The second strategic plan of medical ethics: a national report.

Medical ethics faces several challenges in different aspects of education, research, and treatment in medicine and healthcare practice. Design and implementation of a national strategic plan can pave the way for the development of a roadmap in various countries to strengthen ethics and address these challenges. To create a comprehensive plan compatible with the Iranian healthcare system, a multidisciplinary team of main stakeholders compiled a national strategic plan of medical ethics following several focus group discussion sessions and two workshops (2014-2017). Ultimately, the plan was confirmed by the Supreme Council for the Medical Ethics of the Ministry of Health and Medical Education. The current paper is a national report of the process and the medical ethics strategic plan in Iran. We have also tracked signs of progress and achievements in the country. In conclusion, this valuable effort has led to significant success in the implementation of medical ethics in clinical medicine, medical research, and education by using all the resources in our country. The participation of all the stakeholders, especially healthcare professionals in this way is required.

Introduction

Along with other advancements in healthcare during the recent decades in Iran (1, 2), there have been great efforts to strengthen medical and healthcare ethics to build up the country’s ethics capacity (3, 4). Accordingly, some progress has been made in various fields of research, education, and clinical ethics in Iran in the past years (5, 6).

Medical knowledge and related technologies are rapidly evolving in all disciplines. This requires the close attention of policymakers, healthcare professionals, and bioethicists to provide proper ethical responsiveness and support. Moreover, establishing and sustaining an ethical infrastructure at the national level is necessary to solve the controversial and complex issues that have emerged in the field of bioethics in the past decades.

Strategic planning of the ethics activities to address the key priorities is one of the elements on which the success of integrative ethics initiatives relies (7). Medical ethics strategic planning paves the way for the integration of ethics in the healthcare environment and strengthening ethics in various fields.

There are several advantages to strategic planning in the field of medical ethics. These include assessment of the current situation, evaluation of strengths and weaknesses, ability to set goals at the national level, and empowerment of ethical infrastructure to ensure ethical standards in healthcare practice, education, and research.

Activities toward integration, sustainability, and accountability in clinical bioethics have been carried out through strategic planning in several countries. For instance, the Clinical Ethics Group at the Joint Centre for Bioethics at the University of Toronto has formulated its strategy to “foster an ethical climate and strengthen ethics capacity broadly throughout healthcare settings as well as create models in clinical bioethics that are excellent and effective” (8).

To address the demands in Iran, the first strategic plan in the field of medical ethics was introduced and implemented by the Ministry of Health and Medical Education (MOHME) in 2002 (4). The vision, mission, specific goals, and main activities of the plan were reviewed in a paper published in the Developing World Bioethics journal in 2006 (4).

To review the progress and discuss the achievements and challenges, several workshops and expert panels were held. The Academy of Medical Sciences of the Islamic Republic of Iran (AMS), in collaboration with the Medical Ethics and History of Medicine Research Center (MEHMRC) of the Tehran University of Medical Sciences (TUMS), Medical Council of the Islamic Republic of Iran, and Supreme Council of Medical Ethics of MOHME made substantial efforts to compile the second version of the country’s National Strategic Plan for Medical Ethics (2015-2017). The Supreme Council of Medical Ethics, known as the highest-level medical ethics authoritative body inside MOHME, has been involved in developing this strategic plan. This was done through active and organized participation of the council secretariat and some key members of the council. All the documents and information required for the development of the strategic plan have been provided by this secretariat for the project team.

It is worth mentioning that the second strategic plan is not merely an update of the first one. This article reviews the second national strategic plan for medical ethics and discusses its advantages in comparison to the initial version. We will also mention some similar plans in other countries.

