Health, Spirituality and Medical Ethics

Introduction
Considering patients’ rights is a vital priority in medical care [1]. Rights include what people deserve to enjoy in any social and cultural context [2] that should be observed and respected by others. Rights are very important in forming and regulating human interactions and thus embrace a considerable part of religious instructions [3]. Human beings share principal rights in general and a set of rights for particular conditions and situations. The specific rights in the time of illness that should be identified for recipients of medical care or treatment are termed as patient rights [4, 5]. Awareness about these rights both for patients and caregivers is the main part of high-quality medical services [6]. Humans as multidimensional beings with bio-psycho-socio-spiritual needs should be attended to fully when receiving treatment and care, knowing that neglecting any aspect means ignoring a part of their humanity [7]. Confirming the essential rights of individuals in healthcare, especially respecting their dignity as human beings, becomes more important if we consider that the vulnerability imposed by illness, makes patients subject to be harmed by the violation of their rights by the healthcare system [8]. To meet patients’ eligible physical, mental, spiritual, and social needs, several standards, protocols, and guidelines have been established for the healthcare providers [1, 9]. Charters of patient rights have been prepared in different countries including Iran. The Iranian patient rights charter underscores humanistic values, aiming to maintain, improve, and consolidate the relationship between patients and healthcare providers [10]. Nevertheless, as a result of the cultural and social considerations, it seems necessary to investigate more exactly the patient rights in accordance with the Islamic perspective as the fundamental value system of the country. Islamic worldview poses a different perspective to healthcare. In Islam, providing healthcare is not just a professional duty, but a value-laden responsibility assigned by God himself, and a way to His blessings through maintaining His servants’ needs [11, 12]. Such a worldview is expected to introduce different concepts and constructs in different issues including patient rights. Previous studies have identified the dimensions of patient rights from Islamic perspective including: human dignity, proper communication with patients, respecting their confidentiality, privacy, informed consent, and autonomy, paying attention to the spirituality of patient, providing good care for patient, social justice and public access to medical services [13]. It seems that the Islamic view on the patient rights not only conforms with the current standards of patient rights, but it includes notions neglected in the charters of patient rights. Human dignity, religious values, moralities, and spiritual growth are the most outstanding features of Islamic patient rights. On the other hand, findings indicate that respect for patients’ rights in Iranian healthcare organizations was at a moderate level [14]. This reminds us of the necessity of a closer look at this concept in the country. The shortcomings may be partly due to the unclarity of the concept or its misalignment with social and cultural backgrounds. Thus, the current study was designed to take a closer look at patient rights within the framework of Islamic instructions. To provide an authentic view of the issue, clerics were referred to as a source of explanation of patient rights in Islam through a qualitative content analysis study. The findings then were roughly compared to the existing charter of patient rights to distinguish the probable inconsistencies.
Methods
This qualitative study was carried out with an approach of conventional content analysis. Content analysis is an analytical approach in qualitative studies which is mainly utilized for subjective interpretation of the data to extract and classify the concepts [15].
Study design and setting
The setting of the study was Qom, a central Iranian city. The study was done in 2020 and the data collection and analysis lasted for more than four months. The study population consisted of clerics who were selected through purposeful sampling to maximize variation in terms of age, sex, and education degree. Twenty participants (14 men and six women) were included in the study. The inclusion criteria included being graduate of 3rd or 4th grades religious seminaries (equal to Master’s degree or PhD. respectively), having a history of being hospitalized, and willingness to participate in the study. The hospitalization experience was decided to be an inclusion criterion because it helped the participants achieve a deep familiarity with the environment of medical care centers and thus their opinions sound more realistic.
