CHAPTER 3 THE CALLING OF THE HEALTH CARE PROVIDER The term calling signifies occupation, profession, or trade.

It may imply a response of a human person to a demand, need, or invitation to share in talents, expertise, knowledge, and skills with other in this earthly course of human enterprise to attain quality of life. It may further denote a vocation, which may determine what state in life a person wants to be. This vocation includes the calling of the health care provider to enter into a contract with society in the area of health as their profession. Taking care of the sick, the aged, the disabled, and other persons afflicted with infirmities is, indeed, a noble profession. The Health Care Profession Various professions exist. They exist for the purpose of serving society with its various needs. To meet those needs, professionals have to acquire and develop extensive knowledge, transforming virtues and special skills to live up to the distinguishing attributes of a profession. What is a profession? A profession is a complex, organized occupation preceded by a long training program (Greunding, 1985, as quoted by Burkhardt and Nathaniel, 2002). It is a calling in which its members profess to have acquired special knowledge, by training, or by experience, or both, so that they may guide, advise, or serve others in their specialized field. Health care, modifying the term profession, may refer to watchful keeping of the condition of being well or not sick. It is a means of promoting the patients well-being marks the boundaries of the range of options offered to a patient. It involves his/her informed consent, which is essentially limited to a choice among medically accepted and available alternatives, geared towards promotion of his/her welfare. Moreover, the well-being principle must be in harmony with autonomy. Patients autonomy necessitates freedom from interference or outside control. In health care context, the patients choice prevails over professionals assessment to value clients wish to be an instrument of his/her own welfare, and not of other persons acts of will (Mappes and De Grazia, 2002). However, effective and successful promotions of the values of personal well-being and self-determination lies in shared decision-making and honest-to-goodness dialogue between the patient and professional health care provider. The Health Care Provider A health care provider may be considered as a professional duly authorized to engage in, and granted by applicable law monopoly over health care services. Health care providers may include, but not limited to, physicians, nurses, therapists, dentists, ophthalmologists, pharmacists, dietitian-nutritionists, and medical technologists. The Nurse: A Mother Surrogate The word nurse is derived from the Latin verb nutrire, which means to feed, nourish, or suckle. As a noun, a nurse is one who suckles a child not her own(Websters New Twentieth Century Unabriged Dictionary). As a verb and noun, the dictionary definition implies

that nursing involves caring for children, especially young children, caring for those who are childlike in their dependence, such as the sick, the injured, the aged, and the handicapped. Likewise, it implies that the basic function of a nurse is identical with that of a mother who, in the latters absence, acts as a mother surrogate to the patient who has serious emotional needs. The patient needs motherly encouragement of recovery, reassurance of well-being, sympathy, understanding, anxiety, fear, boredom, and distress, and somebody to confide in and talk to. Under this situation, the person he/she really needs is his/her mother, and the prime concern and job of a nurse is to be a mother surrogate, if and when the biological mother is unavailable. The mother role of a nurse, however, is limited to the nurturing component of maternal role, and is devoid of elements of power and authority that may threaten patients selfdetermination. Along with a mother role, the nurse assumes a subservient role or position, which is compatible with authority. Under this role, the nurse can do nothing to influence or change the course of treatment of the patient. The Nurse as a Professional A professional is one who bound by values and standards other than those of his/her employing organization, setting ones own rules, seeking to promote standards of excellence and being evaluated, and looking for approval from ones own professional peers (Beletz, 1990:18). This immediately preceding description of a professional fits a nurse as such. A professional nurse is one who finished and acquired or gained a high level of specialized skills and knowledge through long years of study in nursing academic setting. This expertise distinguishes him/her from non-professionals, and equips him/her to meet the needs of society, thus, fulfilling the purpose of the nursing profession, Moreover, aside from expertise, there are other defining attributes related and applicable to nursing profession, namely: autonomy, accountability, authority, and unity. The table below demonstrates their interrelationship. Characteristics of Nursing Profession Application/Implication to Definitions/Meanings/Description Nursing Profession Competence or special knowledge Passing Government Board and skills in particular field of Examination and issuance of occupation / calling Certificate of Registration or License to practice professional nursing Self-governing, self-regulating, Autonomous practice serves independence; as safeguard to patient and health care providers; like the Self-regulation is a mark for nurse, he/she is legally and collective professional autonomy, ethically required to use while self-determination is a mark independent judgment in for responsibility, accountability, making nursing decision independence, and willingness to affording safeguard to the take risk for individual autonomy. clients.

Attributes Expertise

Autonomy

Accountability

Authority

Unity

Responsibility, liability, and Readiness of a nurse to answerability for carrying out ones assume responsibility as a obligation or duty; consequence of his/her independent decision and Grounded in the moral principles free acts. of fidelity and respect for the dignity, worth, and selfdetermination of clients. Permission, legitimacy, power, and Authority is granted through expertise on some subject or field; the power of examination and issuance of license to A form of permission for a protect the public from the profession to exist and for its misfits and professionals job members to legitimately practice. territory by establishing a monopoly Oneness, union of parts forming a Through unity, nursing is complex whole; elevated to a noble profession, which is Relates to the ability of nurses to characterized by expertise, organize and be cohesive to autonomy, authority, and achieve the professions goal. accountability.

The Client A client is a person of group for whom a doctor, a lawyer, a nurse, or other professional, person, or service acts. He/she may be a student, a patient, or a customer who has a need or want, and he/she looks for the professional (a physician, nurse, or teacher) to get and satisfy that need. In the health care profession, the client is referred to the patient or any person afflicted with infirmity or disability. Patients Rights and Duties As a noun, and taken in an abstract sense, right means justice, ethical correctness, or consonance with the rules of law or the principles of morals. In a concrete sense, it means a power, privilege, faculty, or demand inherent in one person and incident upon another (Blacks Law Dictionary). On the other hand, duty refers to what a person ought to do. It applies to what a person ought to do at all times because it is legally or morally right (The World Book Dictionary). Right and duty are two inseparable concepts. For every right, there is a corresponding duty. Patients claim of his/her right to effective health care requires or demands a duty to collaborate with physicians, nurses, and other health care providers. Patients Right The American Hospital Association (1992) promulgates and adopts a Patients Bill of Rights. This Bill is presented for consideration and application under Philippine context. It is shown at the table below.

Patients Bill of Rights 1. The patient has the right to a considerate and respectful care. 2. The Patient has the right to and encourage to obtain from physicians and other direct caregivers relevant, current, and understandable information concerning diagnosis, treatment, and prognosis. Except in emergencies when the patient lacks decision-making capacity and the need for treatment is urgent, the patient is entitled to the opportunity to discuss and request information related to the specific procedures and/or treatments, the risk involved, the possible length of recuperation, and the medically reasonable alternatives, and their accompanying risks and benefits. Patients have the right to know the identity of physicians, nurses, and others involved in their health care, as well as when those involved are students, residents, or other trainees. The patient also has the right to know the immediate and long-term financial implications of treatment choices within the institution. 3. The patient has the right to make decisions about the plan of care prior to and during the course of the treatment, and to refuse a recommended treatment of plan of care to the extent permitted by law and hospital policy, and to be informed of the medical consequences of this action. In case of such refusal, the patient is entitled to other appropriate care and services that the hospital provides, or be transfer to another hospital. The hospital should notify patients of any policy that might affect patient choices within the institution. 4. The patient has the right to have an advance directive (such as living will, health care proxy, or durable power of attorney for health care) concerning treatment or designating a surrogate decision-maker with the expectation that the hospital will honor the intent of that directive to the extent permitted by law and hospital policy. 5. The patient has the right to every consideration of privacy. Case discussion, consultation, examination, and treatment should be conducted so as to protect each patients privacy. 6. The patient has the right to expect that all communications and records pertaining to his/her care will be treated as confidential by the hospital, except in cases such as suspected abuse and public health hazards where reporting is permitted or required by law. The patient has the right to expect that the hospital will emphasize the confidentiality of this information when it releases it to any other parties entitled to review information in these records. 7. The patient has the right to review the records pertaining to his/her medical care, and to have the information explained or interpreted as necessary, except when restricted by law. 8. The patient has the right to expect that, within its capacity and policies, the hospital will make reasonable responses to the request of the patient for appropriate and medically indicated care and services. The hospital must provide evaluating service and/or referral as indicated by the urgency of the case. When medically appropriate and legally permissible, or when a patient has so requested, the patient may be transferred or must first have accepted the patient for transfer. The patient must also have the benefit of complete information and explanation concerning the needs for, risks, benefits, and

