Hysterectomy is the second most common operation performed on women after a cesarean section (1). Over half a million women undergo a hysterectomy procedure for reproductive issues each year (2). Most of hysterectomies are performed to treat benign conditions such as uterine fibroids, endometriosis, and symptoms such as uncomfortable menstrual bleeding (3). Some hysterectomies are performed inappropriately and are due to lack of diagnostic evaluation or failure of alternative treatments (4). The prevalence of Peripartum Hysterectomy among Iranian pregnant women was 2.81 per 1000 deliveries (5).
Having a hysterectomy impacts a woman's life in a significant manner. As such, deciding to undergo a hysterectomy is a difficult process for women, especially from a psychological perspective. Following a hysterectomy, women commonly experience changes in body perception, such as perceiving the body as different, feeling disabled, feeling hollow, believing they are different than other women and feeling that their body is attracting notice. The literature reports that women perceive themselves as different, alienated, impaired and changed after a hysterectomy and that they have difficulty making contact with the environment; furthermore, the more changes in body perception increase, the more depression increases (6). Not paying attention to the needs of women undergoing this process is not ethical. There are many effects from humankind relations around it. Therefore, a lot of ethical considerations should be undertaken about this common surgery.
Ethical considerations in the clinical settings refer to a set of principles and values that "must be taken into account in order to prevent harm to others". The 4 main ethical principles, that is beneficence, nonmaleficence, autonomy, and justice (7). Today, women's autonomy in decisions related to hysterectomy, its completely private nature and keeping information confidential, considering women's well-being and psychological satisfaction from care, justice in providing care and fair treatment regardless of socioeconomic status and protecting women regardless of their marital status, ethnicity, and religion is one of the things that should be considered (8).
The majority of women experienced a positive attitude towards their decision to elect a hysterectomy based on their perceived sexual functioning and satisfaction; ideas of womanhood to include motherhood and femininity, and their trust in presurgical information from healthcare professionals, or other women (2). A meta-synthesis to identify and synthesize qualitative research evaluating the real feelings, inner needs and emotional experience of women undergoing hysterectomy found comprehensive consideration before hysterectomy, emotions and experience after hysterectomy, coping strategies such as seeking help from others (9).
The World Health Organization has defined rights for patients, including the right to high-quality care and treatment, the right to fair access to health care and services, the right to access information, the right to confidentiality and privacy, and the right to informed consent including right to free will or independence of vote, the right to health education, the right to protest and complain, and the right to compensation (10). In addition, there are a lot of ethical consideration about hysterectomy as a choice for permanent sterilization (11).
Medical staff, especially doctors and nurses, are required to protect the women's rights and prevent them harm. These supports include informing and learning, honoring and respecting, supporting, protecting and ensuring continuity of care (12). Sometimes, clinical judgments based on the benefit and independence are incompatible. When there is no clear benefit and there are clear risks of hysterectomy, the woman, more than anyone else, is in a position to determine what treatment is best for her (13). Informed consent, as the most obvious manifestation of the moral principle of respect for individual autonomy, is one of the most important elements that must be observed before hysterectomy. The concept of informed consent is recognition of patients' autonomy by health service providers and improvement of relationships with patients. One of the primary purposes of informed consent is to provide information about the treatment process or to improve individuals' health care decisions. Informed consent can have the desired quality only when it reflects moral values (7).
Patients have the right to make a decision about their treatment, and it is necessary to make such a decision by receiving complete information about the benefits and harms, alternative ways and possible costs (14). Medical staff should follow protocols and guidelines for informing about serious diseases such as uterus cancers. If she does not lose his spirit and can make positive decisions or if she has a fragile spirit and informing her will cause mental discomfort and delay in treatment, the patient's condition should be informed to the family (15).
Since ethics in medical centers are sometimes overshadowed by material issues, it is possible that it is not completely in line with the patient's wishes. In many cases, surgeons and medical centers are in conflict between ethical duties. The principles of medical ethics are beneficence (not doing harmful actions), not doing harm, and the right of the individual (7).
There are very few studies on the intra-individual aspect of ethical considerations in hysterectomy. Although this issue is very important in medical ethics. The aspect of disclosing some diseases or surgeries in the common life, workplace, family and close friends has an important place in the field of medical ethics. Disclosure of this issue after marriage in Iran has created fewer challenges due to the necessity of the wife's consent to surgery. However, there are illegal cases of surgery without the consent of the spouse or non-disclosure of the surgery before marriage (16). On the other hand, women’s privacy and confidentiality are very important in hysterectomy (17). Another issue sometimes happens in surgeries is under the table costs imposed on the patient. Determining the doctor's salary is something that must be agreed upon by the parties, and when the doctor and the patient are satisfied with the set amount, the doctor is free to receive it, and basically, under the table does not make sense (18).
Not only moral sensitivity of team of treatment but also support and moral considerations by close family, friends and society directly and indirectly affect on women’s sense towards loss of uterus. This society ranged from close family members, such as the husband, to the broad community cultures about how they see a woman without feminine organs(19). Husband’s support increase self-acceptance after hysterectomy (20). Some cultures support family (especially husband in fertility organ surgeries) involvement in management decisions. Even in these cultures, verifying patients’ preferences about the roles they wish their families to play is an ethical consideration (21). Women need visibility in the society as a whole person after their surgery. Even media as a powerful society arm influence on women’s decisions about hysterectomy. Some of them receive their informational support from the Internet, followed by family/friends, books/magazines, and other resources (19).
Considering the importance of complying medical and general ethics and the lack of a study on determining ethical considerations in the communication network of women undergoing hysterectomy surgery, this study aimed to present these aspects in the patients' lives by a standard researcher-made instrument.