Vol 7 (2014)


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    Applying professional values is an important issue in nursing practice. It is also crucial to find out nurses' perspectives toward ethical and professional values in the clinical environment. For this purpose, we aimed to utilize a standard tool to survey perspectives on applying these values in nursing care in hospitals of Isfahan, Iran. This is a descriptive-analytical study in which 150 nurses working in hospitals of Isfahan, Iran in 2010 were recruited by quota convenience sampling, and their perspectives on professional values were assessed. Data were collected by the Nurses Professional Values Scale (NPVS) and analyzed using SPSS Software version 16 applying descriptive and interpretive statistics. In the present study, 84% of the participants were female and 88% had bachelor's degree in nursing. The average age was 34.2 (SD=7.3), and the average years of working in a hospital were 11 (SD=7.3). No significant association was present between demographic characteristics such as age, sex, educational level or work records and applying professional and ethical values. Results also demonstrated that respect for professional values is similar among nurses of different employment types. In this study, we addressed the most and the less important professional values specified by nurses with different types of employment and also different experiences. Iranian nurses believe in respecting the legal and ethical rights of patients as the most prominent value in the nursing profession. We suggest that these professional values be specified and assessed based on Iranian culture.

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    Recent advances in life-sustaining treatments and technologies, have given rise to newly-emerged, critical and sometimes, controversial questions regarding different aspects of end-of-life decision-making and care. Since religious values are among the most influential factors in these decisions, the present study aimed to examine the Islamic scholars' views on end-of-life care. A structured interview based on six main questions on ethical decision-making in end-of-life care was conducted with eight Shiite experts in Islamic studies, and was analyzed through deductive content analysis. Analysis revealed certain points in Islamic views on the definition of death and the persons making decisions about end-of-life care. According to the participants, in addition to conventional criteria ('urf) such as absence of heartbeat and respiration, the irreversible cessation of human voluntary acts (as a sign that the soul has control over the body and the faculty of thinking) are considered to be the criteria in establishing death. The participants also recognized physicians as the main authorities in verifying signs of death. Furthermore, it was emphasized that life preservation and continuation of care must be sensible, and the patient can request not to have death-prolonging procedures started or continued. In the view of participants, patient's autonomy cannot be the sole basis for all measures, but Islamic ethical and jurisprudential principles should be relied upon to make correct and sensible decisions whether to continue or stop terminal patients' care. Final decisions should be made by a team of experts, and physicians must be at the center of such a team. Finally, we suggest that a guideline in keeping with Islamic norms on human life and death, purpose of life, God's will, boundaries of man's authority, and the physician's ethical duties and obligations should be developed.

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    Moral distress and professional stress are common problems that can have adverse effects on nurses, patients, and the healthcare system as a whole. Thus, this cross-sectional study aims to examine the relationship between moral distress, professional stress, and intent to stay in the nursing profession. Two hundred and twenty full-time nurses employed at teaching hospitals in the eastern regions of Iran were studied. A 52-item questionnaire based on Corley's Moral Distress Scale, Wolfgang's Health Professions Stress Inventory and Nedd Questionnaire on Intent to Stay in the Profession was used in the study. Additionally, demographic details of the study population were collected. No significant correlation was observed between the intensity and frequency of moral distress, professional stress, and intent to stay in the profession among nurses (P > 0.05). There was a significant correlation between moral distress, professional stress, and age, number of years in service and work setting (P < 0.05). Given the important effect of moral distress and professional stress on nurses, in addition to the educational programs for familiarization of nurses with these concepts, it is recommended that strategies be formulated by the healthcare system to increase nurses' ability to combat their adverse effects.