1.  http://www.ams.ac.ir

2.  http://irimc.org/?LANG=EN

Methods

The draft of the strategic plan was prepared by the “Philosophy, Ethics and Biomedical Sciences Department” of the AMS in collaboration with the MEHMRC of the TUMS following several focus group discussion sessions. The first outline of the strategic plan was prepared by the steering committee of the project, which consisted of the vice president and secretary of the Supreme Council of Medical Ethics, Secretary of the National Committee for Ethics in Biomedical Research, one professor of Methodology, and the chairman of medical ethics group of Iranian AMS. The first draft was discussed in two workshops on 9th and 30th January 2014. The 55-member advisory group who discussed and expanded that first outline consisted of 31 medical ethics specialists and Ph.D. Candidates, 13 specialists of various medical sciences disciplines, six specialists from the legal and forensic aspects of medical practice, one religious’ scholar, and one philosopher. Following a series of study group meetings at the AMS, the second draft was introduced during the annual summit of the chairmen of medical sciences universities, and their opinions were gathered. The third draft was assessed and finalized by holding a workshop on 14th October in 2015. Ultimately, the compiled national strategic plan of medical ethics was confirmed by the Supreme Council for Medical Ethics of MOHME, then published and widely disseminated as a booklet in summer 2017.

Experts from various fields of medicine, medical ethics, law, and jurisprudence participated in the workshops and other sessions. Individuals who contributed to this review process are listed in the acknowledgments section.

Results

The “Philosophy, Ethics, and Biomedical Sciences Department” of the AMS decided to reassess the national medical ethics strategic plan in collaboration with other stakeholders after 11 years. The creation of the strategic plan was initiated by contemplating the vision and the mission (Table 1).

Table 1

Vision and mission statement of national medical ethics strategic plan

Element	Definition
Vision	To institutionalize knowledge and practice of medical ethics based on the Islamic and humane values reflected in all individuals and all pillars of the Iranian health system, aiming to establish a responsive system with the utmost respect for human dignity.
Mission	To strive for achieving thorough knowledge and inclusive management (including needs assessment, policymaking, planning, implementation, monitoring, evaluation, and rescheduling) of medical ethics in the fields of education, research, and health services according to the Islamic-Iranian values and by respecting for human dignity and justice in health.

The analysis of strengths (S), weaknesses (W), opportunities (O), and threats (T) (SWOTs) was conducted as a key component of the strategic planning process. SWOTs’ analysis was carried out comprehensively to identify the internal (strengths and weaknesses) and external (opportunities and threats) factors that intervene with achieving the goals set for the plan. Table 2 summarizes the output of SWOTs analysis based on a wide spectrum of the contributing factors.

Table 2

Medical Ethics SWOTs Analysis.

