Ethical issues experienced by otolaryngologists: a conventional content analysis

Abstract

To deliver effective medical services and establish trust and psychological security in patients, care providers must prioritize ethical principles. Developing a comprehensive clinical education program for learners, along with specific ethical guidelines, and implementing managerial and executive interventions necessitates a thorough understanding of the ethical challenges within this field. This qualitative study aimed to elucidate the ethical issues faced by otolaryngologists. Sixteen otolaryngologists participated in the study, selected through purposive sampling. Data were gathered through semi-structured interviews, and the analysis, conducted through conventional content analysis, revealed eight main categories and 38 subcategories encapsulating the identified ethical issues.

The primary categories encompassed ethical issues faced by otolaryngologists concerning patients and companions, education, communication with the treatment team, physicians' rights, medical tourism, medical advertising, cultural considerations, and managerial challenges. resources and treatment approaches in alignment with Iranian cultural norms, address conflicts between treatment and education, and implement sound management plans to uphold rights of the treatment team. Additionally, the study suggests the necessity of ethical advertising programs and the strategic promotion of therapeutic tourism.

Introduction

The adherence to ethical standards has evolved from individual-personal responsibilities to encompass individual-professional obligations. In contrast to the traditional Aristotelian ethical system, which regards ethics as an internal matter, ethical responsibilities now extend to intra-group, organizational, and interpersonal relationships (1). Within the medical profession, given its critical role, ethical considerations become especially paramount, particularly when dealing with the mental or physical vulnerability of the patient.

The institutionalization of medical ethics within a society requires a comprehensive understanding of the pertinent ethical principles. Ethical codes serve as a framework of principles guiding the conduct of individuals and groups (1). Developing ethical codes is essential to serve as a reference for standardizing behavior in health centers, delineating the ethical boundaries of professional duties, and creating educational content for instructing medical students (2). Despite a study report indicating that students lack awareness of ethical codes (3), a significant majority express the need for medical ethics training before graduation.

However, only 36% receive comprehensive ethical training (4).

In their study, Shuman et al. assert that while ethics education is integral to the medical student curriculum, ethical codes should be tailored to the specific needs of individuals. The researchers implemented case-based ethics training sessions within the otolaryngology department, and the results indicated that residents and medical students expressed satisfaction with this program (5).

Beyond the mission of imparting knowledge and skills for patient treatment, professors should strive to strike a balance between the rights of both patients and students in their educational roles. Enhancing professors' knowledge and insight into ethical issues within their working environment not only empowers them to make better decisions but also fosters increased awareness of these issues among students (6).

The initial step in developing an ethical guide involves acknowledging ethical issues and distress. Ethical distress, as initially discussed by Jameton, is characterized by the creation of negative emotions in an individual resulting from the incapacity to engage in moral work and make ethical decisions. In such situations, individuals are aware of their inability to do what is morally right due to existing constraints, leading to internal conflict (7). While common ethical issues exist across various medical branches, it appears that the significance and intensity of these issues vary in specialized fields. Identifying these ethical issues serves as the foundation for the development of ethical guidelines.

Otolaryngologists may encounter challenges associated with advanced treatments aimed at restoring hearing, addressing head and neck cancers, providing cochlear implant services, and adhering to ethical standards for cosmetic surgery (7, 8). The study conducted by Seidman et al. reveals that otolaryngological surgeons experience ethical concerns, particularly when dealing with elderly patients, leading to ethical tension (9).

Hence, the first step is to identify ethical issues within the otolaryngology field, laying the groundwork for subsequent actions. Given that the encounter with ethical issues is a somewhat subjective phenomenon arising from personal interactions, the researchers opted for a qualitative approach. In this study, employing the content analysis method, the experiences of otolaryngologists concerning ethical issues have been elucidated.

Methods

Qualitative approach and research paradigm

This study adhered to the "Standards for Reporting Qualitative Research (SRQR) guideline" for reporting (10). It employed a qualitative methodology utilizing the conventional content analysis approach. The research spanned from February 2020 to March 2021 and involved the participation of otolaryngologists. The research setting encompassed Imam Khomeini Hospital and Amir Alam Hospital, affiliated with Tehran University of Medical Sciences. Owing to Covid-19 restrictions, four interviews were conducted via WhatsApp.