Data collection
Data collection was done through in-depth face-to-face interview sessions held in a place of convenience for the participants. The interviewr was an MD student who was trained to conduct the interviews under the supervision of the thesis supervisor. Every interview session lasted 60-105 minutes, which were audio-taped with previous permission and oral informed consent of the participants. Interviews began with a record of demographic data and general questions about patient rights. The interviewer asked for example: “what do you think of when speaking about patient rights?” and consequently put forth more explorative and follow-up questions like: “would you please elaborate what you just said?” or “what exactly do you mean by …?” to encourage more explanation of the issue. Each interview was transcribed and the analysis was done along with the interviews, which went on until data saturation was achieved and the data analysis did not resulted in new codes.
Data analysis
Any interview was listened to several times by the researchers to be immersed in the data and gain a deep understanding of it. It was then transcribed word by word and typed. The written interview was taken as a whole, and the meaning units were extracted out of words, sentences, or paragraphs and written down on separate files. The texts were reviewed again and the meaning units were compared to remove duplicates and merge similar ones. Codes were merged according to their similarities and rearranged to develop subthemes. The final stage of coding was generating themes from subthemes through comparison, contemplation, and abstraction.
To ensure the rigor of the study, the criteria proposed by Lincoln and Guba were used including credibility, transferability, dependability, and confirmability [16]. The long-term engagement of the researchers with data during the data collection and analysis and member check were used to assure credibility of the study. A full description of the participants and the setting in which the study was conducted was a means of determining transferability. For dependability, we described the research steps, documentation of data, methods, and the end product. These were also helpful to ensure the confirmability that means that the interpretations of the findings were clearly derived from the data.
To compare the findings with the Iranian charter of patient rights as an adjunct objective of the study, the themes and subthemes were checked with the statements of the charter to see if the notions are addressed or not. This was done through one by one comparison of the study findings with the statements of the patient right charter.
Results
The participants consisted of 20 clerics consisting of 14 men and six women. The average age of the particpants was 39 years, ranging from 31 to 50. In terms of education, the number of interviewees were the same in both 3rd and 4th grade, each group consisting of 10 persons. All the participants were Shia Muslims.
In the coding process of the interviews, there appeared 132 preliminary codes. After merging the similar codes and removing the duplicates, the remaining codes were classified under 18 subthemes that are shown in Table 1. Subthemes were analyzed once more to generate more abstract and more general concepts, during which the four themes of the study emerged.
To explain any of the above-mentioned themes and subthemes, the opinions of the participants are summarized to depict an almost common viewpoint of the clerics about the issues, and when necessary, pieces of the participants’ remarks are quoted to strengthen the arguments and provide.
Respect for patient autonomy
The participants consider human autonomy as a blessing of God. So, any attempt to restrict or deprive it is a violation of rights, except what has been determined or permitted by God Himself as explained in Islamic rules. This undoubted right should be respected for patients like other human beings. The participants named different examples of respect for patient autonomy that were summarized in concepts of “freedom of choice among service options”, “informed consent”, and “awareness about treatment process”. A participant emphasized the patient’s right to choose the doctor and the type and place of receiving health services (Participant 3), and another recalled the need to consult with the patient before any such decisions (Participant 11). Regarding informed consent as an essential patient right, the participants underscored the importance of providing adequate knowledge to enable the patient to take the appropriate decision about the procedure.
Considering the non-physical needs of patients
Spiritual needs are more and more perceived during illness and paying attention to them can be helpful for patients’ well-being. The participants declared “Maintaining patients’ connections and communications”, “preparation for religious obligations and rituals”, “improving patient tranquility”, “attention to patients’ spiritual needs”, “strengthening the patient’s hopefulness”, and “respect for patient religious beliefs and values” as the subthemes under this theme.
Patients’ connections and communication with their family members, relatives, and friends during hospitalization, as a source of support and spiritual empowerment of the patients, was emphasized by the participants. They believed Iyadah to be a major right with great effects on their well-being, that healthcare providers should do their best to provide and facilitate it (Participant 9).
Preparing the context for the patients to fulfill their religious obligations and rituals was mentioned as a major patient right. Hospitalized patients experience a kind of vulnerability due to the nature and severity of the disease and face difficulty performing their duties. Nevertheless, patients’ religious obligations are not revoked during their hospitalization and they are expected to fulfill their religious duties. So they may need help for ablution, facilities for performing prayers, and answering religious questions, for which the health care system should be accountable (Participant 7).
