Suggestions for changing professional ethics educational system

Introduction The total sum of behavioral standards a human must consider to have a specific career or vocation is called professional ethics.1 Ethics aims to improve relationships with people who deal with other individuals due to their occupations.2 Professions associated with medicine require specific ethics: medical ethics. Certain behaviors such as the rule of respecting a patient’s choice, being helpful, and not causing harm, as well as regulations to observe justice, honesty, and confidentiality of patient information are the main principles of medical ethics.3 Treatment staff are accustomed to witnessing pain, ache, fear, anger, sorrow, depression, anxiety, and worry of death among patients due to continuous contact with them.4 In the relationship between treatment staff and patients, members of the medical team must deal with patients based on their values5 and take care of all patients with high quality regardless of their position without discrimination and with justice.6,7 Medical ethics specifies a number of frameworks for the actual relationship between treatment personnel and patients, thereby improving this relationship. Various communities have taken measures to improve medical ethics after recognizing its significance. For instance, a number of ethics codes have been considered to provide a behavioral framework for treatment staff in Iran, including Nursing Ethics Regulations8 and the Comprehensive Charter of Patient Rights,9 and professional ethics subjects are included in training courses for medical students. However, a considerable number of patients are not satisfied with the way treatment staff behaves. Research conducted by Rahmati et al found that 43% of patients complained about improper behavior among personnel in the emergency ward at the Shohadaye Tajrish Hospital.10 Gholjeh et al from Zahedan found that 43.3% of patients declared that they did not trust their nurses.11 In a systemic review by Esfahani and Nezamdust,12 in which 52 published essays were examined between 2001-2018, the average patient satisfaction rate was found to be 14.1%, well below average. The main question of this paper is as follows: “What are the ways to reform the professional ethics educational system to reduce patient dissatisfaction rates?”


Introduction
The total sum of behavioral standards a human must consider to have a specific career or vocation is called professional ethics. 1 Ethics aims to improve relationships with people who deal with other individuals due to their occupations. 2 Professions associated with medicine require specific ethics: medical ethics. Certain behaviors such as the rule of respecting a patient's choice, being helpful, and not causing harm, as well as regulations to observe justice, honesty, and confidentiality of patient information are the main principles of medical ethics. 3 Treatment staff are accustomed to witnessing pain, ache, fear, anger, sorrow, depression, anxiety, and worry of death among patients due to continuous contact with them. 4 In the relationship between treatment staff and patients, members of the medical team must deal with patients based on their values 5 and take care of all patients with high quality regardless of their position without discrimination and with justice. 6,7 Medical ethics specifies a number of frameworks for the actual relationship between treatment personnel and patients, thereby improving this relationship.
Various communities have taken measures to improve medical ethics after recognizing its significance. For instance, a number of ethics codes have been considered to provide a behavioral framework for treatment staff in Iran, including Nursing Ethics Regulations 8 and the Comprehensive Charter of Patient Rights, 9 and professional ethics subjects are included in training courses for medical students. However, a considerable number of patients are not satisfied with the way treatment staff behaves. Research conducted by Rahmati et al found that 43% of patients complained about improper behavior among personnel in the emergency ward at the Shohadaye Tajrish Hospital. 10 Gholjeh et al from Zahedan found that 43.3% of patients declared that they did not trust their nurses. 11 In a systemic review by Esfahani and Nezamdust,12 in which 52 published essays were examined between 2001-2018, the average patient satisfaction rate was found to be 14.1%, well below average. The main question of this paper is as follows: "What are the ways to reform the professional ethics educational system to reduce patient dissatisfaction rates?"

Materials and Methods
In this paper, based on the authors' experience and related studies, we make several suggestions for improving the observation of professional ethics among treatment staff.
These recommendations are related to three stages: Before beginning the academic study, during university study, and during work as a treatment staff member.

