فصلنامه اخلاق پزشکی
پیاپی 41 (پاییز 1396)

Nurses are one of the largest service providers who face mental stress in their workplace. Moral distress causes the nurse avoid communicating with the patients and taking care of them. Along these, the basic and physical needs of the patients are not provided and when the nurse feels uncomfortable and injured and with the repetition of this issue, the nurse’s complacency and self-esteem, and the care provided by the nurse fail. This allows nurses to choose negative matching practices such as avoidance of the befallen situation, changing their hospital ward, and quitting their job. This study was conducted to determine the nurses’ perception of moral distress in nurses working in educational hospitals of Yazd city.
A descriptive cross-sectional study was conducted on 370 nurses working in educational hospitals in Yazd, 2012. Moral Distress Scale (MDS) with 95% validity and 97% reliability was used to measure the severity and frequency of moral distress in nurses. This standard questionnaire includes 38 items, each of which describes a stressful situation. This tool shows the frequency and severity of moral distress based on a 7-point Likert scale. To determine the severity of the distress, a score of 0 to 6 is considered for each score. The minimum score for MDS is 0 and the maximum score is 228. To measure repetition of moral distress, participants are asked to indicate the number of exposures to the described situation in the item by a score of 0-6. Sampling was done on a non-random basis. Data were analyzed using SPSS software version 18.
Ethical considerations: After obtaining the permission of the Ethics Committee of the Vice-Chancellor for Research and Technology, Yazd University of Medical Sciences, by the code 1395-132, and considering general code of research ethics, the participants’ consent was obtained after describing the objectives and the research process and ensuring confidentiality of information.
Findings: The age range of the participants was 22 to 52 years old, most of them were women, married and official employee. The mean score of nurses’ perceived moral distress was 3.41 ± 1.28 and the mean score of repeated severity of moral distress was 2.60 ± 1.1. Item No. 35 (working with physicians who do not have the required qualifications to meet the patients’ care needs) had the greatest severity and item No. 2 (pursuing the family request for continued patient life support, despite the patient’s request) had the lowest severity of moral distress. The highest frequency of moral distress was related to item No. 5 (initiation of resuscitation, while I believed it was inconclusive and only prolonged the death process), and the lowest frequency was related to item No. 29 (pursuing the patient’s request of helping him/her to commit suicide when the patient’s prognosis is poor).
There was a negative relationship between age and severity of moral distress (r = -0.1 and p = 0.04). Also, the marital status of participants had a significant relationship with moral distress severity (P = 0.001). There was no statistically significant relationship between the mean score of moral distress and other demographic characteristics (P≥0.05).
Regarding the moderate degree of moral distress in the participants, it is necessary for policymakers and nursing managers to take measures and strategies to reduce the severity of moral distress and also to identify its causes. Considering the destructive consequences of moral distress, including job dissatisfaction, avoiding nurses from presence at the patient’s bedside or leaving their job, it is suggested that workshops be held in this regard. Also, holding educational classes for managers and head nurses of the hospital wards, in order to prepare nurses and create appropriate patterns in dealing with problems happening in the clinic can reduce the severity and frequency of their moral distress.
Please cite this article as: Fazljoo E, Borhani F, Hoseini SH, Abbaszadeh A. Nurses’ perception of moral distress among nurses working in educational hospitals affiliated to Yazd University of Medical Sciences. Med Ethics J 2017; 11(41): 7-15.

Courage is one of the moral virtues and the source of many personal and social achievements that are essential for providing quality care. Moral courage is to take action act fearlessly and act on the basis of will; that is, the individual acts without regard to other factors, only on the basis of values and what is good to others. Nurses are the ethical focus of the professional career group and inspiration source for moral care and compassionate. Moral courage is a professional management competence and the most important elements among the four virtues necessary for management; including foresight, justice and moderation, as well as a factor stabilizing the action. By seeing managers as ethical and behavioral models, nurses learn the correct and expected performance, and the courage to respond correctly to one situation is strengthened in them. The purpose of this study was to compare the mean moral courage of nurses and nursing managers working in hospitals affiliated to Shahid Beheshti University of Medical Sciences.
