of religiosity subscales with euthanasia attitude might be of interest to euthana sia researchers as well as those who are interested in religion studies. we found that intrinsic religi osity has the strongest correlation with the negative attitude towards euthanasia. this could be a supporting evidence for allport’s theory. allport’s model suggests that the intrinsic dimension should j med ethics hist med 2011, 4:9 naser aghababaei, hojjatollah farahani, javad hatami page 4 of 6 (page number not for citation purposes) predict whether religious individuals will act congruently or incongruently with their religious principles (38). since most religions are against euthanasia (39), a stronger correlation between intrinsic religiosity and negative attitude towards euthanasia may be considered as being in congru ence with the allport’s model and theory. lester et al. (40) suggested that death-of-self actions (e.g. suicide) are correlated with psychoti cism, while death-of-others actions (e.g. abortion, euthanasia) are related to neuroticism and irrational thinking. they found that refusal of medical treatment as a moral issue was associated with lower neuroticism and irrationality scores while considering euthanasia as moral was associated with lower lie scale scores. we didn’t find any relationship between attitude towards euthanasia and emotional stability which is defined as reversed neuroticism. although euthanasia involves death of others, a positive relation between euthanasia attitude and psychoticism was demonstrated. this might be, according to lester et al (40), because of the argument that euthanasia can arouse thoughts of one’s own death. as saroglou’s (41, 42) meta-analytic review indicated, religiosity correlates with low psychoti cism (or high agreeableness and conscientious ness), while openness is negatively related to intrinsic-general religiosity. since religiosity strongly correlates with (negative) attitude towards euthanasia (17), it is understandable that attitude towards euthanasia was associated with religion related personality characteristics. despite its importance as being the first study to make a comparison between different euthanasia scales to our knowledge, the current study had several limitations. using a convenient small sample of female students can be considered as the major limitation of our study. although it might be suggested that the proportion of students favoring euthanasia in the current study was similar to that of different national studies, this can be explained by the fact that the youth generally tend to be more liberal and open minded. in fact, a study by horsfall et al (43) showed that positive attitude towards euthanasia is more common amongst students in comparison with the general population. therefore, it can be speculated that positive opinion towards euthanasia may be less common amongst iranian general population than what the findings of our study indicated. our results cannot be generalized to a wider society because of the local sampling of the study. future research on the topic should be carried out on more representative samples. we are still quite unaware of iran’s public opinion towards euthana sia and more research is needed to shed some light on the issue. only a few studies have been carried out in iran and the majority of them indicate that there is moderate to strong opposition to euthana sia. amongst them, two studies were limited to demographic characteristics such as age and gender, and demonstrated no significant correlation between euthanasia attitude and age and gender of the study samples which were consisted of 100 interns and 102 nurses (44, 45). another study conducted on 233 students of university of tehran demonstrated that euthanasia attitude was negative ly correlated with religiosity and agreeableness but showed no relation with age, gender, education, consequentialism and other personality factors (17). it can be suggested that a within-group design is a superior method for comparison of the results of two scales. therefore, using between-group design could be considered as another limitation of our study. in light of our findings, it can be suggested that the eas is more sensitive to individual characteristics. however, such conclu sion requires a within-group design and more research are warranted to explore it further. in conclusion, we would like to highlight the issue that was raised initially in this study: in order to assess attitude towards euthanasia (and other social issues), should we put emphasis on the concept or cases of euthanasia? should we define euthanasia or we should introduce a case of it (without specifically labeling it) to seek the opinion of the public? further study will hopefully shed some light on the issue. page 5 of 6 (page number not for citation purposes) j med ethics hist med 2011, 4:9 naser aghababaei, hojjatollah farahani, javad hatami table 1. comparison of the two groups variables ate scale group eas group t p mean sd mean sd age 21.80 3.88 21.56 1.86 0.53 0.59 personality factors extraversion 3.17 0.71 2.98 0.70 1.87 0.06 agreeableness 3.99 0.48 3.88 0.58 1.46 0.11 conscientiousness 3.56 0.64 3.52 0.72 0.44 0.65 emotional stability 2.95 0.65 2.99 0.66 0.37 0.71 openness to experience 3.65 0.45 3.53 0.58 1.55 0.12 psychoticism 7.56 0.88 7.40 1.05 1.12 0.26 hexaco openness 3.18 0.31 3.24 0.52 0.87 0.38 religious orientation intrinsic 3.40 0.67 3.27 0.75 1.34 0.18 social extrinsic 1.85 0.76 2.04 0.90 1.59 0.11 personal extrinsic 3.87 0.95 3.69 0.99 1.33 0.18 table 2. intercorrelations of euthanasia attitude with religiosity and personality variables variables ate scale eas religious orientation intrinsic -0.34** -0.53** social extrinsic -0.12 0.20* personal extrinsic -0.25* -0.32** personality emotional stability -0.10 0.14 agreeableness -0.08 -0.07 conscientiousness -0.17 -0.23* emotional stability 0.00 -0.12 openness to experience 0.05 0.02 psychoticism 0.17 0.20* hexaco openness 0.14 0.21* *p<0.05, ** p<0.01 page 6 of 6 (page number not for citation purposes) j med ethics hist med 2011, 4:9 naser aghababaei, hojjatollah farahani, javad hatami references 1. grassi l, magnani k, ercolani m. attitudes toward euthanasia and physician-assisted suicide among italian primary care physicians. j pain symp manag 1999; 17(3): 188-96. 2. cohen j, marcoux i, bilsen j, deboosere p, van der wal g, deliens l. european public acceptance of euthanasia: socio-demographic and cultural factors associated with the acceptance of euthanasia in 33 european countries. soc sci med 2006; 63: 743-56. 3. chong am, fok s. attitudes toward euthanasia in hong kong-a comparison between physicians and the general public. death stud 2005; 29: 29-54. 4. karadeniz g, yanikkerem e, pirincci e, erdem r, esen a, kitapcioglu g. turkish health professional’s attitude toward euthanasia. omega 2008; 57(1): 93-112. 5. wasserman j, clair jm, ritchey fj. a scale to assess attitudes toward euthanasia. omega 2005; 51(3): 229-37. 6. rogers jr. assessing right to die attitudes: a conceptually guided measurement model. j soc issues 1996; 52(2): 6384. 7. ramabele t. attitudes of the elderly towards euthanasia: a cross-cultural study. 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(in persian) journal of medical ethics and history of medicine original article analyzing the politico-moral foundations of the iran’s health system based on theories of justice forouzan akrami 1 , mahmoud abbasi 2 , abbas karimi 3 , akbar shahrivari 4 , reza majdzadeh 5 , alireza zali 6 * 1 phd by research candidate, medical ethics and law research center, shahid beheshti university of medical sciences, tehran, iran. 2 associate professor, medical ethics and law research center, shahid beheshti university of medical sciences, tehran, iran. 3 professor, faculty of law and political science, university of tehran, tehran, iran. 4 pharm d, medical ethics and law research center, shahid beheshti university of medical sciences, tehran, iran. 5 professor, community based participatory research center and knowledge utilization research center, tehran university of medical sciences, tehran, iran. 6 professor, functional neurosurgery research center, shohada tajrish neurosurgical center of excellence, shahid beheshti university of medical sciences, tehran, iran. corresponding author: alireza zali address: tajrish, functional neurosurgery research center, shohada tajrish neurosurgical center of excellence, shahid beheshti university of medical sciences, tehran, iran. email: dr_alirezazali@yahoo.com tel/ fax: + 98 21 22724214 received: 09 sep 2016 accepted: 12 mar 2017 published: 08 apr 2017 j med ethics hist med, 2017, 10:4 © 2017 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. abstract public health ethics is a field that covers both factual and ethical issues in health policy and science, and has positive obligations to improve the well-being of populations and reduce social inequalities. it is obvious that various philosophies and moral theories can differently shape the framework of public health ethics. for this reason, the present study reviewed theories of justice in order to analyze and criticize iran’s general health policies document, served in 14 articles in 2014. furthermore, it explored egalitarianism as the dominant theory in the political philosophy of the country’s health care system. according to recent theories of justice, however, health policies must address well-being and its basic dimensions such as health, reasoning, autonomy, and the role of the involved agencies and social institutions in order to achieve social justice beyond distributive justice. moreover, policy-making in the field of health and biomedical sciences based on islamic culture necessitates a theory of social justice in the light of theological ethics. educating people about their rights and duties, increasing their knowledge on individual agency, autonomy, and the role of the government, and empowering them will help achieve social justice. it is recommended to design and implement a strategic plan following each of these policies, based on the above-mentioned values and in collaboration with other sectors, to clarify the procedures in every case. keywords: politics, moral philosophy, public health, justice, iran mailto:dr_alirezazali@yahoo.com j med ethics hist med 10: 4, april, 2017 jmehm.tums.ac.ir forouzan akrami et al. page 2 of 10 introduction public health ethics (phe) is a relatively new field of applied ethics, and is linked to the ethical implications of activities aimed at maintaining and improving health among the population. phe covers both factual and ethical issues in health policy and health sciences (1). article 25 of the universal declaration of human rights explicitly recognizes the right to health. article 12 of the international covenant on civil and political rights emphasizes that governments should recognize everyone’s right to the highest degree of physical and mental health that is possible within each society. therefore, protecting public health (ph) should be the most important goal of governments. in most countries, the health care system is organized at the national level, which indicates the responsibility of the state. however, these systems suffer from various pathologies that affect their performance (2 , 3). ph has affirmative obligations to improve public well-being and reduce evident social inequalities. therefore, a phe framework should not only protect the citizens’ negative rights for not intervening, but also emphasize their positive rights (4, 5). several functional frameworks have been provided by ph professionals to facilitate policyand decisionmaking (6 8). any ethical framework has a background of moral theories or at least an ethical approach to justify the selected moral norms, and various moral philosophies and theories can differently shape these structures. for example in consequentialist theories, the policy or action that delivers the best outcome is considered morally right. in utilitarianism, which is one of the most popular frameworks and is widely used in health policy, the only value is to do the greatest good for the greatest number. on the contrary, in deontological theories, the agent’s acts must only comply with moral duties. phe is connected to overlapping spheres of political, social and moral philosophy. however, the health care system mainly requires a “public philosophy”, which would provide a moral foundation and set limits on ph laws, policies and practices, as well as on social institutions and organizations involved in ph activities (9). the primary moral justification in ph as an institution is social justice, and the focal points of moral necessities are the oppressed and subordinate groups. these include people whose well-being expectations including health are so limited that their life choices differ from those of others; or children whose prospects of welfare are so poor that they are permanently locked in the systematic deprivations of their early years (10). will kymilicka states: “political philosophy is a matter of moral argument, and moral argument is a matter of appeal to our considered convictions. in saying this, i am drawing on what i take to be the everyday view of moral and political argument, that is, we all have moral beliefs; these beliefs can be right or wrong, we have reasons for thinking they are either right or wrong, and these reasons and beliefs can be organized into systematic moral principles and theories of justice. a central aim of political philosophy, therefore, is to evaluate competing theories of justice to assess the strength and coherence of their arguments for the rightness of their views” (11). rajabi et al. in their study aimed to explain the principles and values of the health system to be utilized in iran’s health system reform plan of 2025. while emphasizing respect for human dignity and protection of human prosperity, they concluded that addressing phe challenges necessitates new perspectives on both individuals and the society and the relationship between them (12). designing an ethical framework for health policymaking first requires an analysis of the political philosophy of the country's health care system, since the approach to ph depends on the political philosophy of each country (13). therefore, this study aimed to explain the political philosophy of the health care system based on theories of justice. in this study, after an overview of these theories, we analyzed the general health policies (ghps), which have been codified by the leader of the islamic republic of iran in implementing paragraph i of article 110 of the constitution after consultation with the expediency council. method document analysis is a systematic approach for reviewing or evaluating texts. like other analytical methods in qualitative research, document analysis requires that data be examined and interpreted in order to extract meaning and insight, and develop empirical knowledge (14). in this document analysis, the ghps document was examined to explain the politico-moral foundations of the health care system based on theories of justice and to explore how the moral values were enfolded. additionally, for critical discussion, web of science (isi), pubmed, embase, and scopus databases were purposefully searched using the following keywords: “public health/ethics” [mesh terms] or “public policy/ethics” [mesh terms] not “research” [mesh terms] and “philosophy/ethics” [mesh terms]. theories of justice the libertarian justice theory influenced by philosophers like john locke and robert nozick, a libertarian theory of justice focuses on individual freedom, and thus on our duty to respect the freedom of others, and the duty of governments to protect the freedom of citizens – as their right – when they are at risk. this often means a “minimal state” to prevent or punish breaches of personal boundaries, including individual property j med ethics hist med 10: 4, april, 2017 jmehm.tums.ac.ir forouzan akrami et al. page 3 of 10 rights. in this view, health care is not a right, but people can voluntarily choose the charitable act and contribute in some way to distribute health care in a community. ph can be legitimate, especially if it focuses on protecting people against infectious diseases; a type of boundary violation, preferably to broader concepts of health promotion that is characteristic of contemporary public health (15). libertarians do not oppose to utilitarian and egalitarian distributive patterns, provided that they are chosen freely. any fair distribution can be justified in health care coverage, if and only if people have freely chosen it in the relevant groups. as a result, libertarians generally support those health care systems in which health care insurance is private and purchased voluntarily. in such systems, the investors have the property right in the health care of the insured, doctors have the freedom right and the society is not morally obligated to provide health care. the libertarian interpretation of justice is not based on addressing the citizens’ health needs or the general benefit, but rather on carrying out unrestricted fair activities (16). the utilitarian justice theory utilitarian theories of justice were formed by prominent figures such as jeremy bentham and john stuart mill. the ground conceptions of justice in the principle of utility require policies, actions or rules that produce the maximum benefit. justice, which involves the correlation of rights and duties, is not an independent decision, but rather a derivation of interest. within this framework, the duties and rights in fair health care are the presupposition of net profit foundation. health care and ph can be valuable at least to the extent that they produce net social benefit (15). most of the utilitarian social programs support ph and distribute basic health care among all citizens. nevertheless, rights such as health care – when based on maximizing the ultimate good – will find a fragile basis, because the benefits may change at any time. for example, it seems unfair that a society itself maximizes the ultimate good by eliminating the access of the weakest and the sickest population. therefore, utilitarian principles of justice seem to have very serious problems, but if their inclusion scope is strictly limited, they can play a major role in health policy-making (16). the communitarian justice theory the communitarian justice theory arises from several philosophical views similar to utilitarian theories and do not assign an independent importance to individual rights such as freedom. thus, the perception of health care and a just health system depends on the community perception of health in relation to other primary goods (15). communitarians have a pluralistic view on the principle of justice, believing that they are as varied as the diverse perceptions of good in different societies. the duty of people with respect to justice depends on the criteria in each community. communitarians emphasize both the duties of the society towards individuals and the duties of the individuals towards the community. some communitarians avoid using the language of justice and use one of unity and integrity that includes both the values related to individual obligations and the principles of social ethics based on the common beliefs of a group. justice concepts do not rise from the rational or natural principles outside the community, but from criteria that are shaped internally along with the political development of the society. communitarians believe that emphasis on the community and the common good in health care allocation policies is also evident (16). in this regard, daniel callahan says that “we need to ask what can best guide us towards a good society, rather than whether it is harmful or whether it violates the autonomy of the people” (17). the egalitarian justice theory egalitarian theories draw on old religious perspectives that believe all human beings should be treated as equals in certain respects because they are created equal (16), and this makes the foundations of human rights (18). no prevailing egalitarian theory has been exclusive of a distributive principle based on equal sharing of all primary goods by everyone. it is characteristic of the dominant egalitarian theories to identify basic equalities that allow for some inequalities (16), and many of them recognize the possible legitimacy of a two-layered system, with the minimum decent layer of health care (set by the deliberative democracy). john rawls’ theory of justice is the mildest, most important egalitarian theory that has challenged liberalism, utilitarianism and communitarianism. among those who have been influenced by john rawls, norman daniels argues that justice requires the elimination or reduction of obstacles that prevent fair equality of individuals’ opportunities, including health as a moral importance, to allow people to pursue a variety of objectives and programs of life depending on their talents and skills. this includes programs to compensate for the shortcomings of people such as health deprivation. daniels looks for a comprehensive plan for fair health care and investigates the role of social determinants of health such as education, environmental and behavioral factors, and the socioeconomic status of communities (16, 19). with the start of the 21 st century, some innovative ideas raised debates about justice in the field of biomedical ethics. although this article has been formed in response to rawls’s egalitarian theory, it is not entirely the same in fundamental terms. it is mainly influenced by the ethical theory of aristotle, especially the role and importance of human flourishing states that rely mostly on fulfillment and moral virtue. in the following section, some recent theories of justice will be discussed. j med ethics hist med 10: 4, april, 2017 jmehm.tums.ac.ir forouzan akrami et al. page 4 of 10 the capabilities theory this theory is based on the assumption that the opportunity to reach states of proper functioning and well-being is an object of value and moral importance, and thus capability reflects an individual’s autonomy in selecting one of several alternative lives. people’s quality of life is conditioned by what they are able to do, and a life well lived is one in which people perform and maintain their basic capabilities. this theory was first proposed by amartya sen, and developed in many ways related to biomedical ethics by martha nussbaum. the latter explored the philosophical concept of “frontiers of justice” to address equitable inclusion for persons with disabilities, the poor, and animals. the central idea is that the minimum level of social justice entails the availability of 10 core capabilities for all citizens (16), which means everyone should be able to: 1) lead a normal life without encountering premature death or a deteriorated state unworthy of living 2) have the benefit of physical health 3) enjoy bodily integrity, that is, the ability to live in freedom and have security against violence, sexual satisfaction and fertility choice 4) use the capacity of senses, imagination and thought 5) enjoy emotional attachment to people and other entities and experience a feeling of gratitude 6) apply practical reasoning and participate in serious reflections bearing on one’s life arrangements 7) feel organizational affiliation as the capability to lead a meaningful life in cooperation with a company or others 8) be free to exhibit concern or care for other species 9) play and enjoy creative activities 10) have control over one’s environment as an active citizen the well-being theory the capabilities theory focuses on abilities and opportunities as prerequisites for well-being, but more recent theories have focused on well-being itself. in other words, freedom of action, capabilities, the associated empowerment trainings and resources are considered the well-being equipment (16). powers and faden have formulated a framework for bioethics in ph and health policy by providing a non-distributive theory of justice that complements distributive justice and goes beyond it. they believe that questions about important inequalities can only be answered by examining all the social determinants that increasingly and mutually impact human well-being. according to powers and faden, justice is more than the principles of distribution (10, 16) and beyond the distributive share of each person, and is identically connected to the nature of the relationships between individuals. some topics of discussion in the area of justice both for individuals and for groups include: concerns about social stigma, disrespect, lack of organization and social functions for adequate protection of existing capacities to maintain social independence or autonomy (20). from this perspective, the aim of justice is to ensure an acceptable level of the six basic dimensions of well-being, including health, reasoning, selfdetermination, attachment, personal security and respect for all (16, 21). citizens of countries that lack a comprehensive and coherent system of health care finance and delivery are unfortunately deprived of health services in spite of spending high costs. it is the obligation of governments to promote both utility and justice in the society (16). for this reason, we will analyze the general health policies (ghps) of iran served at the national level based on the aforementioned theories. analysis and criticism of general health policies in iran as the first item of the iranian ghp, “beneficence and service delivery based on islamic human values, spirituality and moral virtues and their promotion in the community” have been emphasized. these issues are clearly linked to social justice, and whenever people are in the position to do good things or impose costs, they will need justice criteria (16). in the context of public health, justice is a core ethical consideration, but unfortunately a theory of islamic justice is presently lacking. in recent decades, significant advances have been made in the field of primary health care, academic education and research in iran. progress in biomedical research has been accompanied by significant activities in legislation, education and research in the field of bioethics (22). however, the first paragraph of the first policy highlights “evolution” in academic environments in accordance with islamic values, medical ethics and professional practice. this implies the poor desirability of the current situation in service provision and the need to reform the health care system based on islamic moral values. moreover, the second paragraph of this policy emphasizes the importance of educating people about their rights and social responsibilities, and utilization of the full capacity of health care environments for the promotion of islamic ethics and spirituality in the society. the second, fifth, and sixth policies of the ghps directly point to egalitarianism, equitable access and fair distribution of health care services based on people’s needs. these sections highlight access to health as a social right, the responsibility of the state to make it happen, and egalitarianism as the dominant theory in the political philosophy of the national health care system. for the purposes of accountability, realization of justice, and provision of desirable medical services, the seventh and eighth policies specify that health resources be managed through the health insurance system, and that services be delivered by both public and private sector service providers in accordance with the legal j med ethics hist med 10: 4, april, 2017 jmehm.tums.ac.ir forouzan akrami et al. page 5 of 10 provisions. the eighth policy further emphasizes the significance of the principle of justice and the importance of accountability, transparent informing, effectiveness, efficiency and productivity in the health care system in keeping with evidence-based ranking and the referral system. the third paragraph of the eighth policy concerns the protection and care of veterans and the disabled community as vulnerable members of the society, and concentrates on empowerment and the promotion of health among them. the third policy focuses on the importance of a healthy lifestyle, and the twelfth policy pertains to healthy nutrition based on traditional iranian medicine, while the fourth policy is dedicated exclusively to the quality and efficiency of services. the eleventh policy is related to “raising awareness, responsibility, empowerment, and active and structured participation of the individual, family and community to provide, maintain and improve health by using the capacity of institutions and cultural, educational and media organizations under the supervision of the ministry of health and medical education”. it is obvious that this is a move aimed at achieving social justice, and therefore cannot be placed under the supervision of the ministry of health and medical education alone. the ninth policy discusses measures including: fair distribution through qualitative and quantitative development of health insurance and its delivery to the public; complete coverage of the basic treatment needs of the people by providing insurance to the whole of the society and reducing the share of the insured in medical costs; and providing services beyond basic insurance through complementary private coverage within the framework of legal and transparent stipulations with an emphasis on high quality basic health services. moreover, paragraph 7 of the ninth policy proposes a number of supplemental mechanisms to ensure public health, for instance reforming the performance-based payment system, raising efficiency, creating fair income and positive motives for service providers, and special attention to health promotion and preventive activities in deprived areas. one problem associated with health related goods and services concerns determination of the precise limits of the right to health. an approach in this respect is equal access to health resources. from a minimalistic standpoint, this means public access to health care, which is in accordance with the idea of some libertarians regarding the right to public resources, although this view is untenable by the justice theories previously mentioned. for this reason, current prominent liberal societies have created significant progress in solving the challenges facing their health care system in connection with the access, affordability and quality of care. as an instance, the united states approved the act of affordable care (aca), and since its adoption, the total rate of the uninsured has decreased by 43%, from 16% in 2010 to 9.1% in 2015 (23). therefore, the aim of moderate egalitarianism may be defined as the right to minimum, decent health care, that is, public access to basic health care and related resources. the standard concept, however, requires a two-layered system as follows (16): 1. compulsory social coverage for basic health needs and common mishaps 2. voluntary private coverage for other health needs and demands the first layer addresses health needs through public access to basic services. this model of a pure protection to all indicates that social requirements can be limited, which necessitates the definition of basic and secondary health needs based on the social norms in each society (19). the tenth policy pertains to “sustainable financing in the health sector” and indicates the prioritization of public health by the state. the third paragraph of this policy discusses “imposing taxes on products and materials, as well as punishments on harmful health services”, which refers to the important role of ph law in its implementation and continuation. moreover, the fourth paragraph covers “paying subsidies to the health sector, targeting health subsidies and treatments aiming at justice and the promotion of health particularly in deprived areas, and providing dedicated help to poor people and lower income groups”. this latter point clearly emphasizes the fairness of needs-based distribution and fair financial contribution. the thirteenth and fourteenth policies imply the importance of the educational aspect of medical sciences in providing efficient local and national human resources in order to improve the overall health of the population (24). these policies also stress the strategic development of medical research with an innovation and planning system approach to achieve excellence in science, technology, and provision of medical services in the region and throughout the islamic world, in accordance with the country’s 20-year vision document and to complement the previous policies. discussion to a large extent, the principles of egalitarian justice, respect for everyone and treating all people as equals comply with the fair procedures doctrine in the distribution of primary goods and not only health care. in the second policy, reference to “realization of a comprehensive approach to health and a healthy society in all legislation and executive policies” is consistent with the approach to health in all polices. the implementation of this approach enables the state to establish an integrated act in response to the health needs and well-being of the people. this, together with the ultimate goal of reducing health inequalities, considers the effects of other policies and laws on health through the social determinants j med ethics hist med 10: 4, april, 2017 jmehm.tums.ac.ir forouzan akrami et al. page 6 of 10 of health (25), and will be realized when healthbased laws and policies are designed, planned and implemented in all areas (26). no dominant egalitarian theory that consists of a distributive principle has been based on equal sharing of all primary goods by everyone. according to daniels, allocation of health care resources should provide justice through fair equality of opportunities. this inspiring theory of rawls has broad implications in national policies of health care. based on this theory, each member of the society should have enough access – not necessarily maximum access – to a level of health care regardless of their assets and positions. the exact level of access depends on the available social resources and public processes for decision-making. daniels believes that the social institutions influencing the distribution of health care should be coordinated so as to allow each person to receive a fair share of the normal range of the opportunities available in the community to pursue the objectives and plans of his or her life (16, 19). according to the theories of “moral desert”, people get what they deserve: good people are rewarded and bad people are penalized (27). from the perspective of defenders of luck egalitarianism, paying higher premiums or taxes by people who have healthier choices is not fair when others may have had morally irresponsible behaviors (28, 29). they believe that discussions on social factors affecting health are untenable. such reasoning is applied to health services in relation to crimes or bans on the access of individuals or groups who choose unhealthy lifestyles. nevertheless, there are reasons for unhealthy behavior that are not mere choices (30). differences in choices and lifestyles can be caused by social conditions and inequalities (31). some characteristics are the consequence of the natural and social lottery, and many people do not have a fair chance to obtain or change them; hence, they cannot be a morally acceptable basis for discrimination in allocation of social resources. accordingly, people with disabilities should receive a higher level of health care to have a fair chance in life. they may not be entitled to health care services if they are responsible for their disability, but if they are not, the principle of fair opportunity requires that they receive services that help them to compensate for the negative effects of lotteries (16). in proposing such an approach, sen has presented an explicit critique of rawls’ “fair equality of opportunity”, arguing that such opportunities are brutal stories, since many options are the outcome of poverty, low literacy, racism, and other similar events that are determined at birth. he argues that the primary and main concern of justice must be something that people are really able to achieve, a situation that amartya sen calls “substantive freedom”. in the view of sen, this includes “the ability of a person to do good actions and reach valuable states of being” (32). if people’s abilities are restricted by the circumstances or a range of limited conditions, the society cannot be considered a just one (33). in this view, injustice can be evaluated by the current practices and policies of major social institutions within the community. such practices enable certain social groups to develop capabilities necessary to obtain a decent and reasonable life, find work or other living arrangements to support their family, and be employed in projects, activities and valuable social relationships. there are occasional conflicts between public interests and autonomy in policy debates of public health that can be resolved by concentrating on the difference between freedom and autonomy. the debates on the potential violation of the principle of autonomy need to refocus on the issue of whether people can make meaningful choices about what they can do in their lives. people may be free to buy a large bottle of carbonated drink, but we cannot be dragged into talking about this deviated way of respecting autonomy, nor should we think that making the purchase of extra-large harmful products difficult is an important step in improving the lives of people and creating a just society (34). although there is not a single theory of justice that is unanimously accepted, “social justice” is a common term in the field of public health these days (35). the recent theories of justice state that having freedom to choose healthy behavior is not enough, and the ability of individuals to reason and their autonomy to make healthy choices must be developed (16, 21). david