alternatives to such transfer. 9. The patient has the right to ask and be informed of the existence of business relationships among hospitals, educational institutions, and other care providers, or prayers that may influence the patients treatment and care. 10. The patient has the right to consent to or decline to participate to proposed research studies or human experimentation affecting care and treatment requiring direct patient involvement, and to have those studies fully explained prior to consent. A patient who declines to participate in research or experimentation is entitled to the most effective care that the hospital can otherwise provide. 11. The patient has the right to expect reasonable continuity of care when approached and to be informed by the physician and other caregivers of available and realistic patient care options when hospital care is no longer appropriate. 12. The patient has the right to be informed of hospital policies and practices that relate to patient care, treatment, and responsibilities. The patient has the right to be informed of available resource for resolving disputes, grievance, and conflicts, such as ethics committees, patient representatives, or other mechanisms available in the institution. The patient has the right to be informed of the hospitals charges for service and available payment methods. Along with or relative to the Patients Bill of Rights, the Council on Ethical and Judicial Affairs of the American Medical Association (1993) made statement asserting and spelling out supplementary and/or complementary patients rights that physicians and allied health care providers are enjoined to foster. The table below shows the following rights. Patients Rights 1. The patient has the right to receive information from physician and to discuss the benefits, risks, and cost of appropriate treatment alternatives. Patients should receive guidance from their physician as to the optimal course of action. Patients are also entitled to obtain copies or summaries of their medical records, to have their questions answered, to be advised of potential conflicts of interest that their physician might have, and to receive independent professional opinions. 2. The patient has the right to make decisions regarding the health care that is recommended by his/her physician. Accordingly, the patient may accept or refuse any recommended medical treatment. 3. The patient has the right to courtesy, respect, dignity, responsiveness, and timely attention to his/her needs 4. The patient has the right to confidentiality. The physician should not reveal confidential communication or information without the consent of the patient, unless provided by law or by the need to protect the welfare of the individual or the public interest. 5. The patient has the right to continuity of health care. The physician has an obligation to cooperate to the coordination of medically indicated treatment with other health care providers treating the patient. The physician may not discontinue treatment of a patient as long as further treatment is medically indicated, without giving the patient sufficient opportunity to make alternative arrangements for care. 6. The patient has the basic right to have available adequate health care. Physicians, along with the rest of society, should continue to work towards this goal. Fulfillment of this

right is dependent on society, providing resources so that no patient is deprive of necessary care because of an inability to pay for the care. Physicians should continue their traditional assumptions as part of the responsibility for the medical care of those who cannot afford essential health care. Physicians should advocate for patients in dealing with third parties when appropriate. Patients Duties/Responsibilities From the above-cited rights, we may derive these corresponding duties and/or responsibilities of a patient. The first and foremost requirement from a patient is his/her wholehearted cooperation and/or active participation in the course of treatment. This collaborative relationship is essential in addressing health-related needs towards the effectiveness of care and patient satisfaction and delight. From this basic requirement and premise, other specific duties and/or responsibilities may ensue. Burkhardt and Nathaniel (2002) suggest some of these responsibilities that the patient should follow: To provide honest information about past illness, hospitalizations, medications, and other matters related to health status To take initiative in requesting additional information or clarification about his/her health status or treatment when he/she does not fully understand such information and instruction. To ensure that the health care institution has a copy of his/her written advance directive if he/she has one; To inform his/her physician and other health care providers, like the nurse, if he/she anticipates problems in following the prescribed treatment; To be aware of the hospitals obligation to be reasonably efficient and equitable in providing care to other patients and the community To make reasonable accommodations to the needs of the hospital, other patients, medical staff, and hospital employees; To provide necessary information for health care insurance coverage and/or claims, and to work with the hospital to make payment arrangements orderly and easy; and To recognize and discern the impact of his/her lifestyle on his/her personal health. Health Care Provider Client Relationship Relationship signifies a state or condition that exists between people or groups that deal with one another. It implies a nexus or connection that binds parties for a common objective. In the matter of health care delivery, important players, entities, or clientele are involved with significant part to play in decision-making affecting health. These parties in collaborative relationship or in teamwork are the health care providers such as the physician, nurses, and other allied professionals, and the clients or patients with their families as the case may be. In this setup, we may speak of and limit to physician-patient or nurse-patient relationship, in either case. There are models or types that describe or direct the range or extent of this relationship. In his article, Client and Profession, edited by Rowan and Zinaich (2003), Paul Faber presents five (5) different types or modes of professional-client relationship. These are shown in the table below.

Professional-Client Relationship Application/Implication to health care As applied to health care, the responsibility to analyze, consider, and decide in the best alternative, and become educated about the problem and its corresponding solution, lies with the client/patient The implication is that agency relationship upholds patients value of self-determination or autonomy in the promotion of his/her personal well-being. The professional assumes responsibility to analyze, consider, and decide on solution to the problem of the client, who is only called to implement some of the decisions or none at all. Under this setup, the clients self-determination and freedom are curtailed to a great extent. However, there is no curtailment if and when the client acts freely due to the absence of coercion, presence of informed consent, and to his/her being competent; the absence of any of these conditions qualifies the relationship to be

Types/models 1. Agency Relationship

Descriptions The professional does not make decision, but the client does. The only thing the professional does is to implement part of clients decision. The professional works as the agent of the client.

2. Paternalism

Metaphorically, it is similar to a fatherchild relationship The professional as caring parent, and the client as the child.

3. Contractual

An agreement entered into and executed by and between the professional and client, stipulating the extent of their respective responsibility in a joint effort to meet a need.

4. Affinity

5. Fiduciary

A relation anchored on trust between the professional and client. The latter trusts the former due to some connection or confidence arising from friendship, expertise, family relation, or membership in religious or ethnic group. Under this relationship, there is an evolving division of responsibilities aimed at the clients wellbeing. As s noun, fiduciary means a person holding the character of a trustee. In a fiduciary relation, the trustee is the professional who is held in trust for the welfare of the client.

appropriately paternalistic. The contractual relationship is doable if and when the levels of knowledge of the problem area between the professional and client are more or less equal; otherwise, the relationship is not appropriate and the clients needs cannot be met. The relationship is appropriate and applicable when the needs of the client are met without encroaching upon his/her freedom.

In health care, the professional (physicians, nurses, and other health care providers) are the trustees in whose highest standard of knowledge and expertise are set, and in whom the welfare and health of human life are entrusted. They are unconditionally, legally, and morally

obligated with utmost diligence by virtue of the nature of their profession. In summary, the above-cited types of professional-client relationship spell out the extent of task each partner does appropriately to meet a need. The five (5) tasks described are: 1) 2) 3) 4) 5) The need or problem must be analyzed; To consider various alternatives or options to respond to the need; To decide on the best option; Education of the client must be done so that there is an informed consent; and Final decision must be implemented.

