NCM 108j – Health Care Ethics

NCM 108j
HEATH CARE ETHICS
MODULE

Prepared by: Ma. Christina B. Celdran – Oraa, PhD, RN

January 2024

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Chapter 1
Theories and Principles in Health Ethics
Purpose

 The purpose of this course is to define the ethical principles and codes of ethics under which
the nurse must practice nursing as well to outline issues of jurisprudence that apply to the field
of nursing, including laws that impact nursing and healthcare.

Ethics – Rules, Principles that guide nursing decisions or conduct in terms of the rightness or
wrongness of that decisions or actions.
• Serves the purpose of governing conduct to ensure the protection of individual’s rights.
• Strictly speaking, morality is used to refer to what we would call Moral Standards and Moral
Conduct.
• While ethics is used to refer to the formal study of those standards and conduct.
• For this reason, the study of ethics is also often called "MORAL PHILOSOPHY."

ETHICS - how people make judgment with regards to right and wrong; making choices best for
individual and society; critical reflection about morality and rational analysis (youtube: Examples of
Autonomy, Beneficence, Nonmaleficence, and Justice - Ethical Principles)

MORALS – specific ways of behaving or the way that people set out to accomplish ethical
practices (norms, policies); social consensus about moral conduct for human beings and society
(human decency, right and wrong, proper or improper, cruel or benevolent)

BIOETHICS - Principles that govern rights and proper conduct of a person regarding life, biology,
& with health professionals

NURSING ETHICS - Is a branch of applied ethics that concerns itself with activities in the field
of nursing.
• Related to all the principles of right conduct as they apply to the profession

A. Ethical Theories
• Ulitarianism
• Deontology
• Teleology

Utilitarian or Teleological –https://www.youtube.com/watch?v=JIK3T6MRs2k –

https://www.youtube.com/watch?v=JIK3T6MRs2kutilitarianism

• The end justifies the means

• "The right thing to do is the good thing to do"; comes from the Greek word telos or "goal or
end";
• If the act helps people, then it is a good one, and if it harms people, then it is a bad one (Joseph
fletcher)

Types of Utilitarian Theories

• Act utilitarianism: suggests that people choose actions that will in any given circumstances
increase the over all-good.
• Rule utilitarianism: suggests that people choose rules that when followed consistently will
maximize the over all good
• Intuitions: The notion that people inherently know what is right or wrong; determining what
is not a matter of rational thought or learning.
o For example, nurse inherently known it is wrong to strike a client, this does not need to
be taught or reasoned out.

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Utilitarian in 3 stages
1. Principles of Utility
2. Principles of pleasure
3. Principles of maximation

Utilitarian ethics is a normative ethical system that is primarily concerned with the
Consequences of Ethical Decisions
• Therefore it can be described as a teleological theory or consequentialist theory , which are
essentially the same thing, both having a notion that the CONSEQUENCE of the act is the
most important determinant of the act being moral or not
• Teleological reasoning takes into consideration that the ethical decision is dependent upon the
CONSEQUENCES (“ends”) of the actions.
• In teleological reasoning, a person will do the right thing if the consequences of his or her
actions are good.
• Additionally, if an action by a person was an act that was “not good,” but the consequences
turned out to be “good,” under some theories of teleological reasoning, the act may be deemed
a good ethical act.
• This is also referred to as “consequentialist moral reasoning,” where we locate morality
in the consequences of our actions.

Deontology: https://www.youtube.com/watch?v=-UhiRLuSlIU
Deontological – Comes from the Greek word “Deon” which means duty
the end DOES NOT justify the means
the acts are the criterion for the determination of good and not the consequence.

A. Natural Law (Thomas Aquinas)

• Good is to be done and pursued and evil is to be avoided
• Rightness is self-evident and determined by nature not by customs or preferences
Intuitionism – people inherently know what is right and what is wrong

B. Duty-based (Immanuel Kant)

• Absolutism
• We can control our motives and intentions, but we are unable to control the consequences
of our actions
• Respect for moral law

Teleology (utilitarian or end based theory)

• Stems from the word “telos” meaning end or purpose
• An action is “good” if it will have a good end or purpose
• Used in philosophy as an argument for the existence of God to suggest that there is order and a
purpose in the world
• This theory looks to the consequences of an action in judging whether that action is right or
wrong.
• According to the utilitarian school of thought right action is that which has greatest utility or
usefulness.
• Utilitarian hold that no action in itself is good or bad, the only factors that make actions good
or bad are the outcomes, or end results that are derived from them.

ETHICS 0F CARE
▪ Moral experiences of women
▪ Emphasis on personal relationships and relationship responsibilities
▪ The situation must be evaluated with:
▪ Caring
▪ Consideration

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▪ Understanding
▪ Generosity
▪ Helpfulness
▪ Willingness to take responsibility

GILLIGAN’S THEORY
• Focuses on a care perspective
• Organized around the notions of responsibility, compassion (care), relationships
• The ethics of justice (fairness) is based of the idea of equality “everyone should receive the
same treatment”
• By contrast, the ethics of care is based on a premise of nonviolence: that no one should be
harmed or abandoned
• Process of developing an “ethics of care”
• Stage I: caring for oneself
• Stage II: caring for others
• Stage III: caring for oneself and others
• Each stage ends with a transitional period (a time when the individual recognizes a conflict or
discomfort with some present behavior and considers new approaches)

B. Virtue Ethics - https://www.youtube.com/watch?v=iSLsUO6uK4M

Aristotle
▪ Aim for a virtuous life
▪ Actions must be:
▪ To the right person
▪ To the right extent
▪ At the right time
▪ For the right reason
▪ In the right way
• Based on the excellence of one’s character
• Originated from Plato and Aristotle, Buddhism and Florence Nightingale

NURSING ETHICS
• Is a branch of applied ethics that concerns itself with activities in the field of nursing.
JURISPRUDENCE
• Is the application and interpretation of the principles of law or legal rules as they relate to
the: PRACTICE OF NURSING
• Obligations nurses have to their clients
• Relationships nurses have with other nurses and health care professionals.

Moral Ground Model Virtues:

INTELLECTUAL
VIRTUES • Awareness and knowledge of the moral nature of nurses’ day-
• Insight to-day work and that moral suffering can be transformed
• Using deliberate reason to direct action
• Practical wisdom
MORAL VIRTUES
▪ Truthfulness • Refrain from deception through false communication
• Refrain from self-deception
▪ Gentleness • Mildness in verbal and non-verbal communication

MORAL VIRTUES
• Compassion • Desire to separate others from suffering
• Lovingkindness • Desire to bring happiness to oneself and others
• Just generosity • Giving and receiving based on need
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• Courage • Putting fear aside in difficult circumstances to act for a purpose

that is more important than one’s fear
• Sympathetic joy • Rejoicing in other’s happiness
• Equanimity • An evenness and calmness of being

NURSING CODE OF ETHICS

Values, Morals, & Ethics

Values:
• are freely chosen, enduring beliefs or attitudes about the worth of a person, object, idea, or
action (e.g. freedom, family, honesty, hard work)

Types of Values
1. Personal Values: Most people drive some values from the society in which they live. Eg:
self-worth, sense of humor, , honesty, fairness and love

2. Professional values: are reflections of personal values. They are acquired during
socialization into nursing. Some of the important values of nursing are:
o Strong commitment to service
o Belief in the dignity and worth of each person
o Commitment to education
o Autonomy

Core Values of a Professional Nurse

• Empathy and Caring
• Empathy is a nurse’s ability to understand, be aware of, be sensitive to, and vicariously
experience the feelings, thoughts, and experiences of the patient and their family.
• it is the nurse’s ability and willingness to “tune in” to and focus on the patient’s
experiences that is fundamental to the methods nurses use to manage care.
• Empathy is based upon respect for the dignity of the client and an appreciation for the
independence and self-actualization of the patient.

Empathy and Caring

• In the Ateneo, we believe caring involves knowing and trusting the patient, an interest in their
growth and well-being, honesty, courage, and humility.
• A caring nurse knows that he or she does not know all there is to know about the patient, and
projects the confidence and patience to help them maintain hope or the sense of continued
possibility for growth and change.
• Caring involves the planning and provision of culturally sensitive and appropriate care.

VIRTUE BASED NURSING MODEL

10 Nursing Ethical Values

1. Human Dignity
2. Integrity
3. Social Justice
4. Autonomy In Decision Making
5. Individual and Professional Competency
6. Commitment
7. Human Relationship
8. Sympathy
9. Honesty
10. Precision And Accuracy in Caring
11. Altruism (additional)

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Ethical Theories
• Moral experiences of women
▪ Emphasis on personal relationships and relationship responsibilities
▪ The situation must be evaluated with:
▪ Caring
▪ Consideration
▪ Understanding
▪ Generosity
▪ Helpfulness
▪ Willingness to take responsibility

Ethical Principles
1. Autonomy
2. Confidentiality/Integrity
3. Veracity
4. Fidelity
5. Justice
6. Beneficence
7. Non-Maleficence

Basic Ethical Concepts (Human Rights)

• Rights form the basis of most professional codes and legal judgments
• Rights to self-determination
• Rights and cultural relativism
• Rights of the unborn
• Rights of privacy and confidentiality

1. AUTONOMY
• States that a person has unconditional worth and has the capacity to determine his own
destiny. It involves self-determination and freedom to choose and implement one's decision,
free from deceit, duress, constraint or coercion.
• Recognizing the individual’s right to self-determination and decision-making.

3 Basic Elements of Autonomy:

(Taken in part in the Patients’ bill of rights)
1. The ability to decide
2. The power to act upon decisions
3. Respect for the individual autonomy of others
▪ Involves the right of self-determination, independence, and freedom.