This descriptive cross-sectional study was conducted for 3 months starting from September to November 2015. A total of 70 nurses and 61 nurse managers were selected using convenient sampling method. Data collection was carried out using the Moral Courage Scale developed by Sekerka et al. in 2009. This scale consists of 15 questions categorized into five areas of moral agency, multiple values, endurance of threats, going beyond compliance, and moral goals. The response scale is 5-point Likert scale that is always arranged from Never (1) to Always (5). This scale was translated and back translated by Mohammadi et al. in Iran, and its validity was assessed through a survey of 10 experts in the field of medical ethics and content validity index (CVI) of 81% was obtained. Cronbach's alpha coefficient of 0.85 was obtained for the instrument reliability. To determine the reliability, the scale was completed by 20 nurses and nurse managers and the Cronbach's alpha of 0.86 was obtained. Data analysis was carried out by SPSS ver.22. Descriptive analysis of data was performed using central indices and comparison of mean moral courage in two groups using independent t-test. Pearson correlation coefficient was used to determine the relationship between age, work experience and moral courage. The response rate was 100% and 87% in the nurses and nursing managers groups, respectively.
Ethical considerations: To carry out the research, the relevant permission was obtained from Ethics Committee of the Shahid Beheshti University of Medical Sciences. The informed consent was obtained from participants after explaining the research aims and its implementation procedure. Also, the researcher assured participants about the confidentiality of their information and documents and explained to them about the freedom to withdraw from the research at any stage without being suffered from any adverse consequences.
Findings: A total of 40 (30.5%), 21 (16%), 38 (29%) and 32 (24.4% ) of cases of the 131 nurses and nursing managers participating in the study, were employed in internal medicine, surgical wards, ICU and emergency departments and the nursing office, respectively. Nursing managers included 31 (23.7%) head nurses, 27 (20.6%), educational and clinical supervisors, and 3 matrons (3.2%). The mean moral courage was 4.31 ± 0.40 and 4.33 ± 0.32 among nurses and nursing managers, respectively. The mean moral courage of the two groups was not significantly different (P= 0.06). There was a significant relationship between age, nursing management experience and moral agency (P= 0.04), as well as nurse's work experience, and then multiple values and going beyond compliance (P= 0.035). The mean moral courage was desirable among nurses and nursing managers. There was no significant difference between nurses and nursing managers in terms of mean of moral courage and its 5 items (moral agency, multiple values, endurance of threats, going beyond compliance, and moral goals).
The desirability of the mean moral courage of nurses and nursing directors in this study is a clear and positive point for health service providers that can be used to promote professional performance. Regarding the fact that there was a significant relationship between increase in age and work experience and the dimensions of moral courage in both groups, and considering that moral behavior and courage may decrease over time due to the influence of anxiety, fear and its negative consequences; therefore, to increase the moral courage of members of the organization, appropriate planning for training staffs, holding workshops and discourse sessions and encouraging and protecting moral behaviors are recommended. Also, strengthening the moral capabilities of managers and nurses having a higher work experience can provide the appropriate models for promoting moral performance in the organization.
Please cite this article as: Moosavi S, IzadiA. Comparison of moral courage of the nurses and nursing managers working in hospitals affiliated to Shahid Beheshti University of Medical Sciences. Med Ethics J 2017; 11(41): 17-24.

One of the main concerns in research is its authenticity. The precise identification of research-related ethical issues can help improve the quality of researches conducted by graduate students and increase their reliability. The nature of some disciplines in different fields, as far as dealing with human beings, their cultural, social, and behavioral occasions can create some research areas in which the researcher needs to observe ethical principles related to these fields. Researchers need to observe ethical principles and values in the various stages of their research. The disciplines of behavioral science, due to their different research nature, require researcher to adhere to some common ethical principles. The present research addresses the various ethical dimensions of behavioral science research.