The five modes of relationship (agency, paternalistic, contractual, affinity, and fiduciary) differ extensively in terms of who (professional or client) performs or responds to the required task. Form among the models of professional-client relationship, it is the contention that the most appropriate and commendable is the fiduciary relationship. Do you agree? Why? The Qualities And / Or Characteristics of Effective Health Care Providers The concept of quality is a dynamic state associated with people, services, processes, and environment that meets or exceeds expectations (Goestch and Davis, 1997). It applies to any distinctive feature or characteristic of an individual. As applied to health care providers, qualities are professionals proficiencies that conform to clients or patients expectation, measured through the satisfaction of clients needs, and treat them with integrity, respect, and courtesy. Qualities may refer, likewise, to desirable personal attributes or traits that health care providers, such as nurses, may possess. They must have and live a quality life first before they can understand the patients perspective of what constitutes quality in their own lives. Nemo dat quod non habet (Nobody gives what he/she does not have), as the Latin saying goes. To be effective in quality service, health care providers must have or possess, among others, the following qualities/ characteristics listed in the table below: Personal Qualities / Characteristics Meanings, Descriptions, and Implications Proper regard for the dignity of ones character or position, with appreciation or recognition of its obligation of worthy conduct. As human persons, health care providers must have a strong sense of self-worth, of who they are in terms of their rational, theological, social, historical, and biological essence. They should have, too, a sense of pride of what they are in terms of their calling or profession, so that they can easily relate to their patients the beauty of

Kinds Self-respect

life that is worth living with and dying for. Self-Transcendence The quality of going beyond ones own self; it is self-giving, selfless love, the death of self so that others may live. For health care providers, like nurses, it implies capacity, readiness, and willingness to sacrifice their comfort zone for the well-being of their client/patient. The quality of being helpful, useful, and generous to others. It implies a value-added attitude of dedication to ones work, not mindful of remuneration paid, time spent, or schedule given. Health care providers, like nurses, must bear in mind that the very nature of their profession is service to the sick, primarily for their welfare, and incidentally for money just enough for them to survive and live a quality of life. The quality of being sincere, true, or straightforward. It implies absence of show or pretension. In other words, for a human person, like a nurse, to be simple, he/she must live with integrity, and not with a split personality. He/she must act according to who and what he/she really is, and not to what he/she is not. He/she must possess only what he/she needs so that others may not be deprived and suffer. Toward this end of simplicity, he/she becomes an advocate of sustainable human development.

Service-Oriented

Simplicity

Sense of Personal Responsibility and The ability to respond to a problem or need, which calls for decision-making, and a Accountability concomitant accountability to answer for any consequence thereafter. It implies total commitment and a sense of social duty, which requires an unfailing service to the needy for the good of society, or the common good. Risk-Taking Personality The quality of being courageous, strong, open, and vulnerable. It implies leaving ones comfort zone and going to his/her courage zone, which is characterized by innovation, change, pressure, exploration, and risk for the

possibility of failure or error. The health care providers, like nurses, have to make a stand in favor of patients well-being, even to the extent of losing their comfort zone. With courage, they disturb the comfortable, and comfort the disturbed. Patience The quality of being willing to put up waiting, pain, or anything that annoys, trouble, or hurts. It implies calmness and self-control, and applies when one is either enduring something unpleasant or merely waiting or doing something that requires steady effort. The caring for the sick is a demanding job because it involves protection, preservation, and extension of healthy human life. It demands an enduring attention and empathy from committed health care providers.

CHAPTER 4 VIRTUES, VICES, AND HABITS OF A HEALTH CARE PROVIDER The health care profession does exist not only by operation of law, but also by application of value-based ethics and the practice of virtues. In a legally-based ethics, a professional has to meet minimum requirements of applicable laws that define the extent of his/her administrative, civil, or criminal liabilities. Beyond legal definitions, value-ethics or the ethics of rights and duties may be observed to spell out obligations in resolving moral dimension. However, virtuebased ethics transcends the legal and moral levels in the hierarchy of ethical sensitivity. Questions may arise from these three-tiered systems of obligations: if an act is legal, is it moral? If it is moral, is it spiritual? Virtues of the Health Care Provider Virtue is referred to as a particular moral excellence. It is synonymous to uprightness or integrity it is simply a praiseworthy trait of human character (Veatch 2007), or a character trait that is morally valued. It is a way of actions, a disposition, or a good habit (Rowan and Zinaich, 2003). Aristotle sees it as a habit that is in the middle between two extremes of deficiency and excess. This is his doctrine of the golden mean. Being virtuous entails acting in moderation. Thus, the moral virtue of courage lies in a mean between the extremes of cowardice (deficiency) and foolhardiness (excess) (Ibid.:43). Moreover, Aritstotle distinguishes moral virtues from nonmoral. The former are habits that are necessary for being a morally good person, such as honesty, generosity, non-malevolence, fairness, kindness and courage. The latter virtues, on the other hand, are practices that may make a human person good in other ways such as optimism, cleanliness, and musical talents (Ibid.:42-43). List of Virtues Virtues may vary among professional, secular, philosophical and religious ethical approaches or systems. Notwithstanding this variation, we may focus on and agree to a list of virtues, which may deem appropriate for and necessary to a virtuous life of a health care provider. In the health care profession, his/her personal life must be characterized by the virtues of: 1) 2) 3) 4) 5) 6) 7) 8) Fidelity Honesty Integrity Humility Respect Compassion Prudence Courage

Fidelity Fidelity is referred to steadfast faithfulness. It is associated with pledge of loyalty or the practice of keeping promises. In the health care profession, faithfulness associated with keeping of promises is demonstrated when professionals, like nurses, spontaneously and consistently show in their personal and professional life their wholehearted support in upholding applicable laws, code of ethics, policies, and promises entered into with clients/patients. Likewise, faithfulness associated with loyalty in the professional-client relationship gives rise to an independent duty to keep contract in force and effect. Honesty Honesty means the quality of being honorable and upright in character and actions. It emphasizes fairness and uprightness in relations with others, refusal to steal, telling a lie, or making misrepresentation. To be fair, upright, and straightforward is to be honest with oneself and in his/her human acts. Self-honesty demands that he/she must not ever fake or try to be something or somebody he/she is not. He/she must be a first-rate version of himself/herself, and not a copycat or second-rate version of others. Moreover, to be honest is synonymous to being morally incorruptible, principled, truth-loving, veracious, real, good, and genuine. The absence of many of these characteristics negates the virtue of honesty, and gives way to the vices of plasticity, artificiality, caprices, and vanity. In the health care profession, this virtue must abound and shine. Integrity Like honesty, the virtue of integrity means the uprightness in character and actions. It implies undivided or unbroken conditions, completeness, and wholeness. It applies more directly to character than to actions, and means soundness of character and possession of very high standards of right and wrong. In health care service, a nurse of integrity can be trusted. He/she can easily attract and win friendship and reliance from his/her client or patient. The absence of integrity splits the personality of a nurse or any health care provider. He/she practices the profession not because of its idealism of service to humanity, but because of material consideration/comfort. Humility Humility is meekness of heart. A person, who is meek, acts with a gentle spirit. It calls for submission, docility, and courtesy. It implies freedom from pride and arrogance, lowliness of mind, a modest estimate of ones worth, and acceptance of ones own human imperfection, sinfulness, and self-abasement. In the health care profession, professionals, like the nurses epitomize the way humility works in their life. Nursing, by its nature, means rendering humble service to the sick and needy.