Researcher characteristics and reflexivity

Throughout the study, ZZ, a medical student, conducted the interviews. MMZ served as an academic member of the School of Medicine in the Department of Otolaryngology. SM, an academic member of the School of Nursing and Midwifery, specialized in teaching methodology and conducting qualitative research. AASh and AP were academic members of the Medical Ethics discipline, providing instruction in methodology and ethics.

Sampling strategy

The research units were selected using a purposive sampling method. For a comprehensive exploration of the concept, a homogeneous sampling method was employed based on the study's objectives and the selection of a specific group with common characteristics. The inclusion criteria mandated a minimum of 6 months of experience in their specialty within the hospital.

Ethical issues: To conduct the research, approval was obtained from the university (IR.TUMS.MEDICINE.REC.1397.926).

The participants were provided with an invitation form to seek their cooperation, and informed consent was obtained from them. The participants received assurance that their opinions would be treated confidentially during the interviews, and any statements made would be reported without disclosing their names. Personal information and recorded interviews were maintained in strict confidence.

Data collection

Data were collected through face-to-face interviews employing open-ended questions. The timing of the interviews was determined in accordance with the participants' preferences, and the duration ranged from 30 to 70 minutes, with an average of 50 minutes.

Data collection instruments and technologies

The interviews followed an interview guide. Initially, coordination was established with the group supervisor. Commencing the interview, participants were asked introductory questions after obtaining written informed consent. Subsequently, the research problem was introduced with a general question, such as "What ethical issues do you face in the workplace in the otolaryngology field?" The interview progressed with follow-up questions like "Can you provide an example?" Finally, concluding with an open-ended question such as "What else would you like to share?" marked the conclusion of the interview.

Study units

Sixteen otolaryngologists (12 specialists and 4 assistants) were purposively selected to participate in the study.

Data processing and analyzing methods

For data analysis, the researchers employed the conventional content analysis approach using the Graneheim and Lundman method. The initial phase involved immersing in the text through repeated readings to develop a general understanding.

The analysis unit was then determined, focusing on

extracting key concepts and meanings to form initial codes. Subsequently, through the examination of relationships, similarities, and differences, these codes were organized into categories and subcategories (11).

Techniques to enhance trustworthiness

To ensure data accuracy and reliability, the researchers applied Lincoln and Guba's criteria (12). Ensuring data credibility involved allocating sufficient time for data collection, maintaining long-term engagement with and immersion in the data, sampling from diverse locations to achieve maximum diversity, and incorporating participant feedback by coding and returning some interviews for review. To assess the dependability of the results, three experienced specialists with a strong background in qualitative studies acted as external reviewers. For the transferability of findings, the researchers aimed to create and describe a comprehensive set of study data during both the data collection and participant description stages. To enhance the verifiability of the data, all research stages, methodologies, and decisions made throughout the research process were described in detail and with clarity, enabling other researchers to follow the procedures if needed (12).

Results

A total of 16 otolaryngologists, comprising 12 faculty members and 4 assistants from Tehran University of Medical Sciences, participated in this study. Among them, 4 were professors at Imam Khomeini Hospital, 8 were professors at Amir-'Alam Hospital, 2 were assistants at Imam Khomeini Hospital, and 2 were assistants at Amir-'Alam Hospital. The participants' average age was 43 years, with 3 women and 13 men. Their work experience ranged from 2 to 20 years. The analysis of 251 extracted codes revealed 8 main themes and 36 sub-themes (Table 1). The themes and subthemes are detailed below:

Table 1.

Categories, sub-categories and quotations based on the experiences of the participants (N=16).

