BIOETHICS

Chapter III:
ETHICAL PRINCIPLES AND NURSING

1. RESPECT FOR PERSONS

Respect for persons incorporates at least two ethical convictions: first, that individuals
should be treated as autonomous agents, and second, that persons with diminished autonomy
are entitled to protection. The principle of respect for persons thus divides into two separate
moral requirements: the requirement to acknowledge autonomy and the requirement to
protect those with diminished autonomy.
An autonomous person is an individual capable of deliberation about personal goals and
of acting under the direction of such deliberation. To respect autonomy is to give weight to
autonomous persons’ considered opinions and choices while refraining from obstructing their
actions unless they are clearly detrimental to others. To show lack of respect for an
autonomous agent is to repudiate that person’s considered judgments, to deny an individual
the freedom to act on those considered judgments, or to withhold information necessary to
make a considered judgment, when there are no compelling reasons to do so.

2. AUTONOMY
Autonomy is the freedom and ability to act in a self-determined manner. It represents
the right of a rational person to express personal decisions independent of outside interference
and to have these decisions honored.
In the domain of health care, respecting a patient’s autonomy includes obtaining
informed consent for treatment; facilitating and supporting patients’ choices regarding
treatment options; allowing patients to refuse treatments; disclosing comprehensive and
truthful information, diagnoses, and treatment options to patients; and maintaining privacy and
confidentiality.
Restrictions on an individual’s autonomy may occur in cases when a person presents a
potential threat for harming others, such as exposing other people to communicable diseases
or committing acts of violence; people generally lose the right to exercise autonomy or self-
determination in such instances.

Respecting patients’ autonomy is important, but it also is important for nurses to

receive respect for their professional autonomy. In considering how the language nurses
choose defines the profession’s place in health care, Munhall (2012) used the word autonomy
(auto-no-my) as an example. She reflected on how infants and children first begin to express
themselves through nonverbal signs, such as laughing, crying, and pouting, but by the time
children reach the age of 2 years, they usually “have learned to treasure the word no”. Munhall
calls the word no “one of the most important words in any language”. Being willing and able to
say no is part of exercising one’s autonomy.
 Pattern of autonomy - 4 basic elements
- Respect for persons - essential element in insuring autonomy
- Implied ability to determine personal goals
- Implied competence to determine personal action
- Certain groups felt to be incompetent (incapable of making choices)
- Children, fetuses, mentally-impaired individuals
- Freedom to act on choices which are made
- Absent in totalitarian, communistic societies
- Absent in instances where means to accomplish choice does not exist
Example: indigent person who does not have health care
insurance

Threats to autonomy
Patient role is dependent one; health care worker in expertise role
Health care industry potential to dehumanizes and erodes autonomy of
consumers
- Disrobed on entering hospital; asked questions regarding private
matters
- Forced to relinquish money and belongings
- Expected to remain in bed; privacy virtually impossible
- Follow hospital schedule and regiment
- Patient’s expected to follow plans else labeled noncompliant

Potential threats to patient autonomy

Nurses may falsely assume patients have same values and goals as provider
- Elderly person choosing to stay at home when viewed as incapable
- COPD patient who smokes
Failure to recognize that patient’s thought processes may differ from provider
- Differences not in values but in thinking patterns
- Backgrounds, cultures, patterns of thinking
Incorrect assumptions regarding patient’s knowledge base
- Providers have specialized health care knowledge
- Failure to recognize deficits in patient knowledge base
“Work of nursing” becomes the major focus
- Frenzied pace and unrealistic workloads, staffing reduction
- Advanced technology, bottom-line management
- Profit centered health care environment

INFORMED CONSENT
- Patients are informed regarding the possible outcomes, alternatives and risks of
treatment
- Required to freely give consent
- Legal protection of patient’s right to personal autonomy concerning treatments and
procedures
Three basic elements that are necessary for informed consent to occur:

1. Receipt of information: This includes receiving a description of the procedure,

information about the risks and benefits of having or not having the treatment,
reasonable alternatives to the treatment, probabilities about outcomes, and “he
credentials of the person who will perform the treatment. Because it is too
demanding to inform a patient of every possible risk or benefit involved with every
treatment or procedure, the obligation is to inform the person about the
information a reasonable person would want and need to know. Information should
be tailored specifically to a person’s personal circumstances, including providing
information in the person’s spoken language.

2. Consent for the treatment must be voluntary: A person should not be under any
influence or be coerced to provide consent. This means patients should not be asked
to sign a consent form when they are under the influence of mind-altering
medications, such as narcotics. Depending on the circumstances, consent may be
verbalized, written, or implied by behavior. Silence does not convey consent when a
reasonable person would normally offer another sign of agreement.

3. Persons must be competent: Persons must be able to communicate consent and to

understand the information provided to them. If a person’s condition warrants
transferring decision-making authority to a surrogate, informed consent obligations
must be met with the surrogate.
3. BENEFICENCE

The principle of beneficence consists of performing deeds of “mercy, kindness,

friendship, charity and the like” (Beauchamp & Childress, 2013, p. 202). Beneficence means
people take actions to benefit and promote the welfare of other people. Examples of moral
rules and obligations underlying the principle of beneficence are listed in Box 2-4.

Because of professional standards and social contracts, physicians and nurses have a
responsibility to be beneficent in their work. Nurses are directed in Provision 2.1 of the Code of
Ethics for Nurses with Interpretive Statements (ANA, 2015) to have their patients’ interests and
well-being as their primary concern. Therefore, though there sometimes are limits to the good
nurses can do, nurses have a more stringent obligation to act according to the principle of
beneficence than does the general public. Doing good toward and facilitating the well-being of
one’s patients is an integral part of being a moral nurse.

Beneficence has 3 major components

Do or promote good
- Questions arise when those involved cannot decide on what is “good”
- Example: patient with lingering, painful, terminal illness
Prevent Harm
“ Nurse acts to safeguard client and public when health care and safety
are affected by incompetent, unethical practice of any person” (ANA
Code for Nurses with Interpretive Statement - 1985)
Remove Harm or Evil
- Code outlines steps to be taken to facilitate removing harm
- Voicing objecting to practice, reporting violations to authority, etc.

NONMALEFICENCE
Nonmaleficence is the principle used to communicate the obligation to do no harm.
Emphasizing the importance of this principle is as old as organized medical practice. Healthcare
professionals have historically been encouraged to do good (beneficence), but if for some
reason they cannot do good, they are required to at least do no harm.
 Nonmaleficence is the maxim or norm that “one ought not to inflict evil or harm”
(Beauchamp & Childress, 2013, p. 152), whereas beneficence includes the following three
norms: “one ought to prevent evil or harm, one ought to remove evil or harm, [and] one ought
to do or promote good” . As evidenced by these maxims, beneficence involves action to help
someone and nonmaleficence requires “intentional avoidance of actions that cause harm”.

Examples
- Prohibition against research that assumes negative outcomes
- Prohibition against unnecessary procedures for economic gain or learning
experience
- Avoid harm as a consequence of doing good
- Prescribing medication where side-effects are worse than disease treated
- Incompetence to practice wherein one fails to recognize and report serious
symptoms

Withholding vs. Withdrawing Care

Ethical decisions can be hard to make in any walk of life. However, when those decisions
directly impact people's lives and well being, they're especially important. In the world
of medical ethics, or the morality of healthcare, one of the biggest questions professionals face
is deciding when to not treat a patient. This can happen in one of two ways. Withdrawing care
means stopping a treatment. Withholding care is never starting a treatment, and there can be
many reasons for both of these. However, in the end, the only reasons that matter are those
agreed upon by physician and patient. So, unlike many questions of ethics, this one isn't about
individual choice. It's all about teamwork.
 Withholding care means that a physician never begins a treatment. For example, if a
patient with cancer and their doctor decide that chemotherapy is not the best option, they
could choose to withhold that treatment. Patients opt to withhold care for many reasons.
Perhaps they fear that the treatment will be worse than the actual medical condition.
Sometimes patients with a terminal illness decide they would rather manage their pain and try
to enjoy the remainder of their lives, rather than fighting against impossible odds and possibly
increasing their suffering. And, where's the physician in this? Making sure that the patient is
fully informed about the benefits and risks of every possible procedure, so that the patient can
make an informed decision about their healthcare.

Withdrawing care is stopping a treatment. Say that a patient is on an experimental drug

that isn't working; they will likely stop using that medicine. People can choose to withdraw care
if a treatment isn't working, this often becomes an issue with terminally ill patients. The choice
to withdraw care can be a powerful moment for people who have accepted their conditions
and are finding peace with their own mortality.

Withholding Withdrawal of Mechanical Ventilators

Not initiating a therapy that has a - Need for inotropes or vasopressors
disproportionate burden without achieving - Physician’s prediction of survival <
reasonable clinical goals 10%
- Physician’s prediction of limitation of
Examples: intubation, vasopressors, future cognitive function
 mechanical ventilation, dialysis, IV fluids, - Physician perception that patient did
enteral or parenteral feeds not want life support used

Ordinary versus Extraordinary Measures

Ordinary Measure
- means reasonable hope of benefit/success; not overly burdensome; does not
present an excessive risk and are financially manageable
- Proportionate to the state of the patient
- “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”

Extraordinary Means
- means no reasonable hope of benefit/success; overly burdensome; excessive risk
and are not financially manageable, no obligation to use it/morally optional.
- “All medicines, treatments, and operations, which cannot be obtained or used
without excessive expense, pain, or other inconvenience, or which, if used,
would not offer a reasonable hope of benefit”

Killing and Letting Die: An

Irrelevant Distinction
The distinction between
killing and letting die is both
relevant and irrelevant to
euthanasia. The relevance of
the
distinction to euthanasia could
be made when a doctor
withdraws
or withholds the treatment to
kill a patient intentionally
who, in
fact, would live longer if
treated properly. On this
formulation,
Killing and Letting Die: An
Irrelevant Distinction
The distinction between
killing and letting die is both
relevant and irrelevant to
euthanasia. The relevance of
the
distinction to euthanasia could
be made when a doctor
withdraws
or withholds the treatment to
kill a patient intentionally
who, in
fact, would live longer if
treated properly. On this
formulation,
Killing Versus Letting go
According to Beauchamp and Childress, 2001:
1. Killing is a casual action that deliberately brings about another’s death.
 In a medical environment it conjures up images of healthcare workers secretly their
patients, handicapped infants and elderly people in an institution being quietly snuffed
out of wicked experimental programs.
2. Letting go/ Letting die is the intentional avoidance of casual intervention as that of disease.
  Suggest the much acceptable practice of “letting nature take its course”, facing up the
limitations of medicine and the fact of impending death and avoiding heroic measures
such as aggressive surgery, drug therapies or intrusive devices.

4. JUSTICE
- Justice, as a principle in healthcare ethics, refers to fairness, treating people equally
and without prejudice, and the equitable distribution of benefits and burdens, including
assuring fairness in biomedical research.
- Ethical principle relating to fair, equitable and appropriate treatment via what is due to
persons

Distributive justice when concept is applied to goods and services

- Impossible for all people to have finite supply of goods and services
- Governments formulate/enforce policies dealing with fair and equitable
distribution
Decisions regarding distributive justice on a variety of levels
- Government: policy on broad public health issues: medicare, immunizations
- Hospitals: intensive care beds, ER services
- Nurses: decide how to allocate time among patients assigned

CONCEPTS IN HEALTH CARE RELEVANT TO DISTRIBUTIVE JUSTICE

1. What percentage of our resources is reasonable to spend on health care?
2. What aspects of health care should receive the most resources
3. Which patients to have access to limited health care staff, equipment,
resources, etc.
Who is entitled to goods and services? Historical approaches vary
- To each equally
- To each according to need
- To each according to merit
- To each according to social contribution
- To each according to person’s rights
- To each according to individual effort
- To each as you would be done by
- To each according to the greatest good to the greatest number

OPPOSING VIEWS
Egalitarian views: systems where all receive equally regardless of need
Proposed nationalized health care system encompasses several principles
- System of entitlement to all - all are eligible
- Needs perspective: some would need more services than others
Practicality issues with limited resources
Friedrich Nietzsche view: to each according to his present or future social contribution
 - Superior individuals exist; society should enhance these “supermen”
- Not very equitable or appealing to many in US
Libertarian view: to each according to his rights
Golden rule view: to each as you would have done by
Work ethic view: receive according to effort put forth - common in US culture
Needs view:
- Entitlement programs: combo of needs and greatest goods theory
- Based on needs of individual
- Greatest good for greatest number of people

5. VERACITY
- Practice of telling the truth
- Truthfulness widely accepted as a universal virtue
- Nursing literature frequently cites Immanuel Kant and John Stuart Mill - both support
truthfulness
- Bioethicists disagree regarding absolute necessity of truth telling

ARGUMENTS FAVORING VERACITY

- Per Martin Buber (1965) communication occurs only where there are no barriers
- Lying and deception creates barrier thus prohibits meaningful communication and
relationships
- Nurses must be truthful to effective communicate where communication is considered
the cornerstone of nurse-patient relationship
- Manipulating info for purpose of controlling others is similar to coercion to control
(Jameton, 1984)
- Lying prohibits others from participating in decisions on an equal basis
Used to benefit patient - constitutes paternalism
Used against patient - fraud
- Deceiving others may constitute an unnecessary assumption of responsibility
- Implication deception: unfortunate consequences suggest that deceiver is
responsible
- Implication veracity: bad consequences which follow truth telling results in
attribution of responsibility to unfortunate nature of reality
- Truth-telling engenders trust where nurse-patient relationship felt to be based
on trust
- Patients are willing to suspend some autonomy on basis of the
relationship
- Without trust some patients’ needs may go unmet
- American Hospital Association supports veracity in Patient’s Bill of Rights
- Patients have right to complete and current info concerning diagnosis,
treatment and prognosis
- Directed at physicians but nurses have responsibility as advocates
 - ANA Code for Nurses with Interpretive statements (1985) supports veracity
- Subsequent statements support principle but recognize situations which
are exception
- Recognize certain situations where patients right to info may be
suspended

ARGUMENTS SUPPORTING NON-VERACITY

- Dramatic discrepancy in literature between nursing and medical perspectives on
veracity
- Perspectives drawn from medical literature
- Physicians often claim that patients do not want bad news and truth in all
settings
- Truth has potential to harm
- Lies may be appropriate in the name of beneficence
- Patients may lack sufficient knowledge regarding physiology to interpret
medical information accurately
- Some patients may not want truth regarding illness
- Physicians do not have absolute responsibility to tell truth particularly where
hope and positive outlook may be life-affirming
- Distinction made between lying and deception
- Absolute duty to avoid lying
- No duty to avoid deceive
- Example: MVA where mom is critical and 2 of 4 children are killed
- Veracity never given much consideration in medical literature
- Veracity absent from all oaths, codes and prayers even Hippocratic Oath
- American Medical Association Code of Ethics (1847) endorses some form of
deception Avoid “all things which have tendency to discourage patient and
depress his spirits” (Bok, 1994 p 683)
- Nursing and medicine have apparent different perspectives
- Recognizing differing viewpoints is essential for collaboration

6. CONFIDENTIALITY
- Nondisclosure of private or secret information with which one is entrusted
- Codes and oaths of nursing and medicine dating back many centuries
- ANA committee on Ethics is unequivocal
- Mentioned on Nightingale Pledge
- Addressed in Hippocratic Oath
- Disagreement regarding the absolute requirement in all situations
- Ability to maintain privacy is an expression of autonomy
- Maintains dignity of individual especially concerning personal details
- Maintains control over one’s own life

Two arguments favor maintaining confidentiality

- Individual’s right to control personal info and protect privacy
 - Private discussions
- Revealing info with other professionals - implications for sensitive info
- Sensitive info: embarrassment, ridicule, discrimination, deprivation of
rights
- Inadvertent revealing of info - partial disclosure
- Argument of utility
- Patients will hesitate to reveal info to providers if they suspect abuse
- Patients will not seek care if info is not confidential
- Mental illness, alcoholism, drug addiction if revealed can lead to public
scorn
- Government policy recognizes the problem
- Confidential nature of family planning is mandated
- AIDS patients

LIMITS OF CONFIDENTIALITY
- Arguments favor questioning the absolute obligation in certain situations
- Issue of harm and vulnerability
- Where maintaining confidentiality results in preventable wrongful harm
to an innocent
- Example: mandatory premarital testing for syphilis
- Example 1976 ruling of wrongful death of Tatiana Tarsolf (California)

Doctors Lawrence Moore and Harvey Powelson were held

responsible for wrongful death when patient, Prosenjit Poddar,
killed Tarsolf after confiding his intention to said psychologist who
failed to inform patient or family. Obligation to protect innocent
third party was held to superceded obligation to maintain
confidentiality

- Foreseeability is important consideration in situations if confidentiality

vs duty to warn
- Must reasonably foresee harm to an innocent other to warrant
violation
- Precludes blanket disclosure that might predict harm to others
- Privacy is held subordinate to state’s fundamental right to enact law to
promote public health
- Vulnerability principle
- Duty to intervene stronger when third party is dependent on others or
vulnerable
- Vulnerable individuals have relative inability to protect selves example
child abuse
- Nurses have absolute duty to report child abuse

7. FIDELITY
 – Principle of faithfulness and practice of keeping promises
- Nursing’s right to practice based on processes of licensure and certification
-Contract with society: rights and responsibilities and mechanism for
accountability
- No other group can practice within domain of nursing as a profession
- Rights also mandate nurses uphold responsibilities inherent in contract with
society
- Members expected to be faithful to society that grants the right to practice
- Uphold professions code of ethics
- Practice within established scope of practice and definitions
- Remain competent in practice
- Abide by policies of employing institutions
- Keep promises to individual patients
- To be a nurse is to make these implied promises

References
Burkhardt, M.A & Nathaniel, A.K. (2002). Ethics and Issues in Contemporary Nursing • NY:
Delmar Outlined by Lois E Brenneman • NPCEU • www.npceu.com
https://study.com/academy/lesson/withholding-withdrawing-care-autonomy-surrogate-decision-
makers.html

https://www.slideshare.net/Jelisa1975/withholding-and-withdrawal-of-medical-therapies

https://www.slideserve.com/flavia-estes/withholding-and-withdrawing-life-sustaining-treatment

https://www.msjonline.org/index.php/ijrms/article/view/1198

Michelle source

https://stanford.edu/class/siw198q/websites/reprotech/New%20Ways%20of%20Making%20Babies/
EthicVoc.htm