Respect The virtue of respect means esteem or honor. Esteem or honor is a quality by which a person shows recognition or high regard to self-worth, self-respect with dignity, respect for authority, and respect for others with tolerance. Self-worth signifies a favorable estimate or opinion of oneself. It is a self-esteem, that is, when one knows well who he/she is, his/her strength and capabilities, as well as his/her weaknesses or limitations, and that he/she can be a worthy instrument of service for others. Self-respect is an appropriate regard for oneself. It is a proper regard for the dignity of ones character or position, with recognition of its obligations of worthy conduct. It implies, then, recognition of worth specifying the element of approval or disapproval. It also implies proper pride that evokes confidence in ones worth as a human person, and prompts concern to sustain it. To sustain self-respect, one must take good care of his/her body, mind, and emotions. Respect for authority is due regard to a person or persons with the right to give commands and power to enforce obedience. These persons may be natural or juridical. In the Philippine context or jurisdiction, natural persons in authority include parents, teachers, elected and appointed government officials, like the Baranggay chairman, mayors, governors, judges, justices, congressmen, senators, cabinet members and secretaries, the Vice-President, and President of the Philippine Republic. The judicial persons may include Congress or Parliament, as the case may be, who enacts laws like the Philippine Nursing Act of 2002 (R.A No. 9173), the Board of Nursing that promulgates the Nursing Code of Ethics, and/or the Philippine Nursing Associations Incorporated (PNA) that embodies the ideals of the nursing profession. As applied to health care providers, their moral obligation is to obey authorities and give them due respect. They must see the practicability, necessity, and benefits of obedience and respect to their respective profession. House rules, school regulations, ethical rules of conduct, and laws are binding in their conscience. Conscience prompts and enjoins them to follow and respect authority figures for the sake of the common good, societal order and harmony, and public welfare. Respect for others may refer to due regard to immediate and distant relatives, neighbors, peers, classmates, friends and non-friends. For health care providers, these others may refer to clients or patients whom they respect and treat with utmost care, diligence, and tolerance. Respect with tolerance is willingness of one to be patient towards others, whose opinions or ways differ from him/her. It is a virtue that respects and upholds human rights. It recognizes diversity of cultures and forms of human expressions. It calls for the eradication of biases, prejudices, and insensitivity (APNIEVE, 34). Compassion Compassion signifies sympathy. It implies feeling for anothers sorrow or hardship that leads to help or pity. To be compassionate is to wish to be of help to those who suffer and who are in dire need of service. It is an act of opening ones heart to truly feel the difficulties and

hardships that another person is experiencing at the moment or here-and-now. It is characterized by related virtues of love and care, sympathy, kindness, and concern for others. To be a genuine and virtuous health care provider, compassion must be in the vein of his/her personal and professional life in order for his/her relation or dealing with patients to be significant and meaningful. Prudence The virtue of prudence signifies carefulness, precaution, attentiveness, and good judgment as applied to action or conduct. This term, in legal parlance, is commonly associated with care and diligence, and contrasted with negligence (Blacks Law Dictionary). It emphasizes cautious good sense in giving thought to ones actions and their consequences. It applies discernment or keenness in seeing, perceiving, or understanding a problem, situation, or issue. To be prudent means to be sensitive, discreet, judicious, and wise. To act with wisdom is to think with foresight, that is, one has to have the ability to see what is likely to happen and prepare for it accordingly (The World Book Dictionary). In the health care profession, this virtue of prudence is a tall order, considering the fact that these professionals, like physicians and nurses, deal with human life. In their decision-making process or judgment, they make or break, let live or let die their patients. It is expedient that health care providers possess the virtue of prudence to be instruments of healthy and long human life, and not to be causes of undesirable loss of it. Courage The virtue of courage signifies bravery and fearlessness. However, courage applies to moral strength that makes a person face any danger, trouble, or pain steadily and without showing fear. On the other hand, bravery applies to a kind of courage that is shown by bold, fearless, and daring action in the presence of danger. The hairline difference is that the former is more of a state or quality of mind and spirit that enables and prompts one to face danger, fear, or vicissitudes with confidence and resolve. The latter shows or demonstrates courage concretely, bodily, and with determination. Vices of the Health Care Provider The human person is a rational animal. This philosophical perspective makes him/her a living paradox. He/she is a rational being, as well as an animal being. The characteristic of rationality raise him/her to the level of the spirits. As such, his/her thoughts, dispositions, and/or human actions tend towards virtuous life as a gateway/passage to the spiritual world. The characteristics of animality put him/her down to the level of the brute. As such, his/her acts move towards evil or vicious life. What he/she does are acts of man under the influence or dictate of the reptilian brain. All persons, including the health care providers, are subject to this human imperfection, and are prone to the commission of vices. A vice is an evil fault, an imperfection, an immoral conduct, tendency, practice, or habit. As applied to an animal nature of a person, it is a bad habit or failing. The human person has so

many vices. As applied and attributed to health care providers, these vices may include, but not limited to the following: 1) fraud, 2) pride, and 3) greed. Fraud The vice of fraud is synonymous to the vices of bad faith, dishonesty, deceit, infidelity, unfairness, perfidy, unfaithfulness, and other analogous terms. It embraces all diverse means that human ingenuity can devise, and which are resorted to by one individual to take advantage over another by misrepresentations, false suggestions, or by suppression of truth. It also includes all surprise, trick, cleverness in deceiving, pretense, disguise, and any unfair way by which another is cheated (Blacks Law Dictionary). Fraud is either actual or constructive. The former consists in deceit, artifice, trick, design, and some direct and active operation of the mind. It is something said, done, or omitted by a person with the design to perpetrate what he/she knows to be a cheat or deception. The constructive fraud, on the other hand, consists in any act of commission or omission contrary to legal or ethical duty, trust, or confidence reposed. It is contrary, as well, to good conscience and operates to the injury of another (Ibid.). In relation to the Nursing Profession, a nurse may be guilty of and penalized for fraud as defined by the Philippine Nursing Act of 2002 (R.A. 9173) in the following instances: He/she practices nursing in the Philippines without a certificate of registration/professional license and professional identification card or special temporary permit, or without having been declared exempted from examination in accordance with the provision of R.A. No. 9173; He/she uses the certificate of registration, professional license, professional identification, and/or special temporary permit of another; He/she uses an invalid certificate of registration/professional license, a suspended or revoked certificate of registration/professional license, or an expired or cancelled special temporary permit; He/she gives any false evidence to the Board in order to obtain a certificate of registration/professional license, a professional identification card, or special permit; He/she falsely poses or advertises as a registered and licensed nurse, or uses any other means that tend to convey the impressions that he/she is a registered and licensed nurse; He/she appends B.S.N., R.N. (Bachelor of Science in Nursing, Registered Nurse), or any similar appendage to his/her name without having been conferred to said degrees or registration; or He/she as a registered and licensed nurse, abets or assists the illegal practice of a person who is not lawfully qualified to practice nursing. Pride The vice of pride is antonymous to the virtue of humility. It is synonymous to conceit which both mean a high opinion of oneself. Pride implies pleased satisfaction with what one is, has, has done, or is doing. It is synonymous with vanity, that is, too much pride in ones looks,

abilities, or accomplishments. It suggests neither proper self-respect nor personal dignity because of real-worth, but excessive self-love and arrogance because of imagined superiority. On the other hand, conceit implies too much high opinion of ones own abilities and accomplishments. It suggests an unpleasantly assertive manner (The World Book Dictionary). A proud and conceited person does not recognize his/her mistakes. He/she thinks that he/she is always right and never goes wrong. He/she points at others to be the culprit, the sinner, the guilty, and not him/her. He/she is just perfect. This kind of person is so called the conventional wisdom person who is totally closed to change, dialogue, and a truly virtuous life. How about a health care provider like a nurse, is he/she prone to this vice of pride? If his/her personal life is clothed with pride and conceit, then, the nursing profession is not meant for him/.her because he/she is called to live with utmost humility, in humble service to the sick, disabled, disturbed, the weak and powerless. Greed The vice of greed is the quality of wanting more than ones share. It is synonymous to avidity, avarice, cupidity, covetousness, and other analogous terms. To be greedy means to want or desire to get for oneself, more than what he/she needs. A greedy person is: a miser who is eager to accumulate much money/wealth, a glutton who wants to eat food excessively, a coveter who wants more things, more wives, or husbands belonging to another, a cupid who desire to arrow more lovers (men, women), a dictator who has an avid desire for more power, and a raven or plunderer who desire to get more things through stealing, robbery, kidnapping, car napping, and other corrupt means. Greed is antonymous to the virtue of simplicity, which is the absence of or freedom form luxury, vanity, and any form of greed. Simplicity regulates human wants and calls for moderation in taking only what are necessary to sustain good life. This virtue of simplicity, and not greed, must be instilled and integrated in the personal and professional life of a health care provider. He/she becomes an epitome of a simple life that the sick, disabled, and the deprived or needy will look up to with hope. Habits of a Health Care Provider The law of repetition, as applied in education, requires that one do things again and again until he/she learns. Students undertake routines in school, at home, and in other places doing the same things they did yesterday, the previous day, and every day for the last semester, or the whole academic year. Most of their student life is habitual. Likewise, in the health care profession, the professionals, like nurses, do things routinely and most of the time, they are hardly aware that they have habits. What is a habit? A habit is a disposition or condition of the body or mind acquired by custom or a usual repetition of the same act or functions (Blacks Law Dictionary). It is also understood as an inclination to perform some particular action, acquired by repetition, and characterized by a decreased power of resistance and an increased facility of performance (Padilla, 2005:38). From