r. buchanan argues that improving public health is better achievable by expanding people’s autonomy through promoting the concept of justice, which is the definition of human progress. according to recent theories of justice, the most important issue in ph is not limiting the autonomy of individuals, for example by restricting the access of minorities and the poor to fast food or sugary, carbonated drinks in the hope of their weight loss, but rather the promotion of autonomy among community members. in other words, autonomy is a core value in a just society in which conditions for fostering the abilities of reasoning and decisionmaking are provided (34). schröder-bäck et al. analyzed the health strategy of european union (eu) via its ethical scope and considered implications for future health policy-making. their study showed that the health strategy of european union is barely documented and discussed in scientific literature, and that no specific attention has been given to its value base. their analysis showed that the mentioned values are particularly focused on health care in general rather than on ph in particular. they also concluded a theory of well-being is needed on a more general level for effective policy-making. therefore, a moral theory is required to explain this and the place of health values in a comprehensive j med ethics hist med 10: 4, april, 2017 jmehm.tums.ac.ir forouzan akrami et al. page 7 of 10 and coherent policy approach (36). although the capabilities theory highlights the important considerations in the analysis of the relationship between agency and structure, according to the theory of well-being, the aim of justice should be to ensure an adequate level of basic welfare, including health, reasoning and autonomy for every person, and not only the capabilities and means to achieve it. in this doctrine the origin of value or obligation is not merely individual choices or exercising one’s intellectual capacity for choosing, but the process of “creativity through choosing” which is integrated in autonomy is considered a part of well-being. ph professionals need to pay attention to much stronger fields, both moral and practical, in advocating for health policies and programs rather than creating bans (34). a healthy lifestyle is influenced by both individual agency and social determinants of health, including structural factors and living conditions (31). recently, personalism has been proposed firstly in regard to human dignity and secondly because of the agency of individuals as social beings who construct the collective good through solidarity, and as the philosophical core of the health care system (2). the concept of lifestyle-related diseases and individual responsibilities for/toward health plays an important role in discussions about fair allocation of scarce health resources. looking into this issue from the perspective of solidarity emerged as a value in the context of a solidarity project in bioethics by nuffield council in 2011. barbara prainsack has analyzed the most important arguments in favor of using lifestyle choices as a benchmark in solidaritybased health policy-making to prioritize and classify access to health care services (30, 37, 38). still, arguments about crimes or prohibitions on the access of individuals or groups that choose unhealthy lifestyles are provided in treatment services. nevertheless, there are different unhealthy behaviors that might not be restricted to “mere choice”, so access to ph based on lifestyle choices is not an exclusively moral issue, and despite the arguments presented to this effect, unhealthy behavior is not a breach of solidarity in itself (30). recent studies have explained the role of moral virtues in ph (39 41). they demonstrate that for the past several decades, the concept of “structure” in moral theology has almost exclusively focused on the structure of the society with regard to the need to change. the structures that have continued unfair positions and created systematic barriers for human development are classified as “structures of sin” and have therefore been the object of social and theological criticism. ph professionals and health policy-makers are attempting to create new structures (i.e. law, policy and environment) that have a positive impact on the lives of individuals and communities. such social structures are formed by individual characteristics and virtues as units of fundamental value that form each person’s habits and behaviors. according to michael d. rozier, “structure is only one part of a larger system of our behavior” (40). we have the disposition rooted in our personality and we want to cultivate it. we identify the habitual behaviors that are transformative, and adopt social norms that encourage the behavior. therefore, we build the social structures that promote social norms and virtues. in this manner, the internalized virtues of moral agents continue to spread across the community and finally to structures that shape the society and agents (40). the constitution determines the special powers of the federal government and limits its authority to protect freedom (42). in other words, the constitution of a country provides a framework for the localization of global treaties including the international declaration of human rights. although the state has the authority to act for the common good, it should also apply the internal power of the limits imposed by the constitution (21). the charter of fundamental rights of the european union has been developed in accordance with the common commitments between international and national laws of the european union in line with the citizen’s rights of member states, including the right to health care (43). in iran, the constitution, the 20-year vision document, and the comprehensive scientific map of health are among the reference documents that have presented the guidelines for involved institutions. the first step towards awareness of a law that can change people’s lives is legal literacy. legal literacy programs educate community members, patients and health care providers about their national and local laws and their rights, and this knowledge enables them to utilize these rights and seek support for specific health needs. some objectives of such programs include: increasing awareness and capacity building, training educators, education and community empowerment, and encouraging law students to work for social justice and solidarity (44). these goals are all considered as moral norms in ph and health policy-making (45). conclusion given the centrality of the principle of justice in public health, in this study we analyzed ghps issued at the national level in terms of the theory of justice. the findings point to egalitarianism as the dominant theory in political philosophy in the country’s health care system. the first policy on the list focuses on beneficence and providing health services based on humanistic/islamic culture and values and their institutionalization in the community without mentioning the fair procedures. although decision and policy-making in the field of bioethics has no justification in muslim societies without paying attention to the islamic culture, justice principles are j med ethics hist med 10: 4, april, 2017 jmehm.tums.ac.ir forouzan akrami et al. page 8 of 10 required in providing goods. the second, fifth, and sixth policies of the 14-item list of ghps directly point to egalitarianism, equitable access of people and fair distribution of health care services based on need. nevertheless, since “social justice” adequately supplies well-being dimensions including health beyond distributive justice, the distinct areas of justice are rejected. it is possible, however, to talk about justice in the ph and health policy-making without referring to the construction of other public policies and social structures. these policies must therefore address something beyond well-being and its basic dimensions such as health, reasoning and autonomy, or the role of agencies and involved social institutions in order to achieve social justice. making people aware about their rights and responsibilities, as well as increasing their knowledge and empowerment, implies the role of individuals’ agency and autonomy in choosing their lifestyle, in addition to the role of governments in achieving social justice. finally, for the institutionalization of humanistic/islamic values in the community, public health structures should aim to promote healthy behaviors. moreover, for the purpose of policy-making in the field of health and biomedical sciences in islamic communities based on islamic culture, a theory of social justice in the light of theological ethics is essential. community participation requires transparency, commitment and responsiveness of health care providers, and solidarity is a core value based on moral responsibility and virtues that support and sustain ph policies, programs and interventions. therefore, it is recommended to design and implement a strategic “how to” plan following each of these policies based on the above-mentioned values and in collaboration with other sectors. j med ethics hist med 10: 4, april, 2017 jmehm.tums.ac.ir forouzan akrami et al. page 9 of 10 references 1. dawson a. public health ethics. usa: cambridge university press; 2011. 2. bielecki a, nieszporska s. the proposal of philosophical basis of the health care system. med health care philos. 2017; 20(1):1-13. 3. bielecki a, stocki r. systems theory approach to the health care organization on national level. cybern syst 2010;41(7):489-507. 4. jonsen a, seigler m, winsladewj. clinical ethics: a 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(accessed on: 2012) 45. den exter a. international health law: solidarity and justice in health care. netherlands: maklu pub; 2008. ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ 1 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e © 2019 medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. original article volume 12 number 9 august 2019 perspectives of hinduism and zoroastrianism on abortion: a comparative study between two pro-life ancient sisters *corresponding author kiarash aramesh 164 cooper hall, 230 scotland road, edinboro, pa 16444, usa. tel: +1 (814) 732 2147 email: karamesh@edinboro.edu received: 4 dec 2018 accepted: 3 june 2019 published: 5 august 2019 citation to this article: aramesh k. perspectives of hinduism and zoroastrianism on abortion: a comparative study between two pro-life ancient sisters. j med ethics hist med. 2019; 12: 9. kiarash aramesh* assistant professor, the james f. drane bioethics institute, edinboro university of pennsylvania, edinboro, pennsylvania, usa; department of biology and health sciences, college of science and health professions, edinboro university of pennsylvania, edinboro, pennsylvania, usa. abstract hinduism and zoroastrianism have strong historical bonds and share similar value-systems. as an instance, both of these religions are pro-life. abortion has been explicitly mentioned in zoroastrian holy scriptures including avesta, shayastnashayast and arda viraf nameh. according to zoroastrian moral teachings, abortion is evil for two reasons: killing an innocent and intrinsically good person, and the contamination caused by the dead body (nashu). in hinduism, the key concepts involving moral deliberations on abortion are ahimsa, karma and reincarnation. accordingly, abortion deliberately disrupts the process of reincarnation, and killing an innocent human being is not only in contrast with the concept of ahimsa, but also places a serious karmic burden on its agent. the most noteworthy similarity between zoroastrianism and hinduism is their pro-life approach. the concept of asha in zoroastrianism is like the concept of dharma in hinduism, referring to a superior law of the universe and the bright path of life for the believers. in terms of differences, zoroastrianism is a religion boasting a god, a prophet, and a holy book, while hinduism lacks all these features. instead of reincarnation and rebirth, zoroastrianism, like abrahamic religions, believes in the afterlife. also, in contrast with the concept of karma, in zoroastrianism, ahura mazda can either punish or forgive sins. keywords: zoroastrianism; hinduism; abortion; religious bioethics; pro-life perspectives of hinduism and zoroastrianism on abortion: a comparative … 2 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 9 august 2019 introduction in the history of human civilization, religions have always been major sources of values with huge impacts on the life decisions of their followers. originating in the dawn of human civilization, zoroastrianism and hinduism are two ancient traditions/religions that have adopted a pro-life approach with an emphasis on reverence for life. although these two sister religions are not compatible in terms of the number of followers (see below), their approaches and perspectives are important and influential in the life decisions of countless people and families around the world. abortion is one of the first topics that appeared in the texts and scriptures related to medical ethics from the early days of this field in ancient times, and still is one of the most debated and divisive issues in the field of bioethics. followers of religions always try to resolve issues such as abortion according to their religion and make their own and their families’ life decisions based on their religious normative approaches. zoroastrianism and hinduism are two ancient inter-related traditions/religions with strong historical bonds that have developed and taken shape in neighboring countries and societies. studying the similarities and differences between these two religious traditions with regard to an important liferelated issue shows the divergent paths of traditions and religions that have the same (or very similar) origins, but have developed in different societies and locations (1). this paper is the result of a library-based comparative study that has assessed the perspectives of these two religious traditions toward abortion. the aim of this paper is to sketch and compare the perspectives of zoroastrianism and hinduism on abortion in the light of the unique specifics and characteristics of these two religious traditions, their moral teachings, and their bioethical approaches. for this purpose, these perspectives must be explained by exploring the main sources of zoroastrian and hindu bioethics. these sources may either pertain to the theoretical/conceptual teachings of these two religious traditions, or their practical approaches in the real world. by paying attention to the very pro-life nature of these two religious traditions one can clearly see that despite some major differences in the bases of their moral thoughts, both oppose abortion except for certain cases under very distinct conditions. two pro-life traditions and a life issue zoroastrianism and hinduism both originated among aryans after their migration to the middle east and south asia. although the theory of the indo-aryan migration has also been the subject of scholarly criticism, the similarities and the existence of many common features between the vedic and avestan texts indicate a strong ancient interconnection (2). while these two religious traditions had been interconnected before and at the time of the great migration, they took separate paths after the settlement of their followers in different geographic areas. regardless of the aramesh k. 3 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 9 august 2019 causes of this divergence, nowadays there are a lot of differences between these two religious traditions in addition to their original similarities. 1.zoroastrianism zoroastrianism is an ancient persian religion that was the official religion of the persian empire from 600 bce to 650 ce (3). estimations on the lifetime of the prophet of this religion, zoroaster or zarathustra (zartosht in current persian), vary between 8000 and 700 bce. however, moubed dr. jahangir ashidari argues that according to historical facts and events, the most realistic estimate of the year of his birth may be 1768 bce (4). zoroaster was born in the present-day azerbaijan province in iran. he moved to khorasan and the city of balkh where he declared his prophet hood, and was successful in establishing a new religion. the king of balkh was among his followers at that time (4). the most prominent source of zoroastrian moral thoughts is the religion’s holy book named avesta (5). only a small part of the current avesta is attributed to zoroaster himself, as a scripture he brought and left among his people. this part is named gatha and consists of mystical hymns and no concrete jurisprudential or ethical debates (6:155-205). the other parts of avesta are as follow: yasna: this is the oldest and most important part of avesta, and includes gatha. it has been argued that this part of avesta has been compiled at the same time as rigveda (see the section on hinduism below) and there are linguistic similarities between the two (5). yashtha: this part of avesta is mostly poetic and includes verses of worship to ahura mazda and amshaspandan (see below). yashtha consists of poems and epics, and does not include moral or jurisprudential elements or teachings (5). visparad: visparad means lords and leaders. this part of avesta includes cosmological and ontological teachings. it also contains general moral wisdom for people, describing the best behavioral models for men and women (6). vandidad: this is the jurisprudential part of avesta. it was compiled centuries after the death of zoroaster and mostly explains how zoroastrian clergy thought or acted in issuing jurisprudential decrees. vandidad is partly related to medical issues such as abortion (5) (see below). khordeh avesta: in 400 ce, moubed azarbad mehraspand compiled this part of avesta to teach zoroastrian rituals to people. at that time, zoroastrianism was the official religion of the sassanids, who were the last dynasty before islam and ruled over the persian empire for more than 200 years (5). in addition to the vandidad part of avesta, there are other holy scriptures like arda viraf nameh and shayast-nashayast that are rich in ethical and jurisprudential teachings. these have been compiled in the centuries after the lifetime of zoroaster, mostly during the dominance and prevalence of zoroastrianism in the persian empire, from perspectives of hinduism and zoroastrianism on abortion: a comparative … 4 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 9 august 2019 about the 5th century bce to the 7th century ce (7). through the seventh and eighth centuries ce, persia gradually joined the muslim world and the dominance of zoroastrianism ended. nevertheless, the cultural influence of this religion has persisted until contemporary times (8). nowadays, the followers of zoroastrianism mostly live in iran, india (the parsis) and western countries. estimations of the present population of zoroastrians worldwide differ between 145,000 and 2.6 million (9). beyond the community of its formal believers, the current and historical influences of zoroastrianism on the iranian culture and even the iranian version of shiite islam have been significant. it has been argued that the iranian/persian culture is a mixture of three different heritages: the islamic/shiite religion/culture, the ancient persian/zoroastrian culture, and the impact of the western/modern culture in recent centuries (10). some foundational features of zoroastrianism that are very important in understanding the spirit of this religion and its bioethical perspectives are as follow: monism vs. dualism zoroastrianism is a monotheistic religion. the dualism of ahura mazda and ahriman in the zoroastrian cosmology has been translated into a dualistic view in theological and moral perspectives (4). therefore, zoroastrian morality is largely based on a type of dualism that believes in the timeless and everlasting combat between good (ahura mazda/sepand minu/ashuns) and evil (ahriman/angra minu/doruj). it is noteworthy that zoroastrianism in its dualistic moral view is more similar to abrahamic religions than to hinduism and other asian religions (4). according to the zoroastrian dualistic view, ahura mazda created all the good in the universe, and ahriman created all the evil (8). human beings were also the creation of ahura mazda, and are therefore considered intrinsically good. however, they have the ability and autonomy to choose between good, which is in concordance with their nature, and evil, which is suggested and encouraged by ahriman. the former follows asha as the divine rule of existence and are called the ashuns, while the latter who choose evil (doruj) are named the dorvands (followers of doruj/evil/lie) (11). according to the aforementioned beliefs and perspective, which consider every unborn human being as a creature of and a future soldier for ahura mazda, zoroastrianism is a pro-life religion. some of the newer parts of avesta explain punishments and difficult steps for purgation of a person who has committed abortion (7). amshaspandan and asha before the time of zoroaster, the aryans, including the group that moved to india and are called hindus, used to worship multiple gods and goddesses. zoroaster introduced a single god named ahura mazda, and the previous aryan gods were then revived as the various reflections or faculties of that single god; these were named the amshaspandan, and were inseparable from ahura mazda. amshaspand means “the immortal pure” and amshaspandan is the plural form of amshaspand. this word is aramesh k. 5 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 9 august 2019 constituted of two parts: amesha and sepanta. amesha means immortal and indestructible, and it also specifies everlasting and beneficent entities such as the four elements, the sun, and houm (healing plant). sepanta means generous, merciful, creator and pure (4). according to zoroastrian teachings, the amshaspandan are as follow: asha: this is a very important concept in zoroastrianism and is rather similar to the concept of dharma in hinduism (4). asha means the eternal law, righteousness, and the unchanging rules of the universe and humanity. people who follow asha and believe in it as the divine rule of existence are the ashuns, while others who choose evil (doruj) are the dorvands (11). vahumana: good behavior, character, and intent. xashtra: god’s city, god’s power, and god’s faculty. armeity: love, devotion, and purity. heorutat: growth, development, and happiness. amortat: immortality, and indestructibility (4). nashu: being clean and pure is very important in zoroastrian teachings and rituals (3). nashu is uncleanliness or a demon, mainly attributed to dead bodies (3). any person contaminated with nashu should be cleaned through a set of sophisticated rituals including being washed with a liquid prepared from cow’s urine (3). zoroastrians do not bury the bodies of the dead because they believe that this practice contaminates the soil. instead, they leave corpses in places named dakhma to be eaten by wild animals and degraded by natural forces (3). since an aborted fetus is a dead body, abortion is considered to contaminate the mother’s body with nashu, which is a great sin (see below for further discussion) (7). 2.hinduism claimed to be the oldest living religion in the world, hinduism is a huge network of concepts, beliefs and rituals initiated more than two thousand years ago in ancient india. today, hinduism has about 900 million followers all around the world. most hindus live in india and nepal, but they also shape large populations in other asian countries like cambodia, thailand, burma and indonesia. in addition, in developed countries like the united states and the united kingdom, hindus are among sizeable minorities. spiritual teachings of hinduism and its sages and spiritual masters have had a great influence on western cultures over the recent decades. hindu spirituality in many direct and indirect forms has changed the culture, spirituality and lifestyle in western societies. as an example, one can mention yoga, which originated in hindu traditions, and has become very popular in western countries in the past century. it is interesting to explore the origin of the word “hindu”. as a huge cultural network, hinduism was born in ancient india, but the name “hindu” was acquired in the medieval perspectives of hinduism and zoroastrianism on abortion: a comparative … 6 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 9 august 2019 centuries to differentiate the religion from others such as islam (12). as a matter of fact, the word “hindu” comes from persian literature. persian geographers coined the name “hindu” for people who lived beyond the river indus (sindhu) (13). addition of the suffix “-ism” is a legacy of british colonialism in the 19th century. in ancient india, hinduism was traditionally called “sanatana dharma”, which connotes the most central concept in this tradition, but cannot be fully translated into english. however, some have chosen “eternal law” as an equivalent. it is difficult, if not impossible, to try to find a set of essentials for all the sects, groups and denominations within the circle of hinduism. one cannot specify a concept, belief, ritual or other element as the common or defining feature of this religion. in fact, features like reverence for vedas (the ancient scripture of hinduism), believing in a system of values named dharma, and even belonging to the indian nation have been mentioned as unifying features of hinduism, but none is common among all hindus. therefore, hinduism can be understood as a network of inter-related ideas without a single unifying feature. in fact, instead of one or a few essential common and allembracing features, one can speak about a wide network with a series of overlapping similarities reminiscent of “family resemblance” as explicated by ludwig wittgenstein for defining other phenomena such as art (14). some scholars argue, however, that the concept of family resemblance cannot solve the problem of lack of common features in the search for hindu moral principles. although the above-mentioned “family resemblance” means that no single unifying essential feature can be found for hinduism, some major characteristics can be identified, which are 1) common among most sects and branches of hinduism, and 2) essential and representative of the nature and main directions, teachings, key concepts, and values of this tradition. a non-inclusive list of these characteristics is presented below. unity in the midst of plurality one characteristic of hinduism is the existence of numerous forms of supreme beings, as can be seen in the enormous number of deities. shiva, shakti, vishnu, ganapati, surya, and subrahmanya are the deities worshiped by different sects of hinduism, but can be considered as different manifestations of a single supreme being. this interpretation of the hindu tradition, which makes it similar to monotheistic religions, is compatible with a famous verse of rigveda: “reality is one; sages call it by different names”; or this verse of bhagvad gita: “even those who are devoted to other gods and worship them in full faith, even they, o kaunteya, worship none but me” . this plurality is not confined to the deities. for instance, hinduism does not have a single founder, but seems to have been created and formed by accumulation of teachings and revelations of numerous sages, gurus and spiritual masters in ancient india (15). this characteristic provides hinduism with an inimitable flexibility and respect for plurality and diversity, which (alongside other qualities like the central concept of aramesh k. 7 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 9 august 2019 non-violence, ahimsa) were very important in the history of this religion and that of india. for example, one can mention the historical acceptance of jewish and zoroastrian immigrants whose lands had been invaded by romans and muslim arabs respectively. another case in point is the specifics of the democracy founded by mahatma gandhi in this huge subcontinent with such a unique variety in cultures, religions, and ways of life. the concept of dharma dharma holds the human community and the entire world together. as explained above, this concept is very similar to the concept of asha in zoroastrianism. in hinduism, dharma illuminates humans’ responsibilities and way of life. as mentioned above, in the ancient indian subcontinent, the followers of hinduism called their religion/tradition sanatana dharma in which the word sanatana means eternal (15). also, in zoroastrianism, the people who are true followers of zoroaster are called ashun. therefore, it seems that attributing followers to the eternal law is a common concept in both zoroastrianism and hinduism. concepts of karma, samsara, and reincarnation karma is one of the most important concepts in hindu ethics and morality. this concept denotes that a law of cause and effect rules the world of human deeds, both mentally and physically. each action produces its own reaction in the world. accordingly, a good action has a good reaction for the human agent in his/her current life or next lives, while a bad action will certainly bring about bad consequences, which, again, can take place in the current or subsequent lives of the human agent. this continuous cycle of action, reaction, birth, death and rebirth is called samsara. this cycle is not endless. one can break the cycle of samsara by good deeds that lead to salvation and getting out of the cycle. this salvation, called muksha (or nirvana in buddhism and jainism), is the ultimate goal of life. therefore, the final purpose of hindu ethics is salvation that is manifested in breaking the cycle of samsara and entering the eternal salvation, sometimes named muksha (15). there are serious controversies among scholars on the existence of a hindu bioethics. like other ancient civilizations, the indian subcontinent had its own medicine and healing tradition called ayurveda (the science of life), which was a sort of humoral medicine (16). the existence of this medicine and its rich literature, mixed with hindu teachings and thoughts about humanity and morality, led some scholars to try to derive from it a kind of hindu biomedical ethics. for example, the ancient hindu stories about gods with human bodies and animal heads were used to conclude the permissibility of xenotransplantation in hindu bioethics (13). some scholars, however, do not agree with this method of constructing hindu bioethics (17). they argue that the mere existence of these traditional schools of medicine in the mostly hindu ancient indian subcontinent does not imply that their literature mirrors hindu bioethics (13). perspectives of hinduism and zoroastrianism on abortion: a comparative … 8 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 9 august 2019 the key point in this regard is that there is no consensus among hindus on all of the concepts and principles attributed to this religion. this vast diversity, as mentioned above, is one of the most important characteristics of hinduism. this characteristic reflects itself in hindu ethics, applied ethics, and bioethics (13). the main question is, how can all these sects and branches of hinduism agree upon a set of principles for applied ethics, since they cover such a diverse variety of beliefs but have no common feature (such as a prophet or a holy book, as is the case with christianity, islam, or buddhism)? therefore, the existence of a hindu bioethics with a distinct set of principles has been a subject of controversy and debate. two kinds of efforts, however, have been made to solve this problem: 1. some scholars have pointed out common concepts, like karma, as the core and unifying concept of hinduism and hindu ethics. by doing so, however, they have broadened the scope of hinduism in a way that even buddhism and jainism can be considered some sort of hinduism. it is obvious that this is too wide-ranging to serve the purpose (17). 2. some other scholars have tried to choose just one sect or group within the wide spectrum of hinduism, and described hindu ethics based only on the values and beliefs of that sect or group. they have been successful in finding a set of principles, but the results cannot be called “hindu bioethics” as they are too narrow in range (13). the aforementioned endeavors, however, show a very historically obvious fact: that the impossibility of attributing a set of common and all-encompassing principles and values to hindu morality and applied ethics does not mean it is impossible to speak about hindu bioethics. three main categories of sources can be used to delineate the content of hindu bioethics, including its values, principles, teachings, and judgments. these categories are as follow: 1every system or set of values, moral principles and ethical deliberations that finds its roots in the hindu religion/tradition can be considered and named hindu ethics, regardless of how many hindu sects and groups it is shared among. when it comes to value-judgments about medicine, healthcare and life sciences, these principles definitely shape hindu bioethics. by the same token, we can reach a set of principles, concepts and values that are not all-encompassing and unifying, but still characterize this very brand of religious bioethics. 2ayurveda and other branches of indian traditional medicine have been used as a rich source of hindu reflections on human life, death, suffering and so on. ayurvedic classical texts like caraka samhita and sustuta samhita are among the sources of hindu reflections about human body and self that have major implications for bioethics (16). 