The present research was conducted in the qualitative approach framework and using analytical content analysis. A semi-structured interview was used to obtain components and indicators of ethics in the research process. The research population consisted of Tehran universities professors of the research methodologies in the behavioral sciences fields. A total of 15 professors were selected using purposive sampling and snowball method. All the participants were informed about time and place of interviews in advance. The duration of each session varied from 20 minutes to more than an hour. Data analysis was performed using deductive content analysis and open categorical source coding method. To ensure the accuracy of the study, the criteria of Guba &Lincoln (1985) were used.
Ethical considerations: Respect for privacy and confidentiality, voluntary participation, awareness of the research purpose, respect for the rights and dignity of individuals were among ethical considerations. Participants’ consent was taken before recording and taking notes and they were assured that the information obtained would be published totally.
Findings: Ethical components in the process of behavioral science research were achieved in the following five stages: ethics in the selection and explanation of the problem (correct identification of the problem; the statement of reality and lack of distortion of facts while selecting the subject; the ability and expertise to perform the research; the importance and necessity of the problem), ethics in data collection (sampling method and validity of research sample; accuracy in data collection), The use of appropriate and standard instruments; non-bias; respect for privacy and confidentiality; respect for participant's rights and informed consent), ethics in the analysis and interpretation of data (authenticity and accuracy of data; honoring the trust, avoiding data fabrication; use of appropriate analytical methods; tolerance and avoid distortion of results); ethics in compiling and publishing results (no distortion of the report; non-copying; considering the rights of all authors; respect for the dignity of the participants in the research; citing credible scientific sources; trusted citations and direct and indirect quotation; supply of research findings in scientific circles) and "paying attention to values and norms of science", which is considered as the competency for doing research. This characteristic may be regarded as the most important characteristic directing the ethical approach to scientific-research ethics. The internalization of the norms and scientific values develops in a biologically scientific process and is related to the spirit of truth and responsibility in how to achieve scientific discoveries. Commitment to science and its norms were expressed in the experiences of one of the professors as follows: "If one is committed to science, he will surely achieve the science and value of science. If anyone achieves the essence of science, he will be considered a committed person and must be fully aware of topics of his discipline by reading relevant articles and researches. To understand theories, one must be aware of the philosophy of science, the history of science, and the circumstances and realities of his own society, and ultimately equip himself with the scientific method ".
Many researches are being designed and carried out and researchers have little knowledge of the ethics of research. Different fields of science, based on the nature of the research methods used, can embody different ethical principles. Considering the importance of the research results in the fields of behavioral sciences, the findings of the present study, which represent the views of the professors of methodology, can lead researchers to genuine and ethical research that contributes significantly to the development of knowledge boundaries. The ethical issues raised by the research process can be a useful guide for students and researchers in the field of behavioral sciences.

Many of the employee's and manager's behaviors and decisions are influenced by their ethical values. Work ethics can affect the performance of employees through better regulation of relationships, reduction of disagreement and conflicts, increasing the atmosphere of understanding and cooperation, and reducing the costs of monitoring. Among the various professions, nursing care can be a clear example of moral performance; the ultimate goal of the nursing profession is the improvement of human health, which can only be achieved through scientific and ethical care and the correct relationship with the patient. Among all kinds of intelligence, moral intelligence is related only to the study of ethics rules and helps us to understand moral teachings. The dimensions of moral intelligence of nurses play an important role in their attitude toward ethical standards. The aim of this study was to determine the moral intelligence of nurses working in hospitals of Arak city.
