During the last two decades, there has been a great deal of interest in addressing issues related to medical and nursing ethics. As these issues are addressed internationally, it is important to consider how ethical principles are interpreted in a national context. This column describes how Iranian cultural beliefs need to be considered while developing ethical guidelines for nurses in Iran.
Iran is an ancient country with more than 2,500 years of civilization. Over 90% of the approximately 72 million people in Iran are Muslim. Since respect for human beings is important in the Iranian Islamic culture, it is surprising that the concept of patients’ rights and ethical codes have not been considered until recently. To bring attention to healthcare ethics and to enhance the quality of healthcare in Iran, the Ministry of Health and Medical Education has introduced a strategic plan to advance the study of medical ethics at the national level (Larijani, Malek-Afzali, Zahedi, & Motevaseli, 2006). The Ministry (2002) also published a Patients’ Bill of Rights. However, the Bill is an amalgamation of western versions of such bills and is not based primarily on the Iranian socio-cultural context. It is not yet clear how this Bill relates to the provision of services offered by the Iranian healthcare system (Joolaee, Nasrabadi, Parsa-Yekta, Tschudin, & Mansouri, 2006).
In over 19 years of nursing practice in Iran, the authors have witnessed incidents in which patients’ rights to practice their religion or cultural beliefs have been ignored and cases in which patients were not even fully aware of their rights. In some situations patients with gastritis were forbidden to fast while they were in the hospital, regardless of their religious obligations. In other situations patients were asked to provide preoperative informed consent themselves (as stated in the international nursing codes); yet this practice contradicts the Islamic rule that one ask the husband to consent to perform a reproductive-system operation on his wife.
Although many aspects of current international codes are practical in Iran, there remains a need to establish ethical guidelines that are compatible with the unique cultural and religious characteristics of the Iranian people in order to provide more effective nursing and medical services to them. During the last two decades, the rapid advances in science and concurrent development of bioethics have prompted important questions which call out for practical answers and appropriate actions in policy-making, organizing, and teaching ethics. Because of the special Iranian cultural beliefs, development of a code of ethics for nurses in Iran is still in the early stages. More research is needed to complete this code. To advance the development of ethical codes in Iran the Medical Ethics Center of Tehran University of Medical Sciences focused their second Medical Ethics Conference on topics of professional commitment, research ethics, the beginning and end of life, teaching ethics to students, resource allocation, and equity in health and medical services (The 2nd International Congress, 2008). The remainder of this column will focus on two important issues that evolved from this ethics conference, namely patients' rights and nursing ethics.
An important tenet of nursing is respecting the human rights and dignity of all patients. The priority of healthcare organizations must be protection of patients’ rights. After the Iranian revolution of 1979, the Iranian government began to focus on specific rights in healthcare and the accessibility of healthcare services for its population. Since that time great strides have been made in the study of biomedical ethics (Hamidian, 2007; Larijani, Zahedi, & Malek-Afzali, 2005). It has been said that one’s rights define the other’s responsibilities; therefore a patient’s rights define the healthcare professional’s responsibilities (Hasanian, 2008). AliAkbari and Taheri (2008) have explained that the Patients’ Bill of Rights was created in order to defend human rights; preserve patients' dignity; and ensure that in case of sickness, and especially in emergencies, patients receive competent care without discrimination. Respect for patients’ rights and the development of a framework to reflect these rights have a long record in the history of Iran’s healthcare services, as reflected in the ten clauses in the charter that have been developed and published by the Ministry of Health.
Joolaee (2008), in her article on the Patients' Bill of Rights in Iran, explained that “despite the sanction of patient’s rights by the Ministry of Health and Medical Education, enough consideration on the patients’ rights has not been provided so far and its most noticeable inadequacy is that in its compilation, patients' attitudes and those of involving groups, nurses and doctors, were not considered” (p. 9). Nasrabadi, Parsa-Yekta, and Joolaee (2008) carried out a phenomenological study designed to examine patients’ rights based on experiences of patients, their relatives, nurses, and doctors. The study showed that human rights are involved in many aspects of patient-oriented care. These rights are advanced through effective communication that includes understanding and sympathy. From patients’ point of view, a willingness to meet their basic needs and to protect them under any circumstances are essential characteristics of healthcare providers.
AliAkbari and Taheri (2008) reported that 78.8% of Iranian nurses believe patients’ rights were observed in hospitals. However, Malekshahi (2008a) reported that patients' rights and privacy were observed in only 56.2% of cases; in addition, 86.6% of patients were not completely aware of their own rights. In other studies the level of consideration of patients' rights and the appropriate privacy provided by nurses was reported to have occurred in only 22.15% - 27.9% of nurse-patient interactions indicating a lack of respect for the inherent dignity, worth, and rights of patients (Malekshahi, 2008b; Rahmani, & Qahremani, 2008a; Rahmani, & Qahremani, 2008b). In their survey Rahmani and Ghahramani (2008b) reported an acceptable level of patients' privacy consideration in intensive care units, but a lesser level in medical-surgical wards. Aghajani and Dehghan Nayeri (2008) emphasized patients' privacy as a primary caring principle and a fundamental right of all human beings.