3deliberations and reflections of hindu scholars on different sorts of bioethical issues provide another main source for delineation hindu bioethics. hindu scholars, sages and spiritual masters have discussed issues like abortion, futile treatment, organ aramesh k. 9 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 9 august 2019 transplantation, contraception and mercy killing. what they have written, taught or told are a rich source for studying hindu bioethics. also, one can induct methods of hindu bioethics by observing the ways in which hindus have approached the above issues and reached judgments and conclusions about them. in their bioethical deliberations, hindu scholars appeal to hindu concepts like karma, dharma (as described above), ahimsa (non-violence) and respect for life and nature. they also appeal to classic texts and scriptures of the religion/tradition from the oldest existing ones, namely vedas, to other essential ones like upanishadha or bhagvad gita. one example of such references to classical scripture is described above on the issue of xenotransplantation (17). hindu bioethics should be seen as a lived experience. from ancient “vedic healers” to modern healthcare professionals, numerous generations of physicians and clinical practitioners in the indian subcontinent have sought the values and principles governing their practice in one of the oldest and richest religions and traditions in the world, that is, hinduism. the spirit of the subcontinent shaped and determined the nature of this value system throughout its long history. this indian spirit is what gives the hindu bioethics a sort of unity in the midst of such vast and wide diversity. hinduism has its own perspective on fundamental aspects of human life. according to this perspective, the moral energy is preserved in the form of karma, and death is not the opposite of life, but is the opposite of birth. this characteristic makes hinduism different from abrahamic religions in which the will of god determines the consequences of good or bad deeds, rather than a natural rule like karma (14). in hinduism, the ultimate purpose of human beings is liberation from the circle of birth, death and rebirth, instead of entering heaven as is the case in abrahamic religions (15). obviously, none of the aforementioned features is unique to and common among all the sects of hinduism. altogether, however, these features are the different surfaces of an underlying spirit: the spirit of hinduism, which is the spirit of the indian subcontinent. this spirit has been the source of inspiration for successive generations of sages, gurus and spiritual masters. the reverence for life and a strong tradition of non-violence (ahimsa) has shaped the perspectives of hindu bioethicists towards key bioethical issues like abortion, euthanasia and brain death (15). virtue ethics also exists in some hindu ethical teachings. this approach to ethics focuses mainly on the moral agent instead of the act itself or its consequences. accordingly, going through a process of self-purification results in achieving a moral character that always chooses to perform the ethically right deeds (18). at the end, the practical results of this type of virtue ethics are somehow different from those of its counterparts in the west or the middle east. this difference is rooted in the spirit of hinduism and the indian perspectives of hinduism and zoroastrianism on abortion: a comparative … 10 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 9 august 2019 subcontinent, and has a great impact on the moral character of the virtuous person. in sum, one can conclude that despite the diversity, which is one of the main characteristics of hinduism, it is possible to delineate some major concepts that shape the infrastructures of morality in this religion/tradition. in the same way, one can sketch the principal values and directions of hindu bioethics. in addition, the present study has pointed out three main sources for bioethical endeavors within the hindu tradition/religion: value-judgments and moral deliberations rooted in and performed within the hindu tradition textbooks and the heritage of ancient hindu medicine, including ayurveda reflections and deliberations made by hindu scholars on bioethical issues that have accumulated throughout a long history, including the modern era hindu bioethics can be sought and learned as the collective lived experiences of hindus on traditional and modern issues that are of biomedical nature. these experiences, which have been accumulated collectively throughout the indian subcontinent and have produced a huge body of literature, are the very nature and unifying umbrella that cover a long history of ethical and moral endeavors of a vast array of sects, branches and groups within the old religion/tradition of hinduism. the importance of the issue of abortion abortion is the intentional termination of the life of an unborn human embryo or fetus. this act is forbidden and considered as inherently evil in all major religious traditions of the world. in the modern era, however, the situation has changed. many factors contributed to bringing abortion to the top tier of the most heated ethical debates among the general public and scholars, and making some moral and religious thinkers and authorities rethink and reconsider the absolute evilness of abortion, at least its indirect forms. the issue of population growth in a number of societies has caused some policy-makers to see abortion as a means for population control and prevention of unwanted and unplanned births. the largest hindu population in the world lives in the indian subcontinent, the birthplace of hinduism (12). in addition, hinduism reflects the very spirit of the subcontinent. therefore, when speaking about abortion in hinduism, it is important to take a look at the realities of its geographical setting. according to the indian law, abortion is permitted until the twentieth week of pregnancy, only for medical and a very limited number of social reasons. one of the social reasons for a massive number of abortions in india is the gender of the fetus. when prenatal sex determination by ultrasound became available, many families killed their unborn daughters to get rid of the social and economic burdens of having a daughter and sometimes hoping to aramesh k. 11 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 9 august 2019 have baby boys in the next possible pregnancies. the selective abortion of female fetuses has increased in india over the past few decades. the 2011 census showed 7.1 million fewer girls than boys aged younger than seven, which showed an increase compared to the 6 million in 2001 and 4.2 million in 1991. the sex ratio in this age group is now 915 girls to 1,000 boys, the lowest since such records began to appear in india in 1961. parents have little problem with their first child being a girl, but want their second to be a boy. in these families, the gender ratio for second births has fallen from 906 girls per 1,000 boys in 1990 to 836 in 2005, implying that an estimated 3.1 to 6 million female fetuses have been aborted in the past decade. it has even been claimed that approximately eight million female fetuses may have been aborted in the past decade, which has been called a “national shame”. similarities abortion has been explicitly mentioned in the zoroastrian holy scriptures including avesta, shayast-nashayast and arda viraf nameh. in addition to regarding abortion as evil and forbidding it, these books prescribe some brutal punishments for women who commit abortion in the afterlife (7). in addition to condemning abortion in the holy scriptures, zoroastrianism provides moral reasoning, according to its own system of beliefs, for regarding abortion as evil. according to the zoroastrian moral teachings, abortion is evil for two reasons: killing an innocent and intrinsically good person, and the contamination caused by the dead body (nashu) (7). on the other hand, as described above, the main sources of hindu bioethics, which are its concepts and traditions, shape its approaches to ethical issues at the margins of life, including abortion. when it comes to the abortion debate, the principal concepts involving moral deliberations are ahimsa, karma, and reincarnation. accordingly, abortion deliberately disrupts the process of reincarnation and kills an innocent human being; therefore, it is in contrast with the concept of ahimsa and imposes serious karmic burdens on its agent. in addition, in major resources of hinduism, abortion has been strongly condemned, which confirms the pro-life approach of this religion/tradition towards abortion. according to hindu bioethics, abortion is allowed only in cases where it is necessary for saving the life of the mother. the perspective of hinduism is a very pro-life one, emphasizing ahimsa and its intrinsic reverence for life. it should be mentioned that in addition to the similarities explained below, there are others in minor aspects such as rituals. for example, considering the cow as a sacred animal and using its urine for cleaning the body after abortion is common practice in both traditions/religions. dharma vs. asha the concept of asha in zoroastrianism is similar to the concept of dharma in hinduism. both asha and dharma refer to a superior law of the universe and the bright perspectives of hinduism and zoroastrianism on abortion: a comparative … 12 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 9 august 2019 path of life, which should be adopted by the believers. in the indian subcontinent, before their historical encounter with other religions and traditions, the followers of hinduism called their religion/tradition sanatana dharma. the word sanatana means eternal (15). also, in zoroastrianism, the true followers of zoroaster are called ashun. therefore, it seems that attributing followers to the eternal law is a common concept between zoroastrianism and hinduism. the approaches of these two religions to moral issues like abortion are consistent with this ontological view of the universe. the entire universe is created and ruled in accordance with dharma/asha, and all the people should follow these eternal rules. morality ultimately means consistency and accordance with these higher entities. in both religions, abortion is a violation of the higher and sacred law of the universe and existence. therefore, abortion, like murder, robbery and other kinds of immoral behaviors, is wrong and unacceptable. reverence for life the most noteworthy similarity between zoroastrianism and hinduism is their prolife approaches. in both religions/traditions, abortion is considered murder and is forbidden. ayurveda and other branches of indian traditional medicine have been used as a rich source of hindu reflections on human life, death, suffering and so on (15). deliberations and reflections of hindu scholars on different sorts of bioethical issues provide another main source for delineating hindu bioethics. in their bioethical deliberations, hindu scholars appeal to hindu concepts like karma, dharma (as described above), ahimsa (non-violence) and respect for life and nature. they also appeal to the classic texts and scriptures of the religion/tradition from the oldest existing ones, namely vedas, to other essential ones such as upanishadha or bhagvad gita. (19) abortion is mentioned in early vedic scriptures. for example, in brahmanas, the second major body of vedic literature, abortion is considered a crime (19: 22-23), and the same approach is adopted by upanishads (19). other classical scriptures of hinduism have also expressed their opposition to abortion in several ways, for instance by comparing abortion with killing a priest, considering abortion a sin worse than killing one’s parents, and threatening the mother to lose her caste. in the modern world, hindu sages and scholars have continued to condemn abortion. as mahatma gandhi once wrote, "it seems to me clear as daylight that abortion is a crime.” it can be argued that the traditional concepts of reverence for life and non-violence (ahimsa) have been most influential on the perspectives of hindu bioethicists towards key bioethical issues such as abortion, euthanasia and brain death (15). as explained above in this paper, ahimsa is a core concept in the approach of hinduism to the issue of abortion. as mentioned above, ahimsa is based on the sacredness of all creatures as manifestations of the supreme being. the reverence and love granted to all aramesh k. 13 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 9 august 2019 manifestations of life results from the very concept of ahimsa, which has made the hindu religion/tradition a strongly prolife one. this pro-life attitude has found its way from hinduism to other asian religious traditions (18, 20). in zoroastrianism, abortion is regarded as killing an innocent and intrinsically good person. concepts like ahimsa do not exist in zoroastrianism, but reverence for human life does. as explained above, morality in zoroastrianism is based on a polarized account of the universe as the everlasting battleground of good and evil, that is, ahura mazda and ahriman (4). since the human being is intrinsically good and has been created by ahura mazda, killing an unborn embryo or fetus is a violation against the forces of ahura mazda and a contribution to the forces of ahriman. therefore, abortion is considered a major sin. accordingly, it is not surprising that he holy scripture of zoroastrianism equates abortion with murder and rules punishments for persons who commit it. also, in other parts of avesta, there are revelations describing brutal punishments for such people in the afterlife (7). exceptions for the ban when it comes to abortion, in addition to adopting a pro-life approach, both religions recognize some exceptions for their ban on abortion. in both traditions/religions abortion is permitted when the life of the mother is in danger. therefore, both give priority to the mother’s life over the life of her unborn child. as a matter of fact, although both zoroastrianism and hinduism ban abortion except for cases in which mothers’ lives are endangered, the bioethical bases of this ban in these two religions are different from each other. in zoroastrianism, the ban is based on abortion being the same as killing an innocent person, and the contamination caused by the dead body. but in hinduism, it is based on the law of karma and depriving a person from one cycle of his or her rebirth. however, regardless of the theoretical bases and theological justifications, both religions give priority to the lives of the mothers over the lives of their unborn children. the recognized exceptions raise a question about the moral status and personhood of the embryo. although not mentioned directly in the original manuscripts, it seems that both these religions regard a moral status for the human embryo from the very first stages of life. this attitude is similar to the perspective of the catholic church that believes in recognition of personhood from the time of conception. however, a minority of hindus believe that incarnation takes place in the 7th month of pregnancy (21). also, it has been shown that the majority of zoroastrians are not against sperm and egg donation that necessitates in vitro fertilization (22). this position makes zoroastrianism different from classical catholicism or other recent pro-life movements (23). differences a comparative study will not be complete without describing the differences between the subjects of comparison. although perspectives of hinduism and zoroastrianism on abortion: a comparative … 14 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 9 august 2019 zoroastrianism and hinduism are ancient sister religions that originated among the same group of people (aryans) after the great migration, their followers settled in two different neighbor countries: persia and india. living in separate contexts and conditions naturally has had its consequences. as mentioned above, zoroastrianism is more similar to abrahamic religions than to dharmic ones in many ways. the main differences between these two religious traditions in terms of their perspectives on abortion are described below. unity vs. diversity one of the main differences between zoroastrianism and hinduism is in the very fact that zoroastrianism is a religion with a god, a prophet, a holy book, and in long periods of its history, a single hierarchical order of clergies. hinduism, however, lacks all these features. there is no single god, prophet, holy book or system of clergies shared among all the groups, sects and communities who call themselves hindu. therefore, in order to find the normative positions of zoroastrianism, for example their perspective on abortion, one can rely on a single defined set of resources. in hinduism, however, each expressed viewpoint only belongs to a number of believers and does not reflect the viewpoint of all religions/traditions. considering this difference between these two religions is important for reading and understanding all the scholarly works that have been published in this regard. in other words, zoroastrianism is a typical religion, while hinduism is a mixture of similar and interrelated traditions/religions. however, considering the familiar resemblance that ties the members of this group to each other, one can consider hinduism a unique, vast tradition reflecting the spirit of the indian subcontinent. afterlife vs. reincarnation one of the most important differences pertains to the concepts of rebirth and reincarnation. unlike hinduism, zoroastrianism does not believe in reincarnation and rebirth, but believes in the afterlife, like abrahamic religions. therefore, in zoroastrianism, abortion is not considered as depriving a person of a cycle of human life, but as denying him or her the only chance of birth and enjoying life on earth. karma vs. omnipotent god in hinduism, killing a living creature, including a fetus, is regarded as interfering in its spiritual evolution. such interference places karmic burdens on its agent. therefore, according to the natural law of karma, the agent(s) of such a crime will definitely encounter it’s just punishment/retaliation in their current or next lives. as an example of how the concept of karma works with regard to abortion, it has been said that abortion is a kind of punishment for meat-eaters. the fetus was a meat eater in his or her previous life, while the mother was a cow in her previous life, now taking revenge according to the rules of nature. according to this belief, meat-eaters and other people who kill live entities cannot escape the retribution set by the laws of aramesh k. 15 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 9 august 2019 karma; thus, in their next lives, they will have to undergo the misfortune, and may be recurrently aborted. it is obvious that the karmic maleficence of abortion is in close relation to reincarnation. this very belief that a human embryo is essentially a human person underlines the karmic effect attributed to abortion in hinduism (19). the concept of caraka (caraka’s theory of causality) shows how the karmic burden/heritage of past lives is transferred to the unborn fetus (19). therefore, killing the unborn child disrupts this process of transferring the karma and imposes karmic burdens on its agent who, by his/her act of abortion, has deprived the unborn baby of one of his or her chances to pursue salvation in a human life. cleanliness, on the other hand, is a very major concept and an emphasized duty for believers in zoroastrianism. one of the most offensive contaminants that can affect the cleanliness of the human body is a corpse. accordingly, there are specific burial rituals in zoroastrianism to prevent contamination of the soil, fire and living bodies by a corpse. according to zoroastrian teachings, abortion exposes the body of the mother to contamination caused by the dead body of the aborted fetus. therefore, in addition to abortion being forbidden, there is a multistep ritual for purgation of the body of the mother, including washing her womb with a liquid made from cow urine (7). the concept of karma, as it exists in hinduism, has no place in zoroastrianism. based on zoroastrian teachings, ahura mazda can punish or forgive sins. therefore, the punishment or forgiveness of bad deeds do not occur as a result of a natural law, but is attributed to ahura mazda, who can either punish or forgive the sinner (4). as a matter of fact, belief in an omnipotent god is not consistent with the concept of karma, because accepting the inviolability of this concept as a natural law ties the hands of god. in zoroastrianism, like abrahamic religions, the omnipotent god defines what is good and what is evil, and punishes or forgives anyone he wants. therefore, he is the one who can establish the immorality of abortion and offer punishment or forgiveness. conclusion zoroastrianism and hinduism are similar to each other in adopting strong pro-life approaches to issues like abortion. although with different theoretical bases, both these religious traditions ban abortion and allow it only if the life of the mother is threatened by continuation of the pregnancy. also, they are fundamentally different in the conceptual and theological bases of their moral approaches. zoroastrianism provides moral reasoning for regarding abortion as evil according to its own system of beliefs. on the other hand, in hindu bioethics, the principal concepts involving moral deliberations on abortion are ahimsa, karma, and reincarnation. accordingly, abortion as deliberately disrupting the process of reincarnation and killing an innocent human being is in contrast with the concept of ahimsa and perspectives of hinduism and zoroastrianism on abortion: a comparative … 16 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 9 august 2019 brings serious karmic consequences for its agent. hindu bioethics condemns abortion and allows it only in cases where abortion is necessary for saving the life of the mother. the concept of asha in zoroastrianism is similar to the concept of dharma in hinduism. both these concepts refer to a superior law of the universe and the bright path of life. the most noteworthy similarity between zoroastrianism and hinduism, however, is their pro-life approach. the perspectives of hindu bioethicists on key bioethical issues such as abortion has been shaped by a strong tradition of nonviolence (ahimsa) and an immense reverence for life. ahimsa is a core concept in the approach of hinduism to the issue of abortion and is based on the sacredness of all creatures as manifestations of the supreme being. in zoroastrianism, abortion is regarded as killing an innocent and intrinsically good person. since the human being is essentially good and has been created by ahura mazda, killing an unborn child is a violation against the forces of ahura mazda and a facilitator to the forces of ahriman, hence a major sin. therefore, both these religions have adopted a pro-life approach toward the abortion debate. in both traditions/religions abortion is permitted when the life of the mother is in danger. therefore, both give priority to the mother’s life over the life of her unborn child. one of the main differences between zoroastrianism and hinduism is in the fact that zoroastrianism is a religion with a god, a prophet, a holy book, and in long periods of its history a single hierarchical order of clergies. hinduism, however, lacks all these features. another important difference between zoroastrianism and hinduism is related to the concepts of rebirth and reincarnation. like abrahamic religions, zoroastrianism believes in the afterlife. therefore, in zoroastrianism, abortion is not considered as depriving a person of a cycle of human life, but it is considered as depriving a person of his or her only chance to be born and enjoy life on earth. in hinduism, killing a living creature, including a fetus, is regarded as interfering in its spiritual evolution, and places karmic burdens on its agent. therefore, according to the natural law of karma, the agent(s) of such a crime will definitely encounter just punishment/retaliation in their current or next lives. the concept of karma, as advocated by hinduism, has no place in zoroastrianism. in zoroastrianism, punishment and forgiveness of bad deeds are not the result of a natural law, but are administered by ahura mazda, who can either punish or forgive the sinner. in sum, one can conclude that zoroastrianism is similar to abrahamic religions in its approach to abortion, and this is what makes it different from its dharmic sister, hinduism. although both these ancient sister religions have adopted pro-life approaches, they are very different in many aspects and features. analyzing the historical course and reasons for the emergence of these differences can be a subject for further studies in the future. aramesh k. 17 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 9 august 2019 acknowledgements the author of this article would like to extend his appreciation to dr. joris gielen for his invaluable guiding comments. also, special thanks go to the reviewers of the journal of medical ethics and history of medicine for their helpful insights. conflict of interests none to declare. no funding has been received for this study. this manuscript has not been submitted to and is not under review for publication elsewhere. perspectives of hinduism and zoroastrianism on abortion: a comparative … 18 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 9 august 2019 references 1. parpola a. the coming of the aryans to iran and india and the cultural and ethnic identity of the dāsas. studia orientalia electronica. 2015: 64:195-302. 2. bryant e. the origins of vedic culture: the indo-aryan migration debate. oxford: oxford university press; 2001. 3. boyce m. a history of 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[razdani, rowshanfekti va dindari]. tehran: serat publisher; 1988. 11. carr b, mahalingam i, eds. companion encyclopedia of asian philosophy: zoroastrian philosophy. uk: routledge publisher; 2000. 12. michaels a. hinduism: past and present. princeton. usa: princeton university press; 2004. 13. sarma d. “hindu” bioethics? j law med ethics. 2008; 36(1): 51-8. 14. wennerberg h. the concept of family resemblance in wittgenstein's later philosophy. theoria. 1967; 33(2): 107–32. 15. damian ci. abortion from the perspective of eastern religions: hinduism and buddhism. romanian journal of bioethics. 2010; 8(1): 124-36. 16. pandya sk. medical ethics in india: now and then.” acta neurochir suppl. 1999; 74: 3546. 17. desai pn. medical ethics in india.” j med philos.1988; 13(3): 231-55. 18. francis x, clooney sj. back to the basics: reflections on moral discourse in a contemporary hindu community. j med philos. 1995; 20(4): 439-57. 19. cromwell cs. dilemmas of life and death: hindu ethics in a north american context. usa: suny press; 1994. 20. cromwell cs. hindu bioethics for the twenty-first century. usa: suny press; 2003. 21. bhattacharya s. magical progeny, modern technology: a hindu bioethics of assisted reproductive technology. usa: suny press; 2006. 22. halvaei i, khalili ma, ghasemi-esmailabad s, nabi a, shamsi f. zoroastrians support oocyte and embryo donation program for infertile couples. j reprod infertil. 2014; 15(4): 222-8. 23. fink d. a pro-life re-alignment: proposing a shift in focus toward demand-side antiabortion advocacy [dissertion]. mississippi (usa). university of mississippi; 2019. journal of medical ethics and history of medicine ethical concerns in early 21st century organ transplantation abdelkarim waness md, cpi, abim, facp, consultant, internal medicine, sheikh khalifa medical city, abu dhabi, uae. *corresponding author: abdelkarim waness address: sheikh khalifa medical city, abu dhabi, uae. postal box: 51900 tel: (+971) 56 73 30 240 fax: (+971) 26 10 20 00 e-mail: awaness@skmc.ae received: 07 sep 2011 accepted: 30 oct 2011 published: 06 nov 2011 j med ethics hist med. 2011; 4:10. http://journals.tums.ac.ir/abs/19532 © 2011 abdelkarim waness; licensee tehran univ. med. sci. abstract keywords: organ donation, informed consent, population vulnerability. introduction since antiquity, shamans, healers, and physi cians have played a pivotal role in safe-guarding individual and public health. in order to be able to better perform their duties they have always been granted privileged ethical and financial positions, and physicians have always been considered as impeccable professionals from an ethical point of view. this image however, is in danger of being distorted as novel medical issues emerge. patient doctor relation used to be quite simple and straight forward in the recent past; today this relationship is facing new challenges as decision-making have become more complex and less transparent. in fact, physicians are integrated into a complex health care system where financial issues and politics play an integral role. organ donation and transplantation have been only recently introduced to the practice of medicine. naturally, the issue faces different ethical, professional and financial challenges in different parts of the world as cultures, laws, and regulations differ vastly. case scenario a 45 year-old immigrant worker was brought unresponsive to an emergency room at a tertiary care center at his host country. primary diagnostic evaluations indicated brain stroke with midline cerebral shift. he received mechanical ventilation and was admitted to the intensive care unit (icu). a perfusion brain scan followed and confirmed the diagnosis of “brain death”. the main responsible medical ethics is an indispensible and challenging aspect of clinical practice. this is particu larly prominent in the field of organ transplantation. in this paper, initially, a clinical case with brain death that ended up as an organ donor will be presented. following the presenta tion, important moral challenges which initially formed medical ethics and some highlights of it in organ transplantation will be discussed in detail. the impact of complex modern influential factors that might interfere with the practice of medical ethics in this field such as patients’ vulnerability, financial temptations, and legal regulations will be also dealt with. finally, we shall propose practical guidelines aiming at improving the practice of medical ethics in the emerging issue of organ transplantation. http://journals.tums.ac.ir/abs/19532 j med ethics hist med 2011, 4:10 abdelkarim waness page 2 of 5 (page number not for citation purposes) physician (mrp) was aware that such cases were usually referred to a local transplantation center for possible organ donation. he was also told that the patient’s family would be “compensated” by the transplantation center. the mrp initiated the process by contacting the patient’s family, employ er and country’s embassy in order to consult the issue of organ donation, and possibly obtain an informed consent. no contact was made back for 2 days. on the third admission day, the mrp was notified that the patient is going to be taken to the operating room (or) for organ procurement. he proceeded to the icu personally to make sure that the informed consent was obtained. within the patient’s chart, he founded an undated, unsigned, hand-written form claiming the approval of the patient’s “cousin” for organ donation. the mrp objected to the “consent” and demanded further clarification from the hospital and the transplanta tion center. he was subsequently contacted by his department’s chairman inquiring about the “delay” in taking the patient to the or. the transplantation center was contacted again and the surgical team postponed their intervention. later on, two different properly prepared informed consents were produced: one from the hospital and the second from the transplantation center. the following morning, the patient was taken to the or where his heart, liver, kidneys and corneas were removed; he was pronounced dead thereafter. background throughout the whole history of human civi lization, doctors and healers have had high social status. physicians were still considered as extreme ly honest and highly trustworthy. in a poll conduct ed in 2009 by the royal college of physicians, it was found that doctors won the highest confidence rate of british adults community (92%) compared to that of politicians who achieved only 13% trust rate (1). it is important to mention that human ethics in general have been traditionally directed and formed by religious and cultural principles. the unique position of mankind and its sanctity has always been respected worldwide. there are several examples of such respect including the following verse from the holy quran, muslims most respected holy book: “and indeed, we have honored the children of adam, and we have carried them on land and sea, and have provided them with lawful good things, and have preferred them above many of those whom we have created with a marked preference” (chapter 17:70) (2). from the old testament: "whoever sheds the blood of man, by man shall his blood be shed; for god made man in his own image" (gen 9:6) (3). in the hinduism, buddhism, and jainism teachings, the concept of “ahimsa” is promoted as the doctrine of respect for all life and therefore an extreme form of refraining from violating it (4). ethics in medicine has been evolving contin uously. the hippocratic oath is probably the first documented evidence in medical ethics (5). ishaq ibn ali ruhawi, a 9 th century physician, wrote a twenty-chapter book titled “adab al-tabib” (conduct of the physician) which can be consid ered as the first treatise exclusively written on medical ethics. he described physicians as "guardi ans of souls and bodies" in his book (6). later on, the concept of written consent and patient physician contract was adopted and enforced by an ottoman empire court in the 15th century (7). in recent years, many philosophers have contributed to the advancement of medical ethics. the 17 th century german philosopher “immanuel kant” laid the foundation of a secular-based theory theory of freedom and autonomy which shaped and influ enced the work of many other intellectuals (8). further progress in medical ethics was only recently made following large scale repugnant atrocities such as the nazi medical experiments or the tuskegee untreated syphilis study (9,10). since then further ethical regulations, such as the “nuremberg code” and the “declaration of helsinki”, were established to strengthen the integrity of medical ethics and to prevent from any further breach of ethical codes in the field of medicine. research regarding organ donation and trans plantation has been growing fast in the past few decades. the first successful kidney transplantation was performed in 1954. the transplantation of body organs was possible by the development of immune suppressive drugs (11). in 1984, the united states congress passed the national organ transplant act (nota) to regulate this practice within the country. breach of the strict nota regulations, such as organ purchase, carries severe penalties (12). although the majority of centers and caregiv ers around the world are following organ transplant legal guidelines, some fail to do so because of different reasons. in this paper, we shall discuss some of the challenges to the practice of organ donation and transplantation. discussion despite the existence of clear delineation of modern medical ethics, physicians are increasingly facing complex moral situations. nowadays their ethical approach to patient’s care can be influenced by health industry regulations or financial motiva tions. the dilemmas in recent medicine and scientific research, such as organ donations and cloning, are really challenging traditional medical ethics. careful analysis of this case scenario puts j med ethics hist med 2011, 4:10 abdelkarim waness page 3 of 5 (page number not for citation purposes) forward a number of complex ethical challenges such as the following ones: 1. patient’s background: he was a migrant worker (presumably poor) away from his immediate family. in a recently published report, the united nations stated that many such workers face different forms of abuse or neglect without proper legal support (13). what makes the prob lem more complex is the fact that most of these workers are from countries where corruption is notoriously rampant according to the reports provided by different organizations such as transparency international (14). in many cases, there is little or no support available for such workers from the embassies of their home coun tries. traditionally, certain groups such as chil dren, pregnant women, prisoners, and the elderly are considered as vulnerable in terms of receiv ing social support. it can be argued that immi grant workers fit into this category and need more stringent protection. further research needs to be carried out to shed some light on the issue of vulnerability of these people and strategies to be taken to protect them (15). 2. third party involvement: with growing demand for human organs, the “transplantation business” is booming. the traditional “patient-physician relationship” is becoming complicated by a third party who is in charge of procurement and provi sion of organs. this third body falls into one of the three following categories:  illegal organ trade: is rampant worldwide. numerous revolting cases of physicians, hospi tals, and brokers who were engaged in these illegal activities are reported (16). obviously, such involvement of doctors or medical institu tions is unethical and against the law. stricter legal enforcement measures should be adopted to deter the criminals.  legitimate transplant centers: stringently regulated and supervised by a set of well defined frameworks and qualified personnel. in such settings, physicians can be of best as sistance to their patients and their families to enable them to make an informed decision in dealing with such challenging situations.  “shady” institutions: health care practitioners can occasionally face the possibility of dealing with local institution that offer questionable service or benefit from under-qualified staff. the physicians should be extremely careful in such situations. they need to be vigilant not only to protect their patients, but also their own ethical values and medical license. 3. documentation requirement: a recent american study reported that many physicians are involved in dubious hospital chart documentation. this can indicate a potentially new trend of changing the paradigm of ethical attitude in regards with evolving factors such as reimbursement regula tions or litigation fear (17). in this case scenario, it is alarming to observe that the level of com munication of an important issue such as organ donation was less than poor. furthermore, the process of obtaining informed consent and its documentation, which is a crucial part in organ transplantation, was inappropriate. physicians should be required to include informed, clear, and legal documentation in their patients’ charts. this should be imperative for an ethical, profes sional, and legitimate practice. 4. financial considerations: financial temptations can be difficult to resist for some patients, doc tors, or hospital executives. this can even occur in wealthy countries with relatively robust health system. a study by kranenburg et al showed that 25% of the general dutch public would consider selling their kidneys for financial benefits such as life-long health insurance or receiving a sum of 25,000 euros ($ 35,000) (18). it can be imagined therefore, how impoverished individuals from economically disadvantaged countries would react to a similar offer. with the increasing trend of illegal organ trade, some governments are adopting stricter laws to stem the tide of this disturbing trade (19). in the presented case sce nario, the issue of “family compensation” was raised. in this regard, three ethically challenging arguments can be put forward.  potentially positive feed-back: the financial temptation can be very hard to resist, even for healthy individuals. obviously, this temptation is much stronger for a sick person and / or his relatives in all likelihood. therefore, such “compensation” can result in an increase in the number of future potential “donors”.  when financial compensation is provided, the action ceases to be organ donation. it can be considered more as an official human organ trade which is obviously an illegal activity with harsh penalties in most countries if not in all of them.  there is a high possibility of conflict of inter est in this transaction. some transplant cen ters have obvious scientific gains in doing such procedures. thus, such financial incentives for scientific advancement do not seem to be ap propriate. this should be clearly differentiated from compensation after a catastrophic physi cal injury suffered by individuals. the latter is well recognized and regulated in many coun tries (20). 5. career fulfillment: physicians have their own professional motivations such as intellectual challenge, research opportunities, and even the desire for future prestige (21). increasing person al income can be another motivation and some doctors may choose to increase their income by getting involved in organ trade (22). academic productivity can be another important element j med ethics hist med 2011, 4:10 abdelkarim waness page 4 of 5 (page number not for citation purposes) that may drive doctors to achieve a higher aca demic status and rank. (23) when dealing with sensitive issues, such as organ transplantation, physicians ought to refrain from any activity that might distort the image of their ethical principles. moreover, they need to learn how to resist pres sures imposed by transplantation institute when their ethical principles are concerned. 