Vol 11 (2018)


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    Prescribing antibiotics to patients represents an ethical dilemma for physicians since the current health needs of the patients have to be balanced with concerns for long term containment of antimicrobial resistance in the community. Overuse of antibiotics is a major pathway for development of antimicrobial resistance. In resource-poor settings a complex social reality can influence antibiotic prescribing behavior among physicians which apparently violates the conventional biomedical ethics principles especially beneficence and justice. These social factors include patient socioeconomic class, patient demand for antibiotics, competition among practitioners and conflict of interest arising from the physician’s social relationship with his/her patient.  Current approaches for combating antimicrobial resistance in the developing countries are inadequate in factoring and dealing with those irrational prescription practices which are driven predominantly by subtle violation of medical ethics as opposed to blatant economic and professional profiteering.

Original Article(s)

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    Privacy and confidentiality are among the inalienable rights of every human being that contribute to preservation of a sense of reverence and dignity. The present study was conducted to examine patients’ awareness of their entitlement to these important rights.This cross-sectional study was conducted on 200 patients in Tehran, Iran during the year 2010. Collected data included patients’ demographics (age, gender, marital status, place of residence, and educational level), type of hospital ward, frequency of hospitalization, duration of hospital stay, and patients’ awareness of privacy and confidentiality. Two trained interviewers gathered the data using a self-made questionnaire, which was specifically designed to assess patients’ awareness of privacy and confidentiality. Validity and reliability of the questionnaire were determined using content validity and Cronbach's Coefficient Alpha (a = 0.7), respectively. To analyze data, patients were assigned to three categories of poor (0 ≤ scores ≤ 3), moderate (4 ≤ scores ≤ 7) and good (8 ≤ scores ≤ 10) levels of awareness. Statistical analysis was performed by SPSS software version 21.

    The results showed that 21% of the patients had poor, 72% moderate, and 7% good awareness of privacy and confidentiality, with a mean of 4.61 ± 1.63. In this study, 153 patients (76.5%) provided a correct definition of privacy, and 161 patients (80.5%) were aware of instances of privacy violation. In addition, a good level of awareness was found in 77 patients (38.5%) in terms of physician confidentiality, and in 158 patients (81.4%) regarding confidentiality of examination results and medical consultations. Our study results highlight the necessity to inform patients about the ethical and legal issues related to privacy and confidentiality, before or during admission.
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    Scientists and researchers have examined spiritual health from different angles and proposed various definitions, but a comprehensive definition does not exist for the term as of now. The present study aimed to offer the definition, components and indicators of spiritual health from experts’ perspective.
    This qualitative study utilized conventional content analysis and individual in-depth interviews with 22 experts in the area of spiritual health in various fields selected through purposeful sampling. Member check, credibility, reliability, transferability and allocation of adequate time for data collection were measured to increase the validity and reliability of the results. Conventional content analysis was performed in three main phases: preparation, organization and reporting, and the categories, subcategories and codes emerged accordingly.
    Participants defined spiritual health in three dimensions: religious, individualistic, and material world-oriented. The study revealed four types of connection in spiritual health: human connection with God, himself, others and the nature. The majority of participants stated that spiritual health and spirituality were different, and pointed out the following characteristics for spiritual health: it affects physical, mental, and social health; it dominates other aspects of health; there are religious and existential approaches to spiritual health; it is perceptible in people’s behavior; and it can be enhanced and improved. Most experts recognized human connection with God as the most important part of the definition of spiritual health. In conclusion, the connection between humans and themselves, others and the nature was not seen as a component specific to spiritual health

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    Moral distress is among the various types of distress that involves nurses and can lead to multiple complications. It is therefore rather important to identify the factors related to moral distress. The purpose of this study was to examine the relationship between futile care perception and moral distress among intensive care unit (ICU) nurses. This cross-sectional study used a descriptive-correlation method and was conducted on 117 ICU nurses of Qom hospitals in 2016. Data were collected using a 17-item futile care perception questionnaire, and Jameton’s moral distress questionnaire containing 30 questions. Data analysis was performed using SPSS 16, descriptive statistics and univariate regression analysis. The results showed that the mean age of the participants was 34.99, and most (about 66.7%) were women. Univariate regression analysis indicated that when ICU nurses’ perception of futile care and work experience increased, their moral distress also increased significantly (P = 0.03 and P = 0.02, respectively). It can therefore be concluded that moral distress is associated with futile care and ICU work experience. It seems that some interventions are necessary in future to place nurses in clinical situations involving futile care, and thus reduce their level of moral distress.