Categories	Sub-categories
The relationship between the physician and the patient and the patient’s companions	Giving bad news (12 participants)
	Confidentiality (6 participants)
	Obtaining informed consent (16 participants)
	Financial relationship between physician and patient (5 participants)
	Physician's relationship with companions (13 participants)
Ethical issues in the field of education	Evaluation (4 participants)
	Interactions of assistants at different levels (15 participants)
	Interactions of assistants and professors (9 participants)
	Taking responsibility (3 participants)
	The conflict of education and treatment (16 participants)
	The presence of professors during the surgical procedure and the necessity of the supervisory aspect (11 participants)
	Improper teaching of the concepts of professional and medical ethics (4 participants)
Ethical issues in the physician-treatment team relationship	Respect for colleagues (6 participants)
	Team work and the need for comprehensive cooperation (11 participants)
Physician’s rights	Income, salary and benefits (12 participants)
	Low tariffs for medical services compared to other professions (8 participants)
	Negative advertisements impacting physicians (7 participants)
Medical tourism	Improper role of intermediaries (5 participants)
	Improper monitoring (5 participants)
	Lack of access of medical tourists to qualified physicians (5 participants)
Medical advertising	The necessity of separating commercial advertising from information (4 participants)
	Misconduct in domestic advertising (6 participants)
	Contrasts in advertising practices: domestic vs. international contexts (6 participants)
	Absence of monitoring in advertisements (6 participants)
	Disqualification of the advertiser (7 participants)
Cultural issues	Challenges in dealing with patients, feigning illness, and beauty surgery (4 participants)
	Challenges of integrating traditional medicine into treatment (4 participants)
	Cultural differences and distinctions (5 participants)
Managerial issues	Selection of assistants (8 participants)
	Failure to determine the responsible party for patient treatment (8 participants)
	Inconsistency of equipment and manpower with the number of referents (3 participants)
	Speculative referral of patients to other hospital centers (3 participants)
	Weakness or lack of trust in the medical system (4 participants)
	Focusing activities on low-risk and high-income areas, neglecting others (5 participants)
	Insurance challenges (4 participants)
	Financial relations of physicians with pharmaceutical companies (5 participants)

1. The Relationship Between the Physician and the Patient and the Patient’s Companions

This theme emphasizes the need to review the concepts of privacy and informed consent, considering the cultural differences between our country and western countries. The participants’ statements in each sub-theme were as follows:

1.1 Giving Bad News

"Our med students, they're not great at delivering bad news. I mean, some of them do it so badly that the patient actually faints on the spot." [Participant No. 4]

1.2 Confidentiality

"Another issue we face is that newly graduated physicians often lack a solid grasp of basic medical issues. Take confidentiality, for example; some of them don't really respect it." [Participant No. 8]

1.3 Obtaining Informed Consent

"In our culture, sadly, the patient himself ends up being the least important person in this whole informed consent ordeal." [Participant No.10]

1.4 Financial Relationship Between Physician and Patient

"In our country, it's a mess—insurances don't step up, and the government is left holding the bag. The absolute worst part of the whole doctor-patient dynamic is the financial side of things." [Participant No. 4]

1.5 Physician's Relationship with Companions

"Sometimes the patient’s companion asks us not to share the details of the disease with the patient, which conflicts with informed consent. It poses a really serious challenge." [Participant No. 9]

2. Ethical Issues in the Field of Education

In this theme, professors discussed the shortcomings in teaching ethical concepts. Many participants stressed the importance of professors being present with assistants to effectively integrate education and treatment principles. Establishing a sincere and friendly relationship between professors and assistants emerged as a significant solution for consensus. The participants’ statements in each sub-theme were as follows:

2.1 Evaluation

"Initially, there's this whole mess with evaluating the residents. Interestingly, we tend to load up the one who has got their act together, giving them more work and trusting them over the others." [Participant No.12]

2.2 Interactions of Assistants at Different Levels

"Certainly, I agree with leveling because it brings order, but there must be supervision. We sometimes hold private meetings with different levels, starting from year 1 to year 2 and so on until the end. This method helps us identify their problems." [Participant No. 9]

2.3 Interactions of Assistants and Professors

"In foreign countries, there's an acceptance of criticism from the professor. If the professor says that you won't make a good otologist, they take it in stride, understanding that it's for their success. Not only does this not ruin their relationship, but it often turns into a long-lasting friendship. Whether this dynamic between a student and a teacher, both transitioning into guests and hosts, exists in Iran is questionable." [Participant No. 7]

2.4 Taking Responsibility

"One existing problem is that, for instance, consultations requested in the emergency department might be handled solely by the resident, and the relevant on-call professor may not be called at all." [Participant No. 6]