Another important aspect of patients' rights is safeguarding autonomy and informed consent regarding healthcare interventions as the healthcare paradigm shifts from a paternalistic to a patient-centered focus of care. Esmailpoor and his colleagues (2008a) found that on surgical wards, patients reported that their understanding and perception of informed consent was generally poor.
Like many other countries, Iran is faced with a serious nursing shortage. This leads nurses to work more than their required 192 hours per month, potentially adding 150 hours per month of overtime in some parts of the country (Joolaee et al., 2006). Most nurses are employed in hospitals where they are responsible for many different tasks, thus making it difficult for them to become engaged in policy development. Tschudin (2009) reported on a study in Iran that provided insight into Iranian nurses’ inner selves as they recounted moments of deep understanding of their work. It was clear that these nurses believed it was important to be able to provide care for their patients that blended spiritual/ethical values with scientific methods.
Teaching ethics has long been recognized as an essential requirement in clinical medicine by Muslim scholars. Memarian, Salsali, Vanaki, Ahmadi, and Hajizadeh (2007) have noted that the acquisition of clinical competency is facilitated by an understanding of professional ethics. Yet the concept of professional ethics has not been clearly defined or taught in nursing schools (Nasrabadi, Joolaee, Parsa-Yekta, Bahrani, Noghani, & Vydelingum, 2009). The authors' experiences in different nursing schools in Iran indicate that the nursing ethics course is often ignored and nursing students are increasingly becoming insensitive to ethical issues in day-to-day nursing work. Negarandeh, Oskouie, Ahmadi, and Nikravesh (2008) have supported Bu & Jevewski’s comment (2007), that the negative way in which health professionals sometimes relate to patients, specifically the disregarding, dehumanizing, controlling, punitive, and judgmental practices of biomedicine, can lead to varying degrees of vulnerability. The traditional approaches to teaching ethics are primarily teacher centered and based on lectures, so students' lack of active participation is a matter of concern. It is hoped that a more effective approach to teaching ethics, one that allows student participation, will help to change students' negative perceptions regarding nursing ethics (Nasrabadi et al., 2009). Esmailpoor and colleagues (2008b) found that 71.1% of the nurses in Gilan Province faced daily ethical challenges thus highlighting the necessity of developing a nursing ethics code. Emphasizing the nurses’ advocacy role, Negarandeh (2008) noted that considering the contextual differences between a country such as Iran, and the West, it is essential to develop a national code of ethics for nurses which reflects the healthcare needs of patients in Iranian healthcare. Negarandeh added that the lack of a code of ethics serves as a barrier to patient advocacy; the development of a code of ethics for nurses in Iran could enhance ethical conduct and patient advocacy.
The availability of a code of ethics for Iranian nurses is becoming increasingly important. The Iranian Nursing System has recently become a member of the International Council of Nurses (ICN). Nurses in Iran now face the challenge of applying the principles found in the various ICN ethical codes to patient care in their country. Valiee and Nikbakht (2008) have explained that as nurses continue to work in a variety of settings and take on different roles, they are being exposed to an increasing number of ethical challenges. Thus, it is necessary that Iranian nurses compile a code of ethics that encompasses nursing care provided to patients having a variety of ethical, cultural, and religious perspectives.
Esmailpoor and Salsali (2008) have reported that nursing ethics codes developed by the American Nurses Association, Canadian Nurses Association, International Council of Nurses, and other nursing associations have been influential in helping Iranian nurses in their ethical decision making related to their educational, managerial, clinical, and research activities. Although these codes vary slightly in content, all of them have underlined important ethical principles, such as doing no harm, beneficence, autonomy, justice, privacy, confidentiality, and human dignity.
Perhaps none of the healthcare specialties need ethical guidelines as much as the specialty of mental health. In providing mental health care it is especially necessary to balance the dangers these patients can present to themselves and society with the need to provide these patients with as much freedom as possible, to ensure that no compulsory treatments are unethical, and to respect human dignity and autonomy. Shojaee and Ma'arefdoost (2008) have described laws and ethical guidelines regarding the care of the mentally ill, They, too, have underscored the need to compile a nursing ethics code in Iran.
The last few decades have seen numerous scientific and technological advances that have raised ethical questions. During the last two decades medical and nursing ethics have been discussed in Iran and a Patients' Bill of Rights has recently been compiled by the Ministry of Health and Medical Education. Developing ethical guidelines for Iranian nurses will be a significant step in addressing the ethical questions nurses face today as science and technology continue to offer new healthcare interventions. Compiling a code of ethics for nurses is still in early stages. Although more research and study are needed, it is hoped that an ethical code will be developed in the near future. Development of this code must be based on nationally accepted values and customs and inspired by international codes of nursing ethics. Whatever code of ethics is developed for Iranian nurses, it should serve as a guide for carrying out nursing responsibilities in a manner consistent with providing quality nursing care and meeting the ethical obligations of the profession.
Acknowledgement. The authors express their appreciation to Dr. Aramesh and the authorities of the Medical Ethics and History of Medicine Research Center of Tehran University of Medical Sciences. Without their help and support, this column would not have been possible.
Tahmine Salehi, Msc, BSc in Nursing
Nahid Dehghan Nayeri, PhD, Msc, BSc
Reza Negarandeh, PhD, Msc, BSc
Article Published July 14, 2010