Participants regarded peacefulness as a patient right for which the healthcare providers are accountable. Giving hope to patients as the advice of the Holy Prophet Mohammad is a means of happiness and calmness for the patients (Participant 13, 19). A participant pointed out that methods such as prayer therapy are used in Western countries and some centers in Iran (Participant 10). He believed that praying is a cause of growth for a patient through increasing coping and the tolerance of pain (Participant 10).
Other participants emphasized the importance of spirituality, stating that praying, invocation, and reciting the Holy Qur’an are among patient rights. You are to provide healthcare for the patient and health is not only physical. Spirituality is helpful in patient recovery (Participant 14).
Participants believe that improving hopefulness in patients is achievable by doctors, healthcare providers, companions, and anyone in communication with patients. This makes the patient feel better. A patient with a better mental state will have a better recovery (Participant 9).
Respect for patient beliefs is another right expressed by the participants. Accordingly, any disrespect or negligence to the beliefs and values of patients is a violation of patient rights. We should not neglect the healing power of the spiritualities to the extent that it does not contradict the therapeutic interventions. Sometimes these are ridiculed (Participant 8).
High-quality healthcare
The participants regarded healthcare services with good quality as an essential right for any patient. The underlying subthemes were “delivering safe health care”, “providing facilities for optimum treatment”, and “considering patient preferences and benefits” as the components of high-quality treatment.
Proper diagnosis of the disease as the prerequisite of effective therapeutic interventions while avoiding complications are among the expectations and rights of patients. Participants regard knowledge of the disease or diagnosis as the basis of any treatment (Participant 1). Other requirements of good treatment are important as such. Adopting the best treatment method while considering the least cost accompanied by ease and speed of the procedures and making the best decision in any situation (Participant 5) were mentioned by the participants.
According to the participants, the priority of patient’s benefits to the interests of the organization or care providers should be kept (Participant 3, 12, 18). For example, if the severe low back pain of a patient can be cured both through a surgical and nonsurgical solution, and the cost of alternative treatment is much less than surgery, the benefit of the doctor and hospital lies in surgery, but it is the priority of the patient that should be regarded (Participant 7).
Moral conduct
Moralities shape a main part of any religious content. Thus, it is not strange that the clerics participating in this study have underscored the moral conduct of the health care providers regarding “respect for patient dignity”, “confidentiality”, “patient privacy”, “maintaining patient trust”, “justice and equity”, and “dedicating adequate time for services”.
The participants cited Qur’an verses and Hadiths to emphasize the necessity of respect for patients’ dignity and keeping good manners in relation with patients, particularly the elderly. They referred to human dignity with which all human beings are born and regarded as God’s most noble creature (Participant 3, 20). They emphasized the strict attention of Islam and the Qur’an on dignity as the most obvious right of the patient (Participant 2, 3).
The participants endorsed privacy as a patient right. They believed Confidentiality as an important moral responsibility since every Muslim is obliged to keep secrets shared with him and never disclose them… a believer is always a secret keeper (Participant 14).
In addition, is an essential patient right, mentioned by
The participants emphasized patient privacy but emphasized an Islamic rule according to which, touching and looking at the bodies of patients of the other sex is prohibited. They referred to instances a patient is asked to raise the sleeve or let the doctor examine a part of his body (Participant 6). They believed these may be embarrassing the patient if done in another patient’s presence (Participant 4).
Establishing and maintaining doctor-patient trust was emphasized as a necessity for the patient to accept the doctor’s diagnosis and prescription. A participant believed referring the patient to another more competent doctor was a way of maintaining the patient’s trust because it is trust that makes a patient put his life in the doctor’s hands (Participant 19).