6. organ shortage crisis: abouna has reported that in 2006, and in the united states alone, the waiting list for organ transplant surpassed 95,000 individuals. this shortage crisis is causing con tinuous decline in patients’ quality of life (24). one could argue that thousands of such patients will fail to procure their needed transplantation organ even illegally. the ethical challenges of organ donation and utilization are common in both developed and developing countries. fortunately, solutions for this important problem are being developed. efforts which are suggested to solve the issue can be categorized in the following different fields: a) medical ethics education: a recent american study concluded that ethics education, when integrated in residency curricula, can lead to significant improvements in resident-centered outcomes, such as knowledge and confidence in handling ethical dilemmas. the study has also shown that most general surgery residency courses do not routinely include in-depth ethics skills training and assessment into their curricula (25). in developing countries, the situation can be even worse. a canadian study raised concerns over the possible exploitation of trainees and their patients (26). medical schools and residency training programs need to develop structured ethical programs to better train future physicians and improve patients’ rights protection. b) ethics courses: during their careers, health care practitioners should benefit from continuous courses in medical ethics, even mandatory if necessary. these courses should be innovative and creative in order to enhance healthcare providers’ ability to solve and cope with complex and challenging ethical issues they might face (27). c) community leaders’ participation: the field of medical ethics involves different layers of human participation. throughout mankind’s history, community leaders such as famous religious figures or prominent political icons have played an important role in maintaining high moral standards within their societies. recent evidence indicates that positive spirituality enhances healing (28). establishment of working partnership and mutual cooperation between such leaders and their health care counterparts can result in better benefiting the society where medical ethics is concerned. the impact of such collaboration on patients and the general public can be substantially important. future research in this aspect is warranted to elucidate the practical ways of contribution of the cleric and politicians. d) national governments regulations: local legislators must be aware of crucial ethical issues within their communities. they must actively participate in drafting laws and endeavor to regulate and monitor them. they should help improve health care quality to limit potential illegal activity such as the illicit organ trade. individuals or institutions who participate in such abhorrent activities must be severely penalized. a recent example of such legislations is the recently adopted (august 29, 2011) law by the government of india to eradicate organ tourist trafficking (29). e) transplantation centers’ accreditation: there are different types of transplant centers and their structure differs vastly from country to country. it can be of great benefit if a universal accreditation body is formed to regularly monitor and supervise the activities of different transplantation centers. the joint commission international (jci) that accredits and monitors different hospitals world wide can be used as a model. f) international cooperation: in 2005, the world health organization (who) reported that 93,000 organ transplantations were performed in 91 countries indicating a rampant “transplant tour ism”. the report describes organ exporting and importing countries supported by many document ed pieces of evidence of illegal activities (30). politicians and legislators all around the world ought to hold meetings to discuss this topic and argue future treaties to ensure that illegal organ trafficking is controlled and the public is protected from such activities. it can be suggested that multinational and international organizations such as the united nations should be involved in any organ trade or donation activity. although illegal organ trade might still continue, its prevalence would be considerably reduced. conclusion the subject of medical ethics has been evolv ing since many millennia ago. it is a dynamic and ever-changing subject that can be influenced by many different contributing factors. health care providers, and especially physicians, are facing ethical dilemmas from trivial cases to complex ones such as organ trade. therefore, they should be better prepared and well equipped with the insight they need to deal with ethically sensitive issues appropriately. as discussed in detail, the ultimate goal of performing ethical organ transplantation seems elusive without active participation and collaboration of religious leaders, politicians, health institutions, community leaders, national legislators, and international organizations. the j med ethics hist med 2011, 4:10 abdelkarim waness page 5 of 5 (page number not for citation purposes) practical guideline of ethically based and legiti mized organ transplantation should include: 1. provision of systematic academic medical ethics education to future caregivers. 2. population education, through mass media, about proper organ donation / transplantation, as well as possible illegal and un-ethical activities in this field. 3. strengthening international and regional train ing activities in the battle against illegal organ trade. 4. 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ramsey km, weijer c. ethics of surgical training in developing countries. world j surg 2007; 31: 2067-9. 27. wiecha jm. ethics in medicine: are we blind? in support of teaching medical ethics at the bedside. j med human 1991; 12: 111-7. 28.wallace k. can spiritual beliefs help patients heal faster? http://psychology.suite101.com/article.cfm/religion_and_medicine_working_together (accessed in 2010) 29. anonymous. clickrally. http://www.clickrally.com/india-introduces-new-law-to-stem-organ-tourist-trafficking/ (accessed in 2011) 30. shimazono y. the state of the international organ trade: a provisional picture based on integration of available information. http://www.who.int/bulletin/volumes/85/12/06-039370/en/ (accessed in 2011) ____________________________________________________________________________________________________________________________________________ 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____________________________________________________________________________________________________________________________________________ 1 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e original article volume 13 number 12 september 2020 copyright © 2020 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. turning unprofessional behaviors around using holmes' reflection approach: a randomized controlled study *corresponding author sara mortaz hejri third floor, no. 57, hojatdoust st., keshavarz blvd., tehran, iran. postal code: 141669591 tel: (+98) 21 88 95 57 12 email: smortaz@tums.ac.ir received: 1 jan 2020 accepted: 31 may 2020 published: 16 sep 2020 citation to this article: naeimi l, asghari f, nedjat s, mirzazadeh a, abbaszadeh m, sima ar, mortaz hejri s. turning unprofessional behaviors around using holmes' reflection approach: a randomized controlled study. j med ethics hist med. 2020; 13: 12. leila naeimi1, fariba asghari 2, saharnaz nedjat3, azim mirzazadeh4, mahsa abbaszadeh5, ali reza sima6, sara mortaz hejri7* 1.researcher, department of medical education, school of medicine, tehran university of medical sciences, tehran, iran; medical education development center, zanjan university of medical sciences, zanjan, iran. 2.associate professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. 3.professor, department of epidemiology and biostatistics, school of public health, tehran university of medical sciences, tehran, iran. 4.associate professor, department of medical education, health professions education research center, tehran university of medical sciences, tehran, iran. 5.assistant professor, department of internal medicine, imam khomeini hospital complex, tehran university of medical sciences, tehran, iran. 6.assistant professor, digestive disease research center, digestive disease research institute, shariati hospital, tehran university of medical sciences, tehran, iran. 7.assistant professor, department of medical education, educational development center, tehran university of medical sciences, tehran, iran. abstract many medical schools around the world have included professionalism training in their formal curriculum. however, these efforts may not be adequate; given the exposure of students to unprofessional behaviors in the clinical settings. in the present study, we aimed to design, implement, and evaluate a longitudinal program to improve professionalism among medical students upon their transition to clinical settings. a total of 75 medical students were enrolled in the study and randomly assigned to two groups. the control group did not receive any training, while for the intervention group; a 10-hour program through 16 weeks was organized based on the holmes' reflection approach. the effectiveness of the program was evaluated by measuring three outcomes in both groups. data analysis was performed using paired t-test and multiple linear regression. scores of judgment of professionalism increased in the intervention group (from 7.56 to 10.17; p< 0.001), while there was no significant improvement in the control group’s scores. students' attitudes towards professionalism and their professional behaviors did not change significantly. based on our findings, the holmes reflection approach helps students improve their cognitive base of professionalism. long-term follow-up and further qualitative studies will help us better understand the effects of this approach on other desirable outcomes. keywords: professionalism; holmes' approach; unprofessional behavior; medical students; reflection. turning unprofessional behaviors around using holmes’ reflection approach … 2 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 12 september 2020 introduction professionalism, one of the six core competencies proposed by the accreditation council of graduate medical education (1), has become increasingly important for the medical community, as well as the public (2,3). the results of previous studies showed that demonstration of professional behaviors by physicians increases patients' satisfaction and trust, help patients adhere to their therapeutic plans, and reduce medical litigations (4-6). hence, medical students should be trained to establish professional behaviors and provide high-quality patientcentered care in the future (1). the development and maintenance of professionalism are one of the challenging issues in medical education. it is important to explicitly teach professionalism and actively reinforce the desired values, throughout both the undergraduate and postgraduate curricula (7). apart from role modeling which seems to be the most effective technique for developing professionalism and besides didactic sessions which are regularly used to provide the cognitive base of professionalism, experiential learning, reflective practice, and methods of critical and guided reflection are strongly recommended for endorsing professionalism (8-10). reflection is described as a core element of clinical competence and a fundamental element in teaching professionalism (11). physicians often have to resolve complex problems with no predefined solutions. hence, exposing students to the complexities of their professional life is essential and guided reflection can help maximize their learning (12). despite its variability, reflection models are not usually integrated into medical education programs due to time constraints and feasibility issues (11). in this study, we decided to use the holmes' reflection approach, which suggests a set of reflective competencies that are helpful, especially for medical students who have been exposed to unprofessional behaviors, during their transition from pre-clinical period to clinical settings (13, 14). in this approach, similar to the schön's model, it is assumed that reflective practice could take place when a person is faced with a real problem that has no simple solution. while the schön's model could be applied for all individuals in any circumstances, the holmes' approach is specifically designed for medical students who have been exposed to unprofessional behaviors in the clinical settings. this model is based on the observation of events in real situations: it focuses on unprofessional behaviors, which are inevitable parts of the hidden curriculum at the workplace; it targets students who are new in their clinical role, and therefore, are more likely to be sensitive toward the professional lapses that occur around them; and it facilitates reflection using certain four-step strategies, namely, priming, noticing, reflecting, and choosing. there is little evidence concerning the application and effectiveness of the holmes' approach. seen from a broader perspective, research in the field of medical professionalism is mostly composed of descriptive reports or qualitative studies, naeimi l., et al. 3 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 12 september 2020 most of which have discussed the importance of professionalism or have elaborated on different methods of teaching professionalism (8, 9, 15). a limited number of studies have focused on the impact of teaching methods and have indeed evaluated the results of educational interventions on professionalism (11, 16-18). these studies have shed light on this area; however, to the best of our knowledge, they have failed to evaluate the impact of their program on the students' knowledge base or actual professional behaviors (15-16), nor have used a particular theoretical framework for reflection (16), or have not recruited an identical control group to provide a basis for more valid comparisons (16-18). in this study, we tried to provide robust evidence by evaluating the educational outcomes of our longitudinal program at different levels of reaction, learning, and behavior using the holmes' reflection approach. we chose clerks (fourth year medical students) because noticing and observing unexpected behaviors, which are in contrast with the ethical values learned in the formal curriculum, more likely occurs at the beginning of a new period of training. method study design this pre-test post-test randomized controlled study was conducted in 2017-2018 on medical students. tums medical students are mainly admitted to the university from high school and the total duration of their training, including the internship, is seven years. the preclinical period is an integrated organ system-based curriculum that continues for three and a half years. these medical students have to follow two unit course in ethics in the pre-clinical period. while these students have an early clinical exposure during the pre-clinical period, their first clinical experience at the patient's bedside starts in the fourth year when they are assigned to the university-affiliated hospitals for their clerkship. the internal medicine clerkship was selected for this study, as it is the longest rotation (16 weeks) and the starting point of clinical practice for many students. in the briefing session at the beginning of the internal medicine clerkship, the study objectives and procedures were described for all students, and those who were willing to participate were enrolled in the study. for data analysis, we excluded students who were absent for two or more sessions as well as those who failed to complete the evaluations. a sample size of 23 was estimated for each group as a prior; however, concerning the probability of dropouts, we considered a larger sample size. students were randomly assigned to the control and intervention groups. the control group did not receive any training, while the intervention group participated in five sessions. to minimize the risk of contamination, participants were asked not to share program details with friends and classmates of the control group (figure 1). turning unprofessional behaviors around using holmes’ reflection approach … 4 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 12 september 2020 figure 1the study design and evaluated outcomes design and delivery of the educational intervention the research team met regularly to discuss the details of the design and structure of the longitudinal program based on the holmes’ approach. they made decisions on the schedule, teaching methods, content, and implementation of the intervention. we finally decided to organize the whole program as five 2-hour sessions within 16 weeks. with regard to the teaching methods, we decided to use the small group technique. hence, we randomly allocated the students into six small groups (five groups of six and one group of eight people). as we needed facilitators to coordinate discussions in small groups, we invited a number of medical interns who were collaborating with the educational development office at the naeimi l., et al. 5 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 12 september 2020 medical school. these medical interns were previously trained to play the role of facilitators; yet, before the beginning of the program, we oriented them about our study objectives, the intervention procedure, and the purpose of the sessions. we also provided them with a written guideline. the facilitators were instructed to use their own experience to encourage discussions in the small groups. with regard to the content of the program, we decided to apply the holmes' steps in five sessions: in the first session, the program was introduced, and the importance and necessity of teaching professionalism were discussed interactively. a notebook was given to the students to record daily diaries immediately to prevent contamination of the memory. then, the first step of holmes' reflection approach, priming, was implemented. for this purpose, some examples of how medical students in a clinical setting might yield to external pressures to engage in inappropriate behaviors were presented. the facilitators shared their experience in this area and encouraged the students to participate in the discussion. the students were asked to pay attention to unprofessional behaviors that might occur in upcoming days during their rotation and to document their daily memories in their clinical notebooks. in the second session, according to the second step of holmes' reflection approach, noticing, the students described the ethical issues that they were exposed to. they were encouraged to share their notes of unprofessional behaviors, to express the emotion that they had felt at those moments, and to discuss their experiences. in the third session, the third step of holmes' reflection approach, processing, was implemented. the objective of this session was to help students develop feasible action plans to deal with similar situations in the future. in the fourth session, we repeated the processing step, so that all students would have the opportunity to reflect deeply and critically on their observations and to receive feedback. in the last session, the fourth step, choosing, was implemented. the objectives of this session were to support students in identifying and adopting behaviors aligned with the profession's values and to avoid misconducts; help students apply their action plans (an outcome of steps 3) in a way that it reinforces their progress without alienating them from their peers or seniors, and show students how to politely disagree with others. in this session, a sample of poor reflections was compared with some good reflections, and group discussions were conducted. each facilitator was assigned to a small group and encouraged students to reflect. the facilitators provided feedback about the students' reflection and helped them distinguish a poor reflection from a good one, using a guideline (19). investigation of outcome the assessment of outcomes was carried out at the beginning of the study and one month after the program, for both intervention and control groups. we used several tools to determine the effectiveness of the program: we evaluated the cognitive base of professionalism (level 2a of kirkpatrick's framework) using a situational judgment test (sjt), consisting of 11 clinical turning unprofessional behaviors around using holmes’ reflection approach … 6 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 12 september 2020 scenarios (seven constructed-response questions and four selected-response questions). some examples of this test are presented in figure 2. the test was designed and scored by a panel of experts, based on medical professionalism guidelines. the total score of this test ranged from 0 to 20. figure 2questions of situational judgment test for assessing students' professionalism cognitive base the students' attitude toward professionalism (level 2b of kirkpatrick's framework (20)) was assessed using the modified version of queen’s university belfast professionalism index (qubpi) inventory. the original version of this questionnaire contains two sections. the first section, with 20 items, evaluates the person’s attitude towards professional behaviors and commitment, and the second part, with 19 items, evaluates the frequency of exposure to unprofessional behaviors naeimi l., et al. 7 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 12 september 2020 (21). in this study, only the first part of this tool was used. this part consists of two subsections, to be rated on a five-point likert scale (completely disagree= 5; completely agree= 1). we translated and validated the questionnaire according to the guideline developed by sousa and rojjanasrirat (22). concerning content validity, which was evaluated by the help of faculty members and medical students, three questions (1, 10, and 20) were removed. therefore, the score of the persian version ranged between 17 and 80. moreover, the reliability of this tool was found to be desirable, based on the results of the intraclass correlation coefficient and cronach's alpha measurements (≥ 0.70). moreover, the students' professional behaviors were evaluated (level 3 of kirkpatrick framework) using the professionalism mini-evaluation exercise (p-mex). the content validity assessment showed that five items (items 4, 5, 12, 20, and 21) were not suitable for evaluating the tums clerks, and thus, were omitted. the internal consistency of the 16-item scale was found to be 0.95, based on cronach's alpha. since each item of the p-mex is graded as follows: 1= unacceptable; 2= below expectations; 3= met expectations; and 4=exceeded expectations, the total score ranged from 16 to 64. interns, residents, fellows, and faculty members used p-mex to assess participants. one of the researchers provided the necessary instructions on the tool before conducting the assessments. data analysis was carried out only for students whose evaluations were completed before and after the intervention, and for those who participated in three sessions and more. statistics the demographics of participants were summarized using frequency, mean, and standard deviation. the paired t-test was performed to compare means of sjt, qubpi, and p-mex scores. multiple linear regression (mlr) was performed using medical students' post-test mean scores of sjt, qubpi, and p-mex as the dependent variables; and the pre-test mean scores and the group as the independent variables. all data analyses were performed using spss version 21(23). the study protocol was approved by the ethics committee of tehran university of medical sciences (tums) (no. ir.tums.medicine.rec.1395.1722). results among 105 eligible students, 75 (71.4%) voluntarily participated in this study and were randomly allocated to the intervention and control groups. the mean age of students in the intervention group was 22.12 years (sd=0.95), and 44.7% (n=17) were female. the mean age of the control group was 22.77 years (sd=0.95), and 35.5% (n=11) were female. there was no significant difference between the mean age of the students in the control and intervention groups. the mean and standard deviation of pretest and posttest scores of judgment (sjt), attitude (qubpi), and behavior (p-mex), turning unprofessional behaviors around using holmes’ reflection approach … 8 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 12 september 2020 before and after the program is presented for the control and intervention groups in table 1. table 1results of paired t-test analyses to compare mean scores of sjt, qubpi, and p-mex in the intervention and control groups, before and after the educational program test (outcome) group pre-test post-test mean standard deviation t sig. mean standard deviation t sig. situational judgment test (cognitive base) intervention (n=31) 7.56 2.49 -1.60 0.11 10.17 2.17 4.81* <0.001 control (n=28) 8.57 2.40 7.71 1.74 queen university belfast professionalism inventory (attitude) intervention (n=36) 56.72 5.48 0.14 0.89 59.17 6.65 0.97 0.33 control (n=31) 56.48 8.34 57.10 10.08 professionalism mini evaluation exercise (behavior) intervention (n=25) 47.42 4.17 -0.53 0.59 48.85 5.51 2.24** 0.03 control (n=25) 48.07 4.36 45.74 4.18 * correlation is significant at the level of 0.05. ** correlation is significant at the level of 0.01. post-test judgment was improved in the intervention group, showing a significant difference between the control and intervention groups (p<0.001). based on the results of the mlr of sjt, independent variables of “group” and “mean pre-test score” explained 64% (r2) of variance scores (dependent variable). considering the students' attitude (qubpi), the mlr showed that independent variables of "group" and "mean pre-test score" explained only 16% of the variance in the mean score. the mlr of students' behaviors (p-mex) showed that independent variables of "group" and "pretest behavior score" could explain only 0.23% of the variance in the mean score. it should be noted that r2 must be somewhere in the range of 0 and 1, where 0 shows that the result can't be anticipated by any of the independent variables and 1 demonstrates that the result can be anticipated without error from the independent variables. based on the results of the mlr of students' judgment, by a oneunit increase in the mean pre-test score, the mean score of the post-test increased by 0.66 units (p< 0.001). also, in line with the paired t-test results, after controlling the confounders using mlr, the students' judgment in the intervention group increased significantly in comparison with the control group (p< 0.001). based on the results of the mlr, by a one-unit increase in the mean naeimi l., et al. 9 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 12 september 2020 pre-test score of the students' attitudes, the mean score of post-test increased by 0.46 units (p< 0.001). however, after controlling the confounders using mlr, in line with the paired t-test results, there was no statistically significant difference between the two groups’ attitudes after the intervention (p= 0.34) (table 2). table 2results of paired t-test analyses to compare mean scores of sjt, qubpi, and p-mex in the intervention and control groups, before and after the educational program. test (outcome) unstandardized coefficients standardized coefficients beta sig. r2 b se situational judgment test (cognitive base) (constant) 10.40 0.96 <0.001 0.64 group -2.80 0.48 0.47 <0.001 pre-test score 0.66 0.09 0.55 <0.001 queen university belfast professionalism inventory (attitude) (constant) 1.76 0.48 <0.001 0.16 group -0.10 0.11 -0.11 0.341 pre-test score 0.46 0.13 0.39 <0.001 professionalism-mini evaluation exercise (behavior) (constant) 2.92 0.71 <0.001 0.23 group -0.17 0.09 -0.23 0.074 pre-test score 0.77 0.23 0.43 <0.001 in the intervention group, in comparison with the control group, the mean score of students' behavior increased by 0.17 units, provided that the variable pre-test value was considered constant (p= 0.07). also, with a one-unit increase in the mean pre-test score of students' behavior, the mean score of the post-test increased by 0.77 units (p< 0.001). however, after controlling the confounders using mlr in line with the paired t-test results, professional behavior in the intervention group did not show any statistically significant difference (p= 0.07). discussion to improve the cognitive base, attitude, and professional behavior of medical students, we conducted a pre-test post-test randomized controlled study by designing and implementing a 10-hour program through 16 weeks, based on the holmes' reflection approach. we found that the students' judgment on professionalism improved in the intervention group compared to their baseline scores and compared to the control group; however, there were no significant difference in the students' attitude or performance. turning unprofessional behaviors around using holmes’ reflection approach … 10 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 12 september 2020 there are few studies that have tried to investigate the impact of eliciting reflection as a method of professionalism training. holtman et al. evaluated the effectiveness of a professionalism course in an academic plastic using a preand post-tests study design. they implemented a 12-hour course through 6-week for health care professionals in plastic surgery (faculty members, residents, nurses, and medical students). teaching methods included didactic lectures, journal clubs, small group discussions, and book reviews. they assessed the outcomes using four levels of the kirkpatrick model. given the qualitative nature of the data extracted from levels 3 and 4 in this study, outcomes were measured by the incidence of sentinel events. the results showed improvement in knowledge and professional behaviors. in addition, the participants were satisfied with the course; however, their attitude toward professionalism did not change. since the authors did not use a randomized design, it is difficult to attribute all the changes to the training program. in addition, participants of the study included a diverse range of health professionals who were more involved in patient care, compared to the clerks in our study (24). given the lack of comparable quantitative, randomized studies on teaching and assessing professionalism, our findings can be considered in a wider context including medical ethics and ethical judgement. murrell conducted a cross-sectional study to evaluate medical students' ethical judgment. the results showed that there was no significant difference between students who participated in the professionalism course and those who did not (25). this finding is consistent with the findings of our study in which confounding factors in the clinical setting as well as the short duration of study might have caused the absence of any difference in the scores. moreover, goldie et al. in a quasi-experimental study evaluated the effectiveness of teaching ethics in small groups. training had a significant positive impact on the students' potential ethical behaviors. it also created a supportive environment for promoting constructive criticism of peers' performance. in this study, again, the intervention group attitude towards professionalism did not differ significantly compared to the control group (26), which is consistent with the present findings. clearly, there are many variables that could have influenced the professional behaviors of learners and their attitudes toward professionalism. hence, we were not able to detect a significant improvement in these two outcomes. the hidden curriculum is a very powerful tool for encouraging professional values (7, 27); yet, it “also has a more pernicious side, whereby professionalism lapses and unethical behaviors are normalized, particularly in the clinical setting” (28). students work in the clinical settings under the supervision of attending physicians and residents and as the lowest-ranking members of the clinical chain, they are subject to implicit learning (25). according to coulehan and williams "the tacit socialization process is powerful because it is continuous throughout the clinical training and is reinforced by doing naeimi l., et al. 11 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 12 september 2020 rather than saying" (29). based on the results of previous studies, conducted in hospitals affiliated to tums, it can be concluded that inappropriate or negative role models may contribute to the inefficacy of the training programs that aim to develop professionalism among students (27, 30). having said that, there might also be other reasons for the lack of significant behavioral differences after the intervention in our study. first, the p-mex might have not been the perfect assessment tool for our study, despite its previous validations and despite our modifications (31). to the best of our knowledge, this is the first true experimental research that evaluated a professionalism training program based on a guided reflection method. the current study had several strengths. first of all, we used a conceptual framework that facilitated guided reflection and feedback in multiple sessions. interestingly, while the holmes' approach is grounded in a theoretical basis, it is very practical and applicable to the real life. to make the most out of this approach, we managed to design our intervention as a longitudinal program, because standalone educational courses are considered to be less effective. besides, to provide robust evidence on the effects of our program, we included a control group and performed prepost comparisons. we also used previously established instruments for all of our measurements, including the cognitive base and attitude of students, as well as their actual behavior, an outcome that has often been ignored in previous studies. on the other hand, our study had also a few limitations. despite orientating the intervention group not to share material with the control group, information exchange was possible between the two groups. in addition, while we tried to minimize the differences between small group facilitators, through training and written guidelines, their diverse experiences might have resulted in different discussions that in turn could have caused inconsistency in our program. as the tums clerks are not involved in direct patient care, so direct observation of their performance using p-mex might have not been always possible. secondly, in spite of our effort to train the raters, it is possible that some of residents, fellows, or faculty members have failed to contribute to a valid assessment due to their high workload. finally, our study was performed on a small scale, we did not evaluate the longterm outcomes, and we did not collect qualitative data which could have provided us with a deep understanding about the impact of the program. conclusion the application of holmes’ reflection approach improved the judgment of professionalism among medical students upon their transition to the clinical settings. it is recommended to conduct mixedmethods studies with long-term follow-ups to better evaluate the effects of reflection on the attitudes and professional behaviors of students. turning unprofessional behaviors around using holmes’ reflection approach … 12 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 12 september 2020 acknowledgements this study was a research project approved under license no.35253 by the research department of tehran university of medical sciences. we are very grateful to the research department for their financial support. we would like to thank dr. nasim khajavirad and dr. mahbube ebrahimipour, for their help with implementing the educational program and collecting the data. we also extend our gratitude to all students who participated in this study. conflict of interests the authors declare no conflicts of interest. naeimi l., et al. 13 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 12 september 2020 references 1. grogan ma. professionalism in the preclinical years: medical students' perspectives [dissertation]. minneapolis (usa): walden university; 2013. 2. howe 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172(2): 291. 25. murrell vs. the failure of medical education to develop moral reasoning in medical students. international journal of medical education. 2014; 5: 219-225. 26. goldie j, schwartz l, mcconnachie a, morrison j. impact of a new course on students' potential behaviour on encountering ethical dilemmas. med educ. 2001; 35(3): 295-302. 27. seif-farshad m, bazmi s, amiri f, fattahi f, kiani m. knowledge of medical professionalism in medical students and physicians at shahid beheshti university of medical sciences and affiliated hospitals iran. medicine. 2016; 95(45): e5380. 28. holmes c. addressing the hidden curriculum at ubc. ubcmj. 2019; 10: 2. 29. coulehan j, williams pc. conflicting professional values in medical education. cambridge quarterly of healthcare ethics. 2003; 12(1): 7-20. 30. nikravan fard n, asghari f, mirzazadeh a. ethical issues confronted by medical students during clinical rotations. med educ. 2010; 44(7): 723-30. 