2.5 The Conflict of Education and Treatment

"The responsibility of treating the patient and, on the other hand, the training of a specialist sometimes clash. If we handle an entire operation on our own, the resident doesn't gain self-confidence. Consequently, they don't evolve into a proficient specialist. However, if the resident conducts the operation independently ..." [Participant No. 2]

2.6 The Presence of Professors During the Surgical Procedure and the Necessity of the Supervisory Aspect

"There have been instances where certain operations were conducted without the direct supervision of a professor. This became more pronounced when the number of faculty members was limited, and one professor had to oversee three operating rooms simultaneously." [Participant No.10]

2.7 Improper Teaching of the Concepts of Professional and Medical Ethics

"The matter of role modeling holds significant importance in medical ethics. Ethics is hands-on, not just a theory, so students need to witness their professor embodying and practicing medical ethics, not merely reading about it in books." [Participant No. 6]

3. Ethical Issues in the Physician-Treatment Team Relationship

This theme delves into the challenges stemming from the lack of teamwork, including minor issues such as disagreements between the anesthesiologist and otolaryngologist in determining the start and end times of operations.

3.1 Respect for Colleagues

"Given that we function as a referral system, malpractice cases from other physicians often land on our plate. Unfortunately, we haven't quite figured out how to respect our colleagues in handling these situations." [Participant No. 11]

3.2 Teamwork and the Need for Comprehensive Cooperation

"At times, because of the prolonged duration of an operation during the final working hours of the operating room, doctors might decline the last operation. Consequently, the procedure is postponed to the next day. This results in both the patient enduring another day of NPO, and the resident missing the opportunity to learn that procedure for the day." [Participant No. 8]

4 . Physician’s Rights

This theme addresses concerns related to the low salaries of academic staff members, criticisms of low tariffs for medical services, and instances of mistreatment and attacks against physicians.

4.1 Income, Salary, and Benefits

"The cancer operation that I conduct, which, unfortunately, cannot be carried out in external facilities, demands around 16 hours of my time. Astonishingly, I receive approximately five dollars (150 thousand tomans of Iranian currency) for this extensive procedure." [Participant No. 2]

4.2 Low Tariffs for Medical Services Compared to Other Professions

"I recently visited a barbershop, and after a session lasting about half an hour, I paid approximately 4 dollars and 60 cents (140 thousand tomans of Iranian currency). Interestingly, the tariff for a doctor’s visit at Amir-‘Alam Hospital is around 18 cents (5 thousand tomans of Iranian currency.)” [Participant No. 7]

4.3 Negative Advertisements Impacting Physicians

“In our online platforms and even in our radio and television, there is no supervision against the advertisements and destructive portrayals targeted at physicians.” [Participant No. 6]

5. Medical Tourism

This theme addresses the importance of establishing accurate and controllable channels for the transfer of foreign patients. While such channels can enhance the country's scientific reputation and bring economic benefits to the academic community, challenges arise due to the current lack of access to competent doctors. The insufficient supervision and involvement of ineffective intermediaries have regrettably contributed to the deterioration of the country's scientific and medical reputation.

5.1 Improper Role of Intermediaries

"Unfortunately, a group has emerged that directs Iraqi patients to specific physicians in Iran. These physicians, in return, provide a percentage to these intermediaries for mediating and guiding the patients to particular offices." [Participant No. 7]

5.2 Improper Monitoring

"Regrettably, the Ministry of Health has not implemented any effective measures in this regard. Additionally, our universities have not taken any actions in this field." [Participant No. 4]

5.3 Lack of Access of Medical Tourists to Qualified Physicians

"Unfortunately, in this situation, patients not only face financial challenges but also may end up seeking advice from physicians who lack adequate skills. This can result in complications for patients and negatively impact the medical and professional image of the country." [Participant No. 3]

6. Medical Advertising

This theme reflects the participants' opposition to the current methods of medical advertising.