Strengths	•   The presence of executives' decision-makers and professionals with insights on the Islamic- Iranian model of progress. •   The stakeholders’ attention towards new issues of medical ethics. •   Feeling the need to work on the new issues of medical ethics due to the raised cultural awareness and knowledge of the health services recipients and their increasing demands as well as the development of science and technology in medical sciences. •   Existence of departments for education, research, and services related to medical ethics. •   Existence of a former version of the strategic plan, the National Comprehensive Health Plan, and other high-level documents. •   Specified structures in the field of medical ethics in the country and the possibility of the formation of new structures based on the emerging needs. •   Educating and training the ethics professionals and promoting the presence of the graduates in medical ethics-related fields. •   Availability of scientific resources related to medical ethics. •   Availability of guidelines and codes on issues related to medical ethics. •   Possibility of studying in medical ethics-related fields. •   Possibility of centralized policy-making in the field of medical ethics.
Weaknesses	•  Lack of transparency in the national macro-management policies in the field of medical ethics and instability of the administratorship in the related fields.• Lack of a coherent theoretical Islamic–Iranian framework to address medical ethics issues in practice.• Limited access to basic and applied research and updated original Iranian-Islamic literature in medical ethics.• Lack of communication, interdisciplinary, inter-sectoral cooperation, and interaction, particularly between the universities and the Islamic seminaries.• Inadequate numbers of medical ethics experts and uncertainty of their position in the organizational chart of the healthcare system.• Insufficient access to the international scientific resources and communications in the related fields.• Unavailability of the necessary resources to support medical ethics research.• Weakness of the educational content and implementation processes of medical ethics educational curriculums.• Ignoring the professional ethical capability in recruiting, the assessment, and promotion of the learners, faculty members, and providers of health services.• Lack of appropriate and consistent rules, regulations, and bylaws about several issues of medical ethics.• Lack of efficient system for monitoring and surveillance of medical ethics.• Absence of an institutional mechanism for ethical appraisal of policies, rules, and regulations in the health system.• Absence of nationwide structures and national, provincial, and organizational ethics committees in areas other than research, e.g., the absence of national committees of clinical ethics and ethics in medical education.• Weaknesses in the management of medical ethics research to direct them towards solving ethical problems of the healthcare system.
Opportunities	• Emphasis of the Supreme leader on theorizing in the field of humanities, knowledge-producing, and discourse based on ethical-spiritual values.• Numerous areas for research in the field of medical ethics.• Islamic-Iranian noble resources of knowledge related to medical ethics.• Growing demand for the ethical improvement of education and research among the scientific and medical community as well as the stakeholders.• Support of the high-level national documents, including the constitution, development plans, and national comprehensive scientific map, for ethical development.• Researchers interested in medical ethics.• Religious beliefs, inner conscious, unconscious ethical, and common cultural, ethical, or moral beliefs among the society.  • Active related intellectual fields such as jurisprudence, philosophy, sociology, etc.• Potential stakeholders' desire to enter this field.• Research and educational institutes in medical universities that are active in the field of medical ethics.
Threats	• The negative influence of the public ethics issues on professional medical ethics.• Reduced public trust in the medical community.• Reduced motivation of healthcare community to work effectively due to the socio-economic conditions. • Insufficient justification of the stakeholders of medical ethics discourse and lack of common language among the clergy, doctors, lawyers, philosophers, and other stakeholders. • Governance of technical-empirical paradigm (worldview) over the humanities worldview in the country. • Growing tendency to use the medical methods and devices for non-medical purposes• Lack of sufficient sensitivity to vulnerable groups including migrants, refugees, and slumdogs.• Lack of public awareness and misunderstanding of medical ethics debates.• Wrong and restrictive perception of laws and regulations affecting the implementation of medical ethics.• Lack of the explanation of the consistency between the Islamic and Iranian medical ethics with the predominant secular discourse of medical ethics.• Uncontrolled and unmannered use of the social networks by students.• Giving the power to enhance commercial, technological, and industrial aspects of medical professions.

As the next step, the measurable goals and objectives towards the fulfillment of the mission were defined and the related activities were stated. The goals were prioritized based on the existing infrastructure and resources.

Table 3 illustrates the defined eight main goals.

Table 3

The main goals of the national strategic plan for medical ethics in Iran.

Goal 1	To attain the basic Islamic-Iranian framework based on the heritage of medical ethics regarding the related contemporary knowledge.
Goal 2	To assemble a national collection of documents stating the approved standards of medical ethics.
Goal 3	To achieve and implement policies, structures, and specific resources in the field of medical ethics.
Goal 4	To obtain the support and involvement of the key stakeholders of medical ethics.
Goal 5	Development of research in the field of medical ethics.
Goal 6	Development of education in medical ethics.
Goal 7	Developing effective national and international communications in the field of medical ethics.
Goal 8	Establishment of a comprehensive system of action plans in the field of medical ethics

The first goal emphasizes shifting the medical professionals’ attention towards the great heritage of Islamic-Iranian knowledge. Four objectives were defined in this regard, as follows:

• Assembling, translating, classifying, and publishing the Islamic texts related to medical ethics.

• Collecting, translating, and critical evaluation of the contemporary knowledge of medical ethics.

• Strengthening the conceptualization and interdisciplinary dialogue in the field of medical ethics.

• Compiling the textbooks related to medical ethics.

To pursue the goal and its related objectives, the 19 defined activities included compiling comprehensive textbooks for the students of different fields of study (general medicine, nursing, dentistry, pharmacy, etc.) and at various education levels. Development of the “Islamic Medical Ethics Encyclopedia” and other reference books are also among these activities.