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    Infanticide is a horrendous crime universally condemned from all ethical, juridical and moral standpoints. However, legislation on infanticide foresees mitigating circumstances for infanticidal mothers, with sentences by far disproportionate to the severity of the crime. The main justification for this abstaining from severe punishments has been the so-called post puerperal psychosis, whose diagnostic criteria and existence are still very confusing. Psychiatric experts and even jurors show excessive feelings of empathy toward defendant mothers, and fair verdicts under this setting and with this judicial tradition are questionable. Albanian courts have in some cases even denied defendant mothers the unwilling albeit necessary psychiatric treatment, thus exposing them to recidivism and to other social difficulties. Upholding the charge of infanticide in an Albanian court is hereby an impossible enterprise, with high chances for defendants to achieve acquittal on mental insanity grounds. Through describing three cases of infanticide and filicide in recent years of Albanian judicial proceedings, authors raise the concern formulated from other sources regarding the excessive empathy surrounding infanticidal mothers, a deleterious obstacle toward achieving justice.

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    This study was done to explore the views of patients and their companions concerning endotracheal intubation training on newly deceased patients and the necessity of obtaining their consent in this regard. In this cross-sectional descriptive analytical study, we used a questionnaire to collect data through structured interviews conducted by the researcher on patient discharge day. A convenient sample of over 18 year old patients hospitalized at a teaching hospital were enrolled, and after receiving patient consent, one of each patient's companions was enrolled in the study as well. In this study, 150 of the approached patients agreed to participate (response rate = 85.0%); of those, 92 (61.3%) allowed their companions to be enrolled as well. Eighty-three persons (55.3%) in the patient group and 68 persons (73.9%) in the companion group agreed to have endotracheal intubation training on their own bodies after death. Among these consenting patients and companions, 75.9% (n = 63) and 91.2% (n = 62) believed it was necessary to acquire patient consent for this procedure. Obtaining relatives' consent was thought to be necessary by 69.9% (n = 72) of the patients and 72.1% (n = 49) of the companions, even when there was patient prior consent. Therefore it seems that asking the patient's consent for doing educational procedures on their dead body is crucial.

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    Asclepius and Hippocrates focused medical practice on the natural approach and treatment of diseases, highlighting the importance of understanding the patient's health, independence of mind, and the need for harmony between the individual, social and natural environment, as reflected in the Hippocratic Oath. The aim of this study was to present the philosophy of care provision in ancient Greece and to highlight the influence of the Hippocratic ideal in modern health care practices. A literature review was carried out using browser methods in international databases. According to the literature, "healthy mind in a healthy body" was the main component of the Hippocratic philosophy. Three main categories were observed in the Hippocratic provision of care: health promotion, interventions on trauma care, and mental care and art therapy interventions. Health promotion included physical activity as an essential part of physical and mental health, and emphasized the importance of nutrition to improve performance in the Olympic Games. Interventions on trauma care included surgical practices developed by Hippocrates, mainly due to the frequent wars in ancient Greece. Mental care and art therapy interventions were in accordance with the first classification of mental disorders, which was proposed by Hippocrates. In this category music and drama were used as management tools in the treatment of illness and in the improvement of human behavior. The role of Asclepieion of Kos was highlighted which clearly indicates a holistic health care model in care provision. Finally, all practices regarded detailed recordings and evaluation of information within the guidelines. The Hippocratic philosophy on health care provision focused on the holistic health care model, applying standards and ethical rules that are still valid today.

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    In Western literatures, "conflict" is a general term that refers to discord between two or more entities. In Islamic jurisprudence, however, in addition to the term "conflict" (Taāruz), there is another term which is called tazāhum. The two terms, however, have different definitions. Conflict between two concepts, for instance, indicates that one is right and the other is wrong, while tazāhum does not necessarily have to be between right and wrong, and may appear between two equally right concepts. Moreover, conflict exists on a legislative level, while tazāhum is a matter of obedience and adherence, meaning that in practice, both sides cannot continue to coexist. Conflict of interest is a known term in Western literatures, and according to D.F. Thompson, it refers to a situation where professional judgment regarding a primary interest is improperly and unjustifiably influenced by a secondary interest. Taking into account Thompson's definition and the distinction between "conflict" (Taāruz) and "tazāhum", the English term "conflict of interest" translates to "tazāhum of interest" in Islamic jurisprudence as it refers to a person's action without reflecting right or wrong, and simply concerns priority of one interest over another. The resolution to tazāhum in Islamic jurisprudence lies in two principles: the principle of significance and the principle of choice. For instance, in case of conflict (the Western term) or tazāhum (the Islamic term) between the interests of patient and physician, the patient's interest should be the main concern based on the principle of significance. Although Western literatures propose methods such as disclosure or prohibition in order to resolve conflict of interest, the foundation for these solutions seems to have been the principle of significance.