Before beginning the academic study Tip 1: Institutionalizing ethics
To be ethical, ethics must be institutionalized. Ethics should not be taught only in one year, but over all years to be institutionalized. 13 Treatment personnel cannot be expected to be ethically minded only by learning ethics during their university study. The seeds of ethics must be sown from childhood and persist through adulthood. Various public institutions and charities should aspire to instruct people of all ages to behave morally, which has not only been neglected, but most of these organizations have driven people towards immorality by enforcing inappropriate laws. 14 Tip 2: Changes in university entrance examinations To reduce patient dissatisfaction and improve the treatment process, it is necessary to make changes in the selection and training of treatment staff. 15 To be admitted to a university in Iran, one first passes the barrier of the entrance examination. Only those with the highest scores are admitted to study medical science majors, which is to say that even the most self-involved persons who do not think of anything but their own profit can be admitted if they put in a great deal of effort. Such people will constitute treatment staff who do not respect human life and only seek higher incomes. They may be less likely to be honest, sympathetic, or attentive to patients and less concerned about patients' rights. To tackle this issue, in addition to passing an entrance examination through the meticulous study of high school curricula, there is also a need for personality tests to evaluate applicants in terms of mettle, egotism and altruism, sympathy, philosophy of life, and other psychological aspects to ensure that not everyone can practice medicine merely by exerting strenuous effort. "Diligence", "altruism", and "psychological resilience" are three principles which medical practitioners need to adhere to, none of which is sufficient on their own without the presence of the others. Nevertheless, the entrance examination in Iran only requires diligence and intelligence from the applicants, which should not be the sole criteria for admission to medical sciences universities.

During the university study period Tip 3: Increasing professional ethics credits
Medical undergraduate and doctorate students are only required to pass a two-credit course in Professional Ethics, with nursing and midwifery students needing one-and-ahalf and one-credit courses, respectively. 7 However, ethics are part and parcel of all aspects of professionalism, 16 and problems ensue when ethics are set aside. 16 How can a one-or two-credit course of ethics ensure professional work ethics? Not only are the students expected to be familiar with the Charter of Patients' Rights, moral codes, treatment staff 's rights, and the like, but they should study these courses to the point where these matters are institutionalized. To institutionalize ethics, it must be taught over all the years, not once during a year. 17 Thus, increasing Professional Ethics credits along with holding classes and workshops are among effective measures to compensate for these current shortcomings.

Tip 4: Teaching professional ethics by medical ethics specialists
More often than not in medical universities, professional ethics are taught by non-professionals, namely those professors with an MSc degree in the operating room who have passed only a one-or two-credit course of professional ethics themselves and are now in charge of teaching undergraduates. Unfortunately, in Iran, the number of medical ethics specialists who are faculty members at universities of medical sciences is much less than that of universities of medical sciences. As of August 30, 2021, medical ethics was the only specialty of 25 faculty members, ' 18 while according to Civilica (Publisher of Iranian Journals and Conference Proceedings), there are 68 medical sciences universities and schools in Iran. 19 As a result, education officials in Iran do not realize the significance of professional ethics and regard it only as a showcase. Allocating a specific budget to universities for hiring faculty members of medical ethics and banning non-professionals from teaching professional ethics courses are two suggestions to remedy professional ethics teaching.

Tip 5: Teaching ethics regardless of religion
Students in Iran pass a two-credit course of general ethics as "Islamic Ethics", in which right and wrong are taught through Islamic criteria. Apart from that, there are several issues; first, students have a negative view of general courses, seeing them only as courses to be passed. 20 Secondly, the professors who teach such courses often do not act according to moral obligations themselves. 20 The third problem is that the course content is not up to date with modern conditions, 20 and the fourth is the premise that all Iranians are Muslims who take action based on Islamic teachings. However, not all Iranian people are Muslims, and the question of whether they abide by Islamic commands is apparent through the corrupt state of affairs in Iran, which is to say that most people do not care for what religion has to say. As such, education officials should compile an ethics book originating in various religions that seeks to address the philosophy of ethics, the reason for the existence of ethics, individual and social consequences of complying with or disregarding ethics, and other dimensions of ethics education.