31. cruess r, mcilroy jh, cruess s, ginsburg s, steinert y. the professionalism minievaluation exercise: a preliminary investigation. acad med. 2006; 81(10 suppl.): s74-8. journal of medical ethics and history of medicine assessment of professionalism in iranian pharmacists mohammadreza javadi 1 , fariba asghari 2 , pooneh salari 2* 1.assistant professor, department of clinical pharmacy, faculty of pharmacy, tehran university of medical sciences, tehran, iran. 2.assistant professor, medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. *corresponding author: pooneh salari address: no.21, 16 azar ave., keshavarz blvd., tehran, iran. tel: (+98) 21 66 41 96 61 email: poonehsalari@gmail.com received: 06 apr 2011 accepted: 11 jun 2011 published: 26 jun 2011 j med ethics hist med. 2011; 4:6. http://journals.tums.ac.ir/abs/18557 © 2011 mohammadreza javadi, fariba asghari and pooneh salari; licensee tehran univ. med. sci. abstract keywords: pharmacy professionalism, altruism, accountability, pharmacy ethics. in the recent years, the role of a pharmacist has been significantly changed. traditionally, in the late 20 th century, a pharmacist's role was considered as merely dispensing medication to patients. this view however, has been significantly altered, and, today, a pharmacist is supposed to provide patients with information regarding the medication they are to take, as well as on different aspects of their disease. therefore, one can suggest that some other factors have recently come into play in the daily tasks of a pharmacist such as accountability and authority. the current cross-sectional survey is conducted on a cohort of community pharmacists attending a continuing education program. a questionnaire comprised of 26 likert-type scale questions was designed to assess pharmacists' attitude towards professionalism and its subscales which are defined later in detail. a total number of 1000 pharmacists were surveyed and 560 of them filled and returned the questionnaires. on a scale from 1-5 on which 1 was corresponded with strongly agree and 5 with strongly disagree, the total score of pharmacists professionalism was 92.9 ± 10.4 out of 130. as regards the subscales, in the subscale of accountability 46.8% of participants, in the subscale of altruism 90.1% of participants, in the theme of duty 85.7% of participants, and in the subscale of working relationship with physicians 84% of pharmacist achieved more than two third of the total score. only in term of conflict of interest 67.9% of participants scored less than two third (17-25) of the total score. women obtained significantly higher scores in altruism (p<0.05). furthermore, there was a correlation between age and the score of accountability and working relationship with physicians; and, the same was observed in regards with work experience with the score of working relationship with physicians. the employment position affected neither our partici pants' response to the whole questionnaire nor any of subscales. although the total score for professionalism was not dramatically decreased, the significantly low results are alarming and they should be considered more seriously. in order to enhance the level of pharmacists' professionalism, especially in some special aspects, it seems necessary to conduct similar surveys on pharmacy students and registered pharmacists with a more comprehensive questionnaire. overall, it can be concluded that designing a proper teaching course in professionalism for pharmacy students is of paramount importance if we are to promote professionalism in future pharmacists. mailto:poonehsalari@gmail.com http://journals.tums.ac.ir/abs/18557 http://journals.tums.ac.ir/abs/18557 j med ethics hist med 2011, 4:6 mohammadreza javadi, fariba asghari, pooneh salari introduction the history of pharmacy dates back to the middle ages when apothecaries used to both make the diagnosis and dispense the medication them selves. their role in health care provision was similar to physicians' and they treated patients independently. however, up to a few years ago, the pharmacists' attitude towards their role in health care provision seemed to have changed and their practice had deviated from their education (1). this had happened, arguably, as a result of commercial ism and consumerism, and it shifted their practice from making diagnosis and preparing medication to merely dispensing them, and consequently, the early codes of ethics regarding diagnosis, was seen exclusively as a responsibility of physicians (2). therefore, industrialization in the twentieth century and thereafter gradually weakened pharmacists’ importance in health care. in fact, it can be argued that their over education and underutilization forced them to follow commercial benefit. however, by the establishment and develop ment of special branches of pharmacy such as clinical pharmacy, pharmaceutics, etc, the pharma cists’ responsibility has recently shifted from merely drug dispensing into face to face communi cation with patients, giving advice, and patient education. naturally, holding the knowledge of pharmacy, especially in the fields of pharmacoki netics, pharmacodynamics, and toxicology can provide an excellent opportunity for pharmacists to get involved in health care system more proactive ly. therefore, one can suggest that more authority and responsibility should be taken into account for this profession. according to the unique role of the pharma cist in relationship with both patients and physi cians, and also, considering emergence of new discoveries in the field, the profession is facing new ethical challenges. therefore, pharmacists’ standards of practice are to be monitored by regulations and revisions. in 2000, the american pharmacists association academy of students of pharmacy (apha-asp) and the american associa tion of colleges of pharmacy council of deans (aacp-cod) proposed assessing professionaliza tion process in colleges and schools of pharmacy. this assessment was followed by including professionalization projects in the curricular contexts of pharmacy courses (3). unfortunately, in iran, there is neither a well organized professionalization project in the curriculum of pharmacy students nor any pharmacy code of ethics for the pharmacists. in addition, there is a scarcity of literature in the field of pharmacy ethics worldwide and iran is no excep tion. considering the importance of pharmacists’ professionalism as well as the need for designing comprehensive curricular and co-curricular professionalization projects, this study was designed to determine the level of professionalism in iranian pharmacists. methods we evaluated pharmacists’ attitude towards a number of principles of professionalism in their everyday working tasks with the use of a self administered questionnaire. the study was per formed on registered iranian pharmacists from may 2010 to february 2011. the professionalism questionnaire, developed by the authors, was consisted of 26 items that were scored on a likert type scale with responses ranging from 1 corre sponding with strongly agree to 5 indicating strongly disagree. higher scores indicated a higher level of professionalism. five subscales were defined as follows: altruism, duty, accountability, conflict of interest, and working relationship with physicians. the validity of the questionnaire was approved by two experts in medical ethics, and, its reliability was confirmed by cronbach's alpha internal consistency which was 0.81. the question naire was consisted of two parts, part one included personal information about study participants, such as age, gender, year of experience, and the industry of employment (pharmacy, manufacturer, and pharmaceutical importing company); and part two was composed of 26 items. the study was conduct ed on community pharmacist attending a continu ing pharmacy education (cpe) program. the survey questionnaire ensured participants' anonym ity and it was confirmed that the participation was voluntarily. the study was approved by tehran university of medical sciences institutional review board. table 1 shows the questionnaire and the percent of the answers to each question. the subscales and their corresponding ques tions are as below: subscale 1 (accountability); questions: 4, 5, 9, 10, 14, 17, 19, 23 subscale 2 (altruism); questions: 6, 21, 22 subscale 3 (conflict of interest); questions: 1, 2, 3, 13, 26 subscale 4 (duty); questions: 7, 8, 12, 15, 16, 18, 24, 25 subscale 5 (relationship with physician); question 20 all data were analyzed using spss software version 16. as the variables skewed (one-sample kolmogorov-smirnov test, p<0.05), non parametirc tests (mann-whitney test, kruskal wallis test) were used for analysis. a p value <0.05 was considered significant. results five hundred and thirty nine pharmacists completed and returned the questionnaires resulting page 2 of 7 (page number not for citation purposes) j med ethics hist med 2011, 4:6 mohammadreza javadi, fariba asghari, pooneh salari page 3 of 7 (page number not for citation purposes) in 56% response rate. seventy four questionnaires were excluded from analysis because of typing errors. a number of 240 participants (53.7%) were female and 207 (46.3%) were male. the mean age of the participants was 43.2 ± 12.5 years. three hundred and eighty participants (88.4%) were employed in pharmacy, 25 (5.8%) in drug compa nies, and 25 (5.8%) in pharmaceutical industry. two hundred and twenty six participants (56.9%) had more than 10 years of work experiences, 89 (22.4%) between 5 and 10 years and 82 (20.7%) less than 5 years of work experiences. the mean of the overall score of all partici pants was 92.9 ± 10.4 out of 130. the mean score for each subscale is tabulated in table 2. women achieved significantly higher scores in altruism (13.02 ± 1.8 in women vs. 12.8 ± 2 in men) (p<0.05) but there was no difference between men and women regarding the scores of the other subscales and the total score of professionalism. the age showed a positive correlation with the score of accountability (r=0.1, p=0.02). the older participants demonstrated a lower score regarding the working relationship with physicians (r=-0.99, p=0.04), and, our results showed that there was a weak reverse relationship between work experience and working relationship with physicians (r=-0.15, p= 0.002). industry of employment did not affect the overall score of professionalism or any of the subscales. regarding accountability, 52.5% of participants scored 16-30 and only 46.8% of them could score more than two third (31-45) of the total. interestingly, in the subscale of altruism 90.1% of participants achieved more than two third (11-15) of the total score. as for duty, 85.7% of participants got more than two third (28-40) of the total score. as regards conflict of interest, 67.9% of participants got less than two third (8-16) of the total score. totally, only 0.2% of pharmacists obtained lower than one third of the total score in professionalism and 78.8% of them got more than two third of the total score (87-130). the scores are tabulated in table 3 in detail. discussion today, it can be suggested that professional ethics has been substituted with general moral philosophy for professionals as the instrument they need to provide a balance among their rights, duties, and responsibilities (4). in health care provision, professional ethics is mainly derived from guidelines based on public sphere, profes sional knowledge, professional values, cultural issues, and possibly, religious ideologies. although pharmacy codes of ethics are compiled based on the principles of bioethics, it also includes virtues and professional and inter-professional autonomy (5-7). having a professional role in health care makes it indispensable that some ethical considera tions should be taken into accounts which are far different from individual's everyday decision making (8). the current study presents the first study of its type in iran for the assessment of pharmacists’ professionalism. the questionnaire was consisted of 26 questions based on 5 tenets of professional ism, namely, accountability, duty, altruism, conflict of interest, and working relationship with physi cians. our results showed that only 46.8% of partic ipants scored relatively high in accountability while 90.1% of them achieved considerably high scores in altruism. in one study, chisholm et al surveyed professionalism in pharmacy students and recent graduates by an 18-item questionnaire, and observed that the mean of the total score of accountability was 8.4 out of 10, and, for altruism, it was 12.4 out of 15 (6). gender seemed to have influenced the results as women could achieve higher scores in altruism (p<0.05). furthermore, older pharmacists scored higher in accountability (there was a weak relationship between age and accountability). place of employment did not affect our participants' response neither to the whole questionnaire nor to each subscale. in a study conducted by cain et al, female students signifi cantly demonstrated more accountability for illegal actions and unprofessional behaviors than their male counterparts (8). the results of a different study by poirier et al on a cohort of pharmacy students demonstrated a significantly increasing trend in the altruism, accountability, and profes sionalism scores from the first year of pharmacy school to the fourth year while their attitude towards duty did not change (9). the great majority of the participants of this study (more than 85%) achieved more than two third of the total score of duty and this could indicate that iranian pharmacists are aware of their duties, although, there are some practical con straints or obstacles which need to be addressed. interestingly, our results are in accordance with those of chisholm et al which showed that the mean of the total score of duty in pharmacy students and graduates, who had been previously trained, was considerably high (8.8 out of 10) (6). again, it seems of crucial importance that students and practitioners of health care teams should be familiar with special regulations, especially through education and vocational training to get a clearer picture of professionalism. many different elements indicate the need for the establishment of interdisciplinary teams for improving the quality of care, such as the increasing complexity of care, different aspects of health care, and the necessity of providing care in different settings. therefore, the pharmacists’ curricula should include teaching interdisciplinary teamwork to increase their clinical experiences and enhance their communication skills with other health care providers. academic j med ethics hist med 2011, 4:6 mohammadreza javadi, fariba asghari, pooneh salari page 4 of 7 (page number not for citation purposes) teachings should lead to professionalism, confi dence in discipline-specific knowledge, and skills necessary to interact with other members of the health care team (5). furthermore, it is highly recommended that pharmacy students spend some time observing health care professionals from different fields of health care during their clinical rotations to foster their interdisciplinary relation ship skills. doing this, students can improve their clinical skills in a real clinical setting, and conse quently, they can be better prepared for their professional career. the precise role of pharmacists in relation with pharmaceutical companies is yet to be elucidated. although there is a great deal of emphasis on pharmacists’ accountability, a lack of balance between pharmacists’ accountability and authority is sometimes observed. bumgarner et al believed that enhancing pro fessionalism needs a change in the culture if we are to achieve long term results. they have strongly recommended that teaching professionalism should be included in the curriculum of pharmacy stu dents, especially before beginning of the first professional year of pharmacy school (7). the lowest total score we observed was re garding conflict of interest which showed that 67.9% of participants achieved less than two third of the total score in this subscale; and, only 22.3% of participants scored greater than two third of the total score for it. the pharmacists’ attitude toward conflict of interest is generally believed to be influenced by business issues. hassel et al put a great emphasis on the importance of considering supply and demand in a trend regarding conflict of interest (10). generally, patients expect that their questions and concerns are answered, and, an appropriate health care service is rendered by a knowledgeable, reliable, and enthusiastic pharmacist. in fact, there is a counterbalance between the pharmacists’ insight into conflict of interest and pharmaceutical companies’ approach (11). there seems to be a contradiction between the pharmacists’ profession al obligation in providing care and selling as much drugs as possible. in addition, a substantial proportion of the products of pharmaceutical industries are of limited therapeutic value, and, a pharmacist, nonetheless, needs to maintain a profitable business by selling them. this, also, can pose them to some degree of conflict of interest. as regards working relationship with physi cians, 84% of participant pharmacists scored more than two third of the total score, however, it is necessary to mention that only one question was allocated to this subscale. overall, the mean score of professionalism in the study participants was 92.9 out of 130 which seems to be approximately in agreement with that of chisholm study which was 77.8 out of 90 (6). one of the limitations of our survey was the low response rate. the authors believe that although the anonymity of the questionnaires was reassured and the pharmacists were not compelled to participate in the study, some of them did not trust it and did not answer the questions properly. in addition, a lack of reliance on the questionnaire or possibly the limited transparency of the ques tions led to missing of some data. therefore improving the questions and obtaining higher consistency coefficient (cronbachs' alpha) would be our first recommendation in future studies. furthermore, we limited the survey to the pharmacists who were mainly employed in community pharmacies with a high probability of face to face interaction with the patients. thus, changing the participants from pharmacists to pharmacy students, pharmacy residents, and different pharmacy specialties including clinical pharmacists can be the next stride. in conclusion, provision of a well organized ethics course in the curricula of the students of pharmacy and residency programs seems to be of paramount importance. in this regard, compiling pharmacy code of ethics and professionalism is likely to improve the current situation regarding professionalism. in order for us to achieve this goal, it can be suggested that the obstacles between practice and communication and workspace thoroughly be evaluated from an environmental, clinical, personal, economical and social aspects. we believe that recognizing these concerns and integrating them into professional educational programs can result in a better and more supportive health care service for the public. acknowledgment this work was financially supported by the medical ethics and history of medicine research center of tehran university of medical sciences. the authors wish to thank all of the participants for their contribution. in addition we thank dr kiarash aramesh for his kind assistance. also the efforts of miss baghbani and her colleagues in 13 aban pharmacy are highly appreciated. page 5 of 7 (page number not for citation purposes) j med ethics hist med 2011, 4:6 mohammadreza javadi, fariba asghari, pooneh salari table 1. the questionnaire and the percent of answers to each question questions answers (%) sag ag n da sda 1. i am interested in providing special condition for drug delivery to nursing homes, etc without extra charge to help marketing. 42.6 30.3 18.3 4.1 4.6 2. i would like to register nursing homes staffs in continuous educa tion programs in order to attract more patients. 16.6 18.7 35.3 9.7 19.8 3. there is possibility to reject the consultation fees to increase the number of customers of the pharmacy. 28.8 27.5 11.6 11.4 20.6 4. in the case of referring a patient with chief complain of fatigue, weakness or other constitutional symptoms i will recommend him/her to take vitamins, minerals or the other supplemental and herbal products. 13.4 41.2 5.3 21.7 18.3 5. according to the possibility of drug shortage in our country if a known patient with a history of a chronic disease refers there is the possibility that i propose buying more drugs than the recommend ed amount by the physician. 6.2 21.6 7.9 17.3 46.9 6. for better marketing i can sell cigarettes or something like that if needed. 0.6 1.5 2.3 4.0 91.5 7. at the time of dug dispensing there is no need to consider drug safety because the physician is responsible about that. 2.3 7.4 3 25.4 61.9 8. at the time of drug dispensing i do not pay enough attention to the efficacy of the drug because the physician is responsible about that. 3.4 12.3 7.0 31.0 46.3 9. in some cases i may recommend using different types of supple ments such as zinc, garlic tablet, ginseng, and royal jelly to the patients. 21.7 50.2 11.6 9.9 6.5 10. if i diagnose vitamin or mineral deficiency i have to recommend them to the patient. 38.4 47.6 6.4 4.9 2.8 11. i dispense drugs without physicians order. 4.0 48.8 6.8 25.3 15.2 12. i believe that the pharmacy should provide most of the patients’ requirements even if it is not related to the health. 1.9 5.9 5.7 22.0 64.4 13. if i find some drugs close to the expiry date in the pharmacy i will inform the physicians who are in close collaboration with me. 26.7 23.9 17.7 14.4 17.2 14. in the case of identifying the benefits of a non-otc drug for a patient i will recommend. 13.1 29.8 7.7 18.6 30.8 15. the pharmacists’ full time attendance in the pharmacy is not necessary. 6.4 10.0 4.0 15.9 63.8 16. in the case of lateness, no need to inform the staff. 4.9 6.2 6.6 19.2 63.1 17. in the case of occurring medical error in my absence i am not responsible for that. 8.1 5.7 5.7 20.0 60.4 18. i am responsible in my duties even if the salary if not enough. 4.0 8.3 7.9 25.5 54.3 19. in the case of occurring medical error in drug dispensing i will inform the patient or the physician as soon as possible. 0.8 0.2 1.3 9.1 88.6 20. at work in the pharmacy, no need for relationship with physicians. 2.8 7.8 5.1 26.9 57.4 21. the social ranking of the patients does not affect my duties. 6.3 15.4 4.9 18.6 54.8 22. in the case of lack of a special drug in my pharmacy i am responsi ble for finding that. 3.0 6.1 5.1 36.4 49.4 23. i always accept the recommendations and criticisms. 0.9 0.4 3.2 20.9 74.7 24. i prefer to act conservatively in explaining my opinions and giving information. 12.8 17.6 11.3 42.6 15.6 25. i accept physicians’ decisions and ideas completely even if it seems to be doubtful because physicians are responsible. 5.4 17.0 9.0 38.9 29.7 26. at the time of buying drugs from manufacturers, mostly i prefer contacting the companies which have more relationships (those sending gifts, invite to a meal, etc) with me. 7.2 20.6 23.8 17.9 30.4 ag=strongly agree; ag= agree; n= neutral; da= disagree; sda= strongly disagree. page 6 of 7 (page number not for citation purposes) j med ethics hist med 2011, 4:6 mohammadreza javadi, fariba asghari, pooneh salari table 2. mean score of each subscale subscale mean (sd) total score accountability 30.2 ± 5.2 45 altruism 12.95 ± 2 15 conflict of interest 13.3 ± 3.7 25 duty 32.1 ± 4.5 40 relationship with physicians 4.27 ± 1 5 sd= standard deviation table 3. the score of participants according to each subscale subscale score of participants <1/3 1/3-2/3 >2/3 total professionalism score 0.2% 21.0% 78.8% accountability 0.6% 52.5% 46.8% duty 0.4% 13.9% 85.7% altruism 0.4% 9.5% 90.1% conflict of interest 9.9% 67.9% 22.3% page 7 of 7 (page number not for citation purposes) j med ethics hist med 2011, 4:6 mohammadreza javadi, fariba asghari, pooneh salari references 1. vitell sj, rawwas mya, festervand ta. the business ethics of pharmacists: conflicts practices and beliefs. j business ethics 1991; 10: 295-301. 2. helper cd, strand lm. opportunities and responsibilities in pharmaceutical care. am j hosp pharm 1990; 47: 533-43. 3. poirier ti, gupchup gv. assessment of pharmacy student professionalism across a curriculum. am j pharm educ 2010; 74(4): 62. 4. anonymous. pharmaceutical society of australia. code of professional conduct. canberra: the pharmaceutical society of australia. http://www.psa.org.au/site.php?id-628. 5. brehm bj, smith r, rourke km. multiskilling: a course to increase multidisciplinary skills in future dietetics professionals. j allied health 2001; 30: 239-42. 6. chisholm ma, cobb h, duke l, mcduffie c, kennedy wk. development of an instrument to measure professionalism. am j pharm educ 2006; 70(4): 85. 7. bumgarner gw, spies ar, scott asbill jdc, prince vt. using the humanities to strengthen the concept of professionalism among first-professional year pharmacy students. am j pharm educ 2007; 71(2): 28. 8. cain j, scott dr, akers p. pharmacy students' facebook activity and opinions regarding accountability and e professionalism. am j pharm educ 2009; 73(6): 104. 9. poirier ti, gupchup gv. assessment of pharmacy student professionalism across a curriculum. am j pharm educ 2010; 74(4): 62. 10. hassell k, rogers a, noyce p. community pharmacy as a primary health and self-care resource: a framework for understanding pharmacy utilization. health soc care community 2000; 8: 40-9. 11. rapport f, doel ma, hutchings ha, et al. eleven themes of patient-centered professionalism in community pharmacy: innovative approaches to consulting. int j pharm pract 2010; 18: 260-8. journal of medical ethics and history of medicine pharmacy ethics: evaluation pharmacists’ ethical attitude pooneh salari sharif 1* , mohammadreza javadi 2 , fariba asghari 3 1.medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. 2.clinical pharmacy department, faculty of pharmacy, tehran university of medical sciences, tehran, iran. 3.medical ethics and history of medicine research center, tehran university of medical sciences, tehran, iran. *corresponding author: pooneh salari sharif address: no.21, 16 azar ave., keshavarz blvd., tehran, iran. tel: (+98) 21 66 41 96 61 e-mail: salari@tums.ac.ir received: 27 feb 2011 accepted: 23 apr 2011 published: 02 may 2011 j med ethics hist med. 2011; 4:5. © 2011 pooneh salari sharif, mohammadreza javadi and fariba asghari; licensee tehran univ. med. sci. abstract keywords: pharmacy ethics, ethical attitude, confidentiality, autonomy. alterations in pharmacy practice from prescription dispensing to more patient-centered relationship intensifies the necessity of clinical decision-making. pharmacists' knowledge as well as ethical reasoning affects their clinical decision-making. unfortunately in iran pharmacy ethics did not develop along with medical ethics and special considerations are of major importance. the study was designed to evaluate pharmacists' attitude toward some principles of bioethics. a cross-sectional survey was performed on a sample of iranian pharmacists attended in continuous education programs in 2010. based on the pharmacists' attitude toward common ethical problems, 9 likert-type scale scenarios were designed. a thousand pharmacists were surveyed and 505 questionnaires were filled. for the whole question naire the strongly disagree answer was the most ethical answer. on a scale from 1-5 on which 5=strongly disagree, the total score of pharmacists ethical attitude was 17.69 ± 3.57. for easier analysis we considered the score of 1 for agree and strongly agree answers, score of 2 for neutral answers and score of 3 for disagree and strongly disagree answers. the total score in confidentiality for all participants was 4.15 ± 1.45 out of 9, in autonomy 6.25 ± 1.85 out of 9, in non-maleficence 5.14 ± 1.17 out of 6 and in justice was 2.27 ± 0.89 out of 3, however there was no significant difference between men and women in the total score and the score of each theme. the older participants (> 40 years) significantly had lower total score (p< 0.05) as well as the score of each theme (p< 0.05), except for non-maleficence. the work experience showed impact on the pharmacists’ attitude toward autonomy and the participants with more than 5 years work experience significantly obtained lower score in this theme. compiling ethical guidelines and improving pharmacy ethics curriculum is highly critical to provide the best pharmaceutical care and to make clinical decisions in critical situations. therefore further quantitative and qualitative investigations into finding pitfalls and challenges in this issue are highly recommended. j med ethics hist med 2011, 4:5 pooneh salari, mohammadreza javadi, fariba asghari introduction the importance of ethical issues in pharmacy practice highlights the necessity of considering ethical principles by pharmacists. in the recent 10 years medical ethics has been followed seriously in the world as well as in iran but pharmacy ethics has not been as developed as medical ethics. teaching pharmacy ethics has been started from about 3 years ago in pharmacy schools however, it is far from standards. in the last two decades pharmacy practice has changed from prescription dispensing to more patient-centered relationships and more emphasis on pharmacists responsibility for the favorable treatment outcomes. therefore, the pharmacists are responsible for providing the best health care services the same as the other health care providers. in this regards pharmacists should cooperate well with other health care professionals, and patients. although ethical problems in pharma cy involve different areas such as clinical pharma cy, pharmaceutical industry, community pharma cies, insurance companies as well as policy makers; however rawwas et al reduced pharmacy ethics into two major issues; pharmaceutical industry and ethical economic questions (1). the most important service provided by pharmacists in iran is answering a wide range of queries of patients. therefore, the pharmacists need to be well-oriented with ethical issues and the way of implementing the best ethical solution at critical conditions. there is no ethical code available for pharmacists in iran and they need to be knowled geable about the ethical principles and be compe tent to conduct a professional judgment. as health care providers, pharmacists are faced with critical thinking and decision-making and have to follow their ethical guidelines; however, their decisions may be influenced by some considerations. very few if no research has been conducted on the ethical dilemmas pharmacists confronted with and the ethical attitude of pharmacists about the dilemmas (2, 3). therefore this study was performed at the aim of surveying pharmacists’ attitude toward special ethical dilemmas to find out pitfalls and incorporate the results of such studies into guidelines as well as designing a proper comprehensive teaching plan in pharmacy ethics. method we surveyed the pharmacists' attitude toward some common ethical issues in everyday working using a self-administered questionnaire. the survey was conducted on authorized iranian pharmacists from may 2010 to december 2010. nine scenarios were developed by authors based on common ethical problems in pharmacy practice. the questionnaire consisted of two parts: the first part assessed demographic data of study participants including age, gender, year of experience, and location of employment (pharmacy, manufacturer, and drug importer company); the second part consisted 9 scenarios using a 5-point likert scale with responses ranging from 1=strongly agree to 5= strongly disagree to assess pharmacists agreement on the presented reaction of the pharmacist in each scenario. two experts in medical ethics reviewed the questionnaire and commented before it was finalized. the survey instrument ensured partici pants anonymity and the participation was volunta ry. the reliability of questionnaire was estimated in 20 pharmacists using the chronbach's alpha coefficient of internal consistency which was 0.53. then the questionnaire was distributed in several continuing pharmacy education programs among pharmacists. the study was approved by tehran university of medical sciences institutional review board. all data were analyzed using spss software version 16. we categorized scenarios into 4 themes: confidentiality, autonomy, justice and non maleficence. for the whole questionnaire the strongly disagree answer was the most ethical answer. for easier analysis we considered the score of 1 for agree and strongly agree answers, score of 2 for neutral answers and score of 3 for disagree and strongly disagree answers. chi-square, one way anova and paired-sample t tests were used. results of 1000 questionnaire distributed between pharmacists, five hundred and five pharmacists (50.5%) completed and returned the questionnaire. three questionnaires were excluded because of printing defects. two hundred and sixty five (52.8%) participants were female and 196 (39%) were male. the mean age of participants was 43.2 ± 18.1 years and the mean work experience was 13.9 ± 10.3 years. of participants 87.8% (n= 390) worked in pharmacy, 5.6% (n= 28) in drug importer companies and 5% (n= 25) in manufactur ers and the rest of them did not mention their location of employment. the themes, and their associated scenarios were as follows: theme 1 (confidentiality); scenarios 1, 3, 7; theme 2 (patients autonomy); scenarios 2, 5, 6; theme 3 (non-maleficence); scenarios 4, 9; theme 4 (justice); scenario 8. participants’ answers to each scenario are summarized in table 1. the total score of the questionnaire calculated as 27, however the mean total score of participants attitude toward ethical issues was 17.69 ± 3.57. the total score in confidentiality for all participants was 4.15 ± 1.45 out of 9, in autonomy 6.25 ± 1.85 out of 9, in non maleficence 5.14 ± 1.17 out of 6 and in justice was 2.27 ± 0.89 out of 3. there was no significant page 2 of 5 (page number not for citation purposes) j med ethics hist med 2011, 4:5 pooneh salari, mohammadreza javadi, fariba asghari page 3 of 5 (page number not for citation purposes) difference between men and women in the total score and the score of each theme. in the theme of confidentiality 49.8% of participants got score 1-3, 40.1% score 4-6 and 10.1% score 7-9. of partici pants 24.7% got total score 9-15, 63.4% score 16 21, and 11.9% score 22-27. in autonomy theme 11.8% got score 1-3, 32.3% 4-6 and 56% 7-9 score respectively. in their attitude toward non maleficence 8.1% of the pharmacists, got 1-3 score and 91.9% got 4-6 score. regarding the age of participants and its effects on their attitude toward ethical issues, the older participants (> 40 years) significantly had lower total score (16.9 ± 3.78 vs. 18.58 ± 3.15) (p= 0.000) as well as the score of each theme (p< 0.05), but their age did not influ ence their attitude toward non-maleficence. the work experience showed impact on the pharmac ists' attitude toward autonomy and the participants with more than 5 years work experience signifi cantly obtained lower score (6.07 ± 1.84 vs 6.48 ± 1.64) in this theme (p= 0.038); however, work experience did not affect their attitudes toward the rest of the themes. the location of employment did not alter the pharmacists' attitude toward ethical issues studied in this survey. discussion overall the study participants obtained 65.5% of total score of ethical attitude which is less than expected and it seems to be because of lack of knowledge in this field. therefore the necessity of teaching ethics is of great importance. supplying enough information to patients by pharmacists raises several doubts about the type of information, the type of provision of information, the amount of information, to whom the information should be given which include considering ethical principles such as patients confidentiality, justice and autonomy, and non-maleficence as bioethics principles (4-6). obviously in ethical conflicts everybody has to choose the least bad option because there is no clear cut. veatch et al explained ethical dilemma as a problem which does not have a single right or wrong solution in which all people will agree (7). in professional ethics, decision making gets involved in procedural rather than normative ethics and is based on moral reasoning (8). in addition sometimes legal obstacles make the issue more complicated. however we suggested that the age, gender, location of employment and work experience of participants may affect their ethical reasoning. wilson et al believes that females show more tendencies toward empathy, verbal and social skills in contrast to men who are more interested in independence, dominance, space, and mathematics (9). latif provided support for this theory and observed higher level of ethical reasoning in female pharmacy students (10). gilligan stated that women show more responsibili ty in care while men have higher attitude toward justice (11). our results show that there is no difference between men and women attitude toward ethical issues such as confidentiality, autonomy, justice, and non-maleficence as well as their whole ethical view. although bill et al observed no difference between men and women attitude toward end-of-life care, female students responded more favorably toward death and end oflife care (7). role-modeling is used in medical teaching as a useful method of education in both ethical and clinical aspects (12). investigations indicate that seniors are considered as a model for their junior colleagues and students in clinical practice (13). so, their professional approach has educational consequences. bearing this in mind, our results worry us about the ethical attitude of seniors and its impact. considering the age, it was surprising that the older ones quantitatively had lower attitude toward justice, autonomy and confidentiality. therefore, they got lower total score of ethical attitude in this survey; while the age of the phar macists did not influence their attitude toward non maleficence. therefore, it is suggested that there is a consensus on the prima facie duty of non maleficence among most pharmacists. our study could not show any difference be tween pharmacists’ ethical attitude according to their neither location of employment nor the themes of confidentiality, autonomy, justice and non-maleficence affected. chaar developed a validated test as professional ethics in pharmacy (pep) and indicated that work place is the most significant predictor for pep test (8). yet the amount of the impact of work place on pharmacist ethical approach has not been described well, we expect community pharmacists rather than phar macists working in drug companies encounter more ethical dilemmas. work experience influenced the pharmacists attitude toward autonomy and the pharmacists who had more than 5 years work experiences had lower level of attitude toward autonomy; while their attitude toward the other themes did not differ. nilsson et al in a qualitative content analysis of interviews found that clinical experience affects clinical decision-making (14). previously vitell et al determined that infor mation disclosure is the most ethical problem the pharmacists encounter with (15). the total score of confidentiality of the study participants was 4.15 out of 9 and cumulatively 89.9% of them got less than 6 score. according to the scenarios, it means that most of the participants agree to disclose patients information to a close relative without patients permission because of utilitarianism and the rest of them (10%) considered patients privacy. these two ways of approaching confidentiality may be displaced at different situations. it seems j med ethics hist med 2011, 4:5 pooneh salari, mohammadreza javadi, fariba asghari page 4 of 5 (page number not for citation purposes) necessary to increase sensitivity of pharmacists to the consequences of their practice when disclosing patient’s information. the data analysis did not reveal any pattern helping in defining the reason underlying the pharmacists’ response. having pointing out these 4 themes as the most important dilemmas in this study, it seems reasonable to investigate further scenarios to find out the other critical issues. it would be of value to interview the pharmacists as well as pharmacy specialists more literally on their conceptions of the importance of these themes to identify the reason of choosing one answer by a pharmacist. the variation in the pharmacists answer to the scenarios might bring their different level of ethical knowledge as well as lack of a uniform approach. regarding the impact of ethical attitude in clinical decision-making, higher level of ethical attitude may provide more adaptability to work related constraints and those professionals with higher ethical attitude may less get involved in questionable clinical decision –making situations. none of the participants passed training course on pharmacy ethics in undergraduate level. it seems that pharmacy educational programs should more focus on enhancing students’ ethical attitude. in agreement with this hypothesis the successful incorporation of a multi-course sequen tial learning curriculum in nursing and dental students education was determined which increased their ethical attitude (12, 16). the authors willingly realize that due to the essence of the investigation, there was no realm for them to verify more details about the scenarios. several respondents revealed that they cannot reply to the questions without further information and the incidence of this was high enough. the response rate was somehow satisfactory however the rate of missing data more complicates the conclusion. it is important to notice that generalizing the conclusion of such studies in the real community using questionnaire is limited. therefore, a qualitative approach considering an interview is highly recommended. furthermore it seems that clinical moral and legal concerns should be incorporate in a pharmacy code of ethics in different specialties. acknowledgment this work was financially supported by the medical ethics and history of medicine research center of tehran university of medical sciences. the authors would like to thank all of the partici pants for their contribution. in addition we thank dr kiarash aramesh for his kind assistance. also the efforts of miss baghbani and her colleagues in 13 aban pharmacy are highly appreciated. table1. relative distribution of response choices for each scenario no of scenarios theme number (%) agree number (%) neutral number (%) disagree 1. disclosing information about a trans plant patient to his fiancé confidentiality 416 (85.8) 17 (3.5) 52(10.7) 2. proposing brands instead of generic drugs according to the insurance coverage autonomy 109 (22.9) 18 (3.8) 349 (73.3) 3. disclosing oral contraceptive usage by a girl to her mother confidentiality 293 (60.4) 28 (5.8) 164 (33.8) 4. dispensing amphetamines to a medical student non-maleficence 124 (25.3) 34 (6.9) 333 (67.8) 5. disclosing side effects of prednisolone to an asthmatic patient autonomy 319 (66.2) 26 (5.4) 137 (28.4) 6. proposing herbal drugs for alleviating postmenopausal symptoms instead of synthetic estrogen and progesterone autonomy 161 (32.9) 37 (7.6) 291 (59.5) 7. disclosing patients hiv/aids to the dentist who is his/her brother confidentiality 418 (86.7) 8 (1.7) 56 (11.6) 8. dispensing tramadol to a non-addict patient instead of an addict justice 143 (29.9) 61 (12.8) 274 (57.3) 9. assisting voluntary abortion in special situation non-maleficence 36 (7.5) 28 (5.8) 419 (86.7) page 5 of 5 (page number not for citation purposes) j med ethics hist med 2011, 4:5 pooneh salari, mohammadreza javadi, fariba asghari references 1. rawwas mya, vitell sj, festervand ta. ethical attitudes of pharmacists. health mark q 1994; 12: 97-112. 