• It refers to the right to make one’s own decisions

• Respect for autonomy means that nurses recognize the individual’s uniqueness, the right to be
what that person is, and the right to choose personal goals
• Nurses who follow the principle of autonomy respect a client's right to make decisions even
when those choices seem not to be in the client’s best interest
• Respect for people also means treating others with consideration
• In the clinical setting, this principle is violated when a nurse disregards client's subjective
accounts of their symptoms (e.g. pain)
• Patients should give informed consent before tests and procedures are carried out
▪ Ex: informed consent; allowing the patient to refuse treatment if he decides against it.

Four factors for violations of patient autonomy

• Nurses may assume that patients have the same values and goals as themselves
• Failure to recognize that individuals’ thought processes are different

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• Assumptions about patients’ knowledge base

• Focus on work rather than caring

Patients’ bill of Rights:

1. Right to considerate and respectful care
2. Right to obtain from the physician complete information of his health and care
3. Right to receive information necessary to give informed consent prior to procedure
4. Right to refuse treatment and be informed of medical consequences
5. Right to every consideration of his privacy concerning his medical care program
6. Right to confidentiality of record pertaining to his care
7. Right to expect reasonable response from hospital to request of service
8. Right to obtain information as to any relationship of his care
9. Right to be advised if the hospital proposes to engage in human experimentation
10. Right to expect reasonable continuity of care
11. Right to examine and receive an explanation of his bill regardless of the source of payment
12. Right to know what hospital rules and regulations apply to his conduct as patient

Autonomy is related to other themes:

1. Informed consent:
• is a process by which patients are informed of the possible outcomes, alternative s and risks of
treatments and are required to give their consent freely.
• It assures the legal protection of a patient’s right to personal autonomy in regard to specific
treatments and procedures.

There are two types of proxy consent for adults.

• The power of attorney to consent to medical care, is usually used by patients who want
medical care but are concerned about who will consent if they are rendered temporarily
incompetent by the medical care.
▪ A power of attorney to consent to medical care delegates the right to consent to a
specific person.
• The living will

Types of consent
• Implied consent - occurs through the actions or conduct of the patient rather than direct
communication through words
• Express consent - is when the patient directly communicates their positive and
explicit consent to the doctor or healthcare provider. This is usually done in writing by
signing papers
• Informed consent - consent given by a person who has a clear appreciation and
understanding of the facts, implications, and future consequences of an action
• Unanimous consent - or general consent, by a group of several parties (e.g., An
association) is consent given by all parties.

2. Paternalism:
• Restricting others autonomy to protect from perceived or anticipated harm.
• The intentional limitation of another’s autonomy justified by the needs of another.
• Thus, the prevention of any evil or harm is greater than any potential evils caused by the
interference of the individual’s autonomy or liberty.
• Paternalism is appropriate when the patient is judged to be incompetent or to have diminished
decision-making capacity.

Non-compliance:
• Unwillingness of the patient to participate in health care activities. Lack of participation in a
regimen that has been planned by the health care professionals to be carried out by the client.
• Noncompliance may result from two factors:
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a. When plans seem unreasonable to the patient

b. Patients may be unable to comply with plans for a variety of reasons including
resources, lack of knowledge, psychological and cultural factors that are not consistent
with the proposed plan of care.

3. Proxy Consent / Legally / Acceptable Representative

• Is the process by which people with the legal right to consent to medical treatment for
themselves or for a minor or a ward delegate that right to another person.

There are three fundamental constraints on this delegation:

1. The person making the delegation must have the right to consent.
2. The person must be legally and medically competent to delegate the right to consent.
3. The right to consent must be delegated to a legally and medically competent adult.

2. CONFIDENTIALITY /INTEGRITY
Nurses are also obligated to preserve the principle of confidentiality in the practice of nursing. The
principle of confidentiality is founded in the patient's right to privacy and the preservation of the nurse-
patient relationship.
• Observing the seal of secrecy
o Privileged communication
o Invasion of privacy
o Hearsay evidence
o Dying declaration or ante mortem statement
o Nurses as witness
o Acting consistently with honesty and basing actions of moral standards.

• Confidentiality comes from Latin: trust

• Confide as to “show trust by imparting secrets”; “tell in assurance of secrecy”; “entrust; commit
to the charge, knowledge or good faith of another”; while
• Confidential or in confidence is “a secret or private matter not to be divulged to others”
Confidentiality in the health care context is the requirement of health professionals (HPs) to
keep information obtained in the course of their work private.

Privacy
• Individual’s constitutional right to be left alone, to be free from unwarranted publicity, and to
conduct his or her life, without its being made public
• Individual’s right to limit access to his/her healthcare information
• Privacy has been defined as the control of a situation, freedom of choice, mutual
interaction, avoidance of communication and an unreachable area.
o Additionally, privacy may be defined as a restriction put by an individual on access to
his/her bodily and mental integrity.
• A patient's right to privacy involves the confidentiality of information related to the patient
and bodily privacy of the patient
• Privacy is important as it provides a secure environment for patients where they receive
medical care and provide complete and accurate information, and which reinforces confidence
in health care and emphasizes the importance of respect for patient autonomy
• Professional codes of ethics (and conduct) will often have statements about professions
maintaining confidentiality
o but confidentiality is often qualified.
o Confidentiality is non-disclosure of private or secret information with which one is
entrusted.
o Legally, this requirement applies to HPs and others, who have access to information
about patients, and continues after the patient’s death.

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• Nurses hold in confidence any information obtained in a professional capacity, and use
professional judgment in sharing such information.
• Each nurse will treat as confidential personal information obtained in a professional capacity.

3. VERACITY
• Telling the truth
o Means accuracy or conformity to truth. Its guides the practice of truthfulness
o Being truthful, trustworthy, and accurate in all interactions with others.
o Veracity binds both the health practitioner and the patient in the association of truth.
The patient must tell the truth in order to be provided appropriate care.
▪ Medical record
• Fraud – deliberate deception intended to produce unlawful gain
o Defamation – character assassination verbal or written
▪ Libel – written
▪ Slander – verbal/oral
• Health care providers obliged to be honest with clients

4. FIDELITY
• Loyalty/faithfulness and keep promises
• Is the ethical foundation of nurse-client relationships.
• Being loyal and faithful to individuals who place trust in the nurse
o Nurses have responsibilities to clients, employers, government, society, the profession,
and themselves
o Circumstances often affect which responsibilities take precedence at a particular time
• Means to be faithful to agreements and responsibilities one has undertaken
* A commitment to FIDELITY explains the reluctance to abandon clients even when
disagreement arises about decisions that a client may make
• Nurses’ commitments to clients include providing safe care and maintaining competence in
nursing practice.
• In some instances, a promise is made to a client in an over way
• Nurse must use good judgment when making promises to client.
• Fidelity means not only keeping commitment but also keeping or maintaining our obligation

5.JUSTICE AND FAIRNESS

• Acting in fairness to all individuals, treating others equally and showing all individuals the
same degree of respect and concern.
• 3 CATEGORIES:
1. Compensatory Justice: concerns the just way in compensating someone for a past
injustice or what he/she lost when wronged by others.
2. Retributive justice: consists in the just imposition of punishment and penalties on those
who do wrong. This is related to procedural justice, referring to fair decision
procedures, practices, agreements.
3. Distributive Justice: involves the fair distribution of benefits and burdens.
• Refers to the principle of fairness, however what constitutes a fair distribution of resources may
not always be clear
• Allocation of goods & services & how or to whom they are distributed.
• Principle in healthcare ethics
• Basis of a duty-based ethical theory
• Treated justly, fairly and equally
o Equality – Everyone receives the same
o Need – Greater services go to those with greater needs
o Merit – Services go to more deserving (used as a criterion for transplant recipients)

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6. BENEFICENCE
• Acting for the good and welfare of others and including such attributes as kindness and charity.
• Taking action to promote the welfare of other people
• Promote the well-being of patients
o Mercy
o Kindness
o charity
• To do good- client advocate
• Nurses should implement actions that benefit clients and their support persons.
• However, in an increasing technologic health care system, doing good can also pose a risk of
doing harm (e.g. intensive exercise program).

7. NON-MALEFICENCE
• Acting in such a way as to prevent harm to others or to inflict the minimal harm possible.
o Do not harm
o Remove harm
o Prevent harm
• Non-maleficence
o Ra 6675 – generics act 1988/medication; orders, drugs & medication
o RA 6425 – Dangerous drug act 1972
o RA 953 – Narcotics drug law
o RA 5921 – Pharmacy act
o BON res. No. 8 s. 1994 (sec. 27 art. V RA 7164)
o Ra 9502 - Cheaper medicine bill

THE STANDARD OF BEST INTEREST

• When a person cannot make informed decision, the health care providers or family make the
decision based on what they believe to be in his / her best interest.

Ethical Dilemma
• Problem in decision making because there is no correct or wrong choice.
• This may result in having to choose an action that violates one’s principle or value in order to
promote another

What is Ethical Decision Making?

• When faced with an ethical dilemma the objective is to make a judgment based on well-
reasoned, defensible ethical principles.
• The risk is poor judgment i.e. a low-quality decision
• A low-quality decision can have a wide range of negative consequences

Two Types of Ethical Choices

• Right vs wrong: choosing right from wrong is the easiest
• Right vs right
o Situation contains shades of gray i.e. all alternative have desirable and undesirable
results
o Choosing “the lesser of two evils”
o Objective: make a Defensible Decision

Factors that influence EDM

1. Codes for Nurses
2. The patient’s rights
3. Social and cultural attitudes
4. Science and technology
5. Legislation

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6. Judicial decisions
7. Funding
8. Personal religious and philosophic viewpoint

Factors in the work environment that affect EDM

1. Status as an employment
2. Collective bargaining contracts
3. Collegial relationships
4. Authoritarian and paternalistic background
5. Ethics committees in health care
6. Consumer involvement in health care

Making Moral Decisions--Some Inappropriate Ways:

• Appeal to Authority
• Appeal to Law
• Appeal exclusively to self-interest

Some Guidelines for Making Ethical Decisions

1. Choose correct moral language. (Often, the way in which you initially conceptualize a
situation will affect what moral conclusions you will make)
2. Be as clear as you can about the facts, both empirical and philosophical
3. Consider the relevant moral principles and rules, and make your best judgment.