The second goal aims to provide necessary national documents, codes, guidelines, and regulations related to medical ethics as indicated in table 3. This is to be fulfilled through the following objectives:

• Development of an appropriate mechanism for the required assessment of ethical standards (laws, regulations, and guidelines related to medical ethics).

• Supporting the development of ethical standards (laws, regulations, and guidelines related to medical ethics).

• Design and implementation of appropriate mechanisms for the approval and legitimization of ethical standards (laws, regulations, and guidelines related to medical ethics).

To achieve these objectives, 35 activities were designed in a detailed and complete way. These activities included the “Establishment of a committee to identify the gaps in legislation and required ethical guidelines in healthcare and drafting the suggested regulations and ethical guidelines”. Compiling ethical codes and guidelines for the dentistry, pharmacy, reproductive health, assisted technologies, organ transplantation, end of life care, emergency medicine, the care of vulnerable groups, the care of patients with mental illness, healthcare in disasters, the use of biobanks, collected health data, the transmission of biologic samples to foreign countries, etc.

Goal 3 focuses on achieving and implementing policies, organizational structures, and resources in the field of medical ethics through the following five objectives:

• Creating the necessary organizational and administrative structures for healthcare institutions.

• Providing required financial and human resources for the healthcare institutions.

• Considering ethical enclosures in all policies, laws, and regulations related to healthcare.

• Ethical surveillance and monitoring of all the healthcare-related policies and regulations.

• Revising the health system regulations and laws based on ethical approaches and concepts.

The establishment of the national committee for clinical ethics and related secretariat office in the MOHME are among 18 activities set to achieve this goal and its associated objectives. Forming the departments of medical ethics in the major organizations such as the “Iranian Medical Council” and the “Nursing Organization of the Islamic Republic of Iran” and providing the checklists and regulations for ethical appraisal of the pharmacies, the drug companies, medical professionals, faculties, fellows, residents, and students in the field of healthcare are among these activities. Likewise, the allocation of specific funds to support the educational, research, and executive affairs of medical ethics by the MOHME is one of the activities related to the third goal.

Involvement of the main stakeholders in the field of medical ethics and attracting their support and contribution have been following through the objectives of the fourth goal as outlined below:

• Developing appropriate strategies for disseminating information to the key stakeholders including the general public and patients.

• Creating appropriate mechanisms for surveillance and obtaining feedback from key stakeholders including the public and patients.

• Providing a supportive environment for the stakeholders’ engagement and their support. • To support founding non-governmental organizations (NGOs) in the field of medical ethics and encourage the existing health-related NGOs to focus on the issues of medical ethics and patient rights.

Activities defined for materializing the goal include teaching general concepts of bioethics, patients’ rights in high schools and compiling age-appropriate books for the children and adolescents to familiarize them with the ethics-related issues.

Six objectives are defined for the fifth goal that targets expanding research in the field of medical ethics. The objectives include:

• Development of necessary strategies for the needs assessment and priority-setting for research in the field of medical ethics.

• Supporting research in the field of medical ethics in all related healthcare sciences.

• Backing the production of evidence-based science in the field of medical ethics.

• Supporting the publication of the scientific literature and improving the quality of the existing journals.

• Provision of the infrastructure needed by medical ethics researchers to access international resources.

• Providing required funds for essential research projects and national initiatives in the field of medical ethics.

Moreover, the foundation of the medical ethics research centers in the leading universities of the country, integrating medical ethics departments within the structure of specialized medical research centers, creating and supporting related journals, holding medical ethics conferences, post-doctorate, sabbatical courses, and providing comprehensive databases of medical ethics studies and researchers are among 11 activities defined for fulfilling the fifth goal.

Goal 6 focuses on education emphasizing the following objectives:

• Qualitative and quantitative improvement in the relevant academic courses on medical ethics as well as expanding the interdisciplinary postgraduate programs.

• Forging regional, and international, scientific, and educational collaborations with prominent universities by supporting the student and faculty exchange programs.

• Improving the quality of medical ethics education provided to the learners in different disciplines at various levels.

• Integration of medical ethics education into the curriculum of all medical and health-related disciplines.