the two immediately preceding definitions, there is a commonality in the use of the term acquired, which may imply that habit is not inborn. It will either make one or break him/her, for he/she becomes what he/she does repeatedly. Relative thereto, the writer Samuel Smiles (quoted by Covey, 1998:8) puts the impact of a habit this way: Sow a thought, and you reap an act; Sow an act, and you reap a habit; Sow a habit, and you reap a character; Sow a character, and you reap a destiny. The immediately preceding beautiful statements may imply that one is still on top of his/her habits. He/she can control, redirect, or change them, geared towards an improved healthful quality of life. For this reason, good habits in and bad habits out will be a tall order. Bad Habit A bad habit is a negative behavior pattern. It may be equivalent to a vice when it has moral implications due to its intimate relation to moral behavior like the habits of drug addiction, cursing, excessive drinking (wine), smoking, gambling, and eating. These instances of bad habits become vices if and when one knows the consequences, but he/she still does and repeats them intently, voluntarily, and consciously, without any effort to avert or avoid them. However, there are habits considered as bad, but short of elements to be a vice. Nevertheless, these habits may become recipes for disaster. Covey (1998) lists seven (7) common bad habits or characteristics as shown in the table below. Bad Habits 1. Reactive Description/Meaning/Implication One tends to act in response to some influence or force. He/she does not take responsibility for his/her life, and is concerned only for his/her rights and never for his/her corresponding duties. He/she blames everybody else and only does anything in response to what others have done. It is a toe for a toe, an eye for an eye, and a tooth for a tooth disposition. One does not believe in planning or in having vision-mission goals; whatever will be, will be (que sera, sera). He/she is only concerned of the here-and-now existence and not tomorrow, which is uncertain or may never come. One does not have priorities. He/she does whatever comes, and important things can wait for tomorrow. It is a maana habit attitude, or

2. Begin with no end in mind

3. Put First Things Last

4. Think Win-Lose

5. Seek First To Talk, Then Pretend to Listen

6. Do not Cooperate

7. Wear Yourself Out

procrastination. One sees life as survival of the fittest. He/she competes to win and makes sure others lose by all means. In case of loss, he/she does not accept defeat. In the win-lose proposition, the law of the jungle applies. One makes it a point to monopolize the talking, and impresses upon others that he/she knows best with incomparable ideas. He/she lets others air their views with a pretext to listen. In this habit, there is an evident superiority complex, which may give way to a vice of pride. One does not see the importance of teamwork. He/she thinks that nobody can do it, except himself/herself One thinks that he/she is an institution, and does not need to improve, or learn new things, for he/she has vast reservoir of stocked ideas.

Good Habits A good habit is a positive behavior pattern. It is analogous to a virtue. Virtuous persons live persistently with good habits. There are seven (7) good habits vis--vis the seven (7) bad habits, which Covey (1998) listed. These good habits are shown in the table below. Good Habits 1. Be Proactive Meaning/Explanation/Implication A person, who is proactive, makes choices based on values and virtues. He/she anticipates trends and works to promote their development. He/she is active in advance. What he/she does is preventive. He/she prevents or keeps a person or thing from doing something or making progress, or acting or setting up an obstacle to stop him or it. He/she takes responsibility for his/her life. He/she thinks before he/she acts, and makes things happen. One defines his/her vision-mission goals in life. He/she is a visionary, mission-oriented, and goal-directed. He/she plans to search for the

2. Begin with the End in Mind

3. Put First things First

4. Think Win-Win

5. Seek First to Understand, Then to be Understood

6. Synergize

7. Sharpen the Saw

eschatology of life. He/she draws up a blueprint to guide him/her in discovering the meaning and purpose of human life. One prioritizes and does the most important things first. He/she manages time so that activities and action plans comes first in the order of importance. Due to this habit, he/she learn to overcome fears, and become courageous with strong will power to say yes to priorities, and no to unimportant things. A win-win proposition is a belief that everybody can succeed. It is anchored on justice and equity. Everyone gets what is his/her due, for there are more than enough opportunities for all. It is a smorgasbord or an all-you-can-eat buffet. There are no sad and angry losers, but all are happy and satisfied winners. One opens himself/herself and listens to people genuinely to understand them who they are. He/she listens with his/her eyes, heart, and ears, stands in their shoes, and practices mirroring or reflection. To be understood necessarily follows leading to a healthy dialogue. A synergize is a harmonizer. He/she provides unity and support. He/she encourages people to work together to achieve more. The key to synergy is teamwork To sharpen ones saw is to take a break or rest, and receive back what he/she has given in work; resting is receiving. It is a good habit to rejuvenate, unleash, take a lateral move, relax, and treat oneself to a little tender loving care.

CHAPTER 5 BASIC ETHICAL PRINCIPLES A principle is a truth that is a foundation for other truths. What constitutes truth? It is conceived as an agreement of thought and reality, an eventual verification (of hypothesis, theory, or doctrine), and consistency of thought with itself. Law and moral ethics are principles. Legal and ethical principles are basic truths that guide decision analysis and decision-making. For health care providers, like nurses, knowledge of and interest in legal and ethical truths are indispensable conditions in the practice of their profession. Consistent adherence to these principles may minimize, if not avoid totally, mistakes, lapses, or vices in the health care services. This chapter limits its presentation to and/or discussion on the following basic ethical principles: Stewardship; Totality; Double Effect; Cooperation; Solidarity; Ross Ethics; and Some major bioethical principles of: o Respect for person o Respect for justice o Non-maleficence, and o Beneficence Principles of Stewardship A steward or stewardess is a person appointed in the place or stead of another. He/she takes charge of representing and protecting anothers interest, and sees to it that the service is carried out faithfully. This management and supervision for others stewardship. The principle of stewardship entails concomitant values and/or virtues of responsibility and accountability. Responsibility is the duty involved when one accepts the task of management. It is the ability of one to respond freely to a call for quality service. This response is characterized by the values/virtues of worthy, good servant. These characteristics imply reliability and is the state of being answerable or liable for carrying out ones right and duty. It goes hand-in-hand with responsibility. Both are obligations that a person is bound in law or justice to perform. By virtue of their chosen profession, the health care providers, like nurses, are changed by society as stewards in the health care services. They are called and mandated to take care of or look after the well-being of the sick, disabled, and other people suffering from physical and psychological infirmities. Equipped with knowledge, skills, right attitude, values, and/or to restore and help sustain good health of those people whom they are changed to serve.