Strategies Of Moral Decision-Making Process

Problem Definition. Problem definition is the clear description of the ethical dilemma and the
circumstances revolving around it.

Data Collection. review of ethical codes, published evidence based practices, declaratory
statements, professional position papers and the professional literature

Data Analysis. The collected data is then organized and analyzed

1. The Identification, Exploration and Generation of Possible Solutions to the Problem and the
Implications of Each. All possible solutions and alternatives to resolve the ethical dilemma
are explored and evaluated.
2. Selecting the Best Possible Solution. All potential solutions and alternatives are considered
and then the best and most ethical action is taken.
3. Performing the Selected Desired Course of Action to Resolve the Ethical Dilemma
4. Evaluating the Results of the Action. Like the evaluation phase of the Nursing Process,
actions to resolve ethical issues are evaluated and measured in terms of their effectiveness
to resolve the ethical dilemma

What are the steps in Ethical Decision Making?

1. Identify and setting up the ethical problem
2. State the relevant facts
3. Identify the stakeholders
4. Identify options or alternatives
5. Determine the most appropriate action

GROUNDWORK FOR MAKING AN EFFECTIVE DECISION

2 CORE PRINCIPLES:
• We all have the power to decide what we do and what we say
• We are morally responsible for the consequences of our choices
Components of Good Choices
• Taking choices seriously

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• Recognizing important decisions

• good decisions are both ethical and effective
• Discernment and discipline
• Stakeholders
Discernment
• Is rooted in the understanding that God is ever at work in one’s life
• Presupposed an ability to reflect on the ordinary events of one’s life
• A prayerful pondering, mulling over the choices a person wishes to consider
• It is both to understand and to decide
Moral Suffering
• Many times, nurses experience disquieting feelings of anguish and uneasiness.
• Situations that are morally unsatisfactory
• Suffering can occur because nurses believe that situations must be changed to bring
well-being to themselves
• Can arise from disagreements with institution policy
• Disagreement with physician’s orders that the nurses believe are not in patient’s best
interest
• Disagree with the way a family treats a patient or makes patient care decisions.
• nurses freely choosing to act in ways in which they, themselves, know is not morally
commendable
• covering up a patient care error made by a valued nurse best friend
• when they act courageously by doing what they believe is morally right despite
anticipated disturbing consequences
Moral Suffering in Nursing
• Disquieting feeling of anguish, uneasiness or angst
• Cause of suffering – not recognizing the impermanence of all things inherent in human
life
• When nurses attempt to sort out their emotions when they find themselves in
imperfect situations that are morally unsatisfactory

Principle of Well-Formed Conscience

• Conscience is a judgment of reason whereby the human person recognizes the moral
quality of a concrete act that he is going to perform, the process of performing, or has
already completed
• Man is obliged to follow faithfully what he knows to be just and right
• It is by the judgment of his conscience that man perceives and recognizes the
prescriptions of the divine law
• Conscience must be informed and moral judgment enlightened
• A well-formed conscience is upright and truthful
• formulates its judgments according to reason
• From the earliest years, it awakens the child to the knowledge and practice of the
interior law recognized by conscience.

Other Relevant Ethical Principles

Thomas Aquinas - is credited with introducing the principle of DOUBLE EFFECT in his
discussion of the permissibility of self-defense in the Summa Theologica.

1. PRINCIPLE OF DOUBLE EFFECT

This doctrine says that if doing something morally good has a morally bad side-effect it's ethically
OK to do it providing the bad side-effect wasn't intended.
• This is true even if you foresaw that the bad effect would probably happen.
• An action that is good in itself that has two effects-

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• An intended and otherwise not reasonably attainable good effect

• An unintended yet foreseen evil effect
• Is licit, provided there is a due proportion between the intended good and the permitted evil
1st criterion- Object of the act must be good- Good or indifferent
• The principle of double effect aims to provide specific guidelines for determining when it is
ethically permissible for a human being to engage in conduct in pursuit of a good end with full
knowledge that the conduct will also bring about bad results.
• The principle of double effect generally states that, in cases where an agent contemplates
conduct that has both good effects and bad effects, the course of conduct selected is ethically
permissible only if it is not wrong in itself and if it does not require that one directly intend the
bad result.
• Requirements:
1. What you perform must be good or indifferent
2. Intention of the agent- Beneficial effect or harmful effect
3. The beneficial effect must be equal or better and greater than the harmful effect, if not the
principle of double effect is illegitimate.
4. Order of time- Beneficial effect, harmful effect, it could happen in the same time.
• This doctrine says that if doing something morally good has a morally bad side-effect, it's
ethically OK to do it providing the bad side-effect wasn't intended.
o This is true even if you foresaw that the bad effect would probably happen.
• This might seem counter-intuitive, but the principle is used in serious argument about some
important issues in ethics.

Criticisms of the doctrine of double effect

• We are responsible for all the anticipated consequences of our actions
o If we can foresee the two effects of our action we have to take the moral
responsibility for both effects - we can't get out of trouble by deciding to intend only
the effect that suits us.
• Intention is irrelevant
o Some people take the view that it's sloppy morality to decide the rightness or
wrongness of an act by looking at the intention of the person who carries it out.
They think that some acts are objectively right or wrong, and that the intention of
the person who does them is irrelevant.
o But most legal systems regard the intention of a person as a vital element in
deciding whether they have committed a crime, and how serious a crime, especially
in cases of causing death.

2. PRINCIPLE OF LEGITIMATE COOPERATION

Cooperation in the ethically significant sense is defined as the participation of one agent in the
activity of another agent to produce a particular effect or share in a joint activity. This becomes
ethically problematical when the action of the primary agent is morally wrong.
1. The cooperation is not immediate
2. The degree of cooperation and the degree of scandal are taken into account
When it is applied
▪ Whenever an act we are considering would assist someone else in committing a morally evil
act.
What it says
• Formal cooperation – when you share the other person’s evil intent
o Could involve approving or taking part in it is never morally permissible, according to
Catholics (Your intent/object is bad)
• Material cooperation – you do not share the other person’s evil intent, but you still
cooperate.
• Immediate material cooperation – when you participate in a way that’s essential to the
commission (completion) of the evil act
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 NCM 108j – Health Care Ethics

o Never morally permissible (you and the other person share the same object)
• Mediate material cooperation – when you participate in a way that’s NOT essential to the
commission (completion) of the evil act.
o Morally permissible if: You have a proportionately good reason for cooperating
o You must try to avoid scandal (anything you do that causes someone else to think or do
evil.)
o If both criteria fail, then the circumstances are bad.

PRINCIPLES OF BIOETHICS

1. Principles of Stewardship and the Role of Nurses as stewards

• Stewardship in Health Care Practice
• Stewardship refers to the execution of responsibility of the health care practitioners to look
after, provide necessary health care services, promote the health and life of those entrusted to
their care.
• Stewardship in nursing involves valuing and respecting patients' priorities and self-
determination.
• Nurses become stewards or teachers to patients who may not have the expertise or experience
in the disease process, but who understand the consequences of their illness.
• Stewardship requires us to appreciate the two great gifts that a wise and loving God has given:
o The Earth, with all its natural resources
• and our own Human Nature, with its biological, psychological, social, and spiritual capacities.
• This principle is grounded in the presupposition that God has absolute Dominion over creation,
and that, in so far as human beings are made in God’s image and likeness (Imago Dei), we have
been given a limited Dominion over creation and are responsible for its care.
• Nurse stewards hold the potential to inform meaningful change in nursing practice, owing to
their capacity to act upon their character qualities, including self-discipline and courage, as well
as engage in practical reasoning, by which the intrinsic value or good of a situation is preserved
and promoted

Role of Nurses as Stewards

• Personal
• Social
• Ecological
• Biomedical

2. Principle of Common Good and Subsidiarity

• to which every aspect of social life must be related if it is to attain its fullest meaning, stems from
the dignity, unity and equality of all people.”
• The principle of the common good, to which every aspect of social life must be related if it is to
attain its fullest meaning, stems from the dignity, unity and equality of all people.
• The principle of subsidiarity protects people from abuses by higher-level social authority and
calls on these same authorities to help individuals and intermediate groups to fulfil their duties.
This principle is imperative because every person, family and intermediate group has something
original to offer to the community.
3. The Principle of Totality and its Integrity
• These principles dictate that the well-being of the whole person must be taken into account in
deciding about any therapeutic intervention or use of technology.
o Therapeutic procedures that are likely to cause harm or undesirable side effects can be justified
only by a proportionate benefit to the patient.
• INTEGRITY refers to each individual’s duty to “preserve a view of the whole human person
in which the values of the intellect, will, conscience and fraternity are pre-eminent”

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 NCM 108j – Health Care Ethics

• TOTALITY refers to the duty to preserve intact the physical component of the integrated
bodily and spiritual nature of human life, whereby every part of the human body “exists for the
sake of the whole as the imperfect for the sake of the perfect”.
o The whole is greater than any of its parts.
▪ Suppose a man’s foot is gangrenous, should he consent to an amputation? Since
the amputation will save the patient’s life and he can still walk through the aid of
crutches or artificial limbs, he can consent to an operation.
o The principle of totality states that all decisions in medical ethics must prioritize the
good of the entire person, including physical, psychological and spiritual factors.