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    We are now more or less confronting a "challenge of responsibility" among both undergraduate and postgraduate medical students and some recent alumni from medical schools in Iran. This ethical problem calls for urgent etiologic and pathologic investigations into the problem itself and the issues involved. This study aimed to develop a thematic conceptual framework to study factors that might affect medical trainees' (MTs) observance of responsibility during clinical training. A qualitative descriptive methodology involving fifteen in-depth semi-structured interviews was used to collect the data. Interviews were conducted with both undergraduate and postgraduate MTs as well as clinical experts and experienced nurses. Interviews were audio-recorded and then transcribed. The data was analyzed using thematic content analysis. The framework derived from the data included two main themes, namely "contextual conditions" and "intervening conditions". Within each theme, participants recurrently described "individual" and "non-individual or system" based factors that played a role in medical trainees' observance of responsibility. Overall, contextual conditions provide MTs with a "primary or basic responsibility" which is then transformed into a "secondary or observed responsibility" under the influence of intervening conditions. In conclusion three measures were demonstrated to be very important in enhancing Iranian MTs' observance of responsibility: a) to make and implement stricter and more exact admission policies for medical colleges, b) to improve and revise the education system in its different dimensions such as management, structure, etc. based on regular and systematic evaluations, and c) to establish, apply and sustain higher standards throughout the educational environment.

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    Receiving information related to patients hospitalized in the intensive care unit is among the most important needs of the family members of such patients. When health care professionals should decide whether to be honest or to give hope, giving information becomes an ethical challenge We conducted a research to study the ethical approaches of Iranian nurses to giving information to the family members of patients in the intensive care units. This research was conducted in the intensive care units of three teaching hospitals in Iran. It employed a qualitative approach involving semi-structured and in-depth interviews with a purposive sample of 12 nurses to identify the ethical approaches to giving information to family members of the intensive care unit patients. A conventional content analysis of the data produced two categories and five subcategories. The two categories were as follows: a) informational support, and b) emotional support. Informational support had 2 subcategories consisting of being honest in giving information, and providing complete and understandable information. Emotional support in giving information had 3 sub-categories consisting of gradual revelation, empathy and assurance. Findings of the study indicated that ethical approaches to giving information can be in the form of either informational support or emotional support, based on patients' conditions and prognoses, their families' emotional state, the necessity of providing a calm atmosphere in the ICU and the hospital, and other patients and their families' peace. Findings of the present study can be used as a basis for further studies and for offering ethical guidelines in giving information to the families of patients hospitalized in the ICU.

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    Monetary compensation for human eggs used in research is a controversial issue and raises major concerns about women’s health and rights, including the potential of exploitation and undue inducement. Human eggs are needed for various types of studies and without payment, it would be impossible to procure sufficient eggs for vital research. Therefore, a solution seems necessary to prevent exploitation and resolve other ethical concerns while ensuring sufficient supplies of human eggs for research. A brief review of legislation in different countries shows the existing diversity and controversy over compensating human egg donation for research purposes. While in more economically developed countries procreative liberty and consumer orientation seem to be defensible, in some developing countries, where concerns about exploitation exist, adopting a more regulated approach to assisted reproduction is more prudent and wise. Egg sharing is a program that has been proposed to solve both the ethical problems of purchasing eggs and the shortage of human egg supply for research. In developing countries, however, regardless of whether the egg sharing or the monetary compensation model is adopted, some steps should be taken to guarantee the ethical nature of this practice. These steps include ensuring the existence of independent institutional review boards (IRBs), confirming the validity of all steps in the process of obtaining informed consent, and ensuring the existence and viability of independent supervising and auditing bodies.