2. wingfield j, bissell p, anderson c. the scope of pharmacy ethics—an evaluation of the international research literature 1990-2002. soc sci med 2004; 58: 2383-96. 3. cooper r, bissell p, wingfield j. a new prescription for empirical ethics research in pharmacy: a critical review of the literature. j med ethics 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____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ 1 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e original article volume 13 number 2 april 2020 copyright © 2020 tehran university of medical sciences. this work is licensed under a creative commons attribution-noncommercial 4.0 international license (https://creativecommons.org/licenses/by-nc/4.0/). non-commercial uses of the work are permitted, provided the original work is properly cited. ethical considerations and challenges of sex education for adolescents in iran: a qualitative study kobra joodaki1, saharnaz nedjat2, marziyeh vahid dastjerdi3, bagher larijani4* 1. phd candidate in medical ethics, department of medical ethics, school of medicine, tehran university of medical sciences, tehran, iran. 2.professor, department of epidemiology and biostatistics, knowledge utilization research center, school of public health, tehran university of medical sciences, tehran, iran. 3.associated professor, department of obstetrics and gynecology, school of medicine, tehran university of medical sciences, tehran, iran. 4.professor, endocrinology and metabolism research center, endocrinology and metabolism clinical sciences institute, tehran university of medical sciences, tehran, iran. abstract adolescence is a period in one’s lifetime during which sexual maturation occurs. major changes and increased sexual instinct raise many questions in the minds of adolescents. receiving wrong education or inappropriate information can affect adolescents’ life and future deeply. obviously, ethical considerations cannot be ignored in nationwide macro policies and educational programs on such a sensitive issue. in this qualitative study, we attempted to explore the ethical considerations and challenges of sex education for adolescents. the study was conducted between may 2015 and march 2017. data were collected through semi-structured in-depth interviews with 25 participants, and maxqda 11 was used for coding. six hundred sixty-two codes (662) were extracted and classified into four categories: 1) the potential risks of sex education for adolescents; 2) the advantages of sex education for adolescents, and the approaches; 3) the challenges in the interval between sexual maturation and marriage, and the role of religion; and 4) the measures implemented in iran. shame, embarrassment, and some cultural beliefs surrounding the subject of sex education are obstacles to providing adolescents with the necessary information. according to the principles of medical ethics, the main principle in sex education is beneficence, and sometimes infringement of confidentiality has its advantages. keywords: ethical considerations; sex education; adolescent; medical ethics; reproductive ethics *corresponding author bagher larijani no. 10, jalal al-ahmad st., next to shariati hospital, chamran hwy., tehran, iran. tel: (+98) 21 88631296 email: emrc@tums.ac.ir received: 25 dec 2018 accepted: 26 jan 2020 published: 11 apr 2020 citation to this article: joodaki k, nedjat s, vahid dastjerdi m, larijani b. ethical considerations and challenges of sex education for adolescents in iran: a qualitative study. j med ethics hist med. 2020; 13: 2. ethical considerations and challenges of sex education for … 2 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 2 april 2020 introduction adolescence is a transitional period in life when rapid physical growth and development and sexual maturation lead to one’s physical capability to reproduce. based on the definition offered by who, adolescents are “young people between the ages of 10 and 19 years” (1). since adolescents and young adults are going through the growth stage, their health can be affected either positively or negatively by their interactions with their environment, their friends and peers, their parents and family members, people in the society, policies and social rules (2, 3). in the course of sexual maturation, adolescents undergo fundamental changes and face with questions and ambiguities, and if they do not receive the right answers, they turn to their peers or media such as satellite tv, internet and cyberspace. in this way, they often do not find proper answers and may even receive wrong ones, which will be problematic in the future. therefore, education on the subject of sex and sex ethics is a necessity that must not be overlooked, and not only has to be provided by the parents and the society, but is also a fundamental right of adolescents (4). due to its unique characteristics, sex education is accompanied by a number of challenges in all countries and cultures, and unique ethical considerations are associated with it (5). talking about these subjects in public is tabooed in some countries (6). in some western countries such as england, having sexual activity is accepted as a norm for young adults, but even in those countries there is a tendency not to talk about sexual intercourse and contraception with adolescents (7). in many muslim countries such as iran, sexual intercourse outside of marriage is prohibited both culturally and religiously (8,9). in such countries, sex education is insufficient and restricted, and is often avoided by teachers since they do not feel right talking about such subjects (10) there is currently no ongoing policy on sex education in iran. although sex education has improved and different aspects of it have been dealt with, there has been little discussion about the associated ethical issues or the development of moral codes (11). many studies have explored education about puberty and sexual matters in iran and have examined the necessity of sex education, the content of the educational material, educators, and time of the training rather than the existing challenges (8, 9, 12, 13, 14, 15). however, no studies have been conducted on the ethical considerations and challenges related to this topic thus far. there have been a few studies on the issue in western countries that have dealt with the ethics of sex education in general rather than adolescents and the issues specific to them (16,17). those studies that have included young adults were mainly focused on criticizing the policies and regulations of western countries in either advocating abstinence or offering comprehensive sex education, and compared the outcomes of the two systems of education with each other; in other words, they have not often dealt with the ethical considerations surrounding sex education (18, 19). joodaki k., et al. 3 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 2 april 2020 it is clear that ethical considerations cannot be ignored when nationwide macro-policies and educational programs are involved, especially regarding such a sensitive issue. in this qualitative study, we tried to clarify the ethical considerations and challenges of sex education for adolescents in iran. methods this qualitative study was conducted between may 2015 and march 2017. we used in-depth interviews and sampling of special or unique cases in this qualitative study due to its being flexible and in-depth (20). participants were selected purposefully, and the attempt was to choose diverse subjects who were knowledgeable and experienced in the topic of the research. to ensure confidentiality, their job and social status were not disclosed. the interviews lasted 25 65 minutes, the average duration being 42 minutes. the questions were open-ended and exploratory to encourage participants to express their personal experiences and help to conduct indepth interviews. the interviews started with an explanation of adolescents’ access to cyberspace and an uncontrollable environment, and information was obtained directly or indirectly about the subject. the main questions were extracted from studies conducted on education about puberty and sexual subject matters in iran, such as the necessity of sex education, the proper training age, choosing a suitable person for the purpose, teaching methods, educational content, the effect of cultural differences, the negative impact of knowledge or lack of education, and the difference between girls and boys. at the end of the interview, if the interviewees had adolescent offspring, they were asked: “what do you do for your adolescent offspring in the way of sex education?” the discussions continued until data saturation was reached when participants proposed no new items in the last three interviews. the interviews were transcribed verbatim. qualitative analysis after a final review of the transcripts, the max-qda 11 software was used for the coding process, and the data were analyzed through corbin and strauss’s content analysis method (21). the first stage or substantive coding was done, a theme was ascribed to basic concepts in sentences and paragraphs, and the main theme was identified. subcategories also emerged when coding at the next stage, and similar themes were placed in one subcategory or group. the classified concepts were then compared with each other and subcategories were put in categories. at the final stage, the main categories were formed. the trustworthiness of the study the trustworthiness of the study was assessed to confirm data accuracy in terms of the following four criteria: dependability, credibility, transferability, and conformability (22). to increase the dependability of the research, the codes were reviewed several times in order to classify them and find the main themes and main categories. knowledgeable participants were selected from a large variety of majors, and triangulation technique was used to increase ethical considerations and challenges of sex education for … 4 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 2 april 2020 the consistency of the study (23). the recorded files of some interviews, their transcriptions, and the extracted codes were sent to some of the participants to confirm the transcription and method of coding (conformability). to heighten the reliability of the research, an external rater was used. five anonymous transcribed files were coded by a researcher who was not involved in the study. the similarity of coding was estimated to be more than 75 percent (transferability). ethical considerations the participants were informed about the purpose of the study and their verbal informed consent was obtained. the researcher guaranteed privacy and confidentiality of the information, protection of recorded voices, and anonymity of the transcriptions. whenever asked by the participants, the researcher would turn the recorder off. it should be added that this article was part of a larger study done for a ph.d. dissertation in medical ethics, approved by the ethics committee of tehran university of medical sciences (approval no. ir.tums.rec.1395.2508). results in the present study, twenty-six participants were interviewed. the demographic and background characteristics of the participants are presented in table 1. after the interviews were transcribed, one of the participants asked to be excluded from the research. table 1. demographic and background characteristics of participants (n=25) demographic no. age (yr.) 25 44 45 64 65 and > 10 11 4 gender female male 16 9 marital status single married 5 20 having teenage children yes no 19 6 education less than high school diploma high school diploma bachelor’s degree master’s degree phd doctor of medicine degree 1 1 4 2 7 10 joodaki k., et al. 5 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 2 april 2020 demographic no. background characteristics of participants  physicians and medical ethicists   doctors of theology (islamic studies) and religious experts   clients in health centers, one with a primary school certificate and one with a high school diploma (12 grades of schooling)  clinical psychologists holding master’s degrees who worked in health centers as psychologists and counselors for behavioral disorders and as mental health experts   midwives: three of them offered contraceptive services as health care providers in a clinic, and one worked in a maternity hospital   medical specialists: one pediatrician; one occupational medicine specialist, and medical ethics teacher; one psychiatrist, religious expert, and medical ethics teacher; one pathologist, religious expert, and medical ethics teacher; three gynecologists and obstetricians experts (graduates) in basic medical sciences including: a phd in clinical pharmacy who is also a medical ethics teacher; a nutritionist, phd, and religious expert; a phd in environmental health; an md, phd in reproductive health; a phd in communityoriented medicine and fellow of sexual behavior (sexology); a phd in epidemiology 3 1 2 2 4 7 6 six hundred and sixty-two (662) codes were extracted from 25 interviews. these codes were classified into 25 themes, 12 subcategories and four categories (table 2). table 2. ethical considerations and challenges of sex education for adolescents categories subcategories themes potential risks of sex education for adolescents harmful effects of sex education on adolescents having sexual intercourse without fear of its consequences encouraging them to practice sex disapproval of sex education by the society and organizations unpreparedness of the society and the educational system interference between cultural and religious affairs advantages of sex education for adolescents, and the approaches harms of not offering sex education to adolescents misconception that adolescents are encouraged to practice sexual acts by being informed violation of adolescents’ rights unwanted pregnancies adolescent sexual abuse disadvantages of not knowing about a healthy spousal relationship getting wrong information from inappropriate resources ethical considerations and challenges of sex education for … 6 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 2 april 2020 categories subcategories themes appropriate age for sex education the necessity for sex education and providing the needed information age-appropriate education educators the role of the family friends and peers the role of cyberspace teachers in schools education by a specialist media pharmacies methods of sex education for adolescents educational content the method for education decreased age of starting sexual intercourse decreased age of learning about sex topics the role of technology advancement and modernity increased sexual relationships in adolescence challenges in the interval between sexual maturation and marriage, and the role of religion the necessity of decreasing the age of marriage the necessity of establishing a moral institution to resolve the challenges pertaining to the interval between sexual maturity and social maturity abstinence creating normal anxiety to prevent sins measures implemented in iran teaching about puberty in universities and schools lack of transparency in the education system of iran inconsistencies related to sex education in schools the four main categories included: the potential risks of sex education for adolescents; the advantages of sex education for adolescents, and the approaches; the challenges in the interval between sexual maturation and marriage, and the role of religion; and the measures implemented in iran. subcategories, themes, and some participants’ statements are presented in tables 3 6. joodaki k., et al. 7 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 2 april 2020 table 3. category of the potential risks of sex education for adolescents subcategories themes quotes and examples harmful effects of sex education for adolescents having sexual intercourse without fear of its consequences one of the medical specialists stated: “we teach them. we help a 13-year-old girl; an 11-year-old boy satisfies his sexual desire. we help them, we prepare the way and the ground for their sexual activities. they experience it whenever they can.” (no. 24) another medical specialist mentioned: “the education is for times when sexual activities are legitimate and within the islamic framework. outside of this framework, adolescents should remain uninformed in order not to be sexually stimulated. once the function of a body organ is known, especially in case of reproductive organs, they want to put it into action to see the effects. simultaneously, their sexual desire is triggered. considering all this, our educational measures help to propagate sexual immorality.” (no. 21) encouraging them to act one of the medical ethicists maintained: “sex is a powerful force. it is neither the desire for something edible or drinkable, nor an artistic work or music, so we cannot expect an adolescent to control himself/herself if he/she craves it. can he/she? definitely not! if you offer him/her sex education, you have actually prepared the ground for him/her to have sexual activities; he/she does it in any possible way, the first opportunity he/she gets.” (no. 16) on the subject of sex education and provoking curiosity in adolescents, one of the medical specialists stated: “i cannot say this for sure, not without evidence, but based on my own experience, i think if sex education starts sooner than the appropriate time, or if it is done very openly, it provokes curiosity.” (no. 7) one of the clients of a health center explained: “sometimes knowledge leads to wrongdoing; perhaps it depends on the kind of family the child is brought up in.” (no. 4) disapproval of sex education by the society and organizations unpreparedness of the society and the educational system highlighting the unpreparedness of the social climate, a ph.d. believed that sex education puts young adults at risk: “naturally, the society is not ready yet so that we can offer sex education directly to adolescents. why isn’t it ready? because the educational system does not have sufficient platforms for this; we are always worrying about the challenges, and we should always be cautious not to jeopardize adolescents and put them at risk by giving them sex education.” (no. 19) interference between cultural and religious affairs one of the medical specialists mentioned: “we have a major challenge: the interference between religious and cultural views. most of the times religion allows us but culture doesn’t. we do not have any rules about this. based on our constitution, we borrowed a rule from religion, but even our religious leaders gave in to politics. this is the very thing that keeps us silent. why should i victimize myself more in my domain of work where i am influential but not supported by the system?” (no. 7) ethical considerations and challenges of sex education for … 8 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 2 april 2020 table 4. category of the advantages of offering sex education to adolescents, and the approaches subcategories themes harms of not offering sex education to adolescents misconception that adolescents are encouraged to practice sexual acts by being informed violation of the rights of adolescents unwanted pregnancies adolescent sexual abuse disadvantages of not knowing about a healthy spousal relationship getting wrong information from inappropriate resources appropriate age for sex education the necessity for sex education and giving needed information age-appropriate education educators the role of the family friends and peers the role of cyberspace teachers in schools education by a specialist media pharmacies methods of sex education for adolescents educational content the method for education decreased age of starting sexual intercourse decreased age of learning about sex topics the role of technology advancement and modernity increased sexual relationships in adolescence table 4-1. subcategory of the harms of not teaching sex education to adolescents themes quotes and examples misconception that adolescents are encouraged to practice sexual acts by being informed one of the phds disagreed with the view that being informed of sexual subject matters encourages adolescents to have sexual relations: “because i am talking about an adolescent, a human being. those who disagree with sex education were themselves once adolescents; they are human beings. firstly, they have to challenge themselves, they should go deep into their mind. you, i, that physician, that religious leader should go deep into our minds and ask ourselves, ‘once i became familiar with sexual relations in my sexual world, did i practice sex?’ ” (no. 19) violation of adolescents’ rights one of the phds considered the necessity of education as one of the main rights of adolescents: “yes, they have a right to know. they have the right to know what the norms of their sexual value system are. they are not like weed that grows automatically. we as adults, we as knowers, i as the mother or teacher should know how to give value to their sexual world. when they understand this value, certainly their responsibility increases.” (no.19) unwanted pregnancies one of the phds explained: “i wonder what the authorities plan to do about what is currently happening and what we hear now and then. it seems they want to ignore these adolescents so that … this means we let young adults give birth to illegitimate children.” (no. 25) adolescent sexual abuse one of the clinical psychologists stated: “we, as psychologists, believe that we should make even pre-school and school children aware of the intimate parts of their bodies to prevent potential abuse. we believe that from 4-5 year-old children and younger to adults who, for instance, are university students, all need to be given scientific and academic sex education under the supervision of a professional. there is no difference; everyone needs sex education their age. children need to be educated due to the rapes that are reported more frequently nowadays.” (no.12) joodaki k., et al. 9 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 2 april 2020 themes quotes and examples disadvantages of not knowing about a healthy spousal relationship a phd, who was also a religious expert, stated: “an important problem is lack of knowledge that is essential for young couples. this shortage manifests itself in disagreements, misunderstandings separations, and other problems.” (no. 23) a gynecologist and obstetrician explained: “we have cases who have been married for a couple of years, but cannot bear the smallest sexual touch or physical contact because of the fears they had, caused by myths their family told them about sexual relationships.” (no. 20) getting wrong information from inappropriate resources many experts pointed out to the harms of getting wrong information from inappropriate resources. one religious expert said: “it is absolutely wrong to keep silent, to keep our mouths shut, not to talk about sexual subject matters, to let them get information from the disturbed market outside and immoral sources while we are happy that they know nothing.” (no. 23) one of the medical ethicists stated: “it may be harmful if the education is inappropriate. for instance, porn movies are the worst kind of education. these movies show sexual violations and unrealistic or wrong sexual behaviors in a way that the adolescent child thinks they are good and healthy sexual relationship. these movies not only are not educational but are absolutely harmful.” (no. 18) table 4-2. subcategory of the appropriate age for sex education themes quotes and examples the necessity for sex education and giving the needed information one of the religious experts explained: “some say that we should talk to adolescents about sexual subject matters when they enter puberty. i do not have a good experience of this. i feel children should be told about sex topics gradually from childhood when they come to understand sexuality – for instance at 9 or 10 years old – and we should make them ready little by little; then we can continue by telling them if extra information and tips are needed.” (no 22). one of the midwives said: “sex education should be started from a very young age. since website contents are replete with inappropriate and uncontrolled information about sex, the sooner sex education starts, the better it is.” (no 11). age-appropriate education a very large number of codes were pertinent to age-by-age and age-appropriate education. in this respect, one of the medical ethicists stated: “i think education should be age-by-age and start from the onset of puberty.” (no. 24) one of the clinical psychologists explained: “some adolescents may concentrate on their studies and some may not. perhaps some adolescents would like to experience sexual activities earlier than others and therefore questions arise for them about sexual topics. these things really matter.” (no.12) ethical considerations and challenges of sex education for … 10 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 2 april 2020 table 4-3. subcategory of educators and the resources for gaining information themes quotes and examples the role of the family one of the clinical psychologists explained: “generally we say that parents should start sex education from childhood by teaching their children the correct names of genital organs as private parts of their bodies. nevertheless, if the parents do not know how to do this, they have to be taught.” (no.12) one of the phds stated: “parents should have a complete parenting education program. they should know how to teach and convey educational contents to their offspring.” (no.19) one of the religious experts said: “i would prefer a friendly teacher as a counselor in the school to tell students about such topics rather than myself; it is better that mothers do not tell them anything.” (no.22) one of the clients of a health center said: “people’s manners of speaking about such topics are very different. someone may speak comfortably, openly, and extensively with no censorship. i myself prefer not to give all the details.” (no. 6) one of the medical ethicists stated: “due to the embarrassment and shame that exist in our families – and many believe there is no reason for it – we cannot talk about such topics. unfortunately, this is the case in our family; therefore, parents cannot act as counselors of sex education for their offspring, even though they are the safest and most empathetic people for their kids. sadly, this is how things are in our society.” (no.16) with regard to the difference between girls and boys, one of the clinical psychologists stated: ” based on what i know and studied and learned in the workshops, it is preferable that sex education be given by the same-sex parent of the adolescent from puberty on; for girls, sex education should start from their first menstrual period. at puberty, a series of changes happen to boys. a 15-16-year old boy may have night-time erections. as parents we should be able to answer the questions of these curious minds.” (no.12) friends and peers most of the participants believed that the role of friends and peers in sex education is negative as they may convey wrong and harmful information. one of the health care experts said: “but if they get the information from their friends, they may be encouraged to have sexual experiences.” (no.12) the role of cyberspace most participants referred to the role of cyberspace in education about these affairs and highlighted its uncontrollability, wide accessibility, and negative effects on the education of adolescents. one of the phds stated: “previously, children’s access to such information was limited. they could only ask their friends. now all of them have access to cyberspace on their cell phones. therefore, they certainly go there and get wrong information.” (no.1) teachers in schools one of the medical specialists stated: “such subjects should be taught by a teacher who is always present in the school, not by someone from outside who teaches and leaves. the reason is that a student may have no questions when he/she is being taught, but that does not necessarily mean that he/she has no problem or will not have any problems in the next week. students should know that they can refer to the teacher who has taught them whenever they have a question. of course, the teacher should be selected very carefully and cautiously.” (no.8) education by a specialist one of the psychologists said: “i emphasize that it should be a reliable form of education under the supervision of specialists. in this way, they are not sexually stimulated.” (no.12) one of the phds explained: “iatrogenic factors that happen in case teachers are non-professional or non-expert in sex education are definitely harmful.” (no.19) media participants advocated making use of the media for sex education, though cautiously. one of the medical ethicists stated: “education has to be started in the family; media should have a role in education too; the significant subject matters should be presented in mass educational media.” (no.13) pharmacies due to adolescents’ referral to pharmacies to get contraceptives, one of the phds suggested the opportunity for sex education in pharmacies and said: “if a 14-15-year old adolescent refers to a drugstore and asks for contraceptives, he/she can receive it. however, firstly he/she has to be guided. here the adolescent is showing that he/she has the right to know. the pharmacist has to give the necessary information to him/her and guide him/her toward safe behaviors.” (no.3) joodaki k., et al. 11 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 2 april 2020 table 4-4. subcategory of the methods of sex education for adolescents themes quotes and examples educational content teaching reliable scientific materials was highlighted by some participants. a clinical psychologist said: “i agree with sex education 100 percent, but the content to be taught should be reliable and offered under the supervision of specialists.” (no.12) considering adolescents’ background information was also highlighted by many participants. one of the gynecologists stated: “it’s almost a crime to cause adolescents to have an unhealthy attitude toward sexual subject matters; or distract the thoughts of adolescents who are only busy with their studies to issues which they were not supposed to know.” (no.20) one of the medical ethicists explained: “some factors are influential here, for example, how much information they get from other resources. because when education is wrong, they may receive wrong information.” (no.18) another question was, “should adolescents’ living place and local culture influence the type and method of education?” some of the participants highlighted the cultural differences between cities or even between various areas within a city, which lead to different needs of the adolescents for education. one of the clinical psychologists said: “education should be given based on adolescents’ continuum of development; it should be appropriate for their age range and in accordance with their culture and the family in which they are growing up.” (no.12) one of medical ethicists said: “there should be a specialized program for education based on adolescents’ age, gender, geographical location, culture, and the content of the subject matter to be taught. for instance, teaching some topics may have priority over some other topics when you are teaching boys; the same is true for education of some topics in accordance with age. or education may be different based on whether you are teaching in a city or a village; it has to be. seemingly we fail if we cannot develop a specialized program for education.” (no.16) the method for education participants insisted on indirect teaching. one of the religious experts said: “we are facing a dilemma: should we be silent and allow adolescents to do as they wish, or should we teach them responsibly and within a framework of educational and moral structure? but this doesn’t have to be announced explicitly on media or in public where 6-year-old children would hear and ask what the whole thing means. the information has to be given wherever it has to.” (no.23) one of the midwives said: “yes, it should not be taught overtly. for instance, we can say to them that there are methods people use to prevent unwanted pregnancies; of course, this should be done as indirectly as possible; however, naming the methods may be inappropriate in some cultures; for instance, telling boys directly to use condoms may be very unpleasant. i myself have a son, it will be very embarrassing for me if someone comes and says this to my son.” (no.14) ethical considerations and challenges of sex education for … 12 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 2 april 2020 table 4-5. subcategory of the decreased age of starting sexual intercourse themes quotes and examples decreased age of learning about sex topics most participants expressed their worries about the decreased age of learning about sexual topics. one health care expert who had been to a middle school to