2. Principles of Ordinary / extraordinary means:

• Ordinary means are "all medicines, treatments, and operations, which offer a reasonable hope
of benefit for the patient and which can be obtained and used without excessive expense, pain or
other inconvenience.
• Refers not only to nutrition hydration or respiration, but also to any treatment or
intervention that others reasonable hope of recovery, or does not make care unreasonably
burdensome.
• Extraordinary means – no reasonable hope of benefits/success; excessive risk and not
financially
Manageable.
• Refers to intervention that does not offer any reasonable hope of recovery, or that which
makes care unreasonable

Euthanasia – Avoid pain and suffering

Active- commission of the act
ex. administration of lethal drugs
Passive- Omission of the act
ex. deny a person for therapeutic intervention

Dysthanasia- prolongation of dying process

- wrong use of medicine and wrong use of health care resources
Orthothanasia- Most ethical, right death
- Process to remove useless care to allow patient to die in a natural way.

3. Principle of Personalized Sexuality

• Sex is a search for sensual pleasure and satisfaction, releasing physical and psychic tensions.
• Sexuality is a complex aspect of our personality and 'self'. Our sexuality is defined by sexual
thoughts, desires and longings, erotic fantasies, turn-ons and experiences.

Norms of Sexual Morality

• Sex is a social necessity for the procreation of children and their education in the family so
as to expand the human community and guarantee its future beyond the death of individual
members.
• Expression of unselfish love, but without any relation to marriage or family.
• For secular humanists, reasonable uses of sex:
• sexual behavior, at least among consenting adults, is entirely a private matter to be
determined by personal choice, free from any moral guilt.

https://www.youtube.com/watch?v=9E_XQKU72fI

https://www.youtube.com/watch?v=h5ow1-ezNyc&t=22s

https://www.youtube.com/watch?v=VJ_s51QGbg8

https://www.youtube.com/watch?v=HceGLqdsMfA
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Chapter 2
Bioethics and its Application in Various Health setting

Bioethics
• A multidisciplinary field, combining philosophy, theology, history and law with medicine,
nursing, health policy and the medical humanities. Because the health care system is so
complex, it is important to consider relevant issues from multiple points of view.

Ethics - is a branch of philosophy that deals with right and wrong.

It is a system of principles and rules of conduct recognized and accepted by a specific group or
culture.
Bioethics - covers a broad set of possible topics, such as ethical standards and moral problems
created by the practice
of medicine, ethical issues in neuroscience, protection of research participants, privacy issues
raised by genome sequencing, and research with children.
Sexuality - A person's behaviors, desires, and attitudes related to sex and physical intimacy
with others.
Clinical Ethics - is a discipline or methodology for considering the ethical implications of
medical technologies,
policies, and treatments, with special attention to determining what ought to be done (or not
done) in the delivery of healthcare

Sexual Ethics or sex ethics (also sexual morality)

• is the study of ethics that combines the study of human sexuality, and sexual behavior
• involve issues such as moral views on:
o Sexuality
o Gender identification
o Sexual orientation
o Consent
o Sexual relations
o Procreation

1. HUMAN SEXUALITY:
• Giving of the best, giving of self
• Giving until more is to give
• Your right to sex involves a duty in others to respect it
• Sex implies moral discipline
Sexual
• Some sexual measure of fulfillment that only the other can give
• One has to be free from self centeredness by opening one to the other person
One has the right or freedom of Sexuality
• Happiness that is sought for ourselves alone can never be found
• For a happiness that is diminished by being shared is not big enough to make us happy
• Making someone happy
Responsibility:
• Commitment consists of:
• care
• Concern
• Responsibility
• Safeguarding the other’s value
• Responsibility to and for one another
• Humanizing – honoring the other person
• Natural Law – HS is sacred and a God given gift

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• Rawles – justice is fairness; never take advantage of persons for own personal gains and
satisfaction
• Kant – act as to treat human as always an end, never as a means
• Fletcher – prostitution out of necessity and survival may be legitimate

Sexual Morality:
Aquinas: Actions are wrong when we treat people disrespectfully; as mere things
Kant: Sexual desire is not an inclination that a person has for another as a human, but an
inclination for
another’s sex, this inclination is a principle of degradation of humanity
•Treat people as ends in themselves, not as means to an end

MORAL PERSPECTIVES OF SEX

•Sex is permissible between legally married man and woman (moral norm)
•Sex is permissible under basic standards that are moral (no one is cheated or harmed)
•Sex is permissible if 2 consenting partners have emotional connection

SEXUAL ETHICS
•Seeks to evaluate and crique the conduct of interpersonal relationships and sexual activities
from social, cultural and philosophical perspectives
•Issues: Gender identification, sexual orientation, consent, sexual relation and procreation.

2. MARRIAGE
•Marriage Fundamentals
•Marital distress, divorce and separation carry negative consequences for mental and physical
health of all family members
•Every interaction is the result of the contribution of two or more individuals

Basic beliefs and characteristics linked to happy marriages

•Respect – a feeling of deep admiration for someone elicited by their abilities, qualities, or
achievement
•Acceptance - A positive welcome, favor and endorsement; consent to receive something
offered
• Many times, receiving is conditional rather than having gratitude for what is offered
• Expectations may hinder the spirit of acceptance
•Attributions to positive - assuming the positive
• Attributing behaviors to negative intent can poison your relationships, create
defensiveness and undermine efforts by your partner.
• Positive interactions - Good things are built on strong foundations

• Happy couples have 5 positive interactions for every negative interaction

•Specific conflict - Happy couples tend to focus on the subject at hand rather than globally
criticizing each other
•Rapid repair - Happy couples repair any ruptures in their relationships quickly
•be the first one to QUICKLY move to repair
•Balance of intimacy and power - Intimacy and power consists of both emotional and physical
aspects
power is demonstrated in the ability to negotiate for needs to be met
•Does your partner’s opinion carry as much import as yours?

FAMILY AND BIOETHICS

•The concept of the family is an important one that cuts across many common bioethical issues
Families are Changing - changes in law and social policy have played a role in the changing
concept of the family
o technologies that allow us to control conception and reproduction
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o Autonomy - the individual and his personal autonomy to live his life as he wishes
autonomy as being without limits
• Equality - In an attempt to ensure equality, governments and policy makers have
accepted that a variety of relationships and domestic situations are equal to marriage,
and should therefore be afforded similar status to marriage and the traditional family.
• Rights - autonomy and equality have been given impetus by a 'rights-based' culture
seeking to ground rights to autonomy and equality not just within a moral framework, but
legally

MARRIAGE IS PART OF GOD’S CREATED ORDER

• Marriage is not merely a social or legal institution developed as a convenient way of ordering
human relationships
• 'Marriage is an exclusive heterosexual covenant between one man and one woman, ordained
and sealed by God, preceded by a public leaving of parents, consummated in sexual union, issuing
in a permanent mutually supportive partnership, and normally crowned by the gift of children'.

4 key characteristics of marriage:

• Exclusivity
• public acknowledgement
• Permanence
• consummation by sexual intercourse

ARGUMENTS AGAINST CONTRACEPTION

Contraception leads to "immoral behaviour"
• makes it easier for people to have sex outside marriage
• leads to widespread sexual immorality
• allows people (even married people) to have sex purely for enjoyment

ARGUMENTS BASED ON LIFE AND THE NATURAL ORDER

Contraception is unnatural
• the natural consequence of having sexual intercourse is conceiving a child
• it is wrong to interfere with the natural order
• therefore birth-control is intrinsically wrong
Contraception is anti-life
• life is a fundamental good
• those who use contraception are engaged in an intentionally "anti-life" act
• it is always morally wrong to do something with a bad intention
Contraception is a form of abortion
• some birth control techniques can operate by preventing the implantation and development
of a fertilized egg.
• those opposed to such methods say that this amounts to an abortion, and that if abortion is
wrong then those forms of contraception must also be wrong.

ARGUMENTS BASED ON SEXUAL BEHAVIOR AND HEALTH

The danger of the "contraceptive culture"
• "The availability of contraceptives leads to promiscuity which then leads to abortion
Contraception carries health risks
• may damage the health of the individual
• allows people to have more sexual partners and thus increases the possibility of catching a
sexually transmitted disease.
Contraception makes it easier for people to have sex outside marriage
• This is certainly true, since sexual intercourse without contraception carries a significant
risk of conceiving a child, which most of those having sex outside marriage would regard as a
deterrent.

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MEDICAL ETHICS AND CONTRACEPTION

•respect the autonomy of the patient
•the patient gets the information and advice they need to be able to choose wisely.
•(British Medical Association) recognize that a doctor has the right to claim a conscientious
objection to prescribing contraception and emergency contraception methods
•Patient should know the hazards and benefits of various methods of contraception.
•Reliability of the method
•Ease of use of the method
•Potential side-effects
•Health risks

ARTIFICIAL INSEMINATION, IN VITRO FERTILIZATION, SURROGATE MOTHERHOOD

•The inability to have a child is a true burden
•Reproductive technologies:
•fertility drugs, artificial insemination, in vitro fertilization (IVF), use of a surrogate mother,
gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), and
intracytoplasmic sperm injection (ICSI)

SURROGATE MOTHERHOOD
•Practice in which a woman (the surrogate mother) bears a child for a couple unable to produce
children in the usual way, usually because the wife is infertile or otherwise unable to undergo
pregnancy.
Use Of Donor eggs:
•Who are the parents?
•Should children know that one or both of his or her (rearing) parents did not provide the egg or
sperm which brought them into being?
•Should children have access to the donor(s) (genetic parents)?
•Should genetic parents have visitation rights?
•violating the "one flesh" model of marriage in Scripture, in which children are literally to be the
result of the two married parents
•Many people experience a very natural urge to be parents.
•Some are seeking to satisfy this urge using reproductive technologies without fully
understanding all their implications.