6.1 The Necessity of Separating Commercial Advertising from Information

"In my personal opinion, engaging in medical advertising may not be the ideal approach. However, given the growth of online platforms, it might not be detrimental to provide informative content in the media, outlining the areas of expertise for each physician." [Participant No. 2]

6.2 Misconduct in Domestic Advertising

"In today’s modern world, online advertising plays a crucial and effective role in the field of medicine. I personally advise all my residents to maintain an Instagram account and share photos and videos showcasing their operations and related work." [Participant No. 8]

6.3 Contrasts in Advertising Practices: Domestic vs. International Contexts

"One of the factors that positions our country at the forefront in the region in terms of medicine is its reputation and the provision of services to neighboring countries. This requires international advertising." [Participant No. 1]

6.4 Absence of Monitoring in Advertisements

"At times, cosmetic surgeries are promoted in an unsightly, unethical, and unscientific manner, and there is no accountability for addressing these cases." [Participant No. 4]

6.5 Disqualification of the Advertiser

"At times, due to the impact of these advertisements, procedures are carried out, resulting in side effects observed in university centers. These may involve injections with low-quality materials, leading to tissue necrosis and infection." [Participant No. 7]

7 Cultural Issues

In addition to addressing the culture of Iranian society, this theme highlights the significant role of the patients' companions and families in influencing treatment decisions. The participants' quotations in each sub-theme are as follows:

7.1 Challenges in Dealing with Patients, Feigning Illness, and Beauty Surgery

"A crucial point in cosmetic surgeries is the distinction between healthy individuals seeking beauty enhancements or correction of defects and patients with unusual inclinations, mentally and psychologically, to alter facial deformities." [Participant No. 9]

7.2 Challenges of Integrating Traditional Medicine into Treatment

"In my field of work, particularly in cancer cases, I often encounter young patients with tongue cancer. They initially present in the T1 stage but choose traditional medicine, returning six months later with the tumor progressed to T4."

[Participant No. 1]

7.3 Cultural Differences and Distinctions

"The most challenging scenario is when a patient provides consent, undergoes the operation, and unfortunately passes away. The patient's companion often poses the most difficulties. This is primarily due to the cultural significance of family in our society." [Participant No. 3]

8 Managerial Issues

Within this theme, the participants reflected on the managerial challenges and inefficiencies concerning insurances and tariffs. These issues often lack balance and harmony with the demanding nature and stress levels of the work. The participants' remarks are categorized as follows:

8.1 Selection of Assistants

"When we discover that an assistant or a trainee lacks the necessary qualifications to become a physician, and we introduce them, the response is that we cannot intervene because this student passed the exam and has been accepted." [Participant No. 9]

8.2 Failure to Determine the Responsible Party for Patient Treatment

"At times, we receive complaints from patients asserting that their surgery card is under a specific physician's name, yet someone else performed the operation. The critical issue is that these explanations be given to the patient." [Participant No. 7]

8.3 Inconsistency of Equipment and Manpower with the Number of Referrals

"The workload in our centers is exceptionally high. As a professor, there are instances where I have to cover three operating rooms simultaneously. Supervising all these operations becomes a significant challenge." [Participant No. 5]

8.4 Speculative Referral of Patients to Other Hospital Centers

"One of the most unacceptable practices is the referral of patients from public centers to private ones, and unfortunately, it occurs." [Participant No. 9]

8.5 Weakness or Lack of Trust in the Medical System

"Patients undergo surgery here in optimal conditions, but their perception, even among the non-affluent class, is that since this is a public and training facility, they prefer private hospitals for their operations." [Participant No. 1]

8.6 Focusing Activities on Low-Risk and High-Income Areas, Neglecting Others

"Due to the disparity in tariffs, residents lose interest in learning about cancer and

otolaryngological surgery. The consequence is an overload of patients in public centers." [Participants No. 7]

8.7 Insurance Challenges

"Laryngectomy is intricate, demanding about 10 days of hospitalization with a high risk of fistula. However, according to insurance laws, complications arising from surgery are not covered." [Participant No. 5]

8.8 Financial Relations of Physicians with Pharmaceutical Companies

"Some physicians establish companies and self-refer patients to these entities, creating ethical concerns." [Participant No. 2]

Discussion

In this study, the experiences of otolaryngologists regarding ethical issues were categorized into eight distinct themes. These include ethical challenges in the doctor-patient and companion relationship, challenges within the realm of education, issues concerning the doctor's relationship with the treatment team, ethical challenges related to doctors' rights, concerns in the field of medical tourism, ethical considerations in medical advertising, cultural issues specific to the otolaryngology specialty, and managerial challenges.