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    Medication errors (MEs) are among the most prevalent health errors threatening patients’ safety and are regarded as an index for determining patients’ well-being in hospitals. The purpose of this study was to explore the ME reporting rate and causes of underreporting among the nursing students in the city of Kerman.
    In this cross-sectional study, 90 nursing students in the seventh and eighth semesters of Kerman University of Medical Sciences and Islamic Azad University of Kerman were selected. Data collection tool was a researcher-made questionnaire consisting of three parts: 1) demographic information, 2) types and causes of medication errors, and 3) causes of underreporting. Data analyses were performed by descriptive statistics and inferential statistics. The SPSS 16 statistical software was used in this study and P values less than 0.05 were considered significant. According to the data, 66.7% of the nursing students in this study had made MEs, and the rate of underreporting was calculated at 40%. The most important causes of MEs were illegible data cards and prescriptions, and the major reasons for underreporting were fear of low evaluation scores, reprimand and punishment. There was no statistically significant relationship between demographic characteristics and underreporting of MEs in nursing students (P > 0.05). Findings of this study showed that the rate of MEs is high among nursing students and that medication errors are a major problem in the field of nursing. Patient safety and MEs are two important topics in health care, and recognition of the factors contributing to the latter may decrease their frequency and consequently improve patient safety and the quality of care.

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    In order to achieve success in today's competitive world, organizations should adapt to environmental changes. On the other hand, managers should have a set of values and ethical guidelines for their administrative and organizational functions. This study aimed to investigate the association between work ethics and attitudes towards organizational changes among the administrative, financial and support employees of general teaching hospitals affiliated to Shiraz University of Medical Sciences. This was an applied, cross-sectional and descriptive-analytic study conducted in 2013. A sample of 124 employees was selected using stratified sampling proportional to size and simple random sampling methods. Data were collected using 2 questionnaires measuring the dimensions of employees' work ethics (four dimensions) and attitudes towards organizational changes (three dimensions). The collected data were analyzed using SPSS 18.0 and statistical tests, including ANOVA, independent samples t-test, and Pearson's correlation coefficient. A P < 0.05 was considered statistically significant. The maximum and minimum score of work ethic dimensions were related to being cooperative (4.60 ± 0.38) and dependable (4.29 ± 0.39) respectively. On the other hand, the maximum and minimum score of attitudes towards the various dimensions of organizational changes were related to the behavioral (3.83 ± 0.70) and the affective (3.55 ± 0.88) dimensions respectively. Furthermore, there was a significant relationship between the work ethics and education levels of the employees in this study (P = 0.003). Also, among work s dimensions, only being considerate had a significant association with attitudes towards organizational changes (P = 0.014) and their cognitive dimension (P = 0.005). To improve employees' work ethics and attitudes towards organizational changes, the following suggestions can be offered: training hospitals managers in participative management style and its application, as well as the importance of meeting the employees' needs and expectations based on their characteristics; familiarizing employees with the Islamic work ethic; educating employees on the importance of being considerate towards their colleagues and subordinates in the workplace, and reinforcing this desirable quality; and finally, clarifying the need for changes in the organization for all employees.

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    Medical ethics is a realm where four important subjects of philosophy, medicine, theology and law are covered. Physicians and philosophers cooperation in this area will have great efficiency in the respective ethical rules formation. In addition to respect the autonomy of the patient, physician's obligation is to ensure that the medical intervention has benefit for the patient and the harm is minimal. There is an obvious conflict between duty of confidentiality and duty of mandatory reporting. Professional confidentiality is one of the basic components in building a constant physician-patient relationship which nowadays, beside the novelty, it is the subject of discussion. Legal obligation of confidentiality is not absolute. In physician-patient relationship, keeping patient's secrets and maintaining confidentiality is a legal and ethical duty, and disclosure of such secrets is mainly through specific statutes. Thus, there are a number of situations where breach of confidentiality is permitted in different legal systems. One of the situations where breaching confidentiality is permitted is the medical mandatory reporting to the relevant authority which is in accordance with many countries' legal systems. Some situations are considered in many countries legal systems' such as notification of births and deaths, infectious diseases, child abuse, sport and relevant events, medical errors, drug side effects and dangerous pregnancies. In this paper, we will examine and discuss medical mandatory reporting and its ethical and legal aspects in the judicial and legal system of Iran and few other countries. Finally we will suggest making Medical Mandatory Reporting Law in Iran.