ISSUES OF SEX OUTSIDE MARRIAGE AND HOMOSEXUALITY

• All cultures - consensual sexual intercourse is acceptable within marriage.
• Some cultures - sexual intercourse outside marriage is controversial, if not totally unacceptable,
or even illegal.

THE ROLE OF THE NURSE IN REPRODUCTIVE AND GENETIC TECHNOLOGIES

• advocating information on assisted human reproduction
• unbiased counselling to clients
• health promotion and disease prevention approaches to the known causes of infertility

Facts on Abortion in the Philippines:

Criminalization and a General Ban on Abortion:
1. For over a century, abortion has been criminalized in the Philippines. The criminal provisions on
abortion do not contain any exceptions allowing abortion, including to save the life of the pregnant
woman or to protect her health.

2. Physicians and midwives who perform abortions in the Philippines with the consent of a
pregnant woman may face up to 6 years in prison under the Revised Penal Code. Women who
undergo abortion for any reason may be punished by imprisonment for two to six years.

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 NCM 108j – Health Care Ethics

3. Because of the lack of access to safe abortion, Filipino women with life-threatening pregnancies
have no choice but to risk their lives, either through unsafe abortion or through continuation of
high-risk pregnancies.

4. The criminal abortion ban has stigmatized the procedure in the medical community, so that
women face tremendous barriers and significant abuse when they seek treatment for abortion
complications. Filipino women who have undergone unsafe abortions for health reasons report that
healthcare workers have not been sympathetic to their situation, but instead continue to abuse and
threaten them.

• As a result of the criminal abortion law and the discriminatory environment in the Philippines,
women are left without means to control their fertility, exposed to unsafe abortions, and made
vulnerable to abuse in the health system.

DIGNITY IN DEATH AND DYING

Euthanasia - Greek “good death” (“Mercy killing”)

1. Active Euthanasia- actions to bring about the client’s death directly, with or without client
consent; forbidden by law (murder); violation of code of ethics for nurses
Assisted Suicide (variation)- giving clients a means to kill themselves if they request it; some
countries permit this

2. Passive euthanasia - “withdrawing or withholding life-sustaining therapy”

-more legally acceptable to most persons than assisted suicide.

DYING PATIENTS
• helping clients die with dignity
• hospice and palliative care
• meeting the physiologic needs
• spiritual support
• supporting family

INVIOLABILITY OF HUMAN LIFE

• any human life is of infinite value as it is a sacred and precious gift from the almighty Creator
• It can never be sacrificed by whatever means for whatever reasons.
• Ex. weighing the value of life against another in difficult cases.
• TO HEAL AND NOT TO KILL
• principle of double effect may be applied by those who are competent.

DYSTHANASIA and ORTHOTHANASIA

• Disthanasia - useless treatment, which values saving the life at any cost and submits patients to
therapies which do not prolong life, but rather the death process
• Orthothanasia
• does not tolerate disproportionate treatments, does not incur in abusive delays, it faces death at
the right time
• It generates the possibility of discussing with people the difference between curing and treating,
between maintaining life when this is the right procedure or signaling death when it time arrives.

HOSPICE CARE
• comprehensive physical, psychological, social, and spiritual care for terminally ill patients.
– goal : achieve a full life as possible, with minimal pain, discomfort, and restriction.
– coordinated team effort to help the patient and family members overcome the severe anxiety,
fear, and depression that occur with a terminal illness
– open communication - evaluating patient care / cope with their own feelings

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 NCM 108j – Health Care Ethics

• NATURAL DEATH ACT OF 2005

Recognizing the fundamental right of adult persons to decide their own health care, including the
decision to have life-sustaining treatment withheld or withdrawn in instances of a terminal
condition or permanent unconscious condition

• ADVANCE DIRECTIVES
SECTION 4. Directive to Withhold or Withdraw Life-Sustaining Treatment.
(1 )Any person of legal age and sound mind may execute a directive directing the withholding or
withdrawal of life-sustaining treatment in a terminal condition or permanent unconscious condition.
2 witnesses:
(a)not related to the declarer by blood or marriage;
(b)would not be entitled to any portion of the estate of the
declarer upon declarer’s decease under any will of the declarer
(c) not the attending physician;
(d) not an employee of the attending physician or a health
facility in which the declarer is a patient
(e)have no claim against any portion of the estate of the declarer upon declarer’s decease at the
time of the execution of the directive.

SECTION 6. Liability of Health Care Provider or Facility. —

• Any physician or health care provider acting under the direction of a physician, or health
facility and its personnel shall be immune from legal liability, unless otherwise negligent.
• SECTION 10. Mercy Killing or Physician-Assisted Suicide Not Authorized.
• SECTION 11. Discharge So That Patient May Die at Home

DNR or END OF LIFE CARE

What kinds of treatments can help to sustain a patient's life
• Nutrition support and hydration
• Cardio-pulmonary resuscitation
• Defibrillation
• Mechanical ventilation
• Dialysis

Do patients have a right to life-sustaining treatments?

• If patients or caregivers demand a treatment that health practitioners have determined to be
useless, a legal resolution may be required.
• Conversely, medical personnel may find it objectionable to withdraw life support when they
know that the inevitable consequence will be the patient's death.

How have the courts resolved conflicts involving nutrition support?

• persistent vegetative state
• advance health care directives

How can people ensure that their wishes will be considered in the event that they become
incapacitated?
• advance directive (living will)
• durable power of attorney (medical power of attorney)
• Signed by 2 witnesses or notarized
• There are many things to think about when writing a living will. These include:
• use of equipment such as dialysis machines (kidney machines) or ventilators (breathing
machines) to help keep you alive.
• Do not resuscitate orders (instructions not to use CPR if breathing or heartbeat stops).
• There are many things to think about when writing a living will. These include:
• fluid or liquid (usually by IV) and/or food (tube feeding into your stomach)

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 NCM 108j – Health Care Ethics

• treatment for pain, nausea, or other symptoms, even if you can't make other decisions (this may
be called comfort care or palliative care).
• donate your organs or other body tissues after death.

How does a “do-not resuscitate” order differ from advance directives?

• Do-not-resuscitate (DNR) order
– withhold CPR
– does not exclude other life-prolonging measures
– physician can write this order but must consult the patient or surrogate if this is done.

What resources are available to individuals who have difficulty making decisions about life-sustaining
medical treatments?
• ethics committee
– update patient care policies pertaining to end of life treatment
• Medical staff - provide referrals for hospice care

Dying Patients’ Bill of Rights

• treated as a living human being until I die
• maintain a sense of hopefulness however changing its focus may be
• express my feelings and emotions about my approaching death in my own way.
• participate in decisions concerning my care
• expect continuing medical and nursing attention even though cure goals must be changed to
comfort goals
• not to die alone
• to be free from pain
• have my questions answered honestly
• not to be deceived
• have help from and for my family in accepting my death
• die in peace and with dignity
• retain my individuality and not be judged for my decisions which may be contrary to the beliefs
of others
• to be cared for by caring, sensitive, knowledgeable people who will attempt to understand my
needs and will be able to gain some satisfaction in helping me face my death.

Nursing Roles and Responsibilities

Ethical Decision-Making Process
• Situation: Mrs. L, a 67- year old woman, is hospitalized with multiple fractures and lacerations
caused by an automobile accident. Her husband, who was killed in the accident, was taken to the
same hospital. Mrs. l, who had been driving the automobile, constantly questions her primary
nurse about her husband. The surgeon has told the nurse not to tell Mrs. L about the death of her
husband; however the surgeon does not give the nurse any reason for these instructions. The nurse
expresses concern to the charge nurse, who says the surgeon’s orders must be followed-that the
surgeon will decide when Mrs. L should be told. However, the nurse is not comfortable with this
and wonders what should be done.

NURSING ACTION CONSIDERATION

Identify the moral aspects.
• alternative actions - tell the truth or withhold it.
• moral principles - honesty and loyalty.
• Conflict - nurse’s honesty to patient without being disloyal to surgeon
• Choice affected by - feeling of concern for patient and surgeon’s incomplete communication
with client and nurse
Gather relevant facts that relate to the issue.
• client’s health problems, who is involved, nature of involvement, motives for acting.
• client-concerned about husband
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 NCM 108j – Health Care Ethics

• husband -deceased
• surgeon
• charge nurse
• primary nurse
• Motives-unknown
• Nurse- wishes to protect therapeutic relationship with patient
• Physician- protect patient from psychological trauma/consequent physical deterioration
Determine ownership of the decision.
For example, for whom is the decision being made? Who should decide and why? •
Decision is being made for the patient.
• Surgeon believes a physician should decide (charge nurse agrees)
• caregivers agree on criteria for deciding and who the decision maker should be
Clarify and apply personal values
• Patient-values husband’s welfare
• charge nurse- values policy and procedure
• Primary nurse-values patient’s right to information
• nurse needs to clarify her own and the surgeon’s, patient’s, charge nurse’s values
Identify ethical theories and principles
• failing to tell patient negates autonomy
• nurse will uphold principle of honesty by telling patient
• beneficence and non-maleficence involved because of the possible effects of
alternative actions on patient’s physical and psychologic well-being
Identify applicable laws or agency policies
• Because the surgeon gave instructions rather than an actual order, agency policies might not
require the nurse to follow the instructions.
• Nurse can clarify this with the charge nurse and be familiar with the nurse practice act
Use competent interdisciplinary resources
• nurse can consult literature to find out whether patients are harmed by receiving bad
news when they are injured
• might also consult chaplain
Develop alternative actions and project their outcomes on the client and family.
Possible because of the limited time available for ethical deliberations in the clinical setting, nurses
tend to identify 2 opposing, either-or alternatives (to tell or not to tell) instead of generating more
options.
1. follow the charge nurse’s advice and do as the surgeon says.
Outcomes:
a. Patient might become anxious d angry when she finds out information was withheld from
her
b. healthcare team may avoid harming patient
2. Discuss the situation further with charge nurse and surgeon, pointing out patient’s right to
autonomy and information
a. surgeon acknowledges patient’s right to be informed
b. surgeon states that patient’s health is at risk and insists that she not be informed until a
later time.
Identify nurse codes of ethics - to help guide actions ( Codes of nursing usually support autonomy
and nursing advocacy).
• If the nurse believes strongly that the patient should hear the truth, then as a client advocate,
the nurse should choose to confer again with the charge nurse and surgeon.
For an alternative action, identify the risk and seriousness of consequences for the nurse (Some
employers may not support nursing autonomy and advocacy in ethical situations.)
• If the nurse tells the patient the truth withour the agreement of the charge nurse and surgeon,
the nurse risks the surgeon’s anger and a reprimand from the charge nurse.
• If the nurse follows the charge nurse’s advice, the nurse will receive approval from the charge
nurse and surgeon; however the nurse risks being seen as unassertive, and the nurse violates a
personal value of truthfulness
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 NCM 108j – Health Care Ethics