In this descriptive cross-sectional study, 176 nurses working in hospitals of Arak city in 2015 were randomly selected. First, according to the statistics of each hospital, the sample size of each hospital were calculated based on the number of nurses working in them. Then, the samples were selected using a random figures table from the hospital statistics. The criteria for entering the research included the minimum degree of nursing bachelor. The data collection tool was a two-part questionnaire. The demographic information included age, marriage, education, sex, type of employment and work experience, and the second part was the questionnaire consisted of 40 questions about moral intelligence. In the present study, following the permission of the researcher, the translated version by Abbaszadeh et al. was used. The questions included the status of the level of moral intelligence based on Likert scale of 5 states. The questionnaire was scored as 5 points = fully agree, 4 points = fairly agree, 3 points = no opinion, 2 points = fairly opposite, 1 point = totally opposite. The score of the respondent's answers to the questions of moral intelligence dimensions including integrity (16 questions), compassion (4 questions), forgiveness (8 questions) and responsibility (12 questions) were recorded as the final score of the nurses. In total, each person earns a score between 20 and 100. According to the toolkit, the score obtained by each individual, up to 53 points of poor moral intelligence, up to 69 as average, to 85 as good, and more, is interpreted very well. Data was collected from all hospitals for 15 days. A total of 180 questionnaires were distributed by the researcher at various times and at the situations that the nurse was prepared to answer the questions. After ten minutes, completed questionnaires were delivered. Data were analyzed using SPSS ver.16 statistical software. Descriptive statistical methods (frequency, mean and standard deviation) and inferential statistics (T-test, fisher, and one-way variance) were used to analyze the data.
Ethical considerations: This research is the result of a research project approved by the Research Ethics Committee of Shahid Beheshti University of Medical Sciences and endorsed with ID No. IR.Arakmu.Rec.1394.33. The oral consent of the participants was obtained for participation in the research and the confidentiality of information was assured.
Findings: Most participants were female, married, officially employed, with a bachelor degree, and a work experience of less than 7 years. 11.4% of nurses had excellent moral intelligence and 18.8% had poor moral intelligence. The mean score of total moral intelligence was calculated to be 32.27 ± 8.28. Also, the mean of integrity dimension was 31.4 ± 4.13, the responsibility rate was 23.23 ± 3.36, the compassion dimension was 7.75 ± 3.1 and the rate of forgiveness was 15.22 ± 3.2. The level of moral intelligence was poor in 33 subjects (18.8%), in 67 subjects (31.8%) were good, in 56 subjects (31.8%) was very good, and in 20 subjects (11.4%) was at the high level. Based on Fisher exact test, there was no significant correlation between moral intelligence and demographic characteristics of the participants (P> 0.05).
The desirable level of moral intelligence in nurses demonstrates the importance of acquiring moral values for them and indirectly reflecting the ethical performance of nurses in clinical settings. This can indicate the importance of nurses respecting ethical standards as well as emphasizing the moral nature of the clinical environment. Therefore, it is suggested that managers of health care centers adopt strategies such as holding educational courses to strengthen nurse's moral intelligence.

Paying attention to spiritual needs of patients as an important aspect of care is not only essential for improving health consequences, but also to respect the dignity of patients. Spiritual care is the major core of the quality of life of patients and their families, which becomes possible through identifying the care needs of clients. Research has shown that the needs of a child and their family from the time of diagnosis of cancer change until the treatment stage and other stages of the disease. The patient child’s parents feel insecure and do not know how they should take care of their patient child. This study has been conducted with the aim of comparatively investigating the spiritual care needs of mothers of children suffering from cancer at early stages of diagnosis as well as terminal stages of the disease.