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    Considering the nature of qualitative studies, the interaction between researchers and participants can be ethically challenging for the former, as they are personally involved in different stages of the study. Therefore, formulation of specific ethical guidelines in this respect seems to be essential. The present paper aimed to discuss the necessity to develop explicit guidelines for conducting qualitative studies with regard to the researchers' role. For this purpose, a literature review was carried out in domestic and international databases by related keywords. Health care providers who carry out qualitative research have an immense responsibility. As there is no statistical analysis in qualitative studies, the researcher has to both evaluate what he or she observes and to interpret it. Providing researchers with the necessary skills and applying stringent supervision can lead to better extraction of reliable information from qualitative studies. This article presents a debate in order to illustrate how researchers could cover the ethical challenges of qualitative studies and provide applicable and trustworthy outcomes. Researchers face ethical challenges in all stages of the study, from designing to reporting. These include anonymity, confidentiality, informed consent, researchers' potential impact on the participants and vice versa. It seems of paramount importance that health care providers, educators and clinicians be well informed of all the different aspects of their roles when acting as qualitative researchers. Hence, these adroit roles need to be well defined, and the use of practical guidelines and protocols in all stages of qualitative studies should be encouraged.

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    In order to improve the ethical climate in health care organizations, it is important to apply a valid measure. This study aimed to investigate the psychometric properties of the Persian version of the Hospital Ethical Climate Survey (HECS) and to assess nurses' perceptions of the ethical climate in teaching hospitals of Iran. A cross-sectional study of randomly selected nurses (n = 187) was conducted in three teaching general hospitals of Tehran, capital of Iran. Olson's Hospital Ethical Climate Survey (HECS), a self-administered questionnaire, was used to assess the nurses' perceptions of the hospital ethical climate. Descriptive statistics, confirmatory factor analysis (CFA), internal consistency, and correlation were used to analyze the data. CFA showed acceptable model fit: an standardized root mean square residual (SRMR) of 0.064, an non-normalized fit index (NNFI) of 0.96, a comparative fit index (CFI) of 0.96, and an root mean square error of approximation (RMSEA) of 0.075. The Cronbach's alpha values were acceptable and ranging from 0.69 to 0.85. The overall Cronbach's alpha coefficient was 0.94. The factor loadings for all ethical climate items were between 0.50 and 0.80, which revealed good structure of the Persian version of the HECS. Survey findings showed that the "managers" subscale had the highest score and the subscale of "doctors" had the lowest score. This study shows that the Persian version of the HECS is a valid and reliable instrument for measuring nurses' perceptions of the ethical climate in hospitals of Iran.

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    Research shows that ancient Iranians were among the pioneers of medical science, and are therefore admired and praised by non-Iranian scholars for their efforts and accomplishments in this field. Investigations of medical and historical texts indicate that between the 10(th) and the 18(th) century A.D., ancient Iran experienced a golden age of medicine. Great physicians such as Rhazes, al-Ahwazi, Avicenna and others reviewed the medical textbooks of civilizations such as Greece and India, Theories were scientifically criticized, superstitious beliefs were discarded, valuable innovations were added to pre-existing knowledge and the ultimate achievements were compiled as precious textbooks. Alhawi by Rhazes, Cannon by Avicenna, and Kamil al-Sina'ah by al-Ahwazi are among the works that were treasured by domestic and foreign scientists alike, as well as future generations who continued to appreciate them for centuries. The above-mentioned textbooks discuss diseases and conditions related to neurosurgery, ophthalmology, ear, nose and throat, gastroenterology, urology, skeletomuscular system and other specialties, as well as cancer and similar subjects. One of the richest texts on the description, diagnosis, differential diagnosis, and prognosis of cancer and therapeutic approaches is Alhawi by Mohammad ibn Zakarya al Razi (Rhazes). This article presents a brief summary of Rhazes' views about the definition of cancer, types, signs and symptoms, prevalence, complications, medical care, treatment and even surgical indications and contraindications. Moreover, his opinions are compared against the views of other physicians and theories of modern medicine. It is also recommended to review the medical heritage of Iran and evaluate the proposed treatments based on modern methodologies and scientific approaches.