offer health education to students stated: “they knew many things, i mean they knew much more than a 40-year-old woman in the past generation, they knew everything. i was supposed to teach them, but they themselves knew everything in detail.” (no.10) another health care expert told about students in the first grade of high school: “i realized from what they said that they knew many things about sexual subject matters, they knew everything, and most of them stated this overtly.” (no.14) the role of technological advancements and modernity with respect to technological advancements and modernity, one of the medical ethicists explained: “if you live in a city where you have electricity, a cell phone, and a tablet, you cannot restrict their accessibility to the resources.” (no.18) table 5. category of the challenges in the interval between sexual maturation and marriage, and the role of religion subcategories themes quotes and examples the necessity to decrease the age of marriage one of the medical ethicists said: “in a religious society, it can be helpful if the education is based mainly on informing adolescents, which leads to abstinence, and simultaneously the policies are to decrease the age of marriage. it is not reasonable to demand that individuals practice abstinence when a very strong force from outside is telling them the reverse. but if you focus your attempts on decreasing the age of marriage to 19 or 20 years, you can expect them to wait because in this way they think that they can marry 2 or 3 years later and tell themselves that when they finish high school, they will. in such conditions, you can expect abstinence from adolescents.” (no.16) the necessity of establishing a moral institution to resolve the challenge of the time between sexual maturity and social maturity one of the medical ethicists said: “in the current situation, it is impossible. therefore, the society can establish a moral institution in which adolescents can have sexual relationships in the interval between puberty and marriage; a relationship acknowledged by the society that commands commitment, not promiscuousness, and is based on common sense and ethical and social principles. meanwhile, adolescents will receive sex education at the right time. such an institution is absent in our society." (no.18) abstinence creating normal anxiety to prevent sins the opinions about abstinence and adolescents’ ability to practice it were different. one of the medical ethicists stated: “you cannot expect an individual whose sexual impulsions have been activated since 15 to practice abstinence. you don’t have the right to pressure him/her to wait until 30 to marry. this means that you want them to practice abstinence for half of their lives. are the teachers who sex educate themselves able to do this?” (no.16) one of the phds believed that intense sexual desire can be controlled through education: “why should young adults be taught to be animalistic or be told they are not able to control their sexual desires? if i am to teach them, i joodaki k., et al. 13 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 2 april 2020 subcategories themes quotes and examples will tell them that sex drive exists, but it is controllable; i will tell them that sexual activities are not the only source of pleasure, we can derive pleasure from drinking this tea as much as the pleasure we derive from watching a woman or a man. now they can choose for themselves. i will give them measuring devices to choose by. i will not speak nonsense. i will tell them to think and see which pleasure has priority for them, so they can choose.” (no.19) one of the phds said: "such moral issues are not resolved by forbidding watching videos or satellite tv. these measures are not helpful. the only way is the way of the prophets. prophets tried to prevent moral corruption by their power. if they had no power, they tried to train and guide human beings. how? by giving human dignity to human beings, through fear of divine retribution and promises of divine rewards.” (no.23) table 6. category of the measures implemented in iran, and the related challenges subcategories themes quotes and examples teaching about puberty in universities and schools one of the specialist physicians stated: “at that time we did this: we set aside the educational system and financially supported any institution that had political power. we were friends with representatives in the iranian parliament, and we knew university authorities. we went ahead and prepared puberty packages and gave them to the girls.” (no.7) a ph.d. said: “in cooperation with the ministry of health, schools and the educational system can set certain objectives and develop a course for education in schools. of course, this education should not violate the norms but should still be informing.” (no.25) lack of regularity in education in iran inconsistency of sex education in schools in this regard, one of the ph.ds. said: “what is happening today is that everyone acts as they wish. one school starts sex education very soon, another teaches all about it in detail, and another one does not offer any education, everyone does whatever they like.” (no.9) 1. the potential risks of sex education for adolescents the participants disapproved of providing adolescents with sex education mainly on account of possible harmful effects. some of the hazards pointed out by the participants were: engaging in sexual activity following sex education; having sexual intercourse without fear of the consequences; being sexually stimulated as a result of curiosity about sexual subjects; and feeling encouraged to experience sexual activities. the participants also emphasized the necessity for conducting a study on the role of sex education in propagating sexual relations. furthermore, they strongly disagreed with open and direct sex education, reasoning that the society and the predominant climate of the iranian educational system are still not ready for it. ethical considerations and challenges of sex education for … 14 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 2 april 2020 most of the participants highlighted the taboo of talking about sex topics in the society and some of them mentioned the prevalent social atmosphere as the reason for their disagreement. this category was classified into two subcategories and four themes. the category and the related subcategories, themes, and some participants’ statements are presented in table 3. 2. the advantages of sex education for adolescents, and the approaches in the current study, most of the participants agreed on the necessity of sex education. although they mentioned the harms of lack of sex education, they indicated the dominant cultural atmosphere of the society and the taboo of talking about sexual subject matters in the society and families, and believed that public presentation of sex education can interfere with modesty and chastity in the society. some of the participants did not see a formal and clear discussion about these subjects as appropriate and proposed certain considerations; for instance, they believed that sex education should not violate the norms or encourage an individual to have sexual activities. most participants agreed on the importance of providing reliable materials for teaching and indirect education, and highlighted the necessity of educating individuals who have risky behaviors. in support of sex education, advocates mentioned the fundamental right of adolescents to be informed about the subject, the decreased age of learning about sexual matters and engaging in sexual relationships, the effect of advancements in technology and modernity on this matter, and the increase in unsafe sexual relationships among adolescents caused by the inappropriate behaviors of families, wrong education, and internet accessibility. as for the disadvantages of not offering sex education and using the reductio ad absurdum rule, they mentioned adolescent sexual abuse, receiving wrong information from inappropriate resources, increased rates of unwanted pregnancies, illegitimate births and abortion, lack of information about proper marital relations, increased divorce rates due to sex-related problems, and fear of building legal and legitimate sexual relationships. some of the participants advocated sex education for adolescents, arguing that it would prevent unwanted pregnancies and thus decrease the rate of abortion and birth of illegitimate children. this category was classified into five subcategories and 20 themes. the category is presented in table 4, and its subcategories and related themes and some interviewees’ statements are separately shown in tables 41, 4-2, 4-3, 4-4 and 4-5. 3. the challenges in the interval between sexual maturation and marriage, and the role of religion one of the challenges proposed by participants pertains to the interval that exists between puberty and marriage. the main concern was that it is not rational to educate adolescents on sexual relations and contraception but expect them to wait until they are married, which may be as long as 20 years away. joodaki k., et al. 15 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 2 april 2020 this category was classified into three subcategories and one theme. the category and its related subcategories, themes, and some interviewees’ statements are presented in table 5. 4. the measures implemented in iran, and the challenges most participants believed that there is no consistent policy regarding sex education in iran, and the predominant atmosphere in the society and the ministry of education prevent the issue from being properly dealt with. they also considered the measures taken in iran as insufficient. they believed that there is no clear policy with regard to sex education in schools, and that sex education is offered based on what the people in charge think should be done. consequently, lots of students do not have sufficient awareness of pubertal health or the necessary skills to select proper sex behaviors. this category was classified into two subcategories and one theme. the category and its related subcategories, themes, and some participants’ statements are presented in table 6. discussion like many other countries, there is no consistent policy on sex education in iran, and the predominant atmosphere in the society is the main cause. some of the arguments that have been proposed in opposition to sex education include the harmful effects of sex education on adolescents, non-existence of the required infrastructures in the educational system and schools, and the clash between culture and religion. however, sexual abuse of noninformed adolescents, and unwanted pregnancies and consequent unsafe abortions were pointed out as some of the harms and unpleasant outcomes of an absence of sex education. we will discuss our findings according to the different categories extracted in this qualitative study. the potential risks of sex education for adolescents only a few participants were against sex education for adolescents, and believed the appropriate time for sex education to be after puberty and at the time of marriage. the reason for their disagreement was the harms brought about by sex education. these results are in accord with those of other studies that showed most parents agreed with sex education for adolescents, and only a few were against it. in a survey, more than 80 percent of the parents agreed with sex education in schools and only a few parents disagreed because they were worried that sex education would provoke the curiosity of adolescents and encourage them to have sexual activities (24). in a nationally conducted study in the usa, the data obtained in surveys from parents of adolescents studying in high schools showed that 90 percent of parents believed that it is either absolutely or almost essential to offer sex education in schools. only seven percent of the parents disagreed with sex education and providing information on contraception in schools. (19) moreover, only a few studies reported that sex education caused an ethical considerations and challenges of sex education for … 16 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 2 april 2020 increase in sexual activities (25). the advantages of sex education for adolescents, and the approaches the findings of our study are in accordance with other studies conducted in iran and elsewhere. kalantary et al. reported that appropriate sex education leads to the development of adolescents’ self-esteem and their skills in decision-making as well as decreased high-risk behaviors (5). the harms of not educating adolescents in sexual matters despite the common belief that sexual health education encourages adolescents to have sexual relations, a study shows that lack of sex education not only does not prevent sexual relationships, but also develops and solidifies false beliefs and information among iranian adolescents. when adolescents do not receive sex education, they turn to porn journals and websites as well as sexual content on satellite tv channels (14). also, a review of 65 articles showed 7.9 percent of the boys and 19.7 of the girls had been sexually abused under the age of 18 (26). the above-mentioned information has been confirmed by numerous studies in which adolescents have expressed their desire for training in sexual matters. they believed that receiving detailed information at a younger age does not increase the chance of practicing sex, but limited knowledge may arouse curiosity and encourage adolescents to experience sexual relations (8). lack of knowledge and the right attitudes toward pubertal and reproductive health may cause many adolescents to have negative feelings and a sense of guilt toward their pubertal processes and sexual desires, which may lead to consequent problems and adverse effects in their future married life (6). one study showed that receiving information about aids and sexual health correlated with more positive attitudes toward sexual abstinence. it also revealed that students’ needs and expectations in terms of learning about aids and sexual health are not satisfied in schools (18). age-appropriate education one of the main challenges with regard to sex education was determining the proper time, and a consensus could not be achieved among participants in this respect. most participants highlighted taking adolescents’ age and background information into account and opted for indirect education. obviously, there is a different time for teaching various aspects of health (physical, sexual, mental and social) in puberty. further investigations are needed to determine the proper time for education in each aspect of pubertal health, considering the sociocultural factors of the society (15). this education has to take place before the beginning of puberty, and the gender of the adolescent needs to be taken into account; in this way, adolescents become familiar with the signs and changes associated with puberty so that they will not be frightened by them, and will thus be able to resolve their problems (27). informing adolescents of sex topics has to start a little sooner than the time they engage themselves actively in these issues (16). most parents and teachers know the time for sex education, for instance issues such as fertilization of ovum and pregnancy may be discussed with girls near joodaki k., et al. 17 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 2 april 2020 the time of marriage, and the best time for teaching about sexually transmitted diseases may be in high school. however, teachers consider the right time for sex education to be sooner than the time pointed out by parents (9). in another study on adolescents in iran (2010), some students believed that education on topics such as menstruation is more helpful in the final years of primary school; they also commented that sex education at the time of marriage – which is common in iran – is too late and senseless (28). in a review article it was mentioned that the proper time for teaching different aspects of pubertal health is different; according to this study, in order to bring about maximum benefits for adolescents, the proper time for sex education should be determined based on the sociocultural conditions of the society. this study pointed out that sex education for girls should be started before puberty and around the ages of 9 to 10 (8). educators and training resources the first resource for education on puberty is families, especially mothers. unfortunately, research findings show parents’ lack of sufficient information or skills for teaching valuable content to their offspring; moreover, feelings of shame and embarrassment lead to negligence in transferring experiences and knowledge by parents, or even in schools (5, 29, 30). also, parents and educators sometimes do not have the necessary information about sexual behaviors and issues related to puberty. they may simply not know how to talk about such subject matters to adolescents (8, 31). in our study, participants named teachers as the most reliable resource for education after parents. however, they emphasized that teachers should have the required skills and proficiency on the subject. in most studies, adolescents reported that they received critical information about sexual subject matters from their friends, siblings and media rather than the material that is formally presented in schools. in a study, malek et al. found out that adolescents’ resources for gaining information about sexual health are their close friends, photos, magazines, books, audiovisual tools, school teachings, physicians, islamic religious leaders, counseling centers, family and close relatives, respectively (32). studies also showed that receiving unreliable information from friends could be a risk factor for highrisk behaviors (33). female adolescents’ primary resource of information about puberty is their mothers and near others in their family. their resources about sexual subject matters, however, are their friends, which they confirmed to be unreliable (34, 35). boys become familiar with sexual subject matters by their friends or in military service (29). numerous studies have highlighted the negative role of satellite tv channels and the internet, which they have shown to be not only unreliable resources for sex education, but also sexually stimulating (36, 37). iranian adolescents are bombarded by multiple sexually stimulating messages that lack right and sufficient information about sexual reproduction. a study showed that learning about sex from peers and media correlates with increased ethical considerations and challenges of sex education for … 18 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 2 april 2020 probability of having sexual intercourse, while learning from adults (parents or religious leaders) will more likely lead to abstinence (38). another source of information that had not been reported by other studies was pharmacists. when adolescents refer to these professionals to obtain contraceptives, they can gain proper knowledge, learn how to protect themselves, and be warned of highrisk behaviors. the other challenge reported by a few other studies (36, 38, 39) was the families’ awareness of sex education offered to their adolescent children. in our study, most participants emphasized that parents have to know the content of materials taught to their offspring and some of them highlighted that no education should be offered to the students without their parents’ permission; they also mentioned that informing the parents should be compulsory, especially when the students were in early adolescence years and under legal age. mothers have been shown to have concerns and fears about their daughters’ vulnerabilities, and potential physical and psychological harm to them. there is a sort of conservatism in iranian families pertinent to their offspring’s sex education. the discussion about such matters seems indecent to typical iranian parents (39). a study showed iranian adolescents and young adults are not sufficiently skilled to manage their sexual activities. the main reason for this problem was pointed out to be inappropriate interactions between parents and offspring (38). a study showed that mothers and fathers employ different methods when dealing with their children’s sexual issues; their approach to the subject is influenced by the sort of sex education that they themselves received, their value and belief system about sexual subject matters, and their attitudes toward such issues (36). a study by sajjadi et al. showed that fathers’ awareness about puberty in boys is not at an acceptable level, and 88.9 percent did not have accurate information about the religious aspects of puberty in boys and the time they are obligated to take full responsibility under islamic law (40). the results of another study which aimed to determine the educational needs of fathers for the puberty period of their sons showed that the highest frequency in the educational needs of boys during puberty is related to religious subject matters (41). lack of fathers’ communicative skills is not exclusive to the iranian society. for instance, mothers talk more than fathers about sexual subject matters to their sons in the us. furthermore, girls are more comfortable talking about sex topics with their mothers than boys (42). method for sex education the results of the current study are in line with those in other studies. sex education should be offered in a way that it would cause the lowest rate of complications possible. considering that all sexual subject matters are not at the same level in terms of being sexually stimulating, it is suggested that subject matters that are more so be educated indirectly (43). educational contents and materials have to be comprehensive, sufficient, and cover all the aspects of puberty. furthermore, the joodaki k., et al. 19 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 2 april 2020 method for teaching the materials must increase the effectiveness of education so that it will lead to skills development through proper planning and use of different methods (8). training should not discourage individual from engaging in sexual practices, and the materials should cater to all personality types in adolescents. it is a widely held belief that that if sex awareness is not formed appropriately, it can be a risk factor for other problems. moreover, sex education has to be proportionate to individuals’ gender, age, level of cognition, and sociocultural background (44). decreased age of starting sexual relations most participants expressed their worries about the decreased age of learning about sexual topics. considering the increase in sexual relationships among adolescents, participants highlighted the necessity of sex education, especially for individuals with high-risk behaviors, in order to improve their knowledge and prevent unpleasant outcomes. some referred to the difference in the increased rate of adolescents’ sexual practices in various areas of the cities, and some who had experienced working in this field saw no such difference, but confirmed that the relationships were safer and more protected among families with higher educational levels. detailed statistics reported in studies of other countries showed that the abovementioned factors were the main reasons for having approved laws for compulsory sex education in schools, but statistics are not accurate in iran. however, according to the statistics published by the iranian ministry of health and medical education and a study conducted by the iranian ministry of education, the condition in iran is similar to that in western countries. one study confirms the increased rate of sexual relationships before marriage among iranian adolescents (6, 45). evidence shows that the pattern of hiv transmission due to sharing needles and drugs injection equipment has changed to unprotected sexual intercourse among iranian young adults (46). in the report titled “islamic republic of iran َ aids progress report: on monitoring of the united nations general assembly special session on hiv and aids”, 6.1% of men and women aged between 19 and 24 answered they had had sexual activities under age 15 (47). the challenges in the time between sexual maturation and marriage, and the role of religion one of the issues mentioned by some of the participants that had not been reported in any other study was about the relatively long time between sexual maturation and marriage. the sexual instinct is at a peak during this time, and there exists an abundance of environmental stimulation while adolescents have no prospect of marriage. the common sense among iranians, the religion of islam, and some abrahamic religions recommends selfrestraint (abstinence) in this period. participants mentioned that it is not rational to expect one to practice abstinence sometimes 20 years after sexual maturation, considering the conditions in the society and ethical considerations and challenges of sex education for … 20 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 2 april 2020 the increased sexual stimulations in the community. temporary marriage (sigheh) was also referred to as one solution to this problem. moreover, the necessity to decrease the age of marriage was mentioned. studies confirm the effectiveness of religious beliefs and faiths on appropriate sex education and controlling and preventing sexual relationships before marriage or out of wedlock. in our research, religious experts and some other participants believed that islamic doctrines are comprehensive in terms of sex education. they mentioned that sexual discipline in islam starts from early childhood by giving gender identity to children. as children and adolescents develop, training should become more specific, deal with physical and psychological health, and highlight the legitimate use of sexual instinct. education on puberty and sexual health is considered to be the duty of parents and is parallel to the educational role of prophets, god’s warnings and promises. they also believed that in addition to providing adolescents with the necessary information on sex topics, creating a fear of the unpleasant outcomes of sexual perversion is very useful. sexual discipline in islam means training individuals who can distinguish between halal (unforbidden) and haram (forbidden) when they reach puberty, recognize marital and spousal duties and responsibilities, refrain from unrestrained sexual relationships, and have virtues of islamic modesty and chastity in their personality and manner of life (5). another study showed that informing adolescents about sexual subject matters and important ethical values are the duty of parents from the islamic perspective (34). a study indicated that religion has a significant role in refraining from high-risk behaviors. the possibility of establishing an illegitimate sexual relationship is 27 to 54 percent lower among religious young adults than unreligious ones. these adults also have fewer sexual partners compared to their peers (48). in a review article, bahrami et al. confirmed the significant role of religion in individuals’ beliefs, especially in discouraging adolescents from having sexual relationships before marriage. this study also showed that the society is moving in the direction of sexual liberation, which endangers the iranian culture and values. besides, they stated that education has little role in postponing sexual behaviors until marriage and mentioned religious faith and spirituality as primary factors in preventing individuals from prohibited sexual relationships in iran and other countries (49). victor et al. studied 2202 adults in terms of the effect of moral perspectives on the number of sexual partners they had over the years (a sexual risk indicator). they concluded that moral worldviews influence sexual behaviors over time. however, they have a considerably protective effect only for individuals who have high levels of moral beliefs (50) a study on the effect of the current policies regarding sex education in high schools of the united states on students’ risky sexual behaviors showed that all the policies advocating abstinence correlated positively with risky sexual behavior; comprehensive policies on sex education that offer a combination of contraception and abstinence, however, caused a decrease in the rate of risky sexual behaviors. this study joodaki k., et al. 21 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 2 april 2020 concluded that policies or programs based on “abstinence-only” as a choice for adolescents are incomplete both scientifically and ethically (51). measures taken in iran and the related challenges most participants believed that on the one hand, there is no consistent policy for sex education in iran, and on the other, the predominant atmosphere in the society and the ministry of education prevents educators from dealing with this issue seriously. although international organizations recognize sexual health education as a human right and a requirement for developing and propagating justice (52), there is a resistance to sex education in iran, which was both pointed out by our participants and inferred from contemporary literature review on the subject and media. so far, it seems impossible to have an integrated and specific policy for sex education within the iranian educational system. in 2005, the ministry of health and medical education and the ministry of education jointly developed and proposed for executing a comprehensive curriculum for health education in schools from preschool to the end of college (53). the second chapter of the curriculum – titled “social and family health” – offered discussions about maintaining sexual self-control, preventing teen pregnancy, and identifying unhealthy and harmful relationships. information on sexually transmitted diseases was sporadically explained among other discussions in other chapters. however, resistance to this curriculum did not allow it to be included in the iranian system of education. ever since, these discussions have been offered at schools sporadically and at the discretion of those in charge, and recently under the title “prevention of social harms” (53). moreover, we can refer to the two courses about puberty and marriage in universities titled “population and family planning” which changed to “population and family knowledge” since the first semester of the 2003-2004 educational year due to changes in the national policies concerning population. this is a core course that university students of all majors must pass to get their bachelor’ degree. ethical challenges that parents or teachers face in sex education are complicated (29). in order to resolve such challenges, we should decide ethically based on the four basic principles of medical ethics (autonomy, beneficence, non-maleficence, and justice) (54). to verify whether a state is ethical or not, we have to determine which principle is superior to the other ones for resolving the ethical dilemma, and then employ this principle to assess the state and make a decision (30). seemingly, nonmaleficence (one ought not to inflict evil or harm) and beneficence (one ought to do or promote well) are two significant principles that have to be taken into consideration. limitations of the study one limitation of the present study was that some people are ashamed to talk about this subject, although due to the scientific outlook and description of the study ethical considerations and challenges of sex education for … 22 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 2 april 2020 objectives, most of the participants answered the questions thoroughly and clearly. if the participants’ answers happened to be ambiguous, the subject would be clarified through more specific, in-depth questions. another limitation of this study was the absence of adolescents among the participants. participants were asked to express whether they desired to have had knowledge of these contents in their teenage years or not to overcome this limitation. conclusion clearly, one of the main issues relating to adolescence is teaching the various aspects of pubertal health. not having information or having wrong information about sexual subject matters not only increase the risk for occurrence of a range of sexual disorders, high-risk behaviors, sexually transmitted diseases, unwanted pregnancies and family problems, but have harmful effects on adolescents’ lives. embarrassment and shame, the taboo of talking about sexual topics, and common sense conventions and beliefs in iran are the barriers to adolescents’ access to the necessary information. stigma and shame are among the main reasons for avoiding sexual discourse, especially at a family level. nevertheless, unwillingness to talk about sexual issues is not exclusive to iran, but is also seen in countries with similar cultural backgrounds. in these countries, there is a stiff resistance to sex education for adolescents due to a wrong understanding of the nature, objectives and effects of such knowledge; as a consequence, adolescents have no access to sex education. on the other hand, the spread of mass media and high-speed information transmission in recent years have set the ground for incorrect sex information transfer. it is not easy for many people to discuss sexuality and acceptable sexual behavior with close friends or peers, or in a broader social environment. furthermore, since these topics concern the most personal and private parts of one’s life, there is a lack of social tendency to talk about them. education should not be sexually stimulating and distract a student whose mind is distant from such environments. cultural and personality differences must be taken into account, and in addition to giving general information to all adolescents, each one should be guided individually, considering his/her needs and in specific cases. the justice principle requires that all adolescents have access to appropriate and necessary information. education should be given based on adolescents’ continuum of development, and it should be suitable for their age, cultural background and family conditions. in accordance with religious experts and islamic scriptures, this education must be embedded in the core of sexual disciplining, which starts with giving gender identity to children and continues in every phase of their physical and mental development, depending on their needs. considering adolescents’ age and background information at the time of sex education is highlighted indirectly. the proper time for education in different aspects of pubertal health (physical, sexual, mental, joodaki k., et al. 23 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 13 number 2 april 2020 and social) is different. it is important that each element of puberty be taught to adolescents at its proper time and considering their cultural and social condition. decision-making is complicated when adolescents’ parents are against such education. it appears that not giving the right knowledge to adolescents, who can access an ample amount of wrong information, is in contrast with principles of non-maleficence and beneficence. in this regard, the degree of adolescents’ understanding and capacity should serve as the criterion, and it is also very helpful to educate and persuade parents in such cases. 