Principle of Totality The term totality connotes wholeness, completeness, or entirety. The principle of totality applies to any entity that is made up of parts that together constitute as a whole. But the whole is greater than any of its parts. As applied to the human person, his/her whole physical body is more important and valuable than any of its part. It may be ethical and legal to sacrifice a part of ones body for the good of his/her whole body. On this basis, a cancerous leg may be amputated, or breast be operated. Removal of either part does not reduce the integrity of the human person. But to reduce or remove a part from the whole unnecessarily or out of vanity, will be contrary to moral integrity or integrity of creation. Transsexual operation or plastic surgery of a natural flat nose is typical examples. Principle of Double Effect The principle contemplates on two effects or outcomes arising from the performance of an action. The first or primary effect results from the agents intent, desire, wish, or will, while the secondary effect is only allowed, tolerated, or permitted. Moreover, the principle distinguishes performance of a good act that has both good and evil effects, from performance of an evil act so that good effect may result therefrom. There are four (4) conditions or elements to consider or fulfill before an action with double effect is justified, namely: The action done or course chosen must be morally good, or at least morally indifferent or neutral; The good effect must come directly form the action itself, and is not coming from or following as a consequence of secondary evil effect; The good effect must be intended or willed and the evil/ harm merely tolerated or allowed, with sufficient reason; and The good effect must outweigh or at least be equivalent in importance to the evil effect. Application of the Principle of Double Effect To an Actual Case Case 1: Ces Drilon of ABS-CBN was kidnapped for ransom. As a policy, payment of ransom money is absolutely prohibited. However, non-payment would mean loss of her life. The family of the victim allegedly paid secretly despite the prohibition and she was released alive. Did the family of the victim act morally? Analysis: The action had two effects: it is violated the no-ransom policy and it saved human life. First, the action of saving human life is, in itself, morally good. Second, such good effect is a direct result of the action itself and not a result of the violation of the policy. Third, the intent, desire, or wish of the family is to save the life of the victim, and not to go against the policy,

violation of which is merely allowed or tolerated. Finally, the saving of the victims life outweighs or is in proportion to the violation of the no-ransom policy, for in the hierarchy of values, life is more valuable or important than property. The Principle of Cooperation To cooperate means to work together, to unite in producing a result, or to desire, intend, or wish in a common thing. Cooperation, then, implies that one works with others in the performance of an act to accomplish a goal. To be able to work with others, he/she should have the knowledge, skills, attitudes, and traits that can guarantee harmonious relationship with others. However, concerted acts may turn out to be either good or evil. If it is good, the morality of cooperation promotes undoubtedly the total well-being of clients. However, the principle of cooperation poses moral problem, when and where acts done are evil, immoral, and illegal. In concerted evil acts, participants may be considered either as principals by indispensable cooperation, or as accomplice who cooperates by previous or simultaneous acts. A co-principal is one who cooperates in the commission of an evil when one does another act, without which it would not have been accomplished. Prior to the performance of such another act, there is an evident conspiracy or unity of evil intent and purpose in the perpetration of an offense. On the other hand, an accomplice is someone who knows the evil design of the principal by induction, and agrees or concurs with the latter of his/her purpose, that the giving material or moral aid, support, or assistance to facilitate the accomplishments of an offense. Illustrative Example/Situation Case 2: The spouses H and W have been legally married for more than a decade, but not blest with a child. They have had regular treatment in the clinic of Dr. X and Nurse Y. The conclusive medical finding is: Low blood count of H is incurable. X and Y, knowing and feeling the great desire and eagerness of the couple to have a child, suggested tubal or human insemination. W prefers the latter option (human insemination) with the consent or approval of H, who even goes his way to look for a partner who may have a carnal knowledge or act with his wife. Analysis: The principals, by induction, were Dr. C and Nurse Y because they induced their clients to resort to evil means. The co-principal, by indispensable cooperation, was the spouse W who concurred with the means, and preferred to have carnal knowledge or sexual intercourse with a man who is not her husband. The accomplice was spouse H who facilitated the commission/accomplishment of the adulterous act of W. Moreover, the foregoing case would not fall under the principle of double effect. The action is neither morally good nor indifferent. It is evil: an immoral and criminal act. The good effect: to have biological child, comes from or is a consequence of the evil effect. As a rule, it is

not morally permissible to do evil in order that good may be derived from it. In this instant case, the end will not justify the means. The Principle of Solidarity To be solid means to be firmly united. It follows that solidarity implies unity or fellowship, arising from common responsibility and interest. Sense of solidarity or unity characterizes quality standing of any profession like nursing. It relates to the ability of its members to organize and standardize the professional values of competence, autonomy, authority, and accountability. Toward this end, there arises the need for a cohesive professional association to solidify harmonious fellowship or relationship of its members who work together to meet the health care needs of society. With the principle of solidarity, one-for-all and all-forone policy is a tall order. Ross Ethics (Mappes and De Grazia, 2002: 24-27) W.D. Ross is an English philosopher. In his book entitled, The Right and Good (1930), he underscores his concern to provide a justifiable account of cases of conscience, or ethical situations confronting people with a pervasive conflict of duties. Which duty takes priority over other pressing duties? To solve this dilemma and provide a defensible account of conflict-of-duty situations, he deems it necessary to introduce the idea of prima facie duty. He, otherwise, intends to call it conditional duty, which is, on its face, prevailing until overcame or overridden by a more impelling prima facie duty. The prima facie duties have no single basis, but arise or sprung from several morally significant relations such as nurse-patient, physician-nurse, lawyer-client, employer-employee, promisor-promisee, and teacher-student relationship. Each of these relationships is the basis or foundation of a prima facie duty. Where one is faced with two or more competing prima facie duties, he/she has to make a reflective, considered decision and come up with only one these duties. This binding duty is the actual duty. Accordingly, Ross proposes seven (7) classifications or divisions of prima facie duties. They are as presented in the table below: Prima Facie Duties Description/Meaning Fidelity is related to the concept of steadfast faithfulness or loyalty. The duties include keeping promises, honoring contracts and agreements, and telling the truth. They rest on the persons previous

Classifications/Divisions 1. Duties of fidelity

Illustrative Examples Professional responsibilities/social roles of: Physician as physician Nurse as nurse Teacher as teacher

2. Duties of reparation

3. Duties of gratitude

4. Duties beneficence

of

5. Duties of maleficence

non-

acts. Reparation is the act or fact of giving satisfaction or compensation for wrong or injury done. The duties include rectifying the wrong perpetrated, returning the goods, wealth, or any property stolen, restoring the reputation of someone slandered, and/or paying damages for injuries suffered. Gratitude is thankfulness or a desire to do a favor in return. The duties rest upon previous acts of another person, and include beneficial services provided by them. The principle of reciprocity applies Beneficence is the practice of doing good, or an act of kindness. The duties include going or searching out to the needy and making a difference in their life. Non-maleficence is the act of not doing evil or injuring harm to others. The duty includes not to make the condition of others being

A returns the cell phone and says sorry to B, the victim C admits cheating and accepts punishment for the same

If one has provided quality service to others when they are in need, the latter stand under a duty to reciprocate service for the former when the same is in need.

To visit the sick, the prisoners, or the victims of calamities To share ones bounty to the needy

The duties of not to kill, to inflict corporal punishment, to commit arson, and/or to defraud others

6. Duties of justice

7. Duties of improvement

self-

worse or difficult. Justice connotes just conduct, fair treatment, or giving and receiving what one deserves. The duties include benefits based on merits, and rectifying unjust patterns of distribution Include the duty to make better ones character, mind, or the like by his/her own effort. The Divine Provider helps those who help themselves, or the sick gets well if he/she cooperates with the health care provider

If a nurse works eight (8) hours plus overtime, he/she must receive the agreed legal compensation plus overtime pay. It is giving what is due him/her.

A nurse keeps on studying things related to his/her profession, attends capacity-building seminars, and takes graduate studies.

Major Bioethical Principles Appropriate identification, analysis, interpretation, and resolution of health problems or issues are made possible and facilitated by way of reference to relevant bioethical principles. Mappes and De Grazia (2002) suggested and came up with four major set of principles, namely: 1) 2) 3) 4) The principle of respect for autonomy; The principle of non-maleficence; The principle of beneficence; and The principle of justice.