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    There is a shortage of quantitative measures for assessing the concept of responsibility as a fundamental construct in medical education, ethics and professionalism in existing literature. This study aimed to develop an instrument for measuring responsibility in both undergraduate and graduate medical students during clinical training. Instrument content was based on literature review and mainly qualitative data obtained from a published grounded theory research. The draft questionnaire (Persian version) was then validated and revised with regard to face and content validity. The finalized 41-item questionnaire consists of four domains that were identified using factor analysis. Test-retest reliability and internal consistency were also assessed. Test-retest reliability was rather high, ranging between 0.70 and 0.75 for all domains. Cronbach's alpha coefficients were 0.75 - 0.76 for all domains and 0.90 for the composite scale of the whole questionnaire. Correlations between the four domains of the instrument were also satisfactory (r ≤ 0.47 for most domains). The correlation between each domain and the composite scale was higher than its correlation with other domains (r ≥ 0.79 for most domains). The instrument demonstrated good construct and internal validity, and can be suitable for measuring the concept of responsibility in practice in different groups of undergraduate and graduate medical trainees (MTs).

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    Breaking bad news is quite often not done in an effective manner in clinical settings due to the medical staff lacking the skills necessary for speaking to patients and their families. Bad news is faced with similar reactions on the part of the news receiver in all cultures and nations. The purpose of this study was to explore the perspectives of Iranian nurses on breaking bad news to patients and their families. In this research, a qualitative approach was adopted. In-depth and semi-structured interviews were conducted with 19 nurses who had at least one year work experience in the ward, and content analysis was performed to analyze the data. Five major categories emerged from data analysis, including effective communication with patients and their families, preparing the ground for delivering bad news, minimizing the negativity associated with the disease, passing the duty to physicians, and helping patients and their families make logical treatment decisions. The results of this study show that according to the participants, it is the physicians' duty to give bad news, but nurses play an important role in delivering bad news to patients and their companions and should therefore be trained in clinical and communicative skills to be able to give bad news in an appropriate and effective manner.

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    Despite the fact that ophthalmology is one of the foremost branches of medicine, conceptualization of the structure and function of the eye barely advanced in ancient Western civilizations. At the early recovery of Persian civilization (9th century AD) after the extinction of the Sassanid Empire (7th century AD), translations of Greek medical textbooks played an important role in the development of medicine and the emergence of great Persian physicians such as Rhazes, Avicenna and others. Rhazes was a leading Persian physician whose medical teachings have as yet not been thoroughly explored. In addition to numerous books and articles in various fields, he authored a great medical Encyclopedia (al-Hawi al-Kabir) in 25 volumes. In this article, we are going to compare Rhazes’ particular viewpoints about ophthalmology with those of other famous Persian physicians and some recent essays and textbooks. For this purpose we reviewed Rhazes’ second volume of al-Hawi that is dedicated exclusively to ophthalmology and contains some major topics of ophthalmology including anatomy, physiology, pathology, diseases, disorders and treatments. Important themes were carefully extracted and compared with the tenets of modern ophthalmology. After collating Rhazes’ viewpoints with the latest findings in this field, it was concluded that he had brilliantly written about the signs and symptoms, etiology and treatment of many eye disorders more than a thousand years ago. The amazing point is that there was no accurate equipment at the time to help him in his investigations. This study proved that Rhazes’ theories conform to recent knowledge about ophthalmology in many aspects, and could therefore be the subject of further investigations.