• Providing and offering medical ethics and professional ethics education in the form of in-service programs and continuing medical education (CME) courses for the healthcare system personnel.

The change of the pedagogical methods in medical ethics from the traditional lectures to the interactive methods such as small group discussion, workshops, case reports, launching dual degree doctorates (MD/Ph.D.), MD/MPH programs, fellowships, and short-term courses in clinical ethics and research ethics are among 13 activities listed under the sixth goal.

The seventh goal aims to promote collaborative activities in the country or around the globe and consists of four objectives, as follows:

• to establish a national medical ethics network with the participation of all main stakeholders.

• To support organizing national, regional, and international conferences on medical ethics.

• To provide Iranian researchers with the opportunity to participate in regional and international conferences.

• To develop international collaborations and partnerships with the universities and institutions scientifically active in the field of medical ethics.

To achieve these objectives, twelve activities including the establishment of a regional medical ethics forum in the Eastern Mediterranean Region, founding the Islamic Medical Ethics Forum within the Islamic countries, facilitating membership in regional and international organizations related to medical ethics, and signing agreements for scientific cooperation with national and international universities have been considered.

Four objectives shed more light on the operational planning of medical ethics as the 8th goal:

• Establishing future studies and a surveillance system for medical ethics in the fields of education, research, and service delivery.

• Establishing a system for monitoring, evaluation, and providing feedback for medical ethics in the fields of education, research, and service delivery.

• Integrating the descriptive and analytical data and findings in the field of medical ethics.

• Establishing a rating, accreditation system, and encouraging ethical features in the healthcare system.

The main related activities are consisted of developing a framework for the national reports in the field of medical ethics, compiling annual reports of “medical ethics strategic planning program”, “ethics in medical sciences research”, “monitoring of medical ethics education”, “observing patients’ rights and the status of the medical professionals' rights”, “evaluating justice in health care”, “analysis of complaints received by the MOHME, the Iranian Legal Medicine Organization (LMO), and the Medical Council of the Islamic Republic of Iran”

Discussion

The historical documents confirm the Iranian physicians’ interests in ethical conduct in their practice for centuries (9, 10), under the influence of the rich culture and the religious principles of Zoroastrianism and Islam (11). Despite facing various difficulties in the recent decades (12), substantial scientific progress has been made in the field of medical ethics in the country (13).

After the compilation of the first national strategic plan of medical ethics in 2002 (4), policymakers, related organizations, faculties, and researchers were responsible for its implementation. Key stakeholders approved the vision and mission of the plan and were committed to achieving its goals. It is worth mentioning that in the current strategic plan, the specified stakeholders consisted of seven groups as follows:

1. International stakeholders (such as UN agencies, regional scientific organizations, associations, universities, and research centers, especially in the Islamic world).

2. Decision-making and policy-making bodies including the Parliament, High Council of the Cultural Revolution, the Guardian Council, and the MOHME.

3. Governing and executive bodies including the MOHME, several related ministries, Iranian Legal Medicine Organization, Red Crescent Society, regulatory authorities, and medical universities.

4. Clients (Patients, their relatives, and the whole community).

5. Unions and Professional Organizations (the Medical Council and the Nursing Council of the Islamic Republic of Iran).

6. Service providers (including Hospitals, clinics, health care providers, insurance companies, and pharmaceutical or medical equipment companies).

7. Professional stakeholders (educational departments and instructors in the field of medical ethics at the universities and the religious seminaries, research centers related to the field of medical ethics, postgraduate students, and faculties).

The process of design and development of the current strategic plan was led by the AMS, a high-level independent scientific authority in the country. This is considered as an advantage and opportunity to generate the plan through the consensus of several stakeholders and reinforce their responsibilities for achieving future goals. It is so important that the AMS set timelines and monitor the progress of the plan towards the goals. Moreover, reviewing the plan would be carried out regularly.

All the key stakeholders are expected to be fully engaged in the implementation of the plan, commit time and efforts to venture out and accomplish the objectives. Despite the consensus on the defined goals and activities, there may be controversies on the priority rankings of the action plan and surveillance strategies.