Justice and equity were expressed as another patient right that should be noted exactly in different inpatient and outpatient environments. Every patient should receive enough attention, enough time, and enough drugs (Participant 13). A form of injustice is spending less time than required for visiting patients so that the doctor cannot duly listen to their talks and carry out diagnostic steps. Doctors should give enough time to the patient to tell everything about his/ her illness, even if they are useless or false. This helps the patient get calm (Participant 20). A patient is not just physically ill. He/ she has other needs. The doctor should attend to his/ her concerns. This is certainly a right (Participant 16).



Discussion
The study was conducted to explain patient rights from the viewpoint of clerics. We explored the Islamic view from the perspective of clerics as owners of a relatively deep knowledge of Islam.
Addressing patient rights has a long history, a great deal of which has its roots in religious concepts and beliefs. Verses of the Holy Qur’an and hadiths of the Holy Prophet and Imams contain a lot of points in this regard. In Islam, a human being is regarded as God's deputy and so, possesses special innate dignity. Man's dignity is associated with rights bestowed on him as a gift from God and no one is allowed to disregard these indigenous rights. Verse 70 in Surah Al-Isra confirms explicitly human dignity: “Verily we have honored the Children of Adam. We carry them on the land and the sea, and have made provision of good things for them, and have preferred them above many of those whom We created with a marked preferment.”
The participants depicted their perception of patient rights in the Islamic framework. The findings indicated that these rights consisted of respect for patient autonomy, considering the non-physical needs of patients, high-quality healthcare, and moral conduct.
Most of the participants of this study considered autonomy as a patient right. Patient autonomy according to the findings of this study consists of freedom of choice among service options, informed consent, and awareness about the treatment process. Autonomy is the main need and one of the four principles of ethical performance in nursing as addressed in nursing ethical codes. Patient autonomy means having the right to know and be valued and the right to make decisions for one's life. Freedom of choice as a patient right encompassing the right to know, to be valued, and to participate in the determination of destiny has been reported in previous studies [17]. This is true about respecting the patient's decision-making right as a component of dignifying patients and observing their rights which considerably influences their satisfaction. Masoudi et al. point out that one of the components of patient rights is respecting the patients' rights in decision-making and providing the context to facilitate their decision-making [18]. Ebrahimi et al. explained the consequences of respecting patients’ autonomy in a clinical situation, stating that respect for patient autonomy leads to mental and physical peace of patients, decreases their dependence, and increases their trust and obedience [19]. Autonomy is regarded as the main element of individualized, patient-centered, and ethical care of hospitalized patients. Studies showed that the challenges of patient autonomy in the Iranian context included intrapersonal factors, ineffective communication, and incompetence of the organization [19].
The participants of this study stated the main rights of patients as maintaining patients’ connections and communications, preparation for religious obligations and rituals, improving patient tranquility, attention to patients' spiritual needs, strengthening the patient's hopefulness, and respect for patients’ religious beliefs and values. These needs were categorized under the theme of considering the non-physical needs of patients. Religion and spirituality-related concepts are outstanding among the findings of the present study. This is in line with other studies since healthcare systems are increasingly addressing the spiritual needs of patients in their policies and practices. Providing the ground for patients to fulfill their rituals and religious duties, recognizing their spiritual needs, and attempting to meet them are among the commitments of healthcare providers in need of proper attention. Religious issues should be acknowledged parallel to physical needs. Though religious needs are mostly addressed in end-of-life care, it has a wider domain and includes ritual needs, hope, questions and uncertainties, worldview, and parent-child balance [20]. The main need of hospitalized patients is to establish proper communication with them. This is, on the other hand, an important duty of the medical staff. Maintaining proper communication with patients leads to better understanding and empathy with patients, emotional and psychological support for them, improved physical and psychological outcomes for patients, and providing patient comfort. Establishing effective communication increases the awareness of patients and improves their decision-making, and reduces the length of their stay in the hospital.