This descriptive-analytical study was conducted on 400 mothers of less than 14-year-old children suffering from cancer at early stages of diagnosis and terminal stages of the disease, hospitalized in blood and oncology wards for children of hospital throughout Tehran in 1394-95. All mothers whose children were hospitalized in the mentioned wards due to cancer and had the inclusion criteria were included in the study through available sampling. The inclusion criteria for the mother to enter the study were: having a child below 14 years of age, hospitalization of the child in the ward for at least two days, having early criteria for diagnosis and terminal stage of the disease (according to the documents available in the patient’s file, diagnosis made by the specialist, guidelines of the ward head-nurses, or the information of the child’s patent), as well as literacy (both reading and writing). The data collection instrument included patient spiritual needs assessment scale, which was translated into Persian and validated. This questionnaire included 18 questions about demographic information of the mother and her child (including 9 questions about the information associated with age, gender, disease, time of diagnosis, place of residence, treatments tried, having a relative with cancer, the number of hospitalization of the child during one month, and 9 questions about the information associated with age, marital status, education, housing situation, level of monthly income, support of social institutions, supportive resources in the family, and correspondent of the child’s disease. Spirit questionnaire includes 70 questions with a Likert scale and two open-ended questions. The first section includes 43 five-option items in relation with reflection of the spiritual care needs of the mother (“never” score 1, “rarely” score 2, “sometimes” score 3, “most of the time” score 4, and “always” score 5). The second section includes 27 four-option items with a Likert scale and questions the affairs that mothers may want the child’s nurse to do those cares for them. The options include: “absolutely disagree” score 1, “disagree” score 2, “agree” score 3, “absolutely agree” score 4). The lowest score of the first section implies more need of mothers to receiving spiritual care, and the lowest score of the second section suggests refusal by the mother to receive spiritual care by a nurse. This scale has no cut-off point, but considering the instrument’s median, the subjects were categorized into three groups of extreme, medium, and low, in terms of spiritual care. The data was analyzed by SPSS 18. The responses given to the open-ended questions of the questionnaire (10 persons from the early diagnostic stage and 20 from the terminal stage) were analyzed and classified in a directed way. Eventually, through a quantitative method, the frequency of the obtained themes was calculated.
Ethical considerations: After receiving confirmation from the ethics committee of Tehran University of medical sciences with the code of (9211196001_137223), the researcher visited the environment of the research and after receiving permission from the hospital officials and explanation about the study objectives, the written informed consent of mothers was received to participate in the study.
Findings: Most children in both groups had an age of between 5 and 14 years old, with 46.1 and 57.7% being in an early diagnostic and terminal stage groups, respectively. In both groups, around half of the children were male and the other half were female. Most of the children in both groups lived in Tehran. The majority of children in the terminal stage group (52.4%) had been hospitalized three times or more per month, while most children in the early diagnosed group (74%) had been hospitalized twice or less per month. A total of 97% of the children in both groups had a second-degree relative with cancer. Further, over 80% of children in both groups had undergone chemotherapy. In both groups, most mothers had an age of between 25 and 35 years old, were married, housewife, and an educational level of diploma. In most families, the main reporter of the family was the father, the average monthly income of the household was less than 250 Dollars and they had rented houses. A total of 59.1% of the families in the early diagnosed group and 44% of the families in the terminal stage group had been supported by social institutions.
The average of spiritual care needs in the terminal stage group was significantly higher than the diagnostic group (p The spiritual care needs in the mothers of the terminal stage group and willingness of the mothers in both groups across different stages of the disease are contemplative. Considering the progressive increase in the rate of cancer in children and spirituality as an inseparable part of the life of patients and their families, measurement of the spiritual care needs of mothers with children suffering from cancer is essential in care planning. Meeting the spiritual care needs should be taken into account in health policymaking through developing trust and companionship of the family, establishing a favorable relationship, providing a silent and peaceful place for mother’s praying, encouraging mothers to talk about their spiritual concerns, and holding praying ceremonies. Accordingly, it is suggested that spiritual care be incorporated in the comprehensive care protocol of these patients and their families.

Moral intelligence means the ability to function based on moral values and principles that is composed of honesty, being responsible, compassion and forgiveness. For some individuals, following the moral principles in decision making related to matrimony and occupational life is an important factor, but for others it is not important. Also, of predisposing factors of extramarital relations we can mention individual, family and social factors. Interaction of three variables of cultural values, couple's self-presenting and strategies of solving conflicts are effective on matrimony satisfaction. This study was performed by the aim of predicting nurse's tendency to extramarital relations based on moral intelligence and related predisposing factors.