The World Medical Association (WMA) adopted a 5-year (2020-2025) strategic plan in 2019, the main purpose of which was to promote international standards in medical ethics. “Medical Ethics”, “Universal Health Coverage”, “Human Rights and Health”, and “Organizational Capacity” are four main strategic priorities. Promoting the international code of medical ethics along with global discussion to provide a new revision of the international code of ethics in 2022, governance development, member integration, and staff development are among the priorities and deliverables.

The Emory Center for Ethics (Atlanta, Georgia, US) has been a leader in several fields of ethics since 1990, creating the first 5-year strategic plan in 2011. The “Vision” of the second strategic plan (2016-2021) is “to inspire and advance scholarship and education in ethics, to ignite the moral imagination of leaders in all walks of life, and to foster lives of moral meaning and ethical engagement”. Key strategic priority areas of the Center consist of:

- Ethical engagement through scholarship

- Ethical engagement in health and science

- Ethical engagement through corporate partnerships

- Ethical engagement through citizenship and the public good

- Ethical engagement in education

- Ethical engagement in Arts

- Ethical engagement through financial stability

For each strategic priority, some initiatives and their metrics are determined. For example, academic books and peer-reviewed journal articles are two initiatives of “Ethical Engagement through Scholarship”. As for “Ethical Engagement in Education”, some initiatives such as developing ethics curriculum and courses (undergraduate, graduate, doctoral) and non-degree educational offerings are defined. Defining metrics for each initiative plays an encouraging role in engaging the faculties and the members in related studies.

Kirigia et al have reviewed and discussed the current status as the way forward to the establishment of the national health research systems in 47 countries of the World Health Organization (WHO) African Region (14). Although “Research for Health” was the subject of their study, their strategies and recommendations are used in other fields as well as for strengthening medical ethics discourse. Several key contributing factors emphasized by Kirigia et al include (14):

- An official national health policy and strategic plan

- Related legislation components

- Appropriate coordination mechanisms

- Regulation mechanisms for scientific and ethical review committees at national and institutional levels and in hospitals and clinics

- Developed collaborative agreements

- Creating and sustaining resources

- Financing and health budgetary planning

- Securing funding by the private sector and local and international NGOs

- Promotion and implementation of research

- Facilitating the production of human resources and strengthening their competencies through design and implementation of master and Ph.D. courses, bursaries, and training grants

- Building or reinforcing necessary infrastructures, such as well-equipped offices and laboratories

All identified factors that enable national health research systems are critical for the establishment and reinforcement of the national medical ethics plans. Fortunately, it seems that the eight goals of our strategic plan cover all emphasized factors stated by Kirigia et al (14).

The national strategic plan working group has approved 60 activities including compiling books and educational resources, ethical guidelines, related codes, and regulations. It has also endorsed 60 recommendations to MOHME to provide the required infrastructure and empower the healthcare professionals. Table 4 summarizes the key activities carried out in recent years, before and after compiling the second strategic plan.

Table 4

Summary of some key activities in recent years

Title/type	Timeline	In accordance with	Responsible Organization(s)
General guideline for Professional Codes of Ethics	2017	Goal 2	The Medical Council of Islamic Republic of Iran
Revising National Guidelines for Publication Ethics	2017	Goal 2,4,5	MOHME
Compiling a textbook as an educational resource for medical residents	2015-2020 / in press	Goals 1,6	MEHRC, the Medical Ethics Group of EMRI of TUMS
Evolution and Innovations packages in Medical Education: 6th package: Promotion of Professional Ethics	2015-2016	Goal 6	MOHME
Herbal Medicine Research Protocol	2015	Goal 2	MOHME
Hidden curriculums as longitudinal themes for “medical ethics and law” and “professionalism”	ongoing	Goal 6	TUMS, and a few other designated universities
The Charter of Rights for clients in Medical diagnostics Laboratories	2012	Goal 2	High Council of Medical Ethics of MOHME
The code of Ethics for National Pharmaceutical System	2012	Goal 2	MEHRC, High Council of Medical Ethics of MOHME
The National Code of Ethics for Nurses	2009-2011	Goal 2	The Medical Ethics Group of EMRI of TUMS, MEHRC, MOHME
Enhancing specific publications such as journals in the field of medical ethics; including the Journal of Medical Ethics and History of Medicine	ongoing	Goal 1	MOHME, Ethics research centers and universities of medical sciences
Annual Medical ethics Congress/ And Training workshops and courses	2013- up to now / ongoing	Goals 3,4,6,7	MOHME, MEHRC, AMS, TUMS and other Universities of Medical Sciences, etc.
Defining an educational package to promote medical ethics and professionalism	2016- now/ongoing	Goal 6	MOHME
Evaluating teaching medical ethics in all medical universities	2018-2019	Goal 6	MOHME