Tip 6: Improving students' imagination and empathy
People with stronger imagination and empathy are more likely to put themselves in the shoes of others. Universities should develop educational programs that enlarge students' imagination and increase their empathy. Such students will then learn codes of ethics and rules themselves to communicate in the best way with others and will be less likely to harm themselves or others. 21 Improving imagination and empathy should be at the core of future medical education programs. 21 Tip 7: Teaching the history of medicine For Iran's Ministry of Health and Medical Education, the history of medicine is not regarded as having great importance, and as a result, students are not provided with a course in the history of medicine. Knowing about the history of medicine will help students prioritize the objectives of their major 22 and get to know about the approaches of their ancestors, which in turn will help them find their way as practicing medical professionals in the modern world. Nietzsche said that history introduces a man to the great works of the past and encourages them to continue the glorious traditions of the past. 23 The history of medicine lets them know about legendary heroes who dedicated their lives to helping others, giving them role models to help guide students. Teaching the history of medicine shows students patterns to try to emulate. It is like a beacon that lights the way. 23 We cannot expect students to be ignorant of Albert Schweitzer and yet follow in his footsteps. Providing a course on the history of medicine is an approach to train more scientists like Schweitzer.

Tip 8: Improving students' social skills and public relations
Higher education policies regarding elite students have often failed to consider the all-encompassing development of talents in humans but instead have often taken a one-dimensional approach toward these individuals. 24 Students who sit for the entrance examination in Iran typically deprive themselves of attending social gatherings and parties for a long time to study. They are onedimensional and lack opportunities to acquire social skills or to learn these skills at university. That may be why many medical staff have poor social skills, which in turn makes them less adept at interacting appropriately with patients. Solving this problem demands multiple levels of growth (universities, colleges, faculty, students) that focus on students in the current setting. 24 Universities need to develop courses to help students improve their social skills and public relations.
Tip 9: Educating psychology as the core of medical education programs Being in a hospital can be a stressful situation. Psychological support can help hospitalized patients cope with stress. Treatment staff should learn to support patients both mentally and emotionally as much as they treat their bodies. Students should be familiar with various psychological theories such as supportive and humanistic psychology to provide patients with mental support along with effective communication with patients.
Tip 10: Logotherapy of students during their student days As can be deduced from its perspectives, the Iranian Ministry of Health and Medical Education (MoHME) does not focus much on students' mental health. Meanwhile, many students have a mental illness, lose their objectives, and approach nihilism during education due to educational stresses and financial strain. By seeking assistance from Logotherapists, the ministry can help students right from the beginning of their education. If students see the meaning of life in helping patients, the students will be more dedicated to what they do and even make personal sacrifices if needed.

During work as treatment staff Tip 11: Supervision by a psychologist
In dealing with patients, treatment staff are constantly exposed to pain, agony, fear, anger, sorrow, depression, anxiety, and fear of death, 4 not to mention long shifts, shortage of personnel, and job strain, all of which put them under intense psychological pressure. They need to be under regular psychological and psychiatric supervision to help address these issues as soon as possible.
Tip 12: Regulating the system of payment An important issue raised by treatment staff is inequity of payments. Surgeons in Iran have much higher incomes than other members of the treatment staff, such that in 2016 the deputy director of Iran's Nursing Organization claimed that there was a pay gap of more than 1000 times between some doctors and nurses. 25 When a treatment staff member feels injustice at work and does not receive what they deserve, they may try to claim those rights on their own and refuse to perform their obligations. 26 The government should examine these inequities and undertake to regulate the system of payment based on criteria such as job difficulty, risk-taking, educational level, patient satisfaction, and so forth. 26 Tip 13: Adjusting the incentive and punishment system Infrastructure can lead to morality or immorality in humans. Infrastructure means laws, processes, administrative, social and political frameworks that affect society. 27 Ethics also need infrastructures such as appropriate legislation, law enforcement without exception, supervision, availability of public courts for settling arguments, and transparency. 13 It seems that in some hospitals of Iran, the manner in which treatment personnel treat patients does not matter much, or at least the foundation for ethics is not yet established. There is no effective disciplinary or encouraging system to monitor treatment staff 's conduct. Encouragement can motivate one to do something passionately, and punishment can deter him/her from doing certain things. Zarei and Nateghi recommend that the supervisor and agent be separated in the system and that a system of monitoring and regular supervision be established. 28 Hospitals must have offices where patients can voice their opinions after discharge regarding their satisfaction or displeasure with the medical team without fear of losing their medical services and privileges.
The medical team and hospital managers should be rewarded or punished based on the information the patients provide. If treatment staff know they are being monitored, they will behave more decently. 29 These sections should be under the direct supervision of the Ministry of Health and Medical Education so that managers and administrators do not exalt themselves by meddling with the opinions. Such information should be accessible to the public.