This study is a correlation-cross sectional research that was done on 130 nurses who worked in Ahvaz hospitals in 2015 which were selected by available method. In this study, all nurses of general sections who desired to cooperation were invited for participating in the study and after expressing study objectives they were asked to read and answer questionnaires accurately. Entry criteria to this study were nursing in general sections, matrimony, being woman and lack of stressful happenings such as divorce and death in past six months. Exiting criteria from study included un-satisfaction for cooperation and uncompleted questionnaire. In this study, in addition to demographic characteristics form of age and education, moral intelligence, loyalty pathology and tendency for extramarital relations questionnaires were used for data collecting. Data were analyzed by descriptive statistical indices and Pearson correlation coefficient and multiple regressions with step by step model using SPSS software version 19.
Moral intelligence questionnaire was designed by Lennick and Kiel. This tool has 40 items and four dimensions of honesty (10 items), being responsibility (10 items), compassion (10 items) and forgiveness (10 items) which was scored by five points scale of Likert (1= never to 5= always). Dimension scores were obtained from item's score summation of that dimension and general score of tools is obtained from items score summation and more score means more existence of that score. In present study, stability of honesty, responsibility, compassion and forgiveness dimension were computed with Cronbach Alpha method 0.90, 0.86, 0.71 and 0.77, respectively.
For measuring predisposing factors of marital relations, achieved questionnaire of loyalty pathology was used. In order to make this tool by Delphi method by 7 specialist persons and performing test in goal group, finally 33 items were extracted. As a result, this tool has 33 items and three dimensions of individual factors (9 items), family factor (13 items) and social factors (11 items) which was scored by using seven degree Likert scale (1= completely disagree to 7= completely agree). Dimensions scores were obtained through items score summation. Formal and content validity of this tool were confirmed by 7 persons of training science and psychological expert's stability of individual, social and family factor's dimensions were computed with Cronbach Alpha method 0.91, 0.84 and 0.86.
Questionnaire of tendency to extramarital relations was designed by Drigotas et al. This tool has 11 items which is scored by Likert five points Likert scale (1-completely disagree to 5= completely agree). Total score of this tool is obtained through summation of item's scores and more score means more desire for extramarital relations. Questionnaire stability in current study was computed by Cronbach Alpha method 0.91.
Ethical considerations: Questionnaires were completed without writing name and family name, by observing secrecy and after written testimonial by participators. Data collecting was done by the same sex participators.
Findings: All participators in this study were women and married and their mean and standard deviation age was 34.90±5.17. Most of participators were in age domain 34-37 years, and had master education 80 (34%). Among moral intelligence dimensions, honesty dimension (r=0.368, p≤0.037) and responsibility (r=0.295, p≤0.001) had a meaningful and negative relation with desire to participant's extramarital relations, but in forgiveness (r=0.113, p≤0.061) and compassion (r=0.083, p≤0.073) dimensions with desire to nurse's extramarital relations, a meaningful relation was not seen. Also, individual factors (r=0.456, p≤0.001) and family factors (r-0.327, p≤0.001) had a meaningful and positive relation with extramarital relations of nurses. In order to specify moral intelligence variables role and predisposing factors in extramarital relations in predicting desire to nurse's extramarital relations, multiple regression with step by step model was used. In first model, individual factors were entered to equation and correlation coefficient of this variable with desire to extramarital relations of nurses was 0.456. This variable could predict 20.7 percent of changes in desire to extramarital relations of nurses (R2=0.207). In second model, after individual factors and after honesty, family factors enter to equation and three variables of individual factors, moral intelligence and honesty dimension and family factors could predict 29.9 percent of changes in desire to extramarital relations of nurses (R2=0.299). Individual factors had the most powerful role in predicting desire to nurse's extramarital relations (β=0.534).
Findings showed that among moral intelligence dimension and predisposing factors of extramarital relations, honesty, individual factors and family factors had the ability of predicting desire to extramarital relations of nurses and individual factors were the most powerful variables in predicting desire to extramarital relations of nurses. As the result, it is suggested that authorities design and perform effective approaches such as holding training terms for reducing desire to extramarital relations of nurses and it is recommended to consulters and therapists that by presenting appropriate trainings, increase the honesty and responsibility rate in nurses; therefore, while women nurses considered concepts and moral principles in their daily interactions as a criteria for their relations and society and family attempt to reduce individual, family and social risky factors. Following the concepts and moral principles and reducing risk factors can provide a protection against desire to extramarital relations.