1Furthermore, Iyadah is a religious concept that provokes family, relatives, and friends to visit patients and puts a framework to make the best of it for the promotion of hope, peacefulness, and contentment of the patients. Meanwhile, Muslims are prohibited from bothering patients with long stays and disregarding their status. Holy Prophet has advised his followers to give hope to the patient, affirming that what you say may not change the destiny, but it delights and makes the patient peaceful [13]. This is important, especially with regard to the recent approach of open, flexible, and unrestricted visits which can pose positive effects on patients, their families, and their adjustment with crisis and increasing satisfaction [21].
The participants stated the need to provide the requirements for performing the religious duties of the patients. According to the severity of the disease and its nature, patients become vulnerable to some degree after being hospitalized and have problems in performing their rituals. Since patients are required to fulfill their religious obligations during hospitalization, they expect to be provided with the requirements in this regard. Studies show that patients have difficulty in performing religious duties after being admitted to the hospital. This has been stated by Karim Elahi and Abedi who mentioned the patients' experience in prayer in the hospital and their confrontation with different obstacles and problems. They emphasized the necessity of providing facilities for prayer and other religious obligations [22].
Khansanami et al. pointed out different obstacles confronted by patients in performing religious obligations, especially praying. The obstacles included both personal factors and the lack of required facilities in hospitals. Some patients were ignorant of the religious rules and supposed that they were exempt from praying in time of hospitalization [23]. It seems that different measures should be taken to facilitate the performance of religious rituals for hospitalized patients.
The participants believed that a major patient right was to provide a peaceful environment for them. According to Yousefi Maghsoudbeiki et al., respect for the privacy of patients and establishing effective communication with them could serve as a factor in their peace and its violation could lead to anxiety, aggression, avoidance of patients from obeying the treatment team, hiding parts of their disease history, and accordingly lowered quality of care [24].
The privacy, dignity, and respect policy document in Britain emphasized personnel help patients access opportunities to accomplish their religious and spiritual needs and follow their religious actions. Furthermore, places should be provided for the accomplishment of these actions [25]. The Australian state has declared the commitments of healthcare centers for the sake of patient-centered care and improvement of patient privacy and dignity. The document focuses on respect to values, preferences, and declared needs of patients and includes statements as sensitivity to values and cultural needs, respect to religious traditions, and access to counselors and chaplains [26]. Strengthening hope among hospitalized patients is among the needs underscored by the participants of this study. Other studies have reported hope-therapy interventions and their positive effects on the overall health of patients with cancer [27].
Participants considered the healthcare providers' adherence to respect their beliefs and values as a patient right. They expected the healthcare providers to accompany patients with their praying and invocations. Tatsumura et al. believe that praying is the most used resource for patients [28]. Bjarnason wrote that understanding the ideas of patients and respecting them deepens the humanistic aspect of the nurse-patient relationship [29]. Studies indicate that the religious beliefs of patients are neglected during hospitalization. Religious beliefs as well as rituals are important in the lives of patients. Nevertheless, most doctors are not able to address the religious and spiritual aspects of their practice [30]. According to the study of Heidari and Nowroozzadeh, respecting the beliefs and values of patients was reported to consist of four sub-themes including respecting the family, facilitating religious rituals, recognizing values, and seeking recourse [31].
More recent approaches in health including patient-centeredness and individualized medicine have underscored the specific characteristics and individual needs of each person receiving healthcare. Some of these needs are rooted in the beliefs and value system of every individual and are expressed in the form of spiritual and religious needs. These are varied and may consist of preparations and facilities for praying, compliance with religious rules [22], respecting patients' beliefs, helping them carry out their rituals, and increasing their calmness through stress management, hope development, and peace and calmness promotion [32]. Obviously, ignoring one's internal values is a threat to their dignity and a loss of their rights.
Participants of this study regarded the right to receive high-quality healthcare as an important patient right. They expected their care providers, especially doctors to adopt the best treatment possible with the least cost and the highest benefit. High-quality care, according to the participants of this study, consisted of delivering safe healthcare, providing facilities for optimum treatment, and considering patient preferences and benefits. Patients’ priority in hospitals and other healthcare-providing centers is receiving medical services. Receiving desirable health services is known as a component of patient rights [33].