The Principle of Respect for Autonomy Autonomy is one of the four basic principles under the ethics of respect for other people, the other three (3) of which are fidelity, veracity, and avoidance of killing. These latter aspects were dealt on closely, but briefly under the Ross ethics. However, it is expedient to know the nature of the ethics of respect for persons. It deals or focuses on actions such as right or wrong, not based on the consequences they produce, but on their inherent content or form (formalism). Likewise, it considers certain behaviors or actions simply to be ones duty, regardless of the consequences (deontology) (Veatch, 2007:65).

The term autonomy comes from two Greek words autos, which means self, and nomos, rule or governance, thus, the idea of self-rule, self-governance, or self-determination applies or extends to individuals. The principle of respect for autonomy means acknowledgement of the persons right to hold views and opinions, to make decisions and choices, and to take action based on personal values, virtues, traditions, and beliefs (Kuan, 2006:53). It implies recognition of the individuals worth with the capacity to develop by oneself. It stresses the right of an independent decision-maker to determine for himself/herself what will be done to his/her body. As applied to health care service, this right of self-determination may limit what physicians, nurses, and other health care providers can do to their patients. Thus, the principle requires that health care professionals must not interfere with the effective exercise of patient autonomy (Mappes and De Grazia, 2002). This autonomy gives rise to the notion of informed consent. Informed consent means that the patient is given the opportunity to autonomously choose a course of action in regard to plans for health care. The choice includes the right to refuse interventions or recommendations about care, and to choose from available therapeutic alternatives (Burkhardt and Nathaniel, 2002: 209). The Principle of Non-Maleficence Under the Ross ethics, the concept of non-maleficence was discussed briefly in relation to duties. As a principle, it requires health care professionals to act in such a manner as to avoid causing harm to patients. It includes deliberate harm, risk of harm, and other harms that may happen during the performance of beneficial acts. It prohibits experimental research that assumes negative impact on participants, and the performance of unnecessary procedures for economic gain or self-interest. The principle may also include the avoidance of harms as a consequence of doing good (Burkhardt and Nathaniel, 2002:50). The concept of non-maleficence may be summed up by the quotations as follows: Do not do to others what you would not wish done to yourself. Confucius

Do not do to others that which would cause You pain if done to you. The Principle of Beneficence The term beneficence comes from two Latin words bene, which means well or good, and facere, to do or make. Thus, beneficence etymologically means doing what is good. It implies the duty to actively do good for patients. It is associated with the concept or virtues of kindness, benevolence, altruism, or humanitarianism. It is described as healing with attention to the psychological, social, and spiritual dimensions of disease, injury, or physical problems (Ibid: 314). The principle of beneficence has three major components, namely: 1) do or promote good, 2) prevent harm, and 3) remove evil or harm. When one does or promotes the good, he/she is an agent of goodness, and an ambassador of goodwill. Prevention of harm is a pro-active disposition. It implies planning and foresight of health care providers who take Mahabharata

appropriate actions to safeguard and sustain their patients well-being. Removal of evil or harm is a reactive disposition. It requires health care professionals to do all they can to restore or bring back their patients good health. Principle of Justice The term justice is associated with the concepts of fairness, rightfulness, deserved reward or punishment, and equity. The principle requires that social benefits, like health care services, and social burdens, like payment of taxes, be distributed in accordance with the demands of justice (Mappes and De Grazia, 2002:28). It implies a sense of duty to treat all people without bias to age, socio-economic status, race, or gender. It applies community extension of necessary treatment to all or to those in need, even though they may not have the means to pay for such treatment (Burkhardt and Nathaniel, 2002:313). The principle of justice may be concluded by the saying that goes: Justice delayed is justice denied. Its application and implication to health care profession in relation to the client or patients well-being in Philippine context may be considered as the following: Slow and delayed enactment and implementation of the Cheaper Medicine Act (R.A. No. 9052) have denied the poor and the needy affordable medicines and aggravated their plight to the extent of loss of life. Sick people are denied access for quality treatment in private hospitals due to lack of financial capacity to pay. To massive out-flux of Filipino doctors nurses to foreign countries may deny necessary health care services to patients.

CHAPTER 6 ISSUES/CASES OF BIOETHICAL CONCERNS This final chapter attempts to apply ethico-moral, spiritual, and legal concepts and principles to issues/cases that affect the health care providers, like the nurses, vis--vis patients well being. In the practice of their profession, they face a concrete dilemma about what appropriate actions to take. The topics herein to be presented are standard problem areas, among others, in bioethics. These are: 1) 2) 3) 4) 5) Plastic Surgery; Organ Transplant and Donation; Sterilization; Abortion; and Euthanasia.

Plastic Surgery Plastic/Cosmetic surgery is a branch of the science of surgery that focuses on the reconstruction or repair of deformity, defect, or bodily injury, and/or improves the appearance or function of outer parts of the body. The surgery may entail the use of bone, cartilage, tendons, and skin being taken from other parts of the body or applying artificial substitutes. However, face lifting, which is the cosmetic removal of excess fat and tightening of the skin, is a delicate and often unsuccessful operation, and the same carries the added risk of infection (The New Websters International Encyclopedia, 1996). The legal and moral dimensions of surgical intervention may be anchored on the principles of totality, autonomy with patients complementary value of informed consent, and double effect. In order for plastic/cosmetic surgery to become legally and morally permissible, it has to comply with the following conditions: The functional integrity of the human body must not be lessened, unless a sacrifice of any part, through surgery, is an extreme necessity to preserve the health and life of the whole body. Both surgeon and patient must have good intention Surgeon must respect patients autonomy and obtain the latters informed consent The intent or motives must be reasonably higher than or proportionate to the extraordinary means employed or allowed Organ Transplantation and Donation Organ transplantation involves the removal of a major or minor part of the human body from one person, and then surgically implanted in another persons body to replace a lost or diseased organ. This immediately preceding description implies an interplay between a giver and beneficiary, or between a donor and a donee. This relation brings us to the idea of a donation. A

donation is an act in which the owner of a thing voluntarily transfers the title and possession of the same from himself/herself to another person, without any consideration. By the civil law, donations are either intervivos (between living persons) or mortis causa (in anticipation of death). The former is an act by which the donor diverts himself/herself, at present and irrevocable, of the things given, in favor of the donee who accepts it. The latter is one which is made in contemplation, fear, or peril of death, and with intent that it shall take effect only in case of the death of the giver (Blacks Law Dictionary). The moral dimension of organ transplantation involves three (3) major issues, namely: 1) The fundamental morality of transplanting body parts; 2) The ethics of organ procurement; and 3) The ethics of allocation (Veatch, 2003). The first moral issue tries to resolve whether transplantation is an intervention or tampering with the humans basic nature in ways that go beyond what is morally acceptable of human conduct. The issue revolves around the idea of human control of life. There are two contentions on the issue: the pessimistic and conservative view, and the optimistic and interventionistic advocacy. The former view contends that medical manipulation is playing God, which role goes beyond the primary purpose of medicine - to save life, cure diseases, and relieve suffering, and that basic changes in the human species, or lessening the functional integrity of human creation lead to bad and harmful biological effects, and that there are moral limits on how far humans should go in using their knowledge of science to change their nature (Ibid,: 109-150). On the other hand, the optimistic view claims that mans use of medical science has improved the /situation. It speaks of human as a co-creator with a moral duty to user their knowledge of science not only to combat diseases, but also to improve on nature. Along with this latter objective, the proponents are concerned of the viability of intervention in genetics (Genetically Modified Organisms, or GMO) and birth technology, such as artificial insemination and contraception, in vitro fertilization (test tube baby), and cloning. The second issue on organ procurement for transplant is much less controversial. Different countries vary in ways of obtaining the same. The several modes of procurement are: 1) A dead person is considered as State property, and it could be automatically taken and used for good social purposes; 2) Routine salvaging of organs of the dead in the absence of explicit objection; and 3) Donation with consent of the person from whom the corpse is taken (Ibid: 137). The third and final issue is on organ allocation. There are two (2) principles that may govern acceptable allocation, namely: 1) principle of social utility, and 2) principle of issue. The social utility principle is the natural consequence of the application of beneficence and non-maleficence. The principle takes into consideration all benefits and harms to all parties. Its goal is the greatest aggregate good. It employs the standard measurement of cost benefit analysis to determine potential benefits and potential costs of alternative uses of resources. This principle is the basis for allocation: to give the organs to the patients who would benefit most. On the other hand, the principle of justice applies when allocation of resources, like organs on the basis of social utility,