Tip 14: Increasing the number of medical staff
The quantity and quality of human resources are important factors affecting the speed and cost of services and the quality of health services. 30 Work pressure ensuing from a staff shortage provokes tension and dissatisfaction among treatment staff. Per capita, the standard specifies 2.5 nurses for each bed while in Iran, the ratio is 1 nurse for each bed. 31 There is also a physician per 1000 population, whereas this number is higher for many countries. 25 This can put pressure on treatment personnel, which adversely affects the quality of services and creates problems in patient care, quality of care and treatment costs, 30 precipitating aggression, negligence of patient, lack of accountability, etc. It is incumbent upon the Ministry of Health and Medical Education to consider this issue. Even with the budget limit, if the authorities do not realize how grave this problem is, it will foment strife among people that could prompt catastrophic ramifications for the country.

Tip 15: Informing people of their rights
Finally, most people are not aware of their rights and how to pursue their complaints, and believe that in case of filing complaints, they will be deprived of health services. Thus they remain silent in the face of treatment staff misconduct. 13 Patient awareness of the Charter of Patients' Rights is directly related to patient demands for rights. 32 People need to be informed about their rights, and just as much as the treatment staff need to be familiar with the Charter of Patients' Rights, so do the patients.

Discussion
Overall, training in ethics should begin from childhood. To be admitted to a university in majors such as physics, chemistry, and biology, and the like, there is a need for personality tests as well as entrance examinations. During their education, students need to be subjected to Logotherapy. Learning ethics and psychology should be at the center of the medical sciences curriculum, and psychologists should be role models for universities to educate treatment staff who can communicate effectively with all sorts of patients. Regular supervision of treatment staff by psychologists and psychotherapists, enforcing discipline and encouraging the following of regulations, monitoring treatment personnel and managers at hospitals, and direct contact between managers and patients to learn about possible shortcomings can help in this regard.
The suggestions we made in this article may not be feasible and could look like Plato's utopia, but they do show the way. We must first have a model of the ideal society and then strive to achieve it.
To rectify the educational system, officials primarily need to address the current shortcomings and then remediate them. At the opening of the seventh National Conference on Medical Ethics that was held in 2020 in Mazandaran, the deputy of the Supreme Council of Medical Ethics in Iran at the time claimed (without presenting any valid reference) that more than 97% of patients are satisfied with hospital services and that the media exaggerate the relevant issues. 33 Meanwhile, a study by Esfahani and Nezamdust 12 suggests that the patient satisfaction rate in Iran is only 14.1%, which is well below average. Insofar as administrators are egotists who may foster less ethical processes, there is still a long way to go for treatment staff to be ethical.

Conclusion
This educational system is comprised in such a way that it cannot train treatment staff who observe professional ethics entirely; therefore, clients may feel dissatisfied with the behavior of treatment staff. Specific changes in the selection method and training of treatment staff are indicated to enhance patient satisfaction levels.
Ethical approval Not applicable.