Moral conduct in different stages of hospitalization is another patient’s right. Participants stated that patients should receive their healthcare with all due respect. Other studies emphasized establishing proper communication with patients with ethical, emotional, and sincere interaction [13]. Moreover, providing care for patients with respect and appreciation of their values is a determining factor of their satisfaction [18].
Burhans and Alligood underscore the role of empathy and respectful behavior as ways of achieving the human needs of patients [34]. The concepts of patient privacy [35] and confidentiality [36] as the main indexes of patient rights leading to improved patient dignity have been endorsed in the literature.
Most of the above-mentioned concepts are not exclusive to Islam but are common principles approved by every belief system. Human beings share values, regardless of their denominations. Thus, this study did not intend to ignore the commonly agreed-upon components of patient rights. Rather, we intended to take into account the culturally specific components that could complement and perfect the existing documents. Therefore, many of the findings of this study are aligned with other studies in different parts of the world.
Parts of a patient's rights to be observed by healthcare providers are defined within the realm of ethics, and some human needs are secured through attention, empathy, and respectful behavior. The medical ethics principles including respect for autonomy, beneficence, non-maleficence, and justice [37] are known throughout the world. Moreover, providing the best healthcare possible with the least risks is another right that should be noted by healthcare providers.
A closer look at the current charter of patient rights in Iran (2009) in light of the findings of the present study reveals that most of the findings have their equivalent in the charter. Nevertheless, the non-physical needs of the patients are nearly absent and have not received adequate attention in the charter. There are brief references to this concept, stating that providing healthcare should be worthy of human dignity accompanied by respect for cultural backgrounds and religious values and beliefs. Another statement points out the need for attention to the spiritual needs of dying patients and their families. Definitely, the religious and spiritual needs of patients are not fulfilled by the charter. It seems that the findings of the present study could help highlight the spiritual/religious issues as the neglected aspects of human rights in Iran.
The main limitation of this study was that the participants were not experts in the field of healthcare and thus, their opinions may not include all the dimensions of patient rights. So, the findings of this study could not serve independently as a basis for determining patient rights.

According to the findings of this study, we suggest revising the Iranian charter of patient rights to enrich it regarding the spiritual issues and include the spiritual issues that are missing in the existing charter.
Conclusion
This study was an attempt to understand patient rights in the context of Islam, based on the opinions of clerics. Patient rights according to the findings of this study, consists of respect for patient autonomy, considering non-physical needs of patients, high-quality healthcare, and moral conduct. Though most of the above-mentioned concepts have not received due attention in the existing charter of patient rights. Because of the importance of the spiritual issues as a dimension of holistic health, the findings of this study could clarify these needs.
Ethical Considerations
Compliance with ethical guidelines
The study was conducted with the approval of Qom University of Medical Sciences Ethics Committee (IR.MUQ.REC.1395.13). At the beginning of each interview, the purpose of the study was started and the interviewees were assured about their anonymity and confidentiality of the conversation. The participants entered the study with verbal informed consent and they were free in their remarks and allowed to leave the interview whenever they decided to stop their participation. The sessions were held at a predetermined time and place according to the interviewees’ convenience
Funding
The study received no funds or financial aids.
Authors' contributions
Conceptualization, Methodology, and data analysis: Akram Heidari and Mohammad Abbasi; Data collection: Khadijeh Rahmatinejad; The original draft preparation: Morteza Heidari; Final approval: all authors.
Conflict of interest
The authors declare that they have no conflict of interest.
Acknowledgments
This article is an output of a general medicine thesis at medical school at Qom University of Medical Sciences. We express our gratitude to all the experts participating and sharing their valuable ideas. We acknowledge our colleague, late Fariba Dehghani who contributed in this research, but she is not with us now. May Allah bless her and make her soul in eternal peace.