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    Maintaining dignity and respect is among patients’ most fundamental rights. The importance of patient dignity, the status quo, patients’ needs, and a shortage of survey studies in this area were the underlying incentives for conducting this study. This was a cross-sectional descriptive study in which data were collected through Patient Dignity Inventory (PDI). The questionnaire was completed by 280 inpatients in 2012 to determine their perspectives on their personal state of human dignity. In this study, the mean score of patients’ dignity was 1.89 out of 5 (SD = 0.81). Results indicated a significant relationship between type of hospital and the distress caused by disease symptoms, peace of mind, and social support (P < 0.05). There were also relationship between type of ward and dependency (P < 0.05), type of disease and dependency (P < 0.05), gender and social support (P < 0.05), household size and peace of mind (P < 0.05). The person’s satisfaction with household income showed significant relationship with symptom distress, dependency and existential distress (P < 0.05). Results showed a significant inverse correlation between age and patient dignity (P = 0.005, r = - 0.166). However, the relationship between employment status, health insurance, education level and the above factors were insignificant. Studies indicate that there is a relationship between patients’ dignity and mental distress, and therefore policy makers and health services officials should establish and implement plans to maintain and enhance patients’ dignity in hospitals. Educating the health team, particularly the nurses can be very effective in maintaining patients’ dignity and respect.

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    The modern infirmary is the evolutional product of the dialectic interface between medical theories at each time and the outcome of their application in clinical practice. The infirmary as we know it today did not exist during antiquity, but the different precursors of the modern hospital emerged as a result of the interaction between medical theory and practice. During antiquity the Hippocratic work decisively contributed to the creation of the Asklipieion, an institution with predetermined structure created to heal diseases. Later in antiquity new types of infirmaries appeared along with the evolution of private practice for physicians. Establishment of the first modern hospitals was an outstanding contribution of Islamic medicine during reign of the Islamic Empire. Although there was little progress in the development of medical theory in medieval West, evolution of the infirmary continued and was mostly influenced by Christian religion and charity. In Constantinople large medieval infirmaries were built, but patient care was frequently offered in monasteries by clergymen. Later on medicine and treatment of diseases were taken over by physicians and taught in universities, and medical theory continued on its course of evolution. It is obvious that the modern infirmary is not only a place for treating diseases, but rather the upshot of a series of advancements in science, the relations between people or even countries, and the way humanity perceives its nature and the future. Our research is focused on the interactive relationship between the evolution of medical theory and the infirmary as an institution during antiquity and the Middle Ages with particular emphasis on the Western World.

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    In recent years, notable measures have been taken to protect the rights of participants in biomedical research in Iran. The present study examines possible trends in adherence to ethical codes regarding informed consent after the development of the National Code of Ethics in Biomedical Research (NCEBR) and establishment of research ethics committees. In this retrospective study, 126 dissertations from Tehran University of Medical Sciences were evaluated for adherence to ethical codes. These dissertations were all in clinical trial design and had been presented in the years 1999 and 2009, that is, precisely before and after the development of the NCEBR. A checklist was developed to evaluate the ethical issues associated with informed consent. A single investigator retrieved and evaluated the consent forms from the dissertations. Borderline cases were discussed with other investigators to reach a consensus decision. Based on the checklist, the Standardized Ethical Score (SES) was calculated for each consent form. The mean SES and the rate of consent form attachment were compared between the two years. In total, 70 dissertations had reported obtaining informed consent from study participants, whereas consent forms were attached in only 22 dissertations (17.50%). The percentage of dissertations with the consent form attached increased over time from 12.2% in 1999 to 20.8% in 2009 (P > 0.05), but the majority still did not include a consent form. Moreover, the mean SES of consent forms was significantly higher in 1999 (0.746) than in 2009 (0.428), highlighting the need for more training of researchers and improved surveillance by the ethics committees. A great amount of effort is still needed to make the consent process more ethical, especially for dissertations as a less visible part of academic research. As for students, more systematic training focused on research ethics should be implemented prior to thesis submission.