are not morally satisfactory. It demands that people in similar situations should be treated equally on the basis of needs-based justice. Priority application of either principle in terms of organ allocation determines practical matters, like who has a better right to live more, and who has to accept the reality of death for lack of resources. Sterilization Sterilization is a surgical procedure designed to prevent conception. It is a medical interventions, which makes a client or a patient incapable of reproduction. In females, the fallopian tubes are cut and tied to prevent eggs from reaching the womb, thus, providing permanent contraception. The methods employed includes: 1) Ophorectomy (complete removal of the ovary, which manufactures germinal cells) 2) Salpingectomy (removal of salpinx of eustachean tube or fallopian tube) 3) Hysterectomy (removal of uterus) In males, sterilization may be achieved by: 1) Castration (removal of testicle) 2) Emasculation (removal of reproductive glands) 3) Vasectomy (the vas deferens on each side is tied off and cut to prevent sperm cells from reaching the seminal vesicles) Sterilization may be indirect or direct. The former is the outcome of a therapeutic intervention on a diseased part of the human body. The removal of which, cure the same and serve the whole organism. The intervention is anchored on the principle of totality. Therefore, it is morally licit and permissible to perform indirect sterilization. On the other hand, the direct sterilization makes procreation not possible. It includes eugenic and contraceptive or preventive sterilization. Eugenic sterilization is done to avoid the birth of a defective or diseased offspring, geared towards the improvement of human race. Preventive sterilization suppresses ovulation to avoid risk of getting pregnant, which pregnancy may aggravate a disease of a woman. The two immediately preceding methods are all morally illicit because they lessen the functional integrity of the human body when such methods do not preserve the health and life of the total well-being (Padilla, 2005). In a word, direct sterilization disables a woman from procreating. Moral liability may fall upon the implementers, as well as policy-makers under the principle of command responsibility in the promotion of the use of contraceptive pills and surgical sterilization to control population growth. Such course of action by these policy-makers and those who implement is tantamount to silent abortion for which they are solidarily answerable. Abortion Abortion is the premature expulsion of fetus or child prior to normal birth. It is either by spontaneous or by induced termination. The former is a miscarriage, that is the fetus or baby is born before it is able to live. The latter implies knowing the destruction of the life of an unborn child, or the intentional expulsion or removal of the same from the womb, other than for the principal purpose of producing a live birth or removing a dead fetus (Blacks Law Dictionary). A

physician and a nurse, or midwife, are criminally liable for causing an abortion or assisting in causing the same by taking advantage of their scientific knowledge and skills. However, if the abortion is done to save the life of the mother, there is no criminal liability. This is known as therapeutic abortion. But abortion, without medical necessity to warrant, is legally and morally punishable, even with the consent of the woman or her husband. There is a wide range of potential reasons for the phenomenon of abortion. Among others, these reasons are: (Mappes and De Grazia, 2002) If the fetus is allowed to develop normally and come to term, the pregnant woman herself will die; It is not the womans life, but her health, physical or mental, that will be severely endangered, if the pregnancy is allowed to continue; The pregnancy will probably or surely produce a severely impaired child; Pregnancy is an outcome of rape or incest. The pregnant woman is unmarried, and there will be the social stigma of illegitimacy; Having a child or another child will be an unbearable financial burden; and Having a child will interfere with the happiness of the woman, the joint happiness of the couple, or the family as a unit. The Pros and Cons of Abortion: Their Moral Dimensions The abortion issues involves two opposing camps that divergent positions: the Pro-life versus the Pro-choice. The Pro-life position is anti-abortion. It resolves that abortion is illegal and immoral, based, among others, on the following grounds: Human life begins at conception; Sanctity or value of life: the unborn child has all the rights as a human person; Abortion starts the domino effect, ending in complete disregard for the value of human life; Abortive methods are medically and psychologically dangerous to the womans life and procreativity; Dangers in pregnancy are relatively safe due to the advances of medical science; Economic reasons are irrelevant and unacceptable; and Viable options to abortion for unwanted babies due to deformity, born out wedlock, or arising from rape and incest. Under the foregoing premises, proponents of Pro-life, conclusively hold that abortion is an illegal and immoral act. It constitutes murder of an unborn, innocent, and helpless person. Because this person possess humanity, he/she must be accorded all human rights, such as the right to life and live. One the other hand, the Pro-choice position is for abortion. It resolves that abortion is legal and moral based on reasonable grounds. Among these grounds are:

Womans autonomy: she has an absolute right over her own body, and she should not be forced to bear a child that she does not want; Human life begins at birth: Actual birth determines the existence of life. If the fetus is still within the womans body, it is, therefore, part of her body, and is subject to her free choice to give life or take it away from the unborn; Problem of unwanted or deformed child. Only really wanted children must be born; otherwise the unwanted add to the problems of over population, pollution and economics, and the same becomes a burden to society; Abortion is relatively safe. The availability of qualified medical personnels (physician, nurse, or midwife) guarantee safe performance and minimal danger; Domino effect argument is not tenable. Abortion will not enhance loss of reverence for human life in any other areas. Instead, the experience of abortion makes woman more loving of their wanted children; and Pregnancy poses danger to the mothers life. In a situation where the mother and childs life are both in danger, that of the mother takes precedence or priority, over that of the child. Thus, abortion is permissible to save a womans life. Under the foregoing grounds, advocates of Pro-choice conclusively hold that abortion is a legal and moral act. It is an absolute right to privacy regarding health care decisions like a womans reproductive choice. Therefore, any form of intervention is a violation or infringement on this privacy. Euthanasia The term euthanasia comes from two Greek words eu, which means good and thanatus, which means death, or a good death. It implies mercy killing. It applies to a practice of hastening or causing the death of a person suffering from an incurable disease, as an act of mercy. It is a painless killing to end ones life as a matter of right. It is allowing someone to die in an easy death, without using medical science and technologies to keep him/her alive. Under the foregoing definitions, there are three key concepts or phrases that need distinction, namely: 1) Mercy killing 2) Mercy death 3) Allowing someone to die, Mercy killing is the involuntary or unintentional termination of the life of a patient by someone. It does not require his/her permission or request. On the contrary, mercy death means someone takes direct action to terminate a patients life upon his/her request. It is an assisted suicide or murder. Allowing someone to die implies withdrawal of treatment, and acceptance of the fact that the patients illness has reached a point where and when no cure is possible, or further curative treatment has no useful purpose. In this situation, he/she should be allowed to die a natural death in comfort, peace, and dignity (Padilla, 2005:142-143).

The above-cited concepts or phrases may be classified into active and passive euthanasia. The active euthanasia is intentional and voluntary. It is an act in which the physician, nurse, or other health care providers not only provide the means of death, but also administer it. Passive euthanasia is an act in which the patients receive the means of death from the physician or nurse, but activate the process themselves. Proponents of the latter process invoke respect for the patients autonomy in choosing to end his/her life. Proponents to the former process invoke sanctity or value of life. Proponents to the former process invoke sanctity or value of life, and such act violates the mandate not to kill human beings (Burkhardt and Nathaniel, 2002:225).