• If the nurse requests a conference, the nurse may gain respect for assertiveness and
professionalism, but the nurse risks the surgeon’s annoyance and having the instructions
questioned.
Participate actively in resolving the issue.
• recommend actions that can be ethically supported, recognizing that all actions have
positive and negative aspects.
• The appropriate degree of nursing input varies with the situation. Sometimes nurses
participate in choosing what will be done; sometimes they merely support a client who’s
making the decision. In this situation, if an action cannot be agreed on, the nurse must
decide whether the issue is important enough to merit the personal risks involved.
Evaluate the action taken. - Involve the client, family, and other health members in the
evaluation, if possible
• The nurse can begin asking, “Did I do the right thing?’ Would the nurse make the same
decisions again if the situation were repeated? If the nurse is not satisfied, the nurse can review
other alternatives and work through the process again.

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 NCM 108j – Health Care Ethics

Chapter 3
Bio Ethics and Research

Research Utilization and Evidence-Based Practice

Research utilization (RU)
• The use of study findings in a practical application unrelated to the original research
Evidence-based practice (EBP)
• Basing clinical decisions on best possible evidence—especially high-quality research

Nurses’ Role in Using Research Evidence

• Read widely and critically
• Attend professional conferences
• Become involved in a journal club
• Pursue and participate in RU/EBP projects

Ethical issues in research

• permitting a cancer patient to smoke marijuana for medicinal purposes
• Tube feedings when patients are unable to sustain nourishment
• Testing of new products to critically ill patients

INFORMED CONSENT
• provides a structure of ethical principles for the hospital to follow when treatment is given
• outlines the type of treatment being given and the potential outcomes
• provides liability protection for the hospital

ETHICAL ISSUES
• Nazi medical experiments (1930-1940)
• Scientists carried out so-called freezing experiments using prisoners to find an effective
treatment for hypothermia.

TUSKEGEE SYPHILIS STUDIES

• conducted between 1932 and 1972 by the U.S. Public Health Service
• studied the natural progression of untreated syphilis
• African American men who thought they were receiving free health care from the U.S.
government

CERVICAL CANCER STUDY

• Dr Herbert Green at National Women's Hospital in Auckland, New Zealand
• over a period of 15-20 years
• without the patients' knowledge or consent
• not treating women who had continuing abnormal cervical smear results in order to establish
the hypothesis of nonprogression
• violation of the requirement of valid consent is examined in relation to the Hippocratic tradition
of paternalism; to clinical freedom; and to the legislative solution proposed by an official inquiry
including a statement of patients' rights, appointing a Health Commissioner to heighten
professionals' understanding of these rights and to mediate grievances, and circumscribing peer
review by a patient advocate.

INJECTING HEPATITIS VIRUS TO MENTALLY ILL CHILDREN

• Severely retarded children at the Willowbrook State Hospital in New York injected with
hepatitis virus
• This Hospital did not admit new patients after 1964, unless their parents "consented" to the
experiment.

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WARTIME EXPERIMENTS ON THE INMATES OF NAZI CONCENTRATION CAMPS

• The idea of, "state before individual" was typical of the Nazi era and physicians began to lose
sight of their moral obligations as they were swept into the dehumanizing Nazi political culture.
• The slew of exotic diseases and afflictions, a condition of the war environment, were seen as a,
"national threat," and it was to these "threats" that German doctors began to assume the
responsibility of acting on behalf of the state in order to improve the health of the nation.
• On the basis of national thought and utilitarianism doctors no longer acted as caretakers but as
puppets of a government obsessed with racial and genetic purity.
• Medical experiments committed under the disguise of scientific research fell into three basic
categories:
1. Medico-Military Research
2. Miscellaneous, Ad Hoc Experiments
3. Racially Motivated Experiments.
• Dr. Josepf Mengele, more familiarly known as the 'Angel of death,' is probably the most
famous of the Nazi doctors who used the prisoners in Nazi concentration camps for medical
experimentation
• Mengele sought to unlock the genetic basis for a superior race and conducted goulish
experiments with precision going even beyond the limits of scientific inquiry.
• He was fanatical about twin studies, obsessing over the differences between twins, and
would make them sit together in the nude for hours while he personally examined them leaving
no body part untouched.
• Furthermore, drawing blood from identical twins was routine, which often left them bleeding
to death. Mengele was also involved in other studies that sought to design better equipment for
the Nazi soldiers, and for this purpose naked prisoners were placed in ice cold vats to determine
the lowest possible temperature in which a human could survive.
• However, Mengele wasn't alone in his medical exploits, many German doctors made trips to
Nazi concentration camps where they could use the large potential subject pool without concern
for the harm of the subjects.
• Following World War II, leading Nazi doctors were brought to justice before the International
Military Tribunal at Nuremberg. 20 doctors (unfortunately Dr. Josepf Mengele was not among
these twenty. He fled Auschwitz in 1945, before the liberation of the camps by the Americans.),
were charged with War Crimes and Crimes Against Humanity.
• The Nuremberg trial of doctors, which began in 1946, revealed evidence of sadistic human
experiments conducted at the Dachau, Auschwitz, Buchenwald and Sachsenhausen concentration
camps.

THE NUREMBERG CODE

• Most important document in the history of the ethics of medical research and the first of its
kind to ensure the rights of subjects
• Formulated in August 1947
• American judges heading the trial of Nazi doctors accused of conducting macabre human
experiments in the concentration camps.
• During the course of the trial the judges at Nuremberg correctly recognized that more than
the Hippocratic ethics and the maxim primum non nocere, were necessary to ensure and protect
the rights of human research subjects.
• Thus the judges defined a set of 10 research principles that were centered on the research
subject rather than the physician. The judges were emphatic about the necessity and quality of
the subject's consent, explicitly adding the subject' s right to withdraw from the experiment.

10 RESEARCH PRINCIPLES OF THE NUREMBERG CODE

1. Voluntary consent is essential
2. The results of any experiment must be for the greater good of society
3. Human experiments should be based on previous animal experimentation
4. Experiments should be conducted by avoiding physical/mental suffering and injury
5. No experiments should be conducted if it is believed to cause death/disability
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6. The risks should never exceed the benefits

7. Adequate facilities should be used to protect subjects
8. Experiments should be conducted only by qualified scientists
9. Subjects should be able to end their participation at any time
10. The scientist in charge must be prepared to terminate the experiment when injury, disability, or
death is likely to occur

The Nuremberg Code - insists that the medical investigators alone cannot set the rules for the
ethical conduct of research, even when guided by beneficence and the Hippocratic ethics.
• In the traditional doctor-patient relationship, the silent and dutiful patient trusted the physician
to act in their best interests or at least do no harm. However, more often than not scientific research
lies outside the beneficient context of the physician-patient relationship whereby the physician's
primary goal is now motivated by a scientific hypothesis and not to treat the patient.
• This breach of trust led the judges heading the Nuremberg trials to merge Hippocratic ethics
and the protection of human rights into a single code.

DECLARATION OF HELSINKI
• Basis for ethical standards in research
• Therapeutic and non-therapeutic researches
• The declaration emphasized the protection of subjects in this kind of research and strongly
proclaimed that the well-being of individuals is more important than scientific and social interests.

COUNCIL FOR INTERNATIONAL ORGANIZATIONS OF MEDICAL SCIENCES

(CIOMS)
• CIOMS Guidelines, formally known as International Ethical Guidelines for Biomedical
Research Involving Human Subjects
• set of ethical principles regarding human experimentation
• Created in 1993 by the Council for International Organizations of Medical Sciences (CIOMS)
and updated in 2002
• 21 guidelines (15 in the original report) address issues including informed consent, standards
for external review, recruitment of participants, and more
• On July 12, 1974, the National Research Act (Pub. L. 93-348) was signed into law, there-by
creating the National Commission for the Protection of Human Subjects of Biomedical and
Behavioral Research.

BELMONT REPORT
1. The boundaries between biomedical and behavioral research and the accepted and routine
practice of medicine
2. The role of assessment of risk-benefit criteria in the determination of the appropriateness of
research involving human subjects,
3. Appropriate guidelines for the selection of human subjects for participation in such research
4. The nature and definition of informed consent in various research settings.
5. Appropriate guidelines for the selection of human subjects for participation in such research
6. The nature and definition of informed consent in various research settings.
• Established guidelines for basic ethical principles, as well as informed consent, the
assessment of risks and benefits and subject selection.
• In response to the infamous tuskegee syphilis study
• Congress passed the national research act, creating the national commission for the
protection of human subjects of biomedical and behavioral research
• This commission met regularly for nearly four years, culminating in a four-day discussion
at the smithsonian institution’s belmont conference center in february 1976.