Despite of medical improvements and increase of survival rate of very premature and patient newborns, in recent years, ethics experts, medicine and parents are in doubt whether maintaining life works for infants that have a little chance for long term survival, is correct ethically or not. Down syndrome is of the most common chromosomal anomalies which almost is diagnosable at primary period after birth and about 10 percent of cases are with gastrointestinal disorders include intestinal obstruction, annular pancreas or imperforated anus. If Down syndrome accompanied with intestinal anomalies, risk of intestinal obstruction is high. As there are disagreements about life-saving treatments in infants and decision making in these patients in terms of medical ethics, this study has been done by the aim of determining ethical challenges in decision making in treatment of a case of newborn with Down syndrome accompanied with intestinal obstruction.
The case is a three days boy infant with Down syndrome who is referred to pediatric special center from one of the hospitals of town by ambulance because of not eating milk and abdominal distention. In physical evaluation, distinct upward corner eyelid gap, epicanthic fold, convex and extruded tongue, short and wide hands, transverse fold in palm, straight club foot, severe hypotonia, fidget, clear abdominal distention and some degrees of respiratory distress were evident. Infant's mother was 35 years old, home wife and his father was worker and rural. Infant was born by natural delivery and was the yield of third pregnancy. There was any history of abortion, dead child and anomalies in infant family and mother just consumed mefenamic acid, diazepam and cephalexin for a short time. Mother was noticed her pregnancy accidently and had not done pre-pregnancy tests. Infant has been born on time with 3100g weight and Apgar 9-10 in a maternity center. Because of lack of any special problem at birth, except clubbing foot and Down syndrome face, infant was discharged 8 hours after birth by personal consent and without meconium excretion. Then, he had been brought to hospital because of not eating milk, two days after birth and primary procedures such as nasogastric tube insertion and fluid medication was done for him. Then, he was sent to city pediatric especial center accompanied with a nurse by ambulance for visiting by a surgeon and immediately was hospitalized in infant's special care. Primary procedures such as IV line, gastric sondage, vascular antibiotic medication, phototherapy and cardiac and surgery consultation. In surgery visit, probable diagnosis of perforation results from intestinal palsy was expressed and ordered to prepared infant for surgery. According to conditions, the surgeon expressed required explanation about infant’s situation and the necessity of surgery. Finally, patient's father expressed his disagreement for surgery after consulting with other family members (grandfathers and grandmothers). Despite supporting works, infant was died after two days of hospitalization in hospital.
Ethical considerations: Meanwhile the observation of honesty and custody in case report, case and his family secrecy were observed.
Findings: Identified ethical problems in this special case, in born place hospital were: infant's discharge permission without meconium exertion, not evaluating Down syndrome in infant and other probable anomalies and not aware parents from infant's situation before obtaining permission of infant's discharge. Therefore, following questions and challenges will express in terms of medical ethics:According to the fact that meconium defecation is one of the criteria for discharging the infant, does respecting the parent's autonomy cause the right of infant's discharge by personal consent for parent? Or in the other word, had parent been able to decide for infant and recognize infant's discharge without explaining and enough understanding of infant's situation by personal consent as the best interest for him? Or Down syndrome appearance of infant causes that treatment team did not pay attention to him and also parent for more evaluations in infant? One of the bigger ethical challenges in this case was the diagnosis for the best interest for infant and correct decision making for medical action (surgery or not surgery for infant):Had surgeon's following of parent decision for avoiding of medication in destination hospital been proposed because of diagnosing being useless medication or low quality of infant's life after surgery? Or had cases such as infant's abnormality, surgery operation's cost and non-desiring of parents been cause not to do the surgery?