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    Human dignity (HD) in patient care is an important concept in clinical ethics that has various definitions in existing literature. This study aimed at analyzing the concept of HD in patient care. To this end, Rodgers' evolutionary concept analysis was used. For this purpose, scientific databases PubMed, Elsevier, ScienceDirect, Scopus, OVID, Web of Science, CINHAL, IRANDOC, Google Scholar, Magiran, SID and IranMedex were searched fusing the words “human dignity”, “patient care” and “ethics”. The main criterion for inclusion in the final analysis was the literature published in English and Persian from 2006 to 2016 in online scientific journals within the context of health care disciplines. Ultimately, 21 articles were selected for the study. The attributes of the concept under study were identified in two areas of individual HD and social HD. Antecedents included facilitators and threats, and the consequences consisted of both favorable and unfavorable consequences. HD forms the essence of patient care and is a value-based and humanistic concept based on respect for the integrity of human beings and their beliefs. This concept, with its holistic approach to humans, takes into account all stages of disease, old age and the end of life period. HD in patient care is influenced by cultural, social, spiritual and religious factors, and with its justice-based approach emphasizes equality of all patients and extends patient care to all areas of society rather than restricting it to hospital settings. In this study, a clear definition of HD is introduced.

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    Metaparadigm concepts comprise the central issues in a discipline. Fawcett has named person, health, environment and nursing as the four main concepts of nursing that need to be comprehensively defined. The Human Caring Theory is significant because of its focus on the spiritual dimension of human beings. The aim of this study was to comparatively explain three of the main metaparadigm concepts of nursing in the Human Caring Theory and Persian mysticism, and find the similarities and differences that can help develop the theory and its application in societies with a theistic point of view. This comparative documentary study was done in two phases. First, a concept analysis was performed to find the attributes, antecedents and consequences of the concepts of human being, environment and health in the two fields of Persian mysticism and Jean Watson’s Human Caring Theory. Then they were apparently and deductively compared with each other. In spite of some similarities between the two perspectives, Persian mysticism was found to provide more comprehensive conceptualizations of the three main concepts of nursing.

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    Informal payments refer to sums that patients may pay to individual or organizational health care providers outside of the official payment channels or approved fee schedules. The aim of the current research was to investigate informal payments and related influential factors in Urmia city hospitals.
    The present study was a cross-sectional survey conducted among post-discharged patients from all Urmia city hospitals during one Iranian calendar month (January 21 to March 19, 2013). Simple random sampling was used to recruit 265 patients to undergo assessment via phone call interviews and complete a questionnaire. Data analysis was performed using SPSS software for descriptive reports, and EViews software for determination of factors affecting informal payments.
    Eleven percent of the patients had made informal payments to physicians (mean amount: 503,000 Tomans, equivalent of $412), 5% to nurses (mean amount: 20,000 Tomans, equivalent of $16), and 17% to other employees (mean amount: 16,000 Tomans, equivalent of $13). Hospital ownership, patients’ place of residence, education and income significantly influenced the payments. Most substantially, patients receiving surgical care were 100 times more likely to make informal payments compared to those who had received non-surgical inpatient care.
    The present study showed that although informal payment is illegal in Iran, it is a common practice among hospitalized patients, and has now become a challenge for the health system. Considering the high prevalence of informal payments and their severe impacts on equity and justice, policymakers have focused on this phenomenon to reduce and eliminate it.

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    Awareness of the occurrence of medical errors is the right of patients and duty of the health service providers. This study was conducted to evaluate to what extent people want to know the occurrence of an error in their medical care, what they expect to be disclosed about medical error, and what are the influential factors in filing a lawsuit against physicians in disclosed medical errors from their point of view. 
    In this cross-sectional survey, 1062 people residing in the city of Qom, Iran, were telephone interviewed using the random digit dialing method. The questionnaire used consisted of 4 demographic questions and 2 scenarios of major and minor medical error; the participants were asked if the physician should disclose the error in each scenario. The questionnaire also consisted of 16 questions about other issues related to error disclosure. Data were analyzed through descriptive and inferential statistics in SPSS software.
    About 99.1% of the study population believed that errors had to be disclosed to patients. They all wished to know that measures would be taken to prevent further errors. Moreover, 93.1% of the participants expected an explanation on the incident. As for the factors that decreased the likelihood of taking legal action against the physician from the viewpoint of the study population, treatment of the complications (96.1%) and honesty of the physician (95.8%) had the highest frequency.
    Based on the considerable preference of patients for error disclosure, it is recommended that physicians disclose all minor and major errors sympathetically and with transparency, honesty, and efforts to prevent future errors.