In the field of otolaryngology, certain cancers can be highly malignant, making the manner in which bad news is delivered particularly crucial. According to a study by Parsa et al., the practice of disclosing bad news directly to the patient is a relatively recent development, even in countries where it is now a common practice. Physicians believe that cultural differences play a significant role in the communication of bad news (13, 14). For instance, in Northern European countries and the United States, it is customary for most physicians to inform the patient of the diagnosis. However, in Southern and Eastern European countries, as well as many Asian countries, patients may not receive such information. Presently, the prevailing opinion is that communicating bad news to the patient is essential, and medical staff should be trained in this regard (13, 14).

The principle of medical confidentiality and the preservation of patients' privacy stands as one of the most crucial ethical duties in the practice of medicine. It is imperative for physicians to have a thorough understanding of the laws governing medical practice in their respective regions (15, 16). Informed consent is a principle heavily influenced by cultural aspects, and it appears that the existing sources of medical ethics may not be fully implementable in our country. One potential reason for this challenge is that, in Iran's health system, the informed consent form is typically obtained by the nurse, whereas this responsibility should ideally rest with the attending physician. Furthermore, sufficient time should be allocated for this critical process (17-19). According to the professors, the primary challenge highlighted in this study is the direct financial relationship between the physician and the patient. In certain super-specialized areas of otolaryngology, particularly in cosmetic and plastic surgeries where insurance coverage is lacking, this financial relationship becomes more pronounced. Jafari et al. reported in their study that, while physicians historically believed in moral integrity, in the present era, some physicians face challenges in meeting their daily living expenses, leading them to perceive patients more as customers (20). The interaction between the physician and the patient’s companions is one of the challenging issues in the field of surgery. In our culture, where the family plays a crucial role, this relationship becomes more prominent. The emotional and informational support provided by companions, especially for the elderly, is beneficial for taking notes and remembering key points. However, there are challenges that may impact the relationship between the physician and the companion (21).

The category of ethical issues in the field of education included seven sub-categories. Professors need to be evaluated to identify needs and expectations, paying attention to the principles and pillars of professional ethics (22).

Ranking (leveling) in the medical education system has long been one of the challenging ethical issues. This ranking should not be considered as a criterion of superiority. Instead, it is meant for each person to understand their role in the system and to move forward with a commitment to fulfilling that role to achieve the system's goals. The relationship between a professor and a student in the classroom is a complex human relationship influenced by various factors (22). Maintaining the dignity and respect of students, observing justice in dealing with students, accepting criticism, and flexibility are some of the most effective factors (23, 24). Medical students and assistants have to spend most of their training time at the patient’s bedside to improve their scientific and practical skills and be involved in the patient’s treatment process, which may not directly guarantee the patient’s interests (25). Professional groups involved in medical education and health policymakers emphasize that a patient’s referral to a teaching hospital or university medical service centers is a sign of their voluntary participation in this process. However, if the necessary arrangements are not made to assess the level of knowledge and awareness of such patients, the simple and primary result will be the patients’ lack of proper understanding of the amount of information, skills, experience, and competence of the people involved in their treatment. On the other hand, clear standards on how to handle educational patients and define permissible limits for such education have yet to be formulated (25, 26). It appears that an effective educational approach involves integrating ethical considerations with clinical problems, teaching medical ethics by incorporating objective clinical examples, and examining ethical cases that arise during patient treatment (27).

The aspects of the relationship between the physician and the treatment team were delineated by two subcategories. Demonstrating patience and exhibiting respect for the human dignity of other members of the health service provider team can markedly enhance medical and paramedical services for patients. In the operating rooms, the most substantial relationships typically form between otolaryngologists, anesthesiologists, and operating room personnel. This collaboration is imperative for ensuring the efficacy of surgeries. The results of a study by Hosseini et al. demonstrated a positive and direct statistical relationship between teamwork and job motivation, indicating that higher job motivation correlates with improved teamwork (28).