Decision making about medication of infants born with anomalies, especially in situations in which facilities are insufficient, is a difficult process that encounters officials of health and parents with ethical dilemma. Considered ethical problems and challenges in this study express decision making complications and their importance in life-saving medications in severe patient infants. Therefore, developing evidence-based clinical guidelines and establishing a committee composed of infant's experts and other medical ethics specialties can help to correct decision making and the best selection for their children by evaluation of scientific evidences and based on infant and his family conditions. In addition to avoid from futile care, this causes to select the best interest for infant by contribution of parents. Moreover, evaluation believes and common thoughts of the people and also of the medical personnel is recommended in order to develop evidence-based national guidelines.

Informed consent is of important moral rules of medicine that paying attention to it before starting every diagnostic or therapeutic procedure facilitates therapy and care process. Informed consent includes having decision making competence, suitable relationship with patient and providing information, understanding them, voluntarily and signing testimonial form. Consent and awareness are two important elements in obtaining informed satisfaction. Statistics show that however there increases a disproportion among available member's numbers for grafting and patients, who are waiting for graft, consent for organ donor remains fixed and insufficient. Thousand persons die because of lack of grantable organs, yearly. According to the fact that multiple factors have a role in obtaining the consent for organ donor, this study was performed by the aim of investigating obstacles and musts of informed consent in organ donation.
In this review, systematic search for English articles, having complete and available context, was done by keywords such as "organ donation" and "informed consent" in PubMed, Science direct and Google scholar database. Also, final resource of articles were evaluated in order to add articles which were eligible for entering but were not obtained in preliminary search. Search was done by first author and then was evaluated and confirmed by second author. In searching and selecting articles, no limitation was applied in terms of type and quality of study. During the search, 126 articles were recovered. 100 articles were deleted because of non-relatedness abstract and because of duplication and 10 articles also were deleted after studying compete context. Finally, among 126 finding articles, 16 related articles were studied and analyzed.
Ethical considerations: Integrity and honesty in reporting, documenting and citing of resources, not to distort and manipulate in findings and their report based on scientific content and abstinence of bias were observed.
Findings: Musts of obtaining informed consent were categorized into two groups related to donor and related to consenter and medical personnel. Most of studies knew informing of donation risks, assurance of competence and decisiveness of organ donor of related cases to donor. Complete medical evaluation, giving information and creating enough understanding are of the related cases to consenter. Obstacles are in three groups related to donors, their family and concenter.
In consenting process, one of the important cased is paying attention and evaluation of donor understanding of given information which should be simple, comprehensive and proportional with organ donor understanding and only, having organ donation card is not a reason for informed consent. In most of countries, in addition to above musts, correctness of consent for organ donation should be confirmed by judge, moral committee, governmental authorities, human tissue organization and special governmental commission. Related information to organ donation trend should be given in written form and by a person other than his or her doctor. Only in Netherlands, in addition to above cases, following program after operation is necessary for both donor and receiver of organ. But there is no commission for evaluation of live dolor competence and live donor should be compatible in terms of genetics, legislatives and companion with receiver of organ. In Saudi Arabia also, financial motivation (in women), and medical motivation (in men) reduce possibility of free selection and informed consent. Among countries, Italia and Spain had the highest consent rates. Of the most important obstacles of informed consent obtaining are insufficient professional training of consenters, lack of grasping donors about serious complications because of abundance of disclosed information during evaluation in live donors and lack of correct understanding of brain death and pressure for organ donation in donor families who are death brain.
Patients are willing to receive important information, especially in graft risks fields and depriving of this information is a basic obstacle for informed consent. In organ donation process, information about grafting operation trend should be presented not only for donor but also for receiver of the organ and informed consent should be obtained. However, most of studies are for donors. Also, donors may be willing to know the conditions of organ receiver health for informed decision making. Therefore, a suitable policy is required for moral disclosure of health information. As organ receiver applicants are more than donors, individual desire for participating in this altruistic work should be increase by applying correct principles and deleting existed obstacles which are proportional to culture, religion and country rules. Clearing the rules for reception personnel, increasing their attention and also explaining consent forms for patients and observing effective musts in consent for organ donation can help to increase donation rate. Results show the necessity of reviewing informed consent trend in order to transfer the information related to organ donation effectively and evaluate donor's understanding.