Summarized the 3 ethical principles guiding human research:

• Respect for persons: All individuals should be treated as autonomous agents, and
persons with diminished autonomy are entitled to protection
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• Beneficence: Researchers should maximize possible benefits and minimize possible

harm
• Justice – All persons should be treated equally, and the selection of research subjects
should be scrutinized so that no one is systematically selected on the basis of race, ethnicity,
class or other factors

The Belmont Report remains a primary ethical framework for researchers today.
• The Belmont Report addresses informed consent as a necessary part of showing respect for
all persons
• all subjects, to the degree that they are capable, should be given the opportunity to choose
what shall or shall not happen to them.
• informed consent requires three elements: information, comprehension and voluntariness.
INFORMATION
• Research subjects “must be given sufficient information about the research procedure,
purposes, risks and anticipated benefits and alternative procedures (where therapy is involved).”
• given the opportunity to ask questions and have the right to withdraw from the research at
any time.
In cases where informing subjects about some pertinent aspect of the research is likely to impair
the validity of the research, the Belmont Report states withholding information is justified only
if the following three criteria apply:
• Incomplete disclosure is truly necessary to accomplish the goals of the research
• There are no undisclosed risks to subjects that are more than minimal
• There is an adequate plan for debriefing subjects, when appropriate, and for disseminating
research results to them
• Researchers should never withhold information about risks for the purpose of getting a
subject to cooperate.

COOPERATION
• “The manner and context in which information is conveyed is as important as the
information itself.”
• allowing too little time for the subject to consider the information could affect their ability to
make an informed choice.
• Related: What Does “Understandable Language” Mean In Informed Consent?
• When a subject’s comprehension is severely limited due to age, disability or other factors,
researchers need to seek the permission of other parties to protect them from harm.

VOLUNTARINESS
• IC means there is no coercion or undue influence
• researchers cannot threaten harm or offer an “excessive, unwarranted, inappropriate or
improper reward” to obtain compliance
• researchers need to take special care when conducting clinical trials involving vulnerable
people who are under the authority of someone else, such as inmates or people who are ill.

Other considerations involving IC:

• What additional considerations apply when informed consent is obtained electronically?
• How can researchers avoid overstating the potential benefits of a medical device?
• How can researchers avoid undue influence when enrolling employees in a clinical trial?
• Research ethics involve the protection of dignity of subjects and the publication of the
information in the research
• when nurses participate in research they have to cope with three value systems; society
(human rights); nursing (ethics of caring) and science (scientific inquiry) which may be in
conflict with the values of subjects, communities, and societies and create tensions and
dilemmas in nursing
• Method and material:
• short description of the nature of nursing, and the advocacy role of nurses
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 NCM 108j – Health Care Ethics

• highlight the possible conflicts that nurses have to deal with, when undertaking or
participating in research.
• Results: The major ethical issues in conducting research are:
a) Informed consent
b) Beneficence- Do not harm
c) Respect for anonymity and confidentiality
d) Respect for privacy

Conclusions:
• Ethical issues, conflicting values, and ambiguity in decision making, are emerging from
literature review on nursing research
• lack of clarity in ethical standards
• must develop an awareness of these issues and an effective framework to deal with problems
involving human rights.

Historical overview- Ethical codes

• Human experimentation has been conducted even before 18th century.
• 1940s - ethical attitudes of researchers drawn the interest of society
• Professional codes and laws were introduced to prevent scientific abuses of human lives.
• In terms of Nursing the first inquiry was the "Nightingale Pledge" (1983)
• significant development of professional codes in conduct and research
• The American Nurses' Association (ANA) Guidelines for Research
• Human Rights Guidelines for nurses in clinical and other research (1985)
• Royal College of Nursing Code for nurses in research (1977) provide a strong assistance to
professional nurses

Ethics - Create challenges to nurse researchers

• Ethical requirements conflict with the need to produce high quality evidence for practice
1. Skills of the Researcher
• Jameton declares that in research the 3 more important elements:
• competency of the researcher
• the careful design
• worthwhile expected outcomes
2. Skills of the Researcher
• careful choice of method for data collection
• ensure validity and reliability

Ethico-moral Obligations of the Nurse in Evidence Based Practices

• Ethics within healthcare are important because workers must recognize healthcare dilemmas,
make good judgments and decisions based on their values while keeping within the laws that
govern them.
• To practice competently with integrity, nurses, like all healthcare professionals, must have
regulation and guidance within the profession. The American Nurses Association (ANA) has
developed the Code of Ethics for this purpose
• The first formal Code of Ethics to guide the nursing profession was developed in the 1950’s
• Developed and published by the ANA
• guides nurses in their daily practice and sets primary goals and values for the profession
• provide a succinct statement of the ethical obligations and duties of every individual who enters
the nursing profession
• provides a nonnegotiable ethical standard and is an expression of nursing’s own understanding
of its commitment to society
• The current version represents advances in technology, societal changes, expansion of nursing
practice into advanced practice roles, research, education, health policy, and administration, and
builds and maintains healthy work environments

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 NCM 108j – Health Care Ethics

Chapter 4
Ethical Consideration in Leadership and Management
“Ethics for a Nurse Leader”

Guidelines and Protocol in Documentation and Health Care Records

• The value of medical records is both scientific and legal
• duplication in future cases and aids in prompt treatment
• supplies rich material for medical and nursing research
• legal protection for the hospital, doctor, and nurse
• if it was not charted, it was not observed or done.
• nurses are expected to record fully, accurately, legibly, and promptly their observations from
admission to the time of the patient’s discharge
• nurses are legally and ethically bound to protect the patient’s chart from unauthorized persons.
• Permission has to be taken from the hospital authorities to secure any information from the
patient’s chart

Charting by Nursing Students

• When a nurse or clinical instructor countersigns the charting of a nursing student, he/she attests
that he/she has a personal knowledge of information and that such is accurate and authentic.
Medical Records in Legal Proceedings
• Important evidence in legal proceedings
• Police investigations, determining cause of death, extent of injury incurred by the patient
• Medical records librarian, by virtue of a subpoena duces tecum, who testifies that the patient’s
records are kept and protected from unauthorized handling and change

Ethical Consideration in Leadership and Management

• Comprehensive documentation and record keeping
• Clear, concise, complete record of clinical care (including assessment, plan of action, outcomes
and evaluation of care)
• Factual, accurate, true and honest record
• Avoids duplication of information
• Legible and non-erasable, permanent, retrievable, confidential, patient-focused and non-
judgmental
• Representative and reflective of professional observations and assessment
• Timely and completed as close as possible after episode of care or event
• chronological record of care (late entries recorded as soon as possible as to rectify the absence)
• Prefaced with date and time of care or event (including recording of late entries, changes or
additions)
• Identifying details of person who provided / documented care
• identifying of source of information (including information provided by another health care
professional or provider)
• Inclusive of signatures (or initials) and professional designation of person recording
information
• Contains meaningful and relevant information (avoids meaningless phrases such as ‘slept well
or ‘usual day’)
• Minimize transcription of data
• Easily interpreted over time and after significant time has elapsed
• Avoid use of abbreviations (other than those approved and documented in organizational policy
by the medical record department)
• Detailed documentation in relation to critical incidents such as patient falls, harm to patients, or
medication errors.

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MEANING AND SERVICE VALUES OF MEDICAL CARE

Allocation of Health Resources - Access to comprehensive, quality health care services is
important for promoting and maintaining health, preventing and managing disease, reducing
unnecessary disability and premature death, and achieving health equity.
3 components of access to care:
• Insurance coverage
• Health services
• Timeliness of care
• When considering access to health care, it is important to also include oral health care and
obtaining necessary prescription drugs.
Barriers to Health Services
• High cost of care
• Inadequate or no insurance coverage
• Lack of availability of services
• Lack of culturally competent care

These barriers to accessing health services lead to:

• Unmet health needs
• Delays in receiving appropriate care
• Inability to get preventive services
• Financial burdens
• Preventable hospitalizations
• Primary care provider (PCP) who serves as the usual source of care
• Provide integrated services while practicing in the context of family and community

Prolonged ED wait time:

• Decreases patient satisfaction
• Increases the number of patients who leave before being seen
• Is associated with clinically significant delays in care

Issues Involving Access to Care

• Improving health care services includes increasing access to and use of evidence-based
preventive services
• Clinical preventive services are services that:
• Prevent illness
• Prevent illness by providing protection to those at risk
• Identify and treat people with no symptoms, but who have risk factors
• emergency medical services (EMS)
• Timeliness - health care system's ability to provide health care quickly after a need is
recognized.
• Increased emotional distress
• Increased complications
• Higher treatment costs
• Increased hospitalizations

Chapter 5
Ethical Issues Related to Technology in the Delivery of Health Care

• Ethical codes are systemic guidelines for shaping ethical behavior that answer the normative
questions of what beliefs and values should be morally accepted.
• It is a formal statement of a group’s ideals and values.

It is a set of Ethical Principles that:

(a) Is shared by members of the group,
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(b) Reflects their moral judgments over time, and

(c) Serves as a standard for their professional actions.

Data Protection and Security

Data Privacy Act 2012
(RA 10173 s 2012)
Declaration of Policy
• Protects individuals from unauthorized processing of personal information that is:
o Private, not publicly available;
o Identifiable, where the identity of the individual is apparent either through direct attribution or
when put together with other available information.

What does this entail?

• All personal information must be collected for reasons that are specified, legitimate, and
reasonable. In other words, customers must opt in for their data to be used for specific reasons that
are transparent and legal.
• Personal information must be handled properly. Information must be kept accurate and
relevant, used only for the stated purposes, and retained only for as long as reasonably needed.
Customers must be active in ensuring that other, unauthorized parties do not have access to their
customers’ information.
• Personal information must be discarded in a way that does not make it visible and accessible to
unauthorized third parties.
• Unauthorized processing, negligent handling, or improper disposal of personal information is
punishable with up to six (6) years in prison or up to five million pesos (PHP 5,000,000) depending
on the nature and degree of the violation.