Ethical issues in the field of physicians' rights encompassed three sub-categories. Physicians' rights can be viewed from two perspectives: rights that may conflict with those of patients and the right to excellence and self-improvement. The traditional viewpoint emphasizing the imbalance of power in the physician-patient relationship, the insufficient emphasis on medical ethics principles within the medical community, the absence of supportive structures, the prevalence of a customer-oriented approach in medicine, and an excessively professional stance are identified as reasons for overlooking physicians' rights in medical ethics literature. Recognizing and addressing physicians' rights is essential not only in its own regard but also as a means to uphold patient rights, a primary goal of medical ethics (29).

Ethical issues related to medical tourism encompassed three subcategories. While medical tourism offers income generation and serves as a tool for a country's development and knowledge and technology transfer, it has drawn attention for its potential benefits such as high profit margins and job creation. However, certain studies suggest that the quality of care in medical tourism scenarios may be lower, with limited evidence of follow-up and consideration of long-term consequences (30).

A study by Iorio et al. on medical tourism highlighted the importance of reliable and responsible care, emphasizing that it should commence with effective communication and planning between the treating physician and the patient. Given that complications can arise unexpectedly, providing thorough counseling to patients is crucial (31).

Ethical issues in the realm of medical advertising encompassed five subcategories. Commercial advertising, at its core, aims to attract customers, boost demand, and ultimately increase sales of products or services. This process begins with informing society about the product or service, guiding customers in the initial stage, and extends towards maximizing profit and staying competitive in the market. This involves inducing a need in the audience, highlighting strengths, and concealing weaknesses of the product or service. While there has been a shift in approach in England and Canada, advertising by physicians is still deemed reprehensible and a potential threat to the medical profession. Interestingly, younger physicians exhibit a notably more positive attitude toward medical advertising compared to their older counterparts (32). Ethical issues in the field of cultural issues were formed from three subcategories. The culture, preferences, and values of the patient and family affect the treatment process, selection, and acceptance of orders and treatments (33).

Ethical challenges in the field of managerial issues comprised eight subcategories. In the selection of assistants approved by the Supreme Council of the Cultural Revolution and the Ministry of Health, none of the articles of the admission criteria mention the need to pass the scientific and skill interview filter of the professors. With this system, it is possible for assistants in the fields to be admitted to specializations that are not in harmony with the system. In their study, Kidd et al. report that in the selection of postgraduate medical students, it is important to pay attention to personality traits, communication skills, emotional intelligence, and adaptability as much as grades and grade point average (34).

In the clinical centers of public hospitals, a contentious challenge arises from the mismatch between the available equipment and the number of clients (35).

Another challenge for public health centers is accountability for patient treatment and follow-up. Patients are initially admitted under the name of professors, and at times, they may be hospitalized and transferred to another professor's service, ultimately being examined and monitored by a resident. Consequently, physicians must maintain consistent communication with assistants and oversee their activities (36).

Limitations and strengths

Clarifying ethical issues is the initial step towards establishing ethical codes in this specialty, serving as a valuable reference for standardizing behavior and mitigating potential issues in physician interactions.

Due to the widespread impact of COVID-19 and the limited availability of otolaryngologists due to their presence in the operating room, accessing them posed a challenge. The collaboration of the manager of the otolaryngology department at the university played a pivotal role in addressing this limitation.

Conclusion

In Iran, where the Ministry of Health oversees medical treatment and education, teaching hospitals often experience moral distresses arising from the conflicting roles of educators and therapists. Identifying and assessing ethical tensions across various medical branches can serve as a foundation for the development of ethical guidelines, educational content, and the review of executive policies and regulations. Ultimately, this can facilitate the transfer and teaching of these concepts to medical students in their respective fields. In this study, through the analysis of findings collected using the theme analysis method, the moral tensions experienced by otolaryngologists were categorized into eight main categories and 38 subcategories. Certainly, the presence of these moral tensions does not necessarily imply that the professors are unaware of ethical concepts. However, within the management context of hospitals or the health system, many of these principles may become obscured and forgotten amid existing problems, anomalies, and limitations in the system.

Notes:

Citation to this article:

Moosavi S, Zandpoor Z, Motasadi Zarandi M, Shojaei A, Parsapoor A. Ethical issues experienced by otolaryngologists: a conventional content analysis. J Med Ethics Hist Med. 2023; 16: 18

Conflict of Interest

None to declare

Funding

None to declare