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    Learning professionalism is a central topic in medical education. While many factors could affect the educational process of professionalism, hidden curriculum is considered one of the most important ones. As the working components of a hidden curriculum might be specific to the settings, this study explored its components in terms of professionalism and ethical conduct from the viewpoint of Iranian undergraduate medical trainees.
    Semi-structured and in-depth interviews were used to collect medical students' experiences and viewpoints, which were then analyzed through simple content analysis and the codes and categories were extracted. Finally, themes were derived as the central organizing concepts.
    Saturation occurred after 17 interviews. Seven main themes were extracted as the working components of hidden curriculum regarding professionalism in the setting: ‘convenient patients’, ‘evaluate me’, ‘trust as the base of team interactions’, ‘perceiving encouragement’, ‘relationship satisfaction and authenticity’, ‘workload and students’ well-being’ and ‘role modeling at the heart of professionalism’.
    Students' perception and experiences are a rich source of gaining a deeper understanding of the working hidden
    curriculum. In this study, two groups of human-related and environment-related elements were extracted. They were effective in the formation of the current 'ethical climate', which shaped the professional and ethical identity of medical trainees. Moreover, specific plans regarding the condition of the settings may provide opportunities for medical educators to enhance professionalism in their institutions.

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    Islamic and non-religious ethics discourses have similarities and differences at the levels of meta-, normative, and applied ethics (e.g. biomedical ethics). Mainstream biomedical ethics (MBME) uses the language of contemporary, non-religious, Western ethics. Significant effort has been dedicated to comparing Islamic biomedical ethics (IBME) and MBME in terms of meta- and normative ethical positions, and final decisions on practical ethical issues have been reached. However, less attention has been given to comparing the general approaches of the two aforementioned discourses to ethical reasoning. Furthermore, IBME uses different languages to approach ethical reasoning, but identification and conceptualization of these approaches are among the important gaps in the literature. The aim of this study was to conceptualize general approaches to ethical reasoning in IBME. Through review and content analysis of the existing literature and the comparison between the languages employed by IBME and MBME, an inductive distinction have been made. The languages used in conceptualized approaches include the followings: (i) a language in common with the one employed by MBME; (ii) MBME language adjusted to the basic, common beliefs of Muslims; (iii) a language based on fatwas; and (iv) a language based on IBME principles. In the authors’ opinion, major challenges of the above-mentioned four approaches include, respectively: identifying the lack of religious sensitivity or Islamic considerations regarding an issue; acknowledging specific beliefs as the basic, common beliefs of Muslims; diverse fatwas and relations between juridical soundness and ethical soundness; and agreement on the same principles and rules as well as who should apply them.

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    Professional commitment plays a significant role in all professions. Moreover, schools are valuable fields for teaching the principles of these concepts especially through novel methods such as gamification. "Earthquake in the city" was implemented in a school in Tehran, Iran, and its effectiveness on learning the concepts of professional commitment was evaluated.
    "Earthquake in the city" was built based upon a fantasy scenario occurring in an imaginary city. Each student took on a role in the city (citizen or healthcare provider). After finishing the game, participants were asked about the concept of professional commitment. Their definition was scored by a group of medical ethics experts separately in terms of compliance with the actual definitions and compared with their peers in the control group who did not participate in the game.
    A group of 16-year-old teenagers studying in the 11th grade participated in this intervention. The average score of conformity with the actual concept of professional commitment among the case group participants was significantly higher than the average value for the control group (P < 0.05).
    The results of this study could provide insights to planners and educators engaged in the education system so that gamification can be incorporated as an influential tool to teach the concepts of professional commitment. This experience can also be generalized to other concepts, but designing the appropriate scenario will be the most important component of the intervention in these cases.