Benefits and Challenges of Technology

• Technology has shaped healthcare in irreversible ways. Innovations like electronic health
records aid convenience and access to information.
5 Benefits of Technology
1. Faster and more reliable communication:
Faster and more reliable communication is also an important factor that enables telecommuting, a
work setup that I've found offers its own set of advantages — particularly the potential for lower
human resources costs and access to high-quality talent in places that are far from the physical
address of a business.
2. Enhanced efficiency and productivity
Technology ushers in efficiency and productivity in many ways.
Multinational companies can employ accounting, billing, payroll, asset management and other
business software to manage their operations more effectively.
On the other hand, technology can help companies automate repetitive tasks that don’t require
sophisticated decision-making. This can result in greater productivity and efficiency.
3. Cost reduction and profit boost
increased efficiency and productivity from technology can result in a decrease in operating costs
(and a corresponding increase in profits).
Using technology has also helped me avoid opportunity costs, as systems backed by modern tech
may be less prone to breaking down or succumbing to avoidable issues.
Also, using advanced communication technologies makes it unnecessary to constantly travel for
meetings and supervisory work, as you can carry out these tasks through live video chat and
collaboration platforms.

4. Greater transparency and interconnected operations

It’s not easy managing businesses with complex bureaucratic processes and countless types of
transactions. However, with the help of advanced business software, you can seamlessly integrate
all business processes, even those in locations where you need to use different languages or

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 NCM 108j – Health Care Ethics

currencies. When it comes to sharing and processing business data, you can automatically gather,
process, and present everything in a form everyone can use.
You can also make accounting, marketing, sales, and other activities of a global business more
easily accessible with the right tools. It’s even possible to use multiple types of business software
from different developers, as most software nowadays supports integration with third-party
software or comes with application programming interfaces (APIs) that allow developers to find
ways to integrate other software.

5. Improved security
New technologies such as blockchain can allow businesses to implement better ways to secure
business transactions without compromising transparency and creating delaying layers of
bureaucracy and security measures. Blockchain could be used to secure financial transactions and
the files companies collaborate on, for example.

6 Challenges Tech Has Brought to Healthcare (And How to Avoid Them)

1. The Challenge of Interoperability
One of the most significant selling points of electronic health records (EHRs) is they allow
practitioners to access relevant patient data instantly.
2. Keeping Up with Old Tech
In spite of all of these technological advances, many facilities still use out-of-date technology.
3. User-Unfriendly Interfaces
Medical technology is advancing by leaps and bounds.
4. Exacerbating Malpractice Claims
MedTech has made many practices easier, but it overcomplicates others. One case from 2013 is an
ideal example.
5. Overcomplicated Asset Tracking
Asset tracking through electronic health records can be both a blessing and a curse.
Medical workers can use it to find anything with a barcode or RFID tracking chip.
6. Overall Implementation
Implementing technology in medicine has a steep learning curve.

Current Technology: Issues and Dilemma

BIT OF HISTORY
1899 – The International Council of Nurses (ICN), which has been a pioneer in developing a code
of nursing ethics, was established.
1900 – The first book on nursing ethics, Nursing Ethics: For Hospital and Private Use, had been
written by the American Nursing Leader Isabel Hampton Robb.
Nursing Codes of Ethics
• Inform the public about the Minimum Standards of the Profession and help them understand
Professional Nursing Conduct.
• Provide a sign of the profession’s commitment to the public it serves.
• Outline the major ethical considerations of the profession.
• Provide ethical standards for professional behavior.
• Guide the profession in self-regulation.
• Remind nurses of the special responsibility they assume when caring for the sick.

The PRIMARY VALUE consideration in nursing ethics has been the determination of the focus of
nurses’ work.

CODE OF ETHICS FOR FILIPINO NURSES

CODE OF GOOD GOVERNANCE
Professional Regulation Commission on July 23, 2003
• States that the Hallmark of all Professionals is their willingness to accept a set of professional
and ethical principles which they will follow in the conduct of their daily lives.

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 NCM 108j – Health Care Ethics

• The acceptance of these principles requires the maintenance of a standard of conduct higher
than what is required by law.

GENERAL PRINCIPLES
1. Service to Others
• This implies a commitment to a life of sacrifice and genuine selfishness in carrying out their
professional duties even at the expense of personal gain.
2. Integrity and Objectivity
• Professionals should perform their responsibilities with the highest sense of integrity and
imbued with Nationalism and Spiritual Values.
• They should maintain objectivity, be free from conflicts of interest, refrain from engaging in
any activity that would prejudice their abilities to ethically carry out their duties nor make any
representations that would likely cause a reasonable person to misunderstood and be deceived.
3. Professional Competence
• A certain level of competence is necessary in undertaking only those professional services they
can reasonably deliver.
• It is their express obligation to keep up with new knowledge and techniques in their field and
upgrade their level of competence, taking part in a lifelong continuing education program.
4. Solidarity and Teamwork
• Each professional shall maintain and support one Professional Organization that promotes a
deep spirit of solidarity and teamwork among its members.
5. Social and Civic Responsibility
• Professionals shall always carry out their Professional Duties with due consideration of the
broader interest of the public, serve them with professional concern consistent with their
responsibilities to society and as Filipinos, contribute to attainment of the country’s national
objectives.
6. Global Competitiveness
• Professionals shall remain open to the challenges of a more dynamic and interconnected world,
rise up to global standards and maintain levels of Professional Practices fully aligned with global
best practices.
7. Equality of All Professions
• All professionals shall treat their colleagues with respect and strive to be fair in their dealings
with one another.
• No one group of professionals is superior to or above others.
• All professions perform an equally important, yet distinct, service to society.
• In the eyes of the Professional Regulation Commission, all Professions are equal and therefore,
every one shall treat other professionals with respect and fairness.

AMENDED CODE OF ETHICS FOR NURSES

• Pursuant to Section 3 of the republic Act No.877 known as the Philippine Nursing Law,
and Section 6 of PD No. 223 the amended Code of Ethics for Nurses recommended and endorsed
by the Philippine Nurses Association was adopted to govern the practice of nursing in the
Philippines.
A. The Code was adopted under Republic Act 9173 and promulgated by the board of Nursing
under Resolution No.220 s 2004 last July 14, 2004

ARTICLE 1 PREAMBLE
• Health is a fundamental right of every individual
• Nurses must have knowledge of man’s cultural, social, spiritual, psychological, ecological
aspects
• Respect and confidence to the community

4 FUNDAMENTAL RESPONSIBILITY OF THE NURSE

• Promote Health
• Prevent Illness
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• Restore Health
• Alleviate Suffering

ARTICLE 2: REGISTERED NURSES AND THE PEOPLE

• Respect for individual values, customs and spiritual beliefs
• Respect for individual freedom to decide
• Confidentiality of information

ARTICLE 3: NURSES AND PRACTICE

• Human life is inviolable
• Quality and excellence in the care of the patients are the goals of nursing practice
• Accurate documentation of actions and outcomes of delivered care is the hallmark of nursing
accountability.

ARTICLE 4: NURSES AND CO-WORKERS

• In solidarity with other members of the healthcare team.
• Maintains collegial and collaborative relationship with other healthcare providers.

ARTICLE 5: NURSES, SOCIETY AND EVIRONMENT

• Preservation of life, respect for life and promotion of healthy environment shall be a
commitment of an RN.
• Establish linkages with the public in promoting local, national and international efforts to meet
health and social needs of the people.

ARTICLE 6: NURSES AND THE PROFESSION

• Loyalty to the nursing profession
• Compliance with by-laws
• Commitment to learning
• Contribution to the improvement of the economy

ARTICLE 7: ADMINISTRATIVE PENALTIES, REPEALING CLAUSE AND EFFECTIVITY

• The certificate of registration of an RN shall be either revoked or suspended for violation of this
code pursuant to section 23

INTERNATIONAL COUNCIL OF NURSES (ICN)

OBJECTIVE:
• To provide a medium through which national nurses associations share common interests by
working together to develop the contribution of nursing to the promotion of health of the people
and the care of the sick.
o nurses worldwide collaborate and strengthen nursing service, education, and professional ethics
o Composed of national nursing organizations from member countries
o PNA became a member in 1929 in Montreal, Canada congress
o Meets quadrennially
o Official organ – International Nursing Review (4x/yr)
o Headquarters: Geneva, Switzerland

IMPLEMENTING RULES IN THE ICN CODE OF ETHICS

• Nurses shall perform professional duties in conformity with the existing laws and generally
accepted principles of moral and ethical conduct and proper decorum
• Nurses must know responsibilities in the practice of the profession
• Solicitation, direct or indirect from patient is repugnant to the honor and dignity of nursing
profession that constitutes unethical conduct

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 NCM 108j – Health Care Ethics

• Nurses must not allow the use of their names in the promotion of any commercial products or
service

MORAL AND SPIRITUAL RESPONSIBILITIES OF NURSES

• When a nurse is confronted with situations where moral judgment is necessary, the nurse may
be guided by the following principles or rules:
o The Golden Rule
o The Two – fold Effect
o The Principle of Totality
o Epikia
• One who acts through an agent is himself responsible
• No one is obliged to betray himself
• The end does not justify the means
• Ethical Issues Related to Technology in the Delivery of Health Care

MORAL PRINCIPLES OF A NURSE

• God-Loving
• God fearing
• Uphold sanctity of human life
• Commitment to Goad and people
• Provide spiritual care

MORAL PRINCIPLES
• A little more or less does not change the substance of an act
• The greatest good for the greatest number
• No one is held to the impossible
• If one is willing to cooperate, no injustice is done
• The morality of cooperation
• Principle relating to the origin and destruction of life

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