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medical ethics and history of medicine research center, tehran university of medical sciences. all rights reserved. review article j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 18 december 2019 the ethics of positive thinking in healthcare *corresponding author gabriel andrade al jurf complex, flat no. 504, building no. 21, ajman, united arab emirates. tel: (+971) 54 45 62552 email: gabrielernesto2000@gmail.com received: 2 sep 2019 accepted: 2 dec 2019 published: 21 dec 2019 citation to this article: andrade g. the ethics of positive thinking in healthcare. j med ethics hist med. 2019; 12: 18. gabriel andrade 1* 1.assistant professor, college of medicine, ajman university, united arab emirates. abstract in continuation with the new thought movement that arose in the united states in the 19th century, there is now a massive self-help industry that markets books and seminars. this industry has also extended to healthcare in the form of positive thinking, i.e., the idea that happy thoughts are essential for health. while some of these claims may seem reasonable and commonsensical, they are not free of problems. this article posits that positive thinking has some ethical underpinnings. extreme positive thinking may promote alternative forms of medicine that ultimately substitute effective treatment, and this is unethical. the emphasis on positive thinking for cancer patients may be too burdensome for them. likewise, unrestricted positive thinking is not necessarily good for mental health. after considering the ethics of positive thinking, this article proposes a more realistic approach. keywords: positive thinking; self-help; cancer; healthcare; positive psychology the ethics of positive thinking in healthcare … 2 volume 12 number 18 december 2019 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e introduction: pessimism and optimism as philosophies “positive thinking” suggests that in order to accomplish good things and pursue happiness, human beings must constantly have positive thoughts and prevent negative thoughts from entering their mind. this can be done by envisioning success, repeating constant affirmations, continuously saying good things to oneself in order to build selfesteem, and arousing happy thoughts that may block stressing ideas from one’s mind. in the last three decades, this trend has been massively popular in psychology, and it has also been extended to healthcare and the business world. positive thinking is also the foundation of the self-help industry, which is estimated to make around 10 billion us$ every year in products such as books and seminars. the healthcare industry has also borrowed ideas from this movement by assuring patients that their prognosis will be dramatically improved if they think positive thoughts. although it may seem like a recent phenomenon (with all the marketing techniques of advanced capitalism), in fact, positive thinking is a very ancient movement, long defended by many philosophers. some philosophers are optimists; others are pessimists. the dialectic between optimism and pessimism is an ancient one, and to a certain extent, discussions about the merits of positive thinking in healthcare and elsewhere reflect this ancient dialectic. pessimist philosophers are prone to see the world as a hopeless place. perhaps the most notorious of all pessimist philosophers, arthur schopenhauer, presented this view in no ambiguous terms: “human life must be some kind of mistake. the truth of this will be sufficiently obvious if we only remember that man is a compound of needs and necessities hard to satisfy; and that even when they are satisfied, all he obtains is a state of painlessness, where nothing remains to him but abandonment to boredom. this is direct proof that existence has no real value in itself; for what is boredom but the feeling of the emptiness of life?” (1). although he founded no school of philosophy, schopenhauer had considerable influence over thinkers such as nietzsche and freud, both of whom also leaned towards grim understandings of human nature and the world. more recently, philosopher david benatar is so disappointed with life, that he makes the ethical case for not having children: “each one of us was harmed by being brought into existence. that harm is not negligible, because the quality of even the best lives is very bad – and considerably worse than most people recognize it to be. although it is obviously too late to prevent our own existence, it is not too late to prevent the existence of future possible people” (2). by contrast, religious thinkers tend to affirm the other end of the spectrum, i.e., optimism. in their view, inasmuch as the world is god’s creation, by necessity it is a good place. obviously, there appear to be many imperfections in the world, but these philosophers typically go to great lengths in order to prove that those imperfections are andrade g. 3 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 18 december 2019 actually part of a cosmic plan for a greater good. this approach, known as “theodicy”, attempts to justify god’s ways to man, and by doing so, attempts to present the world in an optimistic light. perhaps the most notorious philosopher in this regard was leibniz, who affirmed that this is by necessity “the best of all possible worlds” (3). leibniz’ brand of optimism was more cosmic, and it did not provide much solace to people. in his philosophy, the world may seem like a terrible place, but in fact, it is the best one there can ever be. by contrast, some american philosophers and religious authors were presenting a more radical form of optimism by the 19th century. this school of thought came to be known as new thought (4), and its main principle was that “our mental states are carried forward into manifestation and become our experience in daily living” (5). this basically means that our minds are sufficiently powerful to bring about whatever we desire, also presented in the phrase “mind over matter”. in religious terms, this was upheld by the christian science, a movement founded by mary baker eddy, whose main thesis is that disease is fundamentally a state of mind that can be mentally reversed. in the late 20th century, this approach was additionally upheld by new age spirituality. new age actually encompasses a wide variety of beliefs, but one of its recurring themes is the appeal to hindu idealist traditions. according to these doctrines, the material world is an illusion, and it can be changed with the power of the mind. as we shall see, the secret, a major promoter of positive thinking, relies on a variant of hindu idealism adapted to western cultural markets. this is in fact a major shortcoming of positive thinking in the west. in nonwestern cultures, there are numerous traditions that posit specific ideas about wellness. in the last century, these ideas have been introduced in western cultures, and they have been applied in very different contexts from where they originally arose. the result has often been a misapplication of these ideas to entirely different cultural settings (such as ayurvedic medicine in the west), with negligible results. schopenhauer’s gloomy approach is certainly not supportive of health. although schopenhauer was not apologetic about suicide, his pessimistic views about the human condition and the purpose of life may easily lead to neglect of health, for one may wonder what the point of healthy living is, if life is horrible anyways. yet, the kind of optimism embraced by leibniz and the new thought movement is not without its problems. in fact, although voltaire’s candide is not an entirely accurate representation of leibniz’s philosophy, he did raise a legitimate criticism: sometimes optimism can be as cruel as pessimism. to tell someone that they must cheer up in the face of tragedy because this is the best of possible worlds, or because in every crisis there is an opportunity, is despotic on its own. voltaire was not a pessimist. in fact, he seemed to lead a happy life, and he was the ethics of positive thinking in healthcare … 4 volume 12 number 18 december 2019 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e confident that enlightenment was guiding humanity through a good path (6). however, he was aware that optimism can be problematic as well, especially by compelling people to put a smile on their faces when the circumstances do not allow for it. this middle-ground position ought to be defended as the philosophical approach in healthcare. patients should be encouraged to cheer up as far as possible, because optimism can be a good strategy in healthcare. physicians such as patch adams should be ethically praised for their efforts to bring joy to patients through comedy. but ethics also require that limits be placed on the positive thinking trend that is becoming increasingly popular in healthcare, since unrestricted optimism feeds magical thinking (as in mind-over-matter thinking), and the fostering of delusions can never be ethical. as it is usually the case with magical thinking, positive thinking encourages an excessive illusion of control (the tendency to overestimate the ability to control events), and this illusion can lead to unethical outcomes (7). furthermore, unrestricted positive thinking has significant downsides in terms of psychological development, cultivation of healthy habits and care of terminally ill patients, as well as detrimental, larger societal effects. in what follows, i shall explore the ethics of positive thinking in healthcare, pointing out what is reasonable and acceptable, and also highlighting how positive thinking in healthcare sometimes becomes unethical. i will work under the hypothesis that, with some exceptions, positive thinking has increasingly become unethical in healthcare, and healthcare professionals need to be aware of this in order to make the necessary corrections. positive thinking and general health effects for many centuries, people have had the intuition that stress has detrimental effects on health. hans selye’s studies began to empirically test this hypothesis, and his case was fairly convincing, even though there are some concerns about the motivations of his research (he was financed by tobacco companies, who were interested in placing guilt on stress for many diseases, so as to release tobacco of responsibility for health failings) (8). this was even more impressively confirmed by robert ader in a famous experiment (9). he fed rats with a combination of saccharin-laced water, and the drug cytoxan to induce nausea and taste aversion. this combination induced classical conditioning in rats, who came to associate the saccharine-laced water with the drug. afterwards, the rats were fed only the saccharine-laced water, but they died in great numbers nevertheless. ader concluded that even without taking the drug, the rats’ immunological system had been suppressed with the mere stress of drinking water that had previously been associated with nausea through classical conditioning. this experiment laid the basis for what has been called the field of psychoneuroimmunology. this discipline purports to study the interactions between the nervous system and the immune system, and as ader’s experiment adequately proves, high levels of stress result in a diminished andrade g. 5 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 18 december 2019 immunological response, and therefore greater exposure to sickness. it is also true that placebo effects can be powerful, and may be effective in up to 30% of their applications (10). in that regard, encouraging patients to have constant positive thoughts may actually be helpful in the treatment of many conditions. however, the rate of effectiveness of placebos should actually be reduced by considering the hawthorne effect, rogers’s phenomenon, and the simpson paradox (11). furthermore, it must be kept in mind that not all diseases have a psychosomatic aspect, and in some diseases (asthma being the most notorious), placebos can actually be detrimental, for they may take care of the symptoms, but not the disease itself. this can be very dangerous, as the patient does not seek medical care because he/she feels fine, when in fact he/she is not (12). moreover, the application of placebos also has ethical shortcomings, as it is a form of deceit, and this goes against the basic principle of informed consent (13). on the basis of the findings of psychoneuroimmunology, new theories have emerged. it is reasoned that if intense stress results in sickness, then most (if not all) immunological failings are due to lack of positive thinking. and, of all diseases interpreted through this lens, cancer occupies a central place. thus, enthusiasts of positive thinking typically claim that cancer may appear as a result of too much stress, and positive thinking is a very efficient way of preventing it and even curing it. for example, in a book called 9 steps to reversing or preventing cancer and other diseases, shivani goodman argues that this disease comes as a result of “toxic attitudes” and “emotional pain” (14). physician deepak chopra argues that cancer can be cured by visualizing being well (15). even an oncologist, carl simonton, argues that cancer happens as a result of a weakened immunological system (16), and inasmuch as the immunological system has a strong connection with the nervous system (as research in psychoneuroimmunology suggests), thoughts do play a significant role in this disease. there are many reasons to doubt all of these claims. it is beyond question that stress affects health negatively, but that does not imply that constant positive attitudes, unrestrained optimism, happy thoughts and reaffirmations are causes of good health. there certainly is a correlation between optimism and health. for example, optimism is related to a lower mortality rate (17), better standards of health and faster recovery rates in some diseases (18) and improved immunological response (19). we should not assume, however, that happiness and optimism cause good health, since the reverse may actually be the case: someone with a good immunological system seldom gets sick, and as a result, has better opportunities to be happy. in fact, some studies point in that direction (20). we simply do not know sufficiently well the direction in causality, and should not rush to conclusions. be that as it may, when it comes to cancer, there are greater doubts that a positive the ethics of positive thinking in healthcare … 6 volume 12 number 18 december 2019 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e attitude can cure it, or that even the immunological system is involved. if the latter theory were true, common sense would indicate that patients with hiv are at greater risk of developing cancer, since the hiv virus attacks the immunological system; likewise, chemotherapy would strengthen patients’ immunological response. both of these hypotheses are incorrect, and this points in the direction that the immunological system plays little role in cancer. thoughts and mental attitudes are even less relevant in the pathogenesis of cancer. much has been made of alleged personality types being related to cancer (21), but this in fact has been debunked by more competent studies (22). positive attitudes may be a factor in helping to cope with the burdens of cancer treatments, but they are not a factor in the treatment of cancer itself. these empirical data suggest that although the desirable effects of positive thinking on health may have some basis, this is not fully confirmed by science. in a scientific approach, promoters of positive thinking should follow a more cautious outlook, as the evidence is not entirely supportive of their claims. cancer and positive thinking in principle, it makes sense to propose that positive thinking is a much-needed resource in the treatment of cancer. patients struggle throughout the course of this disease, and in order to keep going, they need to find some meaning in their experience. in fact, finding meaning in the face of adversity is an important predictor of survivability. victor frankl’s famous memoir of his days in an extermination camp, man’s search for meaning, makes a strong case that those who find meaning in things (even if they otherwise seem pointless), have greater probability of survival (23). that is why positive thinking has become such a major aspect of cancer treatment. however, the way positive thinking is conducted with cancer patients has many ethical shortcomings. very often, patients’ autonomy is violated. sadness and stress in the face of adversity is a normal response, yet cancer patients are usually overly pressured not to feel sad. joy becomes an obligation, and the concept of “mandatory fun” has an uncanny totalitarian aspect: patients are deprived of their emotional autonomy, and are forced to feel in a particular way. the result is typically that, apart from the burden of dealing with the stress of cancer and the side effects of its treatment, patients now have the additional stress of having to be positive all the time. if they fail to do so (and naturally, most of them do, given the state of their condition), they feel additional sadness, for failing to meet the expectations. cancer patients are not allowed to have autonomy in their feelings, and they end up being conducted by others about how they should feel. by having this autonomy removed, cancer patients are treated as underage subjects (precisely those that, in standard conditions, do not have autonomy). barbara ehrenreich went through this process as a cancer patient, and in her investigation of the positive thinking culture, she provides many examples of the infantilization of cancer andrade g. 7 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 18 december 2019 patients (24). for example, breast cancer patients are offered pink ribbons and teddy bears, as objects to encourage positive attitudes. other objects frequently distributed to breast cancer patients are boxes of crayons, pink objects, perfumes, body creams, and many other items typically reserved for children. ehrenreich also makes the observation that this kind of infantilization is typical in breast cancer patients, but not in, say, prostate cancer patients. she therefore sees some patriarchal overtones in the positive thinking movement, arguing that men see female cancer patients as less than adults. positive thinking is frequently forced on cancer patients in the form of group therapy. patients are encouraged to support each other by sharing their experiences and offering encouragement. of course, there is nothing intrinsically wrong with this approach. however, the way these group therapies are framed makes it too invasive for the patient. the peer pressure coming from the group, overly encouraging the patient to keep a positive mind frame, ends up placing excessive stress on the patient, who feels that his/her sense of autonomy is eroded. in fact, there are studies that show that support groups do not increase survival rates amongst cancer patients (25). even david spiegel, who had originally published prominent research advocating support group therapy for the treatment of cancer, later on agreed that those therapeutically efforts offer no significant results, and concluded that cancer survival is not influenced by a patient’s emotional status (26). in fact, there is hard data suggesting that women who see cancer as something positive (as in the title of one such book, the gift of cancer), end up having worse mental functioning (27). group therapy for cancer patients has other ethical shortcomings. the positive thinking movement has made strides in the business world and in self-help literature. one particular persistent idea in those settings is the ostracization of negative people, as part of a strategy for positive thoughts. self-help books frequently contain passages such as this one: “that may sound harsh, but the fact is that negative people do suck. they suck the energy out of positive people like you and me. they suck the energy and life out of a good company, a good team, a good relationship…. avoid them at all costs. if you have to cut ties with people you’ve known for a long time because they’re actually a negative drain on you, then so be it. trust me, you’re better off without them” (28). on the basis of this idea, cancer support groups occasionally opt to expel those patients that have metastasis (29). the rationale is that these patients bring too much negativity to the group, and thus represent a danger to it. it is not hard to see the ethical problems with these procedures. patients with metastasis are unfairly discriminated against, which goes against the ethical principle of justice. furthermore, they are abandoned and withdrawn from the group, precisely at the moment when they may need the greatest support. this excessive emphasis on positive thinking amongst cancer patients often leads to physicians giving false assurances to the ethics of positive thinking in healthcare … 8 volume 12 number 18 december 2019 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e patients. again, this is ethically problematic, as false assurances violate the principle of autonomy by depriving the patient of a full opportunity for informed consent (30). more deeply unethical are those therapies that urge cancer patients to abandon conventional treatments and opt for alternative methods that rely entirely on positive thinking. the more radical varieties of positive thinking ultimately go back to the mind-over-matter approach of new thought. one particularly recent trend in this movement is the so-called “law of attraction”, made popular by the best-selling book and film, the secret. according to this law, thoughts attract realities. therefore, if someone is diagnosed with cancer, all he/she has to do is to think hard about getting better, and those thoughts have the power to attract health and make cancer go away. with this reasoning, no conventional therapy is needed. needless to say, the “law of attraction” is a form of very naïve magical thinking, which borders on being delusional. parapsychologists have long been interested in studying how the mind may be able to move matter remotely (psychokinesis), but all studies have failed in coming up with evidence for these claims (31). as often happens with promoters of magical thinking in recent decades, these ideas are usually covered with a superficial veneer of scientific-sounding jargon. thus, proponents of the “law of attraction” usually claim that quantum physics proves that the mind has the power to actualize thoughts via remote influences on matter. this is in fact a very misguided interpretation of quantum entanglement (32). tv broadcaster oprah winfrey made sure the secret would get massive readership. eventually, many viewers decided to stop conventional treatment for curable cancer altogether based on the tenets of the secret (33). most ethicists agree that alternative and folk medicine is mostly harmless, and therefore medical students are encouraged to respect patients’ cultural worldviews. however, alternative medicine becomes a problem when it substitutes evidence-based treatments. many alternative medicine treatments rely on positive thinking, and in some cases, patients are encouraged to abandon conventional treatments, so as to fully dedicate to think positive thoughts. ryke geerd hamer’s new germanic medicine was a movement that actively recommended patients to abandon sciencebased treatments in favor of mental cures (34). hamer claimed that all diseases are controlled by the brain, and therefore their cure can be wholly mental. his approach to medicine was deeply unethical, and predictably, his medical license was removed, as many of his patients died from curable diseases. it is important, however, to understand that even if hamer’s approach was extreme, it was still embedded in positive thinking, and his case is an illustration of the unethical variants that unrestrained positive thinking can lead to. one further ethical problem with excessive emphasis on positive thinking is that it ultimately leads to victim-blaming. inasmuch as cancer can be cured with positive thoughts, if someone is not cured or “loses the battle”, it must be because that andrade g. 9 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 18 december 2019 person did not try hard enough to affirm himself/herself, or envision a cure. thanks to the work of melvin lerner, we now know that the “just world” bias is deeply enshrined in the human mind (35). according to this way of thinking, people usually think that everyone gets what they deserve: virtuous actions are rewarded in life, and bad deeds are punished with misfortunes. even though this is a very popular way of thinking, let us not forget that it is a bias. bad things happen to good people, and vice versa. regrettably, the secret does not even have a moral dimension: according to this book’s thesis, disease comes, not necessarily to bad people, but to those who have not had positive thoughts. ultimately, if they do not manage to get better, it is their own fault, for not wanting it and thinking about it hard enough. extreme positive thinking eventually becomes a form of victim-blaming, and this is deeply unethical. as documented by chaple et al., this kind of thinking leads to stigma and shame amongst patients, further adding to their unfortunate condition (36). positive thinking and mental health in all the realms of healthcare, positive thinking has surely been the most enthusiastically upheld by mental healthcare providers. there is in fact a massive industry of books, films, seminars and even branding objects (caps, shirts, key chains, etc.) that repeat ad nauseam the tenets of new thought and positive thinking, promising better results in terms of psychological wellbeing. this industry usually bypasses conventional approaches in psychotherapy (psychodynamic, cognitive behavioral, humanistic), and aims for the procurement of products that allow people to cope on their own, simply by reading books or listening to tapes. it is thus called the “selfhelp” industry. barbara ehrenreich acutely observes that since psychopharmacology has made impressive advances in the last two decades, psychologists feel the threat of being left without much to do in the treatment of mental health. thus, they now have an agenda in pushing positive thinking as the last resource of talking cures, thus strengthening the self-help empire. we know that despite massive revenues, the self-help industry has been deeply ineffective, as the millennial generation is experiencing higher rates of anxiety and depression compared to the previous generations (37). in fact, investigative journalist steve salerno discovered that the most likely reader of a self-help book is a person who had previously bought a similar book not long before (38). the self-help industry executives seem to be fully aware that their products are ineffective, but they unethically remarket the same products over and over again, thus making huge profits. indeed, self-help books are written in repetitive prose. even during the heyday of one of the best-selling self-help books of all time (norman vincent peale’s the power of positive thinking), critics already noted that “…the chapters of his books could easily be transposed from the beginning to the middle, or from the end to the beginning, or from the ethics of positive thinking in healthcare … 10 volume 12 number 18 december 2019 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e one book to another. the paragraphs could be shuffled and rearranged in any order” (39). these books are notoriously simplistic, and require little engagement from readers. they thus unethically contribute to the dumbing down of society. in fact, some selfhelp authors such as jeffrey gittomer explicitly recommend readers not to read or watch news, because they are too negative (40). needless to say, this kind of willful ignorance of current events is detrimental to the adequate education of society. admittedly, some sectors in academia have presented a more respectable form of positive thinking and self-help. the socalled “positive psychology” school, founded by martin seligman, purports to focus on the development of the positive aspects of life, and aspires to document the benefits of happiness and optimism in health and life in general (41). nevertheless, even positive psychology is not without its problems. for one, its concepts are too elusive. happiness is never truly satisfactorily defined by scholars of positive psychology. although seligman’s authentic happiness inventory seems to have acceptable levels of validity and reliability (42), he purports to measure happiness in an equation which is illformulated (43). be that as it may, the truth is that positive thinking has its shortcomings in mental health as well. positive psychology has been additionally criticized for pushing the agenda to pathologize grief. the diagnostic statistical manual (dsm-5) opted to remove the grief exclusion in the diagnosis of major depression, and this has met with strong criticism (44), for it places excessive pressure on patients to not feel sad, even when their loved ones have passed away. julie norem has done extensive research documenting how some people may satisfactorily use pessimism as a defense mechanism. she proved how “individuals may sometimes use low expectations to cope with their anxiety so that it does not become debilitating… low expectations may help individuals negotiate risky situations by showing that interference with the defensive-pessimism strategy impairs performance” (45). consequently, in people who use pessimism as an efficient defense mechanism, constant positive thinking may actually backfire, as subjects are left without a good resource to deal with anxiety. in fact, wood et al. have done important research showing that subjects who kept on making positive self-statements such as “i am a lovable person” or questioned the truth of that statement felt worse compared to those who did not repeat positive selfstatements or did not concentrate on the fact that it was true and false at the same time (46). the key aspect is self-esteem. positive thinking may work better in subjects with higher self-esteem, but in those with lower self-esteem, positive thinking is counterproductive, as subjects easily come to realize that they are engaging in selfdeceit, and that leads to increased depression. in fact, hyper-optimism carries an additional risk of depression, for the hyper-optimist subject may not be adequately prepared in the event of a failure. andrade g. 11 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 18 december 2019 excessive positive thinking may also lead to overconfidence in doing tasks, and consequently to poor performance. for evolutionary reasons, stress has an important physiological function, i.e., warning of dangers via the sympathetic nervous system and the fight-or-flight reaction. admittedly, it is true that our current living conditions are different from the african savannah in which most of human evolution took place, but some measure of stress is needed for everyday living. per the yerkes-dodson law, we know that there is an empirical relationship between arousal and performance that becomes manifest as a curve, and while too much anxiety is prejudicial for performance, too little is prejudicial as well (47). positive affirmations may induce too much relaxation in a task, which may consequently be poorly done. in this regard, a stronger critique of positive thinking is warranted. in fact, we know that negative thinking can make people more analytical so that they will engage more in critical thinking. these are skills that are required for good functioning and adequate mental health. in a review study joseph forgas reports that “negative affect can improve memory performance, reduce judgmental errors, improve motivation, and result in more effective interpersonal strategies” (48). one study by shigehiro oishi documents that moderately happy people are more successful professionally and economically than extremely happy people (49). likewise, von helversen et al. found that depressed subjects are better at decisionmaking (50). daniel kahneman has also done extensive studies showing that people may easily engage in optimism bias, and this may lead to a planning fallacy (thinking that tasks may require far less time), ultimately harming performance tasks (51). this may also have implications in physicians’ performances: one particular study showed that this kind of bias can lead to medical errors, thus affecting healthcare as a whole (52). of course, this does not imply that depression is a good thing by itself, but it does suggest that positive thinking must have limits, because unrestrained optimism can be very distorting. positive thinking has notorious prejudicial aspects in other areas related to healthcare. for example, overly positive people may neglect insurance coverage. people buy insurance thinking of adverse scenarios in advance. according to the “law of attraction”, this would be a sure way of inviting catastrophe, and therefore should be avoided. in countries with socialized medicine this is not necessarily a big problem, but in countries with no socialized medicine (such as the united states), this is a major hassle, for individuals that refused to think about adverse events may end up without adequate healthcare. one study shows that people who do not buy health insurance prefer to spend money on things like alcohol and tobacco (53). surely, in the short term both tobacco and alcohol propitiate happier thoughts and positive thinking than risk assessments. this is the ethics of positive thinking in healthcare … 12 volume 12 number 18 december 2019 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e related to the fact that positive thinking also tends to suspend delayed gratification. by insisting that one must pursue whatever makes one feel good in order to arouse positive thoughts, excessive positive thinking engages in a kind of destructive hedonism that completely disregards risks. it is thus no surprise that excessively optimistic people eat unhealthier foods (54) and have unprotected sex more often (55). academic positive psychology aptly warns that money cannot buy happiness and positive psychology scholars often state that lottery winners ultimately revert to their original happiness levels (56)); however, the more popular variants of positive thinking do emphasize the value of conspicuous consumption. the positive thinking movement is closely associated with the motivational drive that prevails in the sales and business world, and accumulation and display of wealth is an important aspect of this association. self-help classic books such as wallace wattles’ the science of getting rich or napoleon hill’s think and grow rich insist on using positive affirmations as a way of getting rich. failing to be rich (and to show it, of course) would be an indication of poor mental habits (i.e., not enough positive thinking). this also seems to be the message of the so-called “prosperity theology”, although with a religious twist: being rich is an indication of god’s favor, and therefore people must strive to be rich through positive thinking. this excessive emphasis on conspicuous consumption and motivation to accumulate wealth can lead to very dysfunctional behaviors that ultimately result in impaired mental health. there is great self-entitlement in self-help literature and the positive thinking movement as a whole. for example, in the film version of the secret, a woman desires a necklace exhibited in a store; she then concentrates on the thought of getting it and, lo and behold, the film shows her wearing it. we may be left wondering whether she robbed the store, just to accomplish her dreams. motivational literature typically exhorts to go beyond limits; unfortunately, this may occasionally include going beyond moral limits. excessive positive thinking also carries the risk of isolating subjects. for example, the self-help book secrets of the millionaire mind recommends getting rid of negative people (57). it provides no opportunity whatsoever to improve relationships with negative people. obviously, this kind of thinking induces divorce and straining of relationships with some people, just because they happen to not be as positive. conclusion apart from the ethical shortcomings of positive thinking that directly affect patients, there are wider prejudicial effects in healthcare. given its reliance on magical thinking (i.e., the “law of attraction”), the self-help industry incentivizes alternative medicine, and this has ethical problems of its own (58). products that promote self-help and positive thinking are not effective, even though they constantly claim positive results. this kind of deceit is deeply andrade g. 13 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 18 december 2019 unethical as well. there are also concerns with positive thinking that go beyond healthcare. excessive positive thinking may affect society in many ways, and this may ultimately lead to harmful epidemiological affects. for example, ehrenreich makes a convincing case that the 2008 global financial collapse was deeply influenced by excessive optimism from brokers and bankers. likewise, makridakis and moleskis aptly document how positive illusions facilitate wars, since politicians are too confident of victory and undermine risks (59), and that itself also leads to problems of public health. none of this implies that one must assume a schopenhauerian pessimism, and recommend it to patients in health practice. happiness is important, and indeed, it can be sought. when it is achieved, happiness can certainly lead to better health. however, ancient philosophers long knew about the so-called “paradox of hedonism”: the more one tries to find pleasure, the less one finds it. ethicists frequently warn that happiness cannot be sought directly (60). this is not entirely true, as for instance according to william james’ facial feedback hypothesis, smiling constantly does bring about greater happiness, and botox injections may even be a treatment for depression (61). but it is important to note that this is about doing things to be happier, not just having positive thoughts and being irrationally optimistic, in the vain hope that thoughts will magically attract good things. be that as it may, the kind of happiness that is sought should also be based on a deeper philosophical insight. john stuart mill was certainly no pessimist, and his utilitarian philosophy is wholly about happiness and pleasure. but he was onto something when he argued that it is “better to be socrates than a fool satisfied” (62); i.e., happiness is important, but what we should be after is a kind of higher and sublime happiness. unfortunately, positive thinking induces more conspicuous consumption, as in selfhelp guru marianne williamson’s infamous “seek ye the kingdom of heaven, and the maserati will get here” (63). as barbara ehrenreich wisely points out, the alternative to positive thinking is not negative thinking, but rather realism. the world can be a nice place, but in those instances when it is not, it is pointless to delude ourselves and believe that just by thinking it is a good place, it will become so. this applies to patients and health practitioners, as adequate treatments come with adequate diagnoses, but positive thinking runs the risk of dispensing with them. to sum up, wishful thinking is a common logical fallacy, and it should be avoided. likewise, ethics requires that patients be given the right to be sad. urging people to be happy in the face of tragedy is a very oppressive act. voltaire’s contempt for leibniz’s optimism was precisely a protest against the insensitivity of people who believed they had found meaning and joy in things such as the 1755 lisbon earthquake. the ethics of positive thinking in healthcare … 14 volume 12 number 18 december 2019 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e voltaire demanded more empathy from people, so they could understand what sufferers go through. medical ethics require the same from health practitioners. conflict of interests the author declares that there is no conflict of interests. acknowledgements the author wishes to acknowledge ajman university for providing the bibliographic resources in order to carry out this research. andrade g. 15 j o u rn a l o f m e d ic a l e t h ic s a n d h is t o r y o f m e d ic in e volume 12 number 18 december 2019 references 1. schopenhauer a. on the vanity of existence. 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