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    Ethical management with minimum moral distress is one of the main duties of nurse managers. There is no doubt that a better understanding of the experiences of nurse managers in morally challenging situations could have an effective role in improving health care systems. The present study aimed to investigate the lived experiences of clinical nurse managers regarding moral distress.
    This hermeneutic phenomenological qualitative research involved the use of semi-structured interviews with nurse managers. The interviews were transcribed and analyzed by the Diekelman, Allen and Tanner approach. For this purpose, a total of 14 Iranian nurse managers with at least five years of experience in nursing management in hospitals were purposefully selected.
    The findings related to nurse managers’ experiences of moral distress contained two main themes (psycho-emotional trauma and professional desperation syndrome) and four sub-themes (shame, emotional dissociation, helplessness, impaired professional identity).
    The findings of the study indicated that in order to understand the phenomenon of moral distress among nurse managers, it is essential to investigate the moral distress experienced by them. We also found that although they experience moral distress in their daily decisions repeatedly, they are not fully aware of this phenomenon
    According to the results, for clinical nurse managers, moral distress is an ambiguous situation like suspension along with uncertainty, fear and so on. They believed that experiencing this kind of conscious mistake is the reason for the occurrence of professional desperation syndrome and psycho-emotional trauma.

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    End-of-life care and protection of the patient in the near-death moments are part of a patient’s rights and the duties of the medical staff. As the beginning and end of human life are most sensitive moments, there are various religious rules associated with them. The ethical issues regarding practicing medical procedures on nearly dead patients are of particular complexity and are consistent with invaluable and profoundly religious recommendations. In addition, the purpose of medical training is to provide physicians with the knowledge and skills necessary to practice appropriately and within legal and ethical frameworks. Therefore, respecting patients’ cultural and religious beliefs is an ethically accepted principle in the health systems of different countries and is the basis of respect for human dignity. The present study used a qualitative content analysis to explain how to practice medical procedures on a dying or nearly dead patient in accordance with Islamic jurisprudential rules. It was finally concluded that according to the Islamic jurisprudential rules of “authority”, “no harm”, “necessity”, and “public interest”, procedures performed on a dying patient could be used for training purposes under certain circumstances. Nevertheless, such activities should only be done with the patient’s permission and provided they cause no unnecessary harassment, and they may take place in the absence of alternative methods.

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    Part one of the present study presented practical Islamic jurisprudential rules and investigated their application to performing medical procedures on nearly dead patients. It was contended that a dying patient could be used in medical education in cases where there is no alternative method, provided the patient voluntarily consents and is not offended. Part two of the present study addresses the issue by referring to the opinions of Islamic jurisprudents to find an appropriate solution to a challenging question in medicine, namely, whether clinical training of medical students on the dying person is permissible. For this purpose, istiftas (petitions or requests for a fatwa) were sent to prominent contemporary Shiite jurisprudents to solicit their opinions on the use of dying patients for medical education. After exploring the existing views, it was finally concluded that the majority of the jurisprudents allowed the practice in cases of “necessity” and provided that the principles of “no harm” and “consent” were strictly observed. All these terms are found in jurisprudential rules, and we reached the conclusion that Shiite jurisprudents considered this type of training permissible under certain circumstances and in accordance with jurisprudential rules.

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    One issue that has received less attention in present health care protocols is pediatric palliative care (PPC), which is an approach to care starting with the diagnosis of life-threatening diseases in children. It embraces physical, emotional and spiritual elements. Ethical issues are major concerns in today’s pediatric health care guidelines and must be considered by residents and attending physicians in this field.
    The present study was conducted in Namazi Teaching Hospital, Shiraz, Iran. Forty-eight out of 92 pediatricians were enrolled in this research, including 8 attendings, 6 fellows, and 34 residents. The study questionnaire consisted of 66 items. It was built based on previous reliable and validated questionnaire; also the calculated Cranach’s alpha was 0.815. Data were analyzed and presented by mean ± SD and percentage.
    While seventy-five percent of the participants reported involvement in pediatric palliative care, fifty-six percent did not acknowledge any information about the subject. More than half of the participants perceived the pediatric palliative care services in Namazi Hospital as somewhat or completely satisfactory. Furthermore, thirty-five percent of the applicants stated that they encounter an ethical problem with regard to PPC once a week.
    There are many challenges to providing decent palliative care for children, including symptom controlling, shifting to end of life care, background dissimilarities of patients, financial restrictions, and acceptance of death. Our applicants believed that offering psycho-spiritual support was the most important challenge in PPC. However, further investigations are needed to determine other requirements for providing a comprehensive guideline on PPC.

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