To plan and execute the proposed activities to achieve the goals, several tasks are in progress. As an example, the development of the Iranian Code of Medical Ethics (ICOM) to determine the ethical codes of mutual behaviors in the provision of medical services are being pursued by the MEHRC at the Tehran University of Medical Sciences in collaboration with the AMS. The ICOM has been on the agenda with approximately 150 headings; 24 topics of which have already been completed in the public consultation phase. After summarizing and incorporating the feedback from the workshop participants, the codes were published in Farsi (Persian Language) to seek the input of the healthcare academics and practitioners. The final results are reported in a recent report of AMS.

Moreover, the promotion of ethical standards and the development of related guidelines have been high on the agenda during recent years. For example, specific

national guidelines for palliative care in terminal patients have been compiled by the medical ethics department of the “Endocrinology and Metabolism Research Center of Endocrinology and Metabolism Institute (EMRI)” of Tehran University of Medical Sciences (TUMS) in 2017 due to the ever-increasing attention to palliative care in the country. This was supported by a grant from the WHO office in the MOHME. The results of the project were submitted to the High Council of Medical Ethics of MOHME and after approval (February 2019) was conveyed to the medical sciences universities for being implemented in clinical practice.

Education is an integral part of the current strategic plan and has been the focus of accrediting bodies. Although working in the field of medical ethics requires lifelong learning, the educational mission of ethics is never accomplished. This is based on the Henk ten Have stating (15) that the empowerment of medical ethics education has always been one of the main initiatives around the globe. Accordingly, more than twenty projects including the development of textbooks for different graduate and undergraduate programs, ethical guidelines for medical education, and ethical checklists for health professionals have been proposed. To achieve the educational goal of the new strategic plan, we designed a national descriptive survey to evaluate the medical ethics education in medical sciences, which is an ongoing project. Providing higher academic education in the field of medical ethics is also considered an educational achievement in our country (5). The bioethics graduates are now helping to empower medical ethics discourse in the research centers, clinics, and hospitals, to provide specific education, ethics consultations, and to lead ethics ground rounds, and even to contribute to health policymaking.

3.  http://www.wma.net/wp-content/uploads/2020/02/2020-2025-Strategic-plan-1.pdf

4.  https://ethics.emory.edu/who-we-are/about/index.html

5.  http://www.ams.ac.ir/sites/default/files/book%20Akhlagh%201400--02-18-021.pdf

Conclusion

Academic knowledge and practice of medical and research ethics have developed enormously in recent decades. Compared with the first strategic plan (4), we have made great progress in strengthening and flourishing medical ethics throughout the country. However, considering the ethical challenges ahead, it is evident that there is no room for complacency.

The development of the medical ethics strategic plan was an attempt to improve the capacity of the health system to be more proactive in client advocacy. Today, the main challenges facing our healthcare system include increasing moral sensitivity, enhancing adherence to ethical principles amongst medical professionals and promoting a positive ethical climate in the system. It is also known that an acceptable level of accountability of health professionals is necessary to provide decent standards of care in an ethical atmosphere. We hope that achieving the goals and objectives of the recent strategic plan would play an essential role in the promotion of professionalism among healthcare practitioners in Iran. The strategic plan presented in this article can also be adapted for other contexts and environments, taking into account